Friday Afternoon, May 16, 1958

2:00 P.M. Scientific Session: REGULAR PROGRAM -Imperial Ballroom

Address by the President

Brian Blades, Washington, D. C.

7. Surgical Treatment of "Atypical" Patent Ductus Arteriosus.

William P. Young (by invitation), George G. Rowe (by invitation),

Anthony R. Curreri and Joseph W. Gale, Madison, Wis.

Closure of a patent ductus has usually been considered to be contraindicated when pulmonary artery pressure has approached or equaled aortic pressure or when arterial oxygen saturations indicate reverse flow through the ductus. We have found that the majority of such "atypical" ducti can be closed safely.

A rather simple test has been carried out at the time of operation to determine the prognosis if closure were to be done in those patients with pulmonary hypertension. The response of the pressures in the pulmonary artery and the aorta to temporary compression of the ductus is the significant finding. There was 95 per cent survival of the 23 cases in which the pulmonary artery pressure fell and the aortic pressure rose. Only 25 per cent of four cases survived when these changes did not occur. It is felt that the ductus should not be closed if the pressure in the pulmonary artery rises with temporary compression of the ductus.

A total of 188 patients have had their ducti closed. Twenty-seven of these had significant pulmonary hypertension. A mortality rate of 1.2 per cent in those without pulmonary hypertension contrasts with a mortality rate of 15 per cent in those with pulmonary hypertension. The first 93 ducti were closed prior to our use of cardiac catheterization and therefore none of them were "atypical". Twenty-seven or 28 per cent of the subsequent 95 ducti had associated pulmonary hypertension - indicating the importance of the problem.

8. Intrathoracic Aneurysms of the Aorta - Analysis of 160 Cases Treated by Resection.

Michael E. DeBakey, Denton A. Cooley, E. Stanley Crawford

(by invitation) and George C. Morris, Jr. (by invitation),

Houston, Texas

During the seven year period since our first successful resection of an aneurysm of the aorta, we have employed this method of therapy in 160 cases of intrathoracic aneurysms. This report is based upon certain observations derived from an analysis of this experience.

The cases are divided into four categories according to the type and location of the aneurysm: aneurysms involving the arch, 48 cases; aneurysms involving the descending thoracic aorta, 63 cases; thoracoabdominal aneurysms, 19 cases; and dissecting aneurysms, 29 cases. Although the underlying principle of therapy is similar for all cases and consists essentially in resection of the aneurysm, the method of application is somewhat different for these various groups of cases. Emphasis is placed upon recent developments in the technical application of resection and graft replacement, particularly in relation to the use of controlled extracorporeal circulation and the permanent bypass principle.

The gross mortality in this series of cases was 29 per cent. Most important among the factors influencing mortality are age, heart disease, hypertension, and the type, extent and location of the aneurysm. Follow-ups on all patients surviving operation are available, and long-term survival rates are presented. Physiologic considerations in terms of cardiac, neurologic, and renal function are also presented.

9. Experiences with the Davila-Glover Purse String in the Correction of Mitral Insufficiency: A Critical Appraisal.

Edward M. Kent, William B. Ford, John F. Neville, Jr. (by invitation)

and Don L. Fisher (by invitation), Pittsburgh, Pa.

The purse-string technique for the control of severe mitral regurgitation has been employed in 33 patients. The preoperative diagnosis had been confirmed in 30 of these individuals by means of data obtained at left heart catheteriza-tion, including T1824 blue dye injection into the left ventricle and immedate recovery of the dye from the left atrium. The information obtained by these methods will be discussed.

The early and late surgical mortality rate has been high (approximately 50%). The survivors will be discussed from the clinical standpoint with reference to evidences of continuing effective control of regurgitation. The postoperative evaluation of these survivors has also included late repetition of the left heart catheterization and intraventricular blue dye injection as consistently as possible. The degrees of adequacy of control of mitral insufficiency as demonstrated by these techniques will be presented. The results of the operation in our hands have been unfavorable and we have discontinued its use.

10. Technical Considerations in Decortication for the Pleural Complications of Pulmonary Tuberculosis.

Paul C. Samson, Duane L. Merrill (by invitation), David J. Dugan,

Oakland, E. J. Shabart (by invitation), Livermore, Louis Barber

(by invitation), Stockton, and James Yee (by invitation),

Oakland, Calif.

Since 1946 pulmonary decortication has been performed under our direction on approximately 225 patients either as the sole operation, or combined with thoracoplasty and/or resection. The over-all mortality in the patients whose main operation was decortication, was approximately three per cent. There was a good to excellent result with pulmonary re-expansion, hemithoracic restitution and primary healing in more than 85 per cent.

The circumstances in which decortication has been employed include: Incidental decortication; post-pneumothorax unexpandable lung with or without fluid; "false re-expansion"; pure or mixed tuberculous empyema. In the latter two categories it was soon realized that adequate antituberculosis chemotherapy was of the greatest value in preventing the advent of complications.

The use of decortication alone or in combination with thoracoplasty or resection depends upon the status of the underlying lung with particular reference to the presence or absence of active tuberculous disease as well as its capability for re-expansion. Careful estimation of probable expansibility is necessary since prompt complete re-expansion of the lung is the best insurance against space problems and empyema. This evaluation often required the careful assessment of the information obtained from all the available methods of examination.

Decortication in tuberculosis is frequently a much more complicated operation than when carried out for other indications. Particularly it is often necessary to remove the parietal peel preferably without entering the empyema sac, and thus without contaminating the operative field. This can be accomplished in nearly all instances. The technique is similar at its outset to pleuropneumonectomy which can likewise be employed to remove both lung and empyema envelope en masse without spillage.

Attention is called to the value of decortication as an incidental procedure with resection often required to insure prompt and unhampered re-expansion of remaining lobes encased in a thin but inelastic peel.

11. Achalasia of the Esophagus - Further Thoughts on Surgical Management.

William M. Tuttle, Detroit, Mich., and Robert T. Crowley

(by invitation), Williamson, W. Va.

The varied methods of surgical approach to this disease which has not responded to dilatation leads one to believe that the approach has not been adequate. Many and sundry operative procedures have been used. Within the last few years we have employed a transthoracic anterior Heller type of operation, but instead of leaving the muscularis open we have sutured this layer in a horizontal plane. It has been our feeling that this has been a satisfactory operation and, as will be demonstrated by x-ray and clinical histories, has prevented regurgitation and thus esophagitis which has been the plague of other operative approaches. Thirty-five patients have been so approached. The results have been gratifying.