Tuesday Morning, March 29, 1949

9:00 A.M. Business Meeting.

9:30 A.M. Scientific Session.

1. The Surgical Correction of Constrictive Pericarditis.

Emile Holman, M.D., San Francisco, Calif.

In 265 reported operations for constrictive pericarditis 21 deaths occurred on the operating table, 49 deaths occurred in the early postoperative period, 118 cases were considered cured and 44 cases improved.

Although the thickness of the diseased pericardium varies considerably in different areas, a satisfactory and adequate pericardiectomy must include excision of the pericardium over the left ventricle, over the right ventricle and auricle, and over both vena cavae. The inferior cardiac border must be liberated by excision of the usually greatly thickened pericardium lying between the heart and the diaphragm. Failure to relieve constriction of the inferior vena cava may result in failure to correct ascites. Persistence of ascites following pericardiectomy is evidence of an inadequate decortication and demands reoperation and removal of more scar, rather than an omento-pexy or Talma operation.

To achieve the exposure necessary for an adequate inspection and decortication of the heart, a median sternotomy with transverse division of the sternum in the second interspace is recommended. The sternum is reapproximated by several stainless steel sutures inserted through bone, not through avascular cartilage.

The wound should be drained, preferably into the right pleural space from which the fluid can be removed either by aspiration or by intercostal drainage. (Paper illustrated by motion picture of three decortications-12 minutes).

2. A Method for Exposure of the Cardiac Septa.

F. D. Dodrill, M.D., Detroit, Mich.

A method has been used experimentally by which the chamber of the heart, either the right atrium or the right ventricle, is opened, the septum exposed for short intervals and the incision closed. An instrument has been made which consists of a ring clamp on the distal end. The clamp is used to bring the lateral walls of the atria in apposition to the septum. The incision is made within the ring which excludes the circulation from this area. Portions of the atrial septum have been excised and the defect closed. The exposure of the ventricular septum is more difficult but has been accomplished with the same instrument.

3. The Choice of the Side for Approach in Operations for Pulmonary Stenosis.

Conrad R. Lam, M.D., Detroit, Mich.

The experience to be presented was gained in 42 operations on 41 patients with pulmonary stenosis. Blalock operations or attempts were carried out on 34 patients. Two of 5 failures to complete the operation were due to inability to approximate the right subclavian and pulmonary arteries. One of these patients subsequently had a successful modified Potts operation on the left side; an anastomosis was created between the lower branch of the pulmonary artery and the descending aorta. There were two deaths from hemorrhage following completed Blalock operations on the right side in which technical difficulties due to short subclavian arteries had been encountered. This experience has led us to follow the suggestion of Holman and plan all Blalock operations for the left side if the patient has a left heart, regardless of the position of the aortic arch. Twelve of 15 patients operated on since that decision was made have had left arches; all had good results and in no case was it necessary to sever the pulmonary artery proximal to the anastomosis in order to gain additional length.

The Potts procedure was planned for 10 patients, mostly small children. The operation was successful in five patients with left arches and in two with complete dextrocardia. The right approach was used with complete satisfaction in the latter. However, difficulties were encountered when this approach was used in three patients with right arches. In two, the Potts operation had to be abandoned because the aorta and pulmonary artery could not be approximated and unsatisfactory subclavian-pulmonary anastomoses were substituted. In the third, a poor aortic-pulmonary shunt was made with great effort, but the child expired. It is believed that Blalock operations on the left side would have been preferable.

In our hands, the best results have been obtained when the operative approach is on the side of the apex of the heart, regardless of the age of the patient or the position of the aortic arch.

4. The Surgery of Mitral Stenosis.

Dwight E. Harken, M.D., Boston, Mass.

The surgery of mitral stenosis is oversimplified when merely resolved to a discussion of regurgitation versus stenosis.

It has been found that 1) the heart must not be dislocated from the position of optimum function; 2) the direct surgery of the mitral valve is more readily accomplished by approaching the valve from above, through the auricle; 3) certain types of stenosis are better tolerated than others; 4) the heart rate alters the severity of the given lesions.

On the basis of these facts, different types of surgical procedures have been devised for different clinical and pathological categories of patients:

A. Patients in whom the mechanical obstruction due to the stenotic valve is the outstanding feature. In these patients, cardiac output is low and does not go up with exercise. It seems logical to treat these by valvulo-plasty, i.e., enlarging the mitral orifice by cutting away the commissures. This allows some possible return of function with a minimum burden of added re-gurgitation.

B. Patients who suffer from marked mitral regurgitation. The clinical symptoms here are predominantly due to pulmonary hypertension, with the aggravating effect of tachycardia causing frequent episodes of pulmonary edema (or, as we term it, pulmonary decompensation). These patients have a normal cardiac output that can increase with exercise. Interatrial septal defects have been created in two patients to decompress the left auricle and pulmonic bed during periods of stress.

C. Patients so debilitated that they cannot be considered for direct cardiac manipulation and those who have episodes of tachycardia that produce pulmonary edema (pulmonary decompensation). Here, cervicodorsal sympathectomy may maintain a slower pulse rate and also eliminate various cardiopulmonary reflexes that may play a part in the production of pulmonary edema.

A plea is made that patients be selected and evaluated before and after operation by critical, objective methods, including cardiac catheterization.

This report comprehends a study group of 20 patients to date of whom five have been treated surgically. There has been one surgical death.

5. Surgery of Mitral Stenosis.

Charles P. Bailey, M.D., M.Sc., F.A.C.S. and (by invitation)

Robert P. Glover, M.D., M.Sc. and Thomas J. E. O'Neill, M.D.,

Philadelphia, Pa.

A. Historical review.

B. Modern concept of pathology and possibilities of altering the changes. This embraces the various shunt operations: (1) azygos vein-pulmonary vein anastomosis, (2) perforation of the interauricular septum, and (3) production of a tricuspid re-gurgitation. It also considers the various operations upon the mitral valve: (1) simple dilatation, (2) cutting across the valve cusps (3) excision of a portion of the valve ring (simple), and (4) directed excision of the valve-valvulo-plasty, and (5) com-missurotomy under direct digital control.

Presented are 10 cases of commissurotomy for mitral stenosis, one case of digital dilatation of the valve, and one case of opening of the interauricular septum. Discussion of failures and successes will be directed toward better selection for surgery and better technique and management.