Tuesday Morning, May 4, 1954

8:30 A.M. Scientific Session: THORACIC SURGICAL FORUM.

13. Use of the Endotracheal Tube in Pulmonary Edema.

Watts R. Webb (by invitation) and Guy D. Campbell (by invitation),

Sanatorium, Mississippi

Pulmonary edema which develops during an operation or early in the postoperative period is a distressing and frequently fatal complication, regardless of its etiology. Utilization of currently described medical measures often fails, usually due to drowning of the patient in retained alveolar fluid.

It is desirable not only to apply positive pressure oxygen to prevent anoxia and retard further transudation but to remove mechanically the accumulating fluid. By maintenance of an indwelling endotracheal catheter with an inflated cuff in the trachea, positive pressure oxygen has been given continuously for long periods, with frequent very brief interruptions for endotracheal aspirations. Always the volume of fluid to be aspirated has been far greater than anticipated. Successful clinical experience in combatting pulmonary edema is briefly described in three patients, each of whom was undergoing or had just undergone a pneumonectomy. In the light of previous experience, it is believed that recovery could not have been possible without utilization of the indwelling endotracheal tube to remove a great volume of aspirated pulmonary fluid.

It is suggested that this technique will have applicability in medical as well as surgical cases of severe pulmonary edema.

14. A Satisfactory Shunting Technique for Surgery of the Aortic and Pulmonary Valves and Proximal Great Vessels.

Frederick S. Cross (by invitation) and Earle B. Kay, Cleveland, Ohio

Work has been underway to develop a shunt: (1) to bypass the aortic and pulmonary valves; (2) to operate in a dry field; (3) to carry out surgery on the great vessels at the base of the heart.

Such a shunting mechanism has been developed out of plastic tubing fitted with a special leaflet type valve to prevent regurgitation into the ventricles. The proximal end of the shunt is sutured into the right or left ventricle, the distal end into the right pulmonary artery, or the descending aorta corresponding to the ventricle from which the blood is being shunted. It has been shown that they are well tolerated since with the shunts in place and the aorta and pulmonary artery cross-clamped at the base of the heart, it has been possible to bypass the aortic and pulmonary valves simultaneously in dogs for periods over an hour with no apparent harm. Using this shunting technique in experimental animals, direct exposure of the pulmonary valve has been possible; the aortic valve has been approached and dilated in a retrograde manner, and it has been possible to divide and resuture the aorta and pulmonary artery at the base of the heart.

The structure of the shunts, as well as the surgical technique for their insertion, will be reported in detail. The application of such shunting procedures to the problems of aortic stenosis and insufficiency, pulmonary valvular stenosis, as well as transposition of the great vessels, will be discussed.

15. The Closure of Interventricular Septal Defects in Dogs During Open Cardiotomy with the Maintenance of the Cardiorespiratory Functions by a Pump Oxygenator.

Bernard J. Miller (by invitation), Hans C. Engell (by invitation),

Anthony R. Dobell (by invitation) and John H. Gibbon, Jr.,

Philadelphia, Pa.

Interventricular septal defects were produced in dogs using a 9.3 mm. cork borer in a manner previously described. After an average interval of 53 days, 15 dogs were subjected to a second operation for the repair of the defect under direct vision.

The systemic venous return to the heart was deviated to the extracorporeal circuit containing an artificial lung. Oxygenated blood was returned from the apparatus to the femoral artery of the dogs. A left ventricular vent was employed as a method for avoiding air embolism to the systemic circulation. While the cardiorespiratory functions were maintained by the extracorporeal circuit, a right ventricular cardiotomy was performed and the repair of the interventricular septal defect accomplished under direct vision.

In three of the 15 dogs, healing had nearly completely closed the interventricular septal defect. The murmur, originally loud and coarse, became just audible. In these instances, it was necessary to recreate the defect by excising the scar at the second operation. The defects in the remaining 12 animals approximated their original size. All defects were closed with three or four cotton sutures and interrupted mattress sutures produced a more satisfactory closure.

