Sunday Afternoon, May 18, 1958

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

37. Pulmonary Resection in the Treatment of Tuberculosis - Experience with 1700 Cases.

Raymond J. Barrett (by invitation), Richard Jankoska (by invitation),

J. Claude Day, Paul V. O'Rourke and E. J. O'Brien, Detroit, Mich.

A review of all pulmonary resections performed for tuberculosis at Herman Kiefer Hospital is presented. Resection is increasingly the method of choice so that at present only about 10% of cases are treated by thoracoplasty - the latter being reserved for cases deemed not suitable for resection.

A previous report giving experiences prior to 1950 with a mortality rate of 12% is incorporated in the present resume which gives an overall mortality rate of approximately 3% and a current mortality rate of below 2%.

The bronchopleural fistula rate, while it has been halved from 12% to 6% still remains the number one complication. Delays in expansion are a frequent complication although not, in the majority of cases, requiring further surgery. Fistula and delayed expansion are much more prone to occur in tuberculous than in non-tuberculous resections.

Spread or reactivation of disease has become a relatively rare happening, occurring in less than one per cent of cases in the past five years.

The extent of resection has been steadily refined so that pneumonectomy is now done very rarely, whereas segmental resection is rapidly becoming the most common operation.

38. Pulmonary Infarction Complicating Segmental Resection.

John M. Salyer and Harold N. Harrison (by invitation), Denver, Colo.

During the past three years 13 of 398 patients having segmental resections in the treatment of pulmonary tuberculosis have developed a peculiar sort of postoperative difficulty. Such complications are attributable to post-resection segmental or subsegmental infarction. In our recent experience such untoward events alone have given a complication rate of 3.2 per cent. Further consideration of this problem seems indicated since the course of events which results in serious postoperative complication, to our knowledge, has been alluded to only twice in the voluminous literature dealing with complications following pulmonary resection.

Study of such infarcted contiguous segments removed at subsequent thoracotomy have demonstrated that pathologic changes resulting from venous obstruction and/or thrombosis usually begin at the intersegmental surface and proceed centrally. Other changes such as congestion, hemorrhage, infarction, liquefaction, occasional abscess formation and associated organization and fibrosis have been demonstrated. Air leaks along the segmental plane may create tension pleural spaces. If proper management is delayed, empyema, bronchopleural fistula, delayed hemorrhage and perhaps progression of tuberculous disease can be expected. None so diagnosed has progressed beyond the tension pleural space stage. 12 of the 13 patients had secondary thoracotomy from 9 to 19 days after primary resection. One was not properly managed until 144 days had elapsed. All recovered uneventfully after the condition was corrected. To date none have had recurrence of tuberculous disease.

Suggestions for prevention and recommendations as to surgical management will be discussed.

39. Creation of a Temporary Artificial Ductus in the Surgical Correction of Ventricular Septal Defects Associated with Severe Pulmonary Hypertension. A Two-Stage Operation.

Howard D. Sirak (by invitation) and Don M. Hosier (by invitation).

Sponsored by H. William Clatworthy, Jr., Columbus, Ohio

Surgical correction of interventricular septal defects employing open-heart technique is associated with a high operative mortality whenever severe pulmonary hypertension is present. In contrast, cases of "atypical" ductus with a similar degree of pulmonary hypertension have been successfully treated. Therefore, a two-stage operation was devised in order to permit a more gradual reversal of the pathophysiology. This procedure has been employed only in individuals who had essentially equal pressures in both the pulmonic and systemic circulations.

At the time of the open-heart surgical correction, but prior to the injection of heparin, an artificial ductus is created between the ascending aorta and pulmonary artery. This is accomplished by anastomosing a homograft, 5-6 mm. in inside diameter, in end-to-side fashion to each of these structures at a point about 4 cm. from the heart. After a few minutes to permit clotting at the suture lines, the open-heart surgery is accomplished in the usual fashion. At the conclusion of the by-pass, the artificial ductus, which had been temporarily occluded during the perfusion, is opened. After an interval of 3 to 6 months the artificial ductus is divided through a relatively minor operation performed through the right chest.

The smaller diameter of the artificial ductus as compared with the original septal defect reduces but does not obliterate the left-to-right shunt, thus allowing a partial return to the normal state. It also serves as an escape valve for the right ventricle should the resistance in the lungs be excessive. From a physiologic point of view, staging the repair reduces the final operation to closure of an "atypical" ductus.

Six patients have been treated in this manner. One died because one of the leaflets of the tricuspid valve was distorted during closure of the septal defect and another because the hypertensive changes in the lungs were so far advanced that very little residual shunt through the interventricular septal defect remained. This patient was essentially an Eisenmenger's syndrome and should not have been selected for the operation. A discussion of clinical and laboratory findings of each of the cases and the operative technique will be presented.

