Tuesday Morning, April 25, 1961

8:30 A.M. Scientific Session: THORACIC SURGERY FORUM Grand Ballroom

14. Profound Hypothermia with Simplified Equipment: A Disposable Stainless Steel Blood Heat Exchanger of High Efficiency

William G. Esmond (by invitation), John Stram (by invitation),

Safuh Attar (by invitation), and R Adams Cowley, Baltimore, Md.

Experience with a blood heat exchanger of the usual parallel tube type has indicated that priming volumes are excessively high, efficiency based on size and weight relationships is relatively low, the units are difficult to clean properly, and the design does not incorporate "fail safe" features. We have succeeded in producing a heat exchanger that incorporates the following features: (1) Low priming volume (60 cc); (2) lightweight (8 ounces); (3) "fail safe" features (blood and water can only leak externally and cannot mix together should a leak develop); (4) construction - stainless steel; (5) improved efficiency; (6) can be installed in the pump-oxygenator line in less than 30 seconds.

15. Gas Chromatography: A Simple, Rapid, Reliable Method for Blood Gas Analysis

Russell H. Wilson (by invitation), Bruce Jay (by invitation),

and Robert H. Holland, Dallas, Tex.

Gas chromatography utilizes two unique properties of each gas; namely, the adsorption coefficient and the thermal conductivity. Simplified diagrams will be used to illustrate how the apparatus employs these properties for the separation and detection of the gases after they are liberated from the blood. The original apparatus was modified in our laboratory to facilitate repeated analyses and to deliver a larger, more accurately measured volume of blood to the mixing chamber. These features will be illustrated and discussed.

16. A New Reflection Oximeter

P. F. Ware, M. L. Polanyi (by invitation), R. M. Hehir

(by invitation), J. F. Stapleton (by invitation), J. I. Sanders

(by invitation), and S L. Kocot (by invitation), Worcester, Mass.

A new type reflection oximeter has been developed and used experimentally and clinically by us in the past two years. It provides: (1) Absolute values for oxygen saturation at all points of the dissociation curve, (2) results that are rapidly or continuously obtained and are reproducible; (3) values that are independent of hemoglobin level and temperature. Blood samples analyzed with this reflection oximeter have been cross checked against Van Slyke and Beckman determinations and more recently by gas chromatography.

17. The Repair of Circumferential Defects of the Trachea by Direct Anastomosis: Experimental Evaluation

James R. Cantrell (by invitation), Seattle, Wash., and

J. Roland Folse (by invitation), Bethesda, Md.

End-to-end anastomosis of the trachea has been shown to be feasible, and it appears important to determine its limits of feasibility. Thirty-three dogs were subjected to resection of lengths of cervical trachea that ranged from 8 to 27 rings. Reconstruction was accomplished by end-to-end suture. Suture-line tension was measured and varied from 400 to 3100 grams. All anastomoses performed under a tension less than 1700 grams (18-22 rings) proved successful; the healing of anastomoses performed under tensions greater than 1700 grams was unpredictable. When tension was not too great, anastomotic healing was remarkably satisfactory and only minimal stenosis was observed. A case of congenital stenosis of the thoracic trachea successfully treated by this technique will be presented.

18. The Pulmonary Arterial Blood Flow Through an Acutely Atelectatic Lung

Rudolph C. Camishion (by invitation), Yoshinori Ota (by invitation),

Vincent D. Cuddy (by invitation), and

John H. Gibbon, Jr., Philadelphia, Pa.

A square-wave electromagnetic flowmeter was used to measure the pulmonary arterial blood flow through the left lung of dogs at thoracotomy. The oxygen saturation of the systemic arterial blood was measured by a cuvette oximeter. After the blood flow through the pulmonary artery, and the systemic blood pressure, had remained stable for one hour, the left lung was deflated by manual compression and the bronchus ligated. With the establishment of atelectasis, the pulse rate and the peripheral arterial blood pressure both rose and the oxygen saturation of the systemic arterial blood fell. During the first 30 or 45 minutes, the blood flow through the left pulmonary artery usually increased. After one hour, the blood flow had stabilized and was approximately that existing before the lung was collapsed. During the next two hours, the blood flow diminished and the oxygen saturation of the systemic arterial blood rose. After three hours, the lung was re-expanded. The oxygen saturation of the peripheral arterial blood promptly returned to normal. At the end of one hour, the blood flow through the lung had increased but was usually less than that existing before bronchial occlusion.

19. The Effects of Positive Pressure Lung Inflation upon Pulmonary Vascular Dynamics

Paul H. Gerst (by invitation), New York, N. Y.

The effects of varying levels of positive pressure lung inflation ranging from complete collapse to distension at 30 cm. of water upon pulmonary vascular dynamics were determined. In the collapsed lung, flow resistance is high and vascular compliance is low. In the open chest lung inflation facilitates pulmonary blood flow up to levels of 15 to 20 cm. of water pressure after which it is again hindered. In the closed chest any increase in endotracheal pressure interferes with optimum blood flow. The clinical significance of these findings in regard to controlled ventilation and per-fusion of the lung will be discussed.

20. Bronchogenic Carcinoma Produced Experimentally in the Dog

E. J. Beattie, Jr., E. W. Staub (by invitation), N. O. Correll (by invitation),

and G. Hass (by invitation), Chicago, Ill.

In reversed autologous tracheal grafts in the dog the regenerated cilia retain polarity and ever after beat caudad. The cephalad anastomosis develops squamous metaplasia, but the caudad anastomosis is rich in cilia with "trapped mucus". A carcinogen (7, 12-dimethyl