Five of the 15 dogs failed to survive the repair of the septal defect. Of the remaining dogs, six were sacrificed from one week to three months following repair. At the time of sacrifice, a well-healed scar was observed at the site of the sutured defect and there were no associated thrombi. In one instance in which gross pleural and pericardial infection were present, friable vegetations covered the healed defect. The ventricular wounds were well healed and were without aneurysms.

Four dogs are still well and will be sacrificed later.

16. Studies of the Venous Collateral Circulation of the Lung.

Alfred Hurwitz, Averill A. Liebow (by invitation),

Paul Kunkel (by invitation), Massimo Calabresi (by invitation) and

Ronald W. Cooke (by invitation), New Haven, Conn.

After ligating the major pulmonary veins close to the auricle in dogs, infarction of the lung does not occur. Ligation of the pulmonary veins was performed as a two-stage procedure on the right side and as a single operation on the left without a mortality. As in previously reported observations in man, the bronchial veins of the dog are joined by short broad channels to the largest pulmonary veins and permit of a sufficient drainage. Within three months a very extensive venous collateral circulation is found to deliver the blood from the lung on the side of ligation to the right auricle. It is apparent from the study of bronchovascular casts that some of the collateral vessels communicating with the pulmonary veins at the hilum represent an expansion of the bronchopulmonary venous system. Others are obviously newly formed vessels, since they enter via adhesions, on the mediastinal aspect largely from the internal mammary veins (superior caval system), and on the lateral aspect from the intercostal veins (azygous system). Many collateral vessels of the last two groups are remarkable in that they join the distal ends of pre-existing pulmonary veins, end-on. The mechanism for establishing these connections is unknown, and its elucidation would contribute to the solution of some of the fundamental problems of the development of collateral circulation in general.

Correlated functional observations in these animals have indicated also a striking rise in the oxygen content of the azygous vein.

One application of this work may be in the treatment of congenital transposition of the great vessels, in which ligation of the pulmonary veins of one lung should create a left-to-right shunt, useful in carrying oygenated blood to the right heart and transposed aorta.

17. The Physiological Basis for Utilization of Esophagocardiomy-otomy in the Treatment of Achalasia-an Experimental Study.

Paul Nemir, Jr. (by invitation) and H. R. Hawthorne (by invitation).

Sponsored by Julian Johnson, Philadelphia, Pa.

We have performed esophagocardiomyotomy on a large number of patients having cardiospasm. Follow-up study has been for from six months to five years. The results with this procedure are unequivocally better than with other surgical procedures, and the complications of esophagitis, hemorrhage, and perforation have been, thus far, much less frequent and less severe.

The method by which this procedure exerts its beneficial effect is not clear. Studies were undertaken to clarify this aspect of the problem. Utilizing a triple lumen tube with attached balloons, esophageal motility patterns at various levels of the esophagus have been concomitantly recorded on the Sanborn Electromanometer before, and at varying periods following esophagocardiomyotomy. Alterations of the patterns with the use of various drugs have been studied also. The manner in which procaine exerts its beneficial effect was clarified.

Special fluoroscopic observations have been performed in conjunction with the motility patterns. Preliminary experiments indicate a possible explanation for the better results obtained with esophagocardiomyotomy. While regurgitation of gastric contents into the lower espphagus is almost an invariable accompaniment of operations upon the esophago-gastric junction, its occurrence is less frequent following esophagocardiomyotomy. Studies indicate a definite relationship between regurgitation and recurrence of symptoms or complications.

18. The Effect of Intrapericardial and Intracardiac Procaine Upon the Circulation in Man.

E. M. Papper, Hugh Fitzpatrick (by invitation), Enzo Krahl

(by invitation), F. F. McAllister (by invitation) and

George H. Humphreys, II, New York, N. Y.

Operations upon the heart have been associated with disorders of cardiac rate and rhythm. Among the methods of prophylaxis and therapy have been the injection of procaine into the pericardial sac and within the heart itself.

This presentation will be concerned in part with the theoretical and pharmacological implications of the use of procaine for this purpose. In addition, studies on a series of patients subjected to a variety of operations upon the heart will be presented. Continuous recordings of arterial pressure were made with Lilly Capacitance Manometers and continuous electrocardiography was employed. Suitable control studies without the use of procaine were also undertaken.