40. Corrective Surgery in the Presence of Far Advanced Pulmonary Hypertension.

C. Walton Lillehei, Donald J. Ferguson (by invitation) and

Richard L. Varco, Minneapolis, Minn.

Pulmonary arteriosclerosis resulting in elevated pulmonary pressure due to greatly increased vascular resistance is a common accompaniment of many congenital and some acquired cardiac lesions and now that open heart methods have been perfected has proved to be the principle limiting factor to successful surgical therapy in these far advanced cases.

Two approaches to this problem are possible. The first is to define certain contra-indications for surgery and then reject for operation those patients who might be anticipated as having a high risk with the usual treatment.

The alternative, which we have preferred, is to consider that virtually all of these patients are basically curable if enough knowledge concerning their pathologic physiology can be acquired. Research upon this problem has been both experimental and clinical. The study of the lung biopsy in correlation with these other clinical and physiologic findings including the response to corrective surgery has been the key to progress.

First, the method of death in these patients has been accurately identified by serial pressure measurements and other observations during this event. Confirmation by reproduction of this picture in dogs has been carried out. Two factors of importance have emerged: abnormal vascular resistance and abnormal lung compliance.

With this knowledge two basic methods found of great therapeutic value clinically have evolved. First, are the measures directed to the lungs. These vary from (depending upon the severity of the pulmonary vascular disease and the patient's age) the use of a closed system with aid to the respiratory effort ranging from supply of 100% oxygen in a closed system by a demand respirator to complete mechanical respiration at positive pressure.

Second, in the severest cases where the above methods have been insufficient, the construction of temporary decompressing shunts at the time of corrective surgery is necessary. The indications for, technique of, and physiology of these lifesaving shunts is presented.

As a consequence of these measures it has been possible to both reduce operative mortality and to extend corrective surgery to patients previously considered inoperable. Moreover, experience has indicated that if even these patients with such advanced states of pulmonary arteriosclerosis can be successfully guided through this crucial period of readjustment immediately post-correction, their lung pathology will heal in most cases in the succeeding months. Thus, the premium upon learning how to manage these patients though undeniably great has permitted the adoption of a considerably more optimistic attitude concerning pulmonary hypertension.

41. Surgical Treatment of the Tetralogy of Fallot by Open Intra-cardiac Repair.

John W. Kirklin, F. Henry Ellis, Jr. and Dwight C. McGoon

(by invitation), Rochester, Minn.

Experience with the intracardiac repair of the tetralogy of Fallot is now sufficiently extensive to warrant an initial critical review, both in an effort to determine the efficacy of the method as compared to other methods and to assess the new technical knowledge which has been gained thereby.

At the time of writing of this abstract, 60 patients who had this particular intracardiac malformation have undergone surgical repair of it. Data concerning these patients, as well as others operated upon prior to the final preparation of the manuscript, form the basis of the report.

Features of the whole-body perfusion peculiar to this particular type of intracardiac surgery are discussed. Surgical technics for the repair of this defect are described. Although a low operative mortality rate can be quoted for selected groups within the series, or for patients operated upon recently, the nonsurvival rate for the entire series is approximately 30 per cent. This mortality rate is analyzed relative to the anatomic and technical factors which appear to have produced it. Among these is the adequacy of repair, documented in most cases by postcardiotomy studies of hemodynamics. The excellence of the result attainable for surviving patients by means of intracardiac repair is demonstrated.

An attempt is made to compare the hazards and results of this surgical technic with those of the shunt procedures, this comparison suggesting to the authors certain tentative conclusions regarding the surgical methods of treating the tetralogy of Fallot.

42. Atrial Septal Defect, Secundum. Observations on One Hundred Patients Treated by Open Operation.

Henry Swan, D. Hywel Davies (by invitation) and S. Gilbert Blount, Jr.

(by invitation), Denver, Colo.

This report concerns 100 consecutive patients with atrial septal defect of the secundum variety not associated with pulmonic stenosis, all of whom were treated by repair of the lesion under direct vision, using general body hypothermia.

An analysis of the diagnostic features and a discussion of the nature of the hemodynamic and structural alterations due to the abnormality will be presented. Since almost all of these patients underwent cardiac catheterization preoperatively, and a majority were similarly studied postoperatively, considerable data has accumulated for study.

A wide variety of defects, of course, were observed. The frequency of multiple defects, of associated aberrant pulmonary veins and of aberrant entrance of the inferior vena cava into the left auricle emphasize the importance of visual guidance in the repair of these lesions.

Ninety-three patients, including the last 56 consecutive cases, survived the procedure and are alive and well at the present time. Careful postoperative observations on the effect of closure of the defects on the disordered circulation has led to some opinions concerning the relationship between the stage of the disease and the probable result of surgery. On the basis of these observations, and the demonstrated safety (less than 2% risk) of the current technique, our indications for surgery have approached those which are now accepted for patent ductus arteriosus.