Tuesday Afternoon, April 26,1955

2:00 P.M. Scientific Session: REGULAR PROGRAM.

38. The Development of the Pleural Partition to Prevent Over expansion of the Lung Following Partial Lung Resection.

Lyman A. Brewer, III, Angel F. Bai (by invitation) and W. M. Jones

(by invitation), Los Angeles, Calif.

The management of a large pleural dead space created by partial pulmonary resection usually presents a difficult clinical problem. The ill effects of overexpansion and emphysema of the remaining lung tissue, leading to lung rupture in some instances, are well known. The organization of the fluid which accumulates to fill the pleural space results in a marked decrease of the functions of the unresected portions of the lung. The usual methods employed to decrease this space are (1) thoracoplasty, (2) phrenemphraxis, (3) pneumoperitoneum, and (4) the insertion of various foreign body prostheses, lucite spheres, zirconium, ivalon sponges, etc. Each of these methods have certain inherent disadvantages.

The authors present an original concept of developing an intrapleural partition which effectively limits the expansion of the lung without certain of the drawbacks of the commonly used methods. The technique of fashioning this partition is described along with general results of this procedure in a series of experimental studies in dogs. A critical appraisal of the various materials used in forming the partition is made. The effect on the remaining pulmonary tissue, the fate of the space above the partition, and the clinical application of this procedure are presented.

39. Operative Thoracic Ductography: Report of Three Cases Illustrating Its Value.

Allan Stranahan, Ralph D. Alley and Harvey W. Kausel

(by invitation), Albany, N. Y.

The experience of others in the surgical management of persistent chylothorax of spontaneous or traumatic origin is briefly reviewed. Previously reported anatomical studies of the thoracic duct system which disclose a significant incidence of anatomical variation are also discussed and supplemented with our own observations obtained by contrast radiographic examination of the thoracic duct system in fresh autopsy material. Such anatomical considerations suggested the desirability of obtaining visualization of the thoracic duct system by radiographic means at the time of surgical exploration in cases requiring interruption of the system. A method for thoracic ductography which demonstrates the variations of the system which may be present was therefore developed. The technique for exploring the thoracic duct system through either hemithorax, as well as the advantages and disadvantages of each is described.

One case of postoperative chylothorax and two cases of chylous effusion resulting from malignant lymphoma in which surgical interruption of the thoracic duct system was undertaken are presented. In each instance thoracic ductography yielded important anatomical data. In one case there was reduplication of the duct in its midportion, another had two major ducts which united within a centimeter of the left subclavian vein, and in the third the system had a plexiform pattern. It is concluded that the anatomical variations of the thoracic duct system demand preliminary contrast visualization where complete surgical interruption of the system is contemplated. A practical method for thoracic ductography is reported.

40. Complications of Mitral Valve Surgery with Particular Reference to the Post Commissurotomy Syndrome.

Charles B. Ripstein, New York, N. Y.

Direct surgical attack on the diseased mitral valve has become a well accepted procedure and many patients are now being subjected to operation. The results in general have been good but certain complications and sequelae have been observed which are peculiar to this type of surgery and which greatly increase the mortality and morbidity.

This paper deals with the immediate and late complications seen in a series of 250 patients undergoing surgery for mitral stenosis or insufficiency. The methods evolved for preventing and treating these complications are discussed. The following classification has been used:

I. Technical Complications at Operation: (1) laceration of the auricle; (2) injury to the circumflex branch of the left coronary artery; (3) arterial emboli; (4) production of mitral insufficiency.

II. Immediate Postoperative Complications: (1) cardiac arrhythmias; (2) shock syndrome; (3) cardiac failure; (4) bacterial endocarditis.

III. Later Postoperative Complications: The post commissurotomy syndrome.

Of these, arterial emboli constitute the cause of the greatest mortality and the post commissurotomy syndrome the cause of the greatest morbidity. With increasing experience the prophylaxis against emboli has become so effective that they have occurred in only 1% of operations and no fatalities have resulted from them. The post commissurotomy syndrome has been effectively prevented by the routine postoperative use of cortisone so that it no longer impairs the result of surgery.