It was clearly demonstrated that the use of intrapericardial and intracardiac procaine produced a significant rise in heart rate and a fall in blood pressure in the majority of cases. In the control series these changes in circulation did not develop. The most common arrhythmia observed was ventricular extrasystole. The incidence was approximately the same in the two groups. It was concluded that procaine does not exert an anti-arrhythmic influence of significance and that it may produce harmful sequelae upon the circulation.

19. Intracardiac Surgery with the Aid of Artificial Operative Tunnels.

William K. Swann (by invitation), Jacob T. Bradsher, jr. (by

invitation) and Jorge Rodriguez-Arroyo (by invitation), Knoxville, Tenn.

The principle of the operative tunnel, or sleeve, as employed in mitral valve surgery utilizes the left aurical appendage as the sleeve device.

The authors have attempted to substitute a fabric or plastic sleeve for use in approaching other areas of the heart where tissue such as an auricular appendage is not available.

On the basis of operations on dogs suitable materials were selected and the best size and configuration of the sleeves were determined. In some experiments a bifid or "inverted pair of pants" sleeve was used to allow simultaneous digital visualization and operative maneuver. In the animals the method was used to operate on the aortic valve through the aorta and on the pulmonic valve through the pulmonary artery. The mitral valve was approached through the wall of the left auricle, and the tricuspid valve through the wall of the right auricle. The interauricular septum was similarly approached through the wall of the right auricle.

The authors first applied this method in a human patient in June, 1953, when a transaortic aortic valve commissurotomy was done. This and subsequent operative experiences are described.

20. Cardioangiography.

Philip W. Smith (by invitation), Hugh Craig (by invitation) and

Karl P. Klassen, Columbus, Ohio

In 1951 Pomsdomenech and Nunez reported on visualization of the chambers of the heart and of the great vessels by direct cardiac puncture and injunction of contrast media. After preliminary animal experiments they carried out the procedure in 30 humans without mortality.

The method appeared simple and offered theoretical advantages over presently accepted techniques. Intravenous aniocardiography permits dilution of the contrast media with venous blood so that sharp radiographic contrast is often lacking, particularly in the left side of the heart. The X-ray value of cardioangiography should include a better visualization of the chamber of the left side of the heart, the thoracic aorta and its branches, and visualization of septal defects and certain valvular deformities. We felt that clarification of the advantages, disadvantages, damages and safeguards of the method was in order.

Fifty cardiac punctures were accomplished in 13 dogs with electrocardiographic tracings throughout the procedure. Injection of contrast media into the right or left ventricle was accomplished with fluoroscopic or radiographic control. Ventricular fibrillation and cardiac arrest were not observed. Coronary artery laceration was not encountered with the infra-xyphoid approach to the diaphragmatic surface of the heart. Pericardial bleeding was minimal. Autopsies were performed at varying intervals after puncture with gross and microscopic study of the heart. The method as finally evolved proved safe in dogs. The radiographic detail obtainable was excellent.

We have applied this method in humans and thus far there has been no mortality. The dangers and safeguards of the method will be discussed.

21. Creation of Autogenous Vessels.

Newton Chun (by invitation), Richard Forney (by invitation)

and Egbert H. Fell (by invitation), Chicago, Ill.

The need for large vessel grafts has given rise to the use of homogenous aorta grafts and the development of blood vessel banks. This is definitely an advance in vascular surgery. Because of the need and the acknowledged superiority of autogenous grafts to homogenous grafts, an experimental study has been in progress to determine if autogenous vessels can be made to size, using vein and fascia, supported by a prosthesis and then placed subcutaneously.

These vein-fascia tubes have been removed from their subcutaneous environments one to four weeks after implantation, a portion removed for microscopic study and the remainder of the tube is used to replace a portion of either the thoracic or abdominal aorta. Postoperative studies consist of aortagrams, gross and histological studies of the vein-fascia aorta as compared to the normal aorta. The results are most encouraging and the procedure may be practical for the human.

