Saturday Afternoon, May 10, 1952

2:00 P.M. Scientific Session.

27. Surgical Treatment for Congenital Aortico-Pulmonary Fistula: Experimental and Clinical Aspects.

H. William Scott, Jr. and David C. Sabiston (by invitation),

Baltimore, Md.

Aortico-pulmonary fistula resulting from a congenital defect in the aortic septum is an unusual malformation. The clinical syndrome associated with it is similar to that of patent ductus arteriosus of large caliber. In an effort to develop a method for closure of this window-like type of fistula experiments were carried out in a series of animals. The anomaly was reproduced in dogs by constructing a lateral anastomosis between the aorta and the pulmonary artery near the base of the heart. A number of these animals were re-explored at varying intervals and a technique for closure of the aortico-pulmonary fistula by division and suture was devised.

This technique has been employed successfully recently in the closure of a congenital aortico-pulmonary fistula measuring 16 mm. in diameter in a ten-month-old baby. Lantern slides.

28. Pulmonary Function after Bilateral Multiple Segmental Resection for Bronchiectasis.

Richard H. Overholt, Benjamin Etsten (by invitation) and

James H. Walker (by invitation), Boston, Mass.

The degree of relief of toxicity and distressing symptoms in bilateral bronchiectasis parallels the extent of the surgeon's ability to remove the diseased tissue. Furthermore, in many cases, the conservation of all possible normal tissue is obligatory if crippling pulmonary function is to be avoided following bilateral excisional therapy. Prior to the development of safe techniques for segmental resection, it was often impossible to remove all the involved segments and still insure adequate function. Postoperative pulmonary function studies have been made of a number of patients who have had bilateral and multiple segmental resections. An analysis of these studies will be given. Results indicate that the postoperative pulmonary function parallels one's ability to preserve healthy segments.

29. The Indications for and the Results of Commissurotomy for Mitral Stenosis.

Robert P. Glover, Thomas J. E. O'Neill, James M. Harris (by invitation)

and O. Henry Janton (by invitation),

Philadelphia, Pa.

With the development of any new and radical departure in the treatment of a common disease entity such as mitral stanosis there must be much initial conjecture and speculation as to its proper application. Since it has now become clear, after four years of surgical investigation, that over 75% of the patients submitted to surgery show definite improvement, in many instances of great magnitude, the time has come to examine in detail the factors responsible for these results. By such analysis obvious errors in the past may be aired and rectified and the entire program, both medical and surgical, may thereby be placed on a sound and coordinated basis.

In 1949, before this association, the surgical technique of commissurotomy was described as applied to the first seven cases so treated. The personal experience of the authors has now been expanded to include over 200 cases. Sufficient time has elapsed in over 150 of these (6 months to over 3 years) to permit certain conclusions to be drawn. It has become obvious that the greatest single factor in the successful performance of surgery for mitral stenosis is the proper selection of cases. The indications for such selection are therefore considered under eight major categories. The history, the age of the patient, the valvular defect or defects, the cardiac size, the electrocardiographic findings, the catheterization data, the functional capacity and complicating factors such as rheumatic activity, arrhythmias, and embolic episodes.

Results, both anatomical and functional, have been exhaustively studied and their correlation subjected to analysis. The overall mortality in the entire series has been less than 7% and that since January, 1951 (150 cases) has been approximately 4%.

30. The Cure of Two Aneurysms Associated with Patent Ductus with a Resume of Seventy Cases of Patent Ductus Surgically Treated.

Emile Holman and Frank Gerbode, San Francisco, Calif.

In this paper there is included: (1) A report of an aneurysm of the ductus following two previous ligations complicated by a persistent staphylococcus albus infection; (2) A report of an aneurysm of the pulmonary artery opposite the patent ductus also associated with an endocarditis; (3) A report of identical patent ductus in identical twins; (4) Patent ductus with reversal of flow and with preponderant hypertrophy of the right ventricle; (5) An analysis of 70 ligations of the patent ductus indicating that 36 operations were performed for minor or no symptoms except for murmur, and 34 operations performed for major symptoms, with one death.

31. Anatomical (Histological) Basis and Efficient Clinical Surgical Techniques for the Restoration of the Coronary Circulation.

Charles P. Bailey, R. C. Treux (by invitation),

George Geckeler (by invitation) and Nicholas Antonius (by invitation),

Philadelphia, Pa.

Gross (L), O'Shaughnessey, Beck, Thompson and Raisbeck, Fauteux, and Vineberg have all attempted to add to or to replace the diminished coronary circulation in arteriosclerotic disease. Their methods have varied, clinical results have been variable, and much doubt as to their logic and basic soundness exists even to the present time. It is the purpose of the authors to present: (1) The sound anatomical basis for certain of the procedures; (2) The clinical evaluation of the results in a small series operated on by apparently the most promising of these methods; (3) A modification of the original technique which renders the operation technically simpler, appreciably lessens the operating time, and presumably renders the percentage of clinical effectiveness greater.

32. Pulmonary Valvulotomy: Description of a New Operative Approach with Comments About Diagnostic Characteristics.

Harris B. Shumacker, Jr., Indianapolis, Ind.

A series of nine valvulotomies, eight for pure pulmonic stenosis, and one for tetralogy of Fallot associated with a stenotic calcified valve, are analyzed. All patients survived. In the first seven cases the usual anterior intercostal approach with section of costal cartilages was used. In more than one-half some difficulty was encountered in dislocating the heart into the left chest so as to permit proper placement of sutures in the appropriate portion of the right ventricular wall. Such maneuvers were often associated with cardiac irregularities. In two cases it was necessary first to place traction sutures in the wall of the left ventricle in order to accomplish this end. Because of these experiences the heart was approached through a complete midsternal-splitting incision in the last two cases. Initial experiences suggest that it is a superior approach, giving far better exposure of the anterior surface of the right ventricle and pulmonary conus.

The eight cases of pure pulmonic stenosis have deviated widely from the classical picture as far as diagnostic features are concerned. In some there was no X-ray evidence of marked enlargement of the pulmonary artery segment. One patient, severely incapacitated, with marked cyanosis and hemoconcentration, had a small pulmonary artery and no thrill. The artery increased significantly in size immediately after valvulotomy and the patient has had an excellent response to operation. A number of patients have not shown diminished vascular markings in the periphery of the lung fields. Only two of the eight showed, on electrocardiographic study, definitely high P waves and one borderline P waves.

Comments will be made about the operative technique, the problem of diagnosis, postoperative complications and results of treatment.