41. The Surgical Treatment of Aortic Stenosis.

Charles P. Bailey, H. E. Bolton (by invitation), W. L. Jamison (by invitation)

and H. T. Nichols (by invitation), Philadelphia, Pa.

Aortic stenosis may be of congenital, arteriosclerotic, or rheumatic origin. In the latter type of case commissural fusion of the valve leaflets is a constant and prominent feature. This pathological feature suggests, and provides, the feasibility of accomplishing improvement in function by anatomical separation of the valve elements. While a variable degree of valve calcification is present in over 90% of these cases, it usually does not preclude, although it may limit, the effectiveness of surgery.

Two reasonable approaches to the stenotic aortic valve have been devised - the transventricular, and transaortic. The latter implies the preliminary attachment of a plastic or tissue pouch to the wall of the ascending aorta. This method permits actual digital palpation of this valve, and in favorable cases (over 50%) simple separation of the commissures by blunt pressure. When an instrument is required it may be inserted along the finger through the pouch.

Our entire experience with the surgical treatment of this disease beginning on March 9, 1950, will be presented. By the time of presentation the total number in our series should be in excess of 300 operated cases. Suggestions for exact pre-operative diagnosis, selection of cases, and method of management will be made. A follow-up on the operated cases with pre and postoperative physiological examinations will be included.

42. The Use of Shunts in the Resection of the Thoracic Aorta.

J. MaxwellChamberlain, Robert Klopstock, Peter Parnassa (by invitation),

A. grant (by invitation) and J. J. Cincotti,

New York, N. Y.

The resection of aortic aneurysms does not always require an artificial shunt, but occasionally a shunt is paramount to success. A shunt is usually necessary when the surgeon anticipates encroachment upon the cerebral circulation. Hypothermia may remove the tension of working against "time" or cerebral anoxia, but in the older patient the hazard of ventricular fibrillation must be considered. Furthermore, cerebral hypertension, and left ventricular strain accompany cross-clamping of the aorta. Experimental work will be presented to demonstrate this influence on the heart and cerebral circulation when the aorta is clamped under normal and hypothermic states.

Temporary shunts of plastic materials and heterologous blood vessels have been used experimentally and clinically. Blood pressure proximal and distal to the different shunts have been electronically recorded. The advantages of each will be discussed.

A short movie will be presented to demonstrate the use of a shunt made from a sterilized 225 lb. pig aorta during a 10-hour resection of an aorta in a 62-year-old male containing four aneurysms; the first in the arch opposite the innominate artery and the fourth at the level of the crux of the left diaphragm.

43. Patent Ductus Arteriosus with Hypertension: Analysis of Cases in Which Operation Was Performed.

F. Henry Ellis (by invitation), John W. Kirklin and

Earl H. Wood (by invitation), Rochester, Minn.

Clinical and physiologic data have been accumulated in recent years to help clarify those atypical cases of patent ductus arteriosus in which there is an associated pulmonary hypertension. There is, however, considerable disagreement as to the correct surgical management of these patients. The indications for operation are ill-defined and there is no clear concept of the postoperative results.

An analysis has therefore been made of approximately 25 cases of patent ductus arteriosus with pulmonary hypertension in which an operation was performed. Pre-operative physiologic data have been obtained by cardiac catheterization in all cases. The analysis will dc presented in some detail to emphasize certain hemodynamic features such as the bidirectional nature of some of the shunts and the variability of peripheral cyanosis in patients with right-to-left shunts. Physiologic data gathered at the time of operation and during the postoperative period in many cases will also be presented.

On the basis of these findings, cases of patent ductus arteriosus with pulmonary hypertension have been classified as follows:

1. Cases in which pressure in the pulmonary artery is elevated but is less than systemic arterial pressure.

2. Cases in which pressure in the pulmonary artery is equivalent to systemic arterial pressure.

a. With predominantly a left-to-right shunt.

b. With predominantly a right-to-left shunt.

The analysis of cases has led to certain conclusions concerning the surgical management of these patients particularly with reference to: (1) Criteria for the selection of patients for operation; (2) technical factors of importance during the operation and the postoperative period; (3) prognosis following operation.