22. Experimental Esophagogastrectomy. Evaluation of Gastric Drainage Procedures Performed in Association with Esophagogastrectomy.

Harold W. Neuman (by invitation) and F. Henry Ellis (by invitation).

Sponsored by Herbert W. Schmidt, Rochester, Minn.

Acid-peptic esophagitis is a well-known complication of esophagogastrectomy. Experimentally, this complication usually can be prevented by resecting all the acid-secreting portion of the stomach. The addition of pyloromyotomy to experimental esophagogastrectomy has been shown to facilitate gastric emptying.

The purpose of this study was to evaluate various gastric drainage procedures performed in association with esophagogastrectomy. Three such procedures were studied in dogs: pyloromyotomy, gastroenterostomy and pyloroplasty. The results in these animals were compared with results in a group of dogs that underwent esophagoduodenostomy. Esophagoscopic examinations and studies of gastric secretion were carried out postoperatively before death or disposal of the animals.

A high incidence of ulcerative esophagitis due to regurgitation of alkaline secretions occurred after gastroenterostomy and esophagogastrectomy with removal of all the acid-secreting portion of the stomach. Pyloroplasty was accompanied by a moderate degree of esophagitis somewhat comparable to that seen following esophagoduodenostomy. Pyloromyotomy, when performed with esophagogastrectomy and anastomosis of antrum to esophagus, resulted is mild esophagitis in only an occasional instance.

23. Experimental Pedunculated Flaps Used for Cardiac Abnormalities in Dogs.

Arnold E. Botwin (by invitation), Kansas City, Kansas

A technique for the construction of a pedunculated flap from the anterior atrial wall has been developed in dogs and these pedicled flaps have been used for the repair of various intracardiac lesions. This procedure has been used in 10 dogs with interatrial septal defect, in 10 dogs with mitral insufficiency and one dog with tricuspid insufficiency. All of the dogs survived operation.

The pedunculated flap is fashioned by clamping the anterior portion of the left atrium, incising the edges of this segment, and then rotating and suturing the lateral segments of atrial wall over the strip of atrium to be used for the flap. Thereby, the defect is over one-half closed before the atrial chamber is entered. Sutures to secure the flap in its future position are placed, the distal end of the flap cut free and swung into the chamber, and the remaining defect in the atrium closed.

In repairing atrial septal defects, from the left side, two sutures are used, one medial to the superior vena cava and one medial to the inferior vena cava. From the right side the repair is made with two or three sutures placed medial to the inferior vena cava and through the septum. Mitral insufficiency is repaired with one suture through the posterior left ventricular wall and tricuspid insufficiency with one suture through the posterior right ventricular wall.

Slides showing the steps of operation, short and long term results, and pressure studies will be shown.

24. Synchronous Combined Abdomino-Right Thoracic Approach for Carcinoma of the Upper Thoracic Esophagus.

Hawley H. Seiler (by invitation), Tampa, Florida

There has been controversy regarding the merits of a right versus a left thoracic approach to lesions of the middle and upper thirds of the esophagus. Esophageal dissection and esophagogastric anastomosis are somewhat facilitated when performed through the right chest, especially when the lesion is in the area of the aortic arch. Rather than being a handicap as is true on the left side, the aortic arch may act as a buttress against which tumor dissection can more readily be accomplished.

When the right-sided approach is used it is also necessary to perform laparotomy in order to mobilize the stomach and explore for metatases. Some surgeons have preferred to space the two operations a few days apart and in certain instances the patient's condition has deteriorated in the interval to the point where the thoracic operation could not be performed. On the other hand, when the laparotomy is performed first and immediately followed by the right thoracic operation at the same sitting, the procedure is unduly long and may prove to be too extensive for the patient who is already in poor condition.

The combined abdomino-right thoracic approach has been used by the author, the two procedures being performed synchronously. The patient is positioned on the table at a 45 degree angle and two surgical teams are used, one performing laparotomy and mobilizing the stomach while the other carries out the right thoracotomy. The stomach is then drawn into the right chest, the esophagus amputated, and esophagogastrostomy performed. Operating time has been considerably shortened.

