Monday Afternoon, March 30, 1953

2:00 P.M. Scientific Session.

28. The Role of the Bronchial Artery Circulation in the Etiology of Pulmonary and Pericardial Suppuration: An Experimental Study.

Richard S. Hahn (by invitation) and Emile Holman,

San Francisco, Calif.

A series of experiments were designed to determine the functional role of the bronchial artery circulation in the production of lung abscess, pericarditis and suppurative lesions of the mediastinum and chest cavity.

The right posterior bronchial artery was cannulated via a standard thoracotomy approach. A suspension of staphylococcus aureus and clotted whole blood was injected in Group I animals. Group II animals received the organisms and blood clot mixed with an equal quantity of Bismuth oxychloride and Gum Acacia in solution. Extreme care was taken to avoid the slightest gross contamination of the surrounding tissue. No antibiotics were used.

Results: Of five animals in Group I, two died within two weeks. Both displayed massive mediastinitis and empyema. One animal was sacrificed after three weeks and no abnormal findings were noted. Two are living, one of which is obviously quite ill with empyema.

Of three dogs in Group II, all died within 24 hours. At autopsy each manifested a marked hemorrhagic, inflammatory reaction of all pleurae. Fluid was found in the free chest cavity, pericardium and mediastinum. The tracheobronchial tree and esophagus were edematous and hemorrhagic. Petechial hemorrhage of the myocardium and the fatty areolar tissue was seen. The dye medium was found to be dispersed in the arterial bed of all structures involved.

It would appear that the bronchial artery circulation has a degree of collateralization hitherto not appreciated. Virulent organisms when injected into this system have been capable of producing primary empyema, mediastinitis, pericarditis and myocarditis. Lung abscess has not been produced. This is contrasted with the results of Holman, et al, in which septic emboli of the pulmonary arterial system resulted uniformly in lung abscess and a notable lack of involvement of other structures.

It would thus appear that septic emboli or bacteremia disseminated by way of the bronchial artery circulation has little or no propensity for initiating lung suppuration. Indeed, its importance in primary suppurative processes of the mediastinum, chest walls, pericardium and heart itself appears to be of greater significance. The clinical application of the findings bear evaluation.

29. The Production and Repair of Interatrial Septal Defects Under Direct Vision with the Assistance of an Extracor-poreal Pump Oxygenator Circuit.

Bernard J. Miller (by invitation), Victor F. Greco (by invitation),

Burgess A. Smith (by invitation) and John H. Gibbon, Jr.,

Philadelphia, Pa.

Despite recent reports of occasional successes in the closure of interatrial septal defects in human patients, it appears to us that the problem is far from being satisfactorily solved. We believe that the solution will probably lie in careful closure of these defects under direct vision. We would, therefore, like to report a series of 10 dogs in which interatrial defects were created and closed with pericardial grafts at the same operation.

The systemic venous return to the heart and cardiac venous blood were diverted from the right atrium through an extracorporeal pump oxygenator circuit. This blood was oxygenated, cleared of carbon dioxide, and continuously returned to the animal through a centrally directed cannula in the femoral artery. The atrium was then widely opened. An excellent view of the interatrial septum was obtained. Defects measuring between 0.8 cm. and 1.8 cm. were made in the atrial septum Repair was effected by suturing pericardial grafts to the free edge of the defects. In three instances, the graft was separated from its pericardial attachment, while in the remaining seven, the graft remained attached to the pericardium. Three animals died. The remaining seven animals are all alive and in good condition without any clinical evidence of an interatrial defect. The animals will be sacrificed after several months, and the gross and microscopic appearance of the pericardial grafts will be reported.

A brief motion picture will be shown illustrating the technique of this repair of interatrial defects.

30. The Oxygenator Pump in Total By-Pass of Heart and Lungs: Laboratory Evaluation and Clinical Use.

James A. Helmsworth, Leland C. Clark, Jr., (by invitation),

Sam Kaplan (by invitation), Roger T. Sherman (by invitation) and

Thomas Largen (by invitation), Cincinnati, Ohio

The oxygenator pump, developed by Dr. Leland C. Clark, Jr., has been used by the authors in more than 85 experiments. In each instance, the subject dog had complete by-pass of its heart and lungs for at least thirty minutes. In the most recent group of experiments, cardiotomy was performed during total by-pass, and observations were made on venous return to the so-called "bloodless" heart. Measurements of the volume of combined bronchial and coronary venous return will be given. Technical problems related to operative surgery on the cardiac septa will be mentioned.

A detailed report will also be given describing total by-pass of the heart and lungs in a child with a ventricular septal defect. The closure of a portion of the defect was successfully accomplished. However, sixteen hours later the patient succumbed to the delayed effects of hypotension. A possible explanation for this hypotension will be offered and the lessons learned from this initial experience will be summarized.

31. Experiences with Cardiopexy in the Treatment of Coronary Disease.

Samuel A. Thompson, New York, N.Y.

For the past 14 years, cardiopexy has been performed upon a group of patients most of whom were completely incapacitated, because of severe coronary disease and angina. The rationale of the operation is to change the ischemic myocardium of coronary disease to a myocardial hyperemia. This is accomplished by distributing magnesium silicate powder over the myocardium inside the pericardial sac. The powder produces a foreign body reaction and a granuloma which involve the superficial myocardium and pericardium; it stimulates the development of intercoronary anastomosis, and it produces adhesive pericarditis. The new collateral circulation to the myocardium is thus both intra-cardiac and extracardiac in origin.

Fifty patients have been followed from the time of operation up to 14 years, with the idea of determining the degree of relief and the length of life after operation. Ninety percent of the patients were more than 50 percent improved; 40 percent of the patients were more than 75 percent improved, while only 10 percent were less than 50 percent improved.

Thirty-three (66 percent) of the patients are still living and of the 17 who have died, their average life span after cardiopexy was five years.

A short description of the operation is given and other pertinent data such as the age and sex of the patients, initial symptoms, length of symptoms before operation, and a comparison of the life span of the operated patients with the average span of the non-operated ordinary coronary patients is shown.

Microscopic slides from autopsy specimens show the persistence of the granuloma for as long as 10 years.

32. Cardiac Surgery Under Hypothermia.

Charles P. Bailey, Brian Cookson (by invitation), William Likoff

(by invitation), H. E. Bolton (by invitation), D. F. Downing

(by invitation) and W. B. Neptune (by invitation), Philadelphia, Pa.

The works of Temple Fay, of W. E. Bigelow and of W. C. McQuiston and W. Potts have clearly portended the trend toward the utilization of lowered bodily temperature (and metabolism) for the performance of both open and closed intracardiac surgery. Following their lead, and after the employment of this modality in a considerable series of animal experiments, the authors have become emboldened to apply the technique to human cardiac surgery. The first patient was operated upon on August 29, 1952, in an unsuccessful attempt to repair an interatrial septal defect.

Since that time and up to the time of submitting this abstract, seven additional patients have been operated upon under hypothermia, both by the open and closed technique. Undoubtedly, by the time of presentation of this material, additional cases can be reported.

The indications to date for the employment of this method have been: interatrial septal defect; pulmonic stenosis; tetralogy of Fallot; mitral regurgitation and complete transposition (congenital) of the great arteries.

The experiences and results achieved with this method of management in our hands have been, on the whole, encouraging. It is felt that while there are distinct limitations to the .successful clinical application of hypothermia, it does permit surgical correction of certain lesions which are not presently amenable to any other operative approach.

33. The Management of the Dangerously Torn Auricle.

William K. Swann (by invitation), Thomas L. Lomasney

(by invitation) and Jorge Rodrigues-Arroyo (by invitation),

Knoxville, Tenn.

The utilization of the left auricular appendage as an avenue of approach to the diseased mitral valve has now been widely adopted for commissurotomy in mitral stenosis.

There are certain normal and pathological variations in the auricle and its appendage which may render the procedure extremely hazardous. The auricular appendage may be so small as to not permit introduction of the operative ringer after amputation or wide opening of the appendage. This may require a lower and more unsafe application of the clamp to the wall of the auricle itself. The usually friable auricular tissue may become even more surgically unacceptable in the presence of adhesive pericarditis. In the presence of a greatly enlarged auricle or an eccentric location of the mitral orifice, or both, manipulation by the operative finger may create exceptional pressure or torsion at the site of entrance into the auricle.

Any one or a combination of the above listed factors may result in a tear in the auricle and this tear may readily extend below the previously applied purse string.

There are several dangers that are inherent in attempting to control hemorrhage from the torn auricle. This report deals with the detailed anatomy in this region of the heart. The authors have had occasion to manage auricular tears in two of their patients. The successful outcome was realized only because of attention to certain anatomic details. These are illustrated and a detailed report of the surgical management of one patient with a severely torn auricle is given.