25. Differential Behavior of Arterial Homografts Implanted in the Thoracic and Abdominal Aorta.

Edmund A. Kanar, Lloyd M. Nyhus, Everett J. Schmitz, Lester R. Sauvage,

Horace G. Moore, Jr., Ralph K. Zech and Henry N. Harkins (all by invitation).

Sponsored by K. Alvin Merendino, Seattle, Wash.

Many of the beliefs concerning the fate of arterial homografts implanted into the thoracic aorta are based on assumptions derived from experience in the abdominal aorta. No single report is available wherein the behavior of aortic homografts is evaluated with respect to the anatomic site of implantation. Most investigators have chosen the abdominal region alone for vascular experimentation.

This communication gives data showing that aortic homografts act quite differently when implanted in the chest as compared to the abdomen. Up to the present time we have implanted 403 vascular grafts of various types into the abdominal aorta and 226 into the thoracic aorta. Our observations are based on this overall experience with experimental vascular grafts, but special emphasis is placed on a detailed analysis of 42 aortic homografts of the thoracic aorta and 55 homografts of the abdominal aorta in growing pigs. These homografts were implanted for an average of 191 days (thoracic aorta) and 204 days (abdominal aorta).

A distinctly higher incidence of late and serious degenerative changes, including calcification and subendothelial plaque formation, was observed in the homografts implanted into the thoracic aorta. This unexpected finding occurred even following implantation of fresh aortic homografts. The relationship of these degenerative changes to growth of the host animal, site of graft implantation, period of preservation, and length of the graft are discussed. The overall biologic significance of these findings to chest surgery will be stressed.

26. A Method of Supplementing the Coronary Circulation by a Jejunal Pedicle Graft.

James A. Key (by invitation), Frederick G. Kergin, Yves Martineau (by invitation)

and R. G. Leckey (by invitation), Toronto, Ont.

A method has been devised to increase the blood supply of the dog's heart by grafting a segment of jejunum with intact blood supply onto the myocardium. The segment of bowel is split along the antimesenteric border, the mucosa removed and the raw submucosal surface is sutured to the surface of the heart. One hundred experiments on 50 dogs have been carried out to date.

Various investigations to determine the efficiency of the graft have been carried out. The graft afforded 100% protection against death from ligation of the anterior descending branch of the left coronary artery in 20 dogs as opposed to a 75% mortality rate in a control series. In the grafted animals, following coronary ligation, electrocardiograms were normal or indicated minimal infarction. Autopsy confirmed that the area of infarction was much smaller than in the control animals which survived ligation. Injection studies have demonstrated free communication between the jejunal artery and the coronary arteries. Histologic studies have confirmed the presence of patent vascular channels between the graft and the myocardium.

Among the advantages of this method are its relative simplicity, the fact that the graft affords a good arterial supply with a large surface area of contact, and that it stimulates intercoronary as well as extracoronary anastomoses. The investigation is being continued.

27. Controlled Cross Circulation for Intracardiac Surgery.

Herbert Warden, Morley Cohen, Raymond C. Read and

C. Walton Lillehei (all by invitation).

Sponsored by Richard L. Varco,

Minneapolis, Minn.

A less complicated method is presented for performing intracardiac operations under direct vision in the open heart. By using a donor individual as an oxygenator and a simple mechanical pump as the heart, surgery can be prolonged for relatively unlimited periods.

The circulatory flow required has been based upon the "azygos flow principle". The required blood flow has been supplied by a single pump which circulates equal amounts of oxygenated blood from the donor's artery to the recipient's aorta, and venous blood from the recipient's cavae to the donor's venous circulation. Under these conditions the recipient's cardiac inflow may be totally occluded, a cardiotomy performed, and an intracardiac procedure easily carried out. This method has the advantage of prolonging the safe operating time in a dry field, it is simple to apply and at the same time has carried very little risk to either donor or recipient.

Numerous detailed physiologic and metabolic data will be presented from a series of animals subjected to total cardiac inflow stasis for approximately 30 minutes or longer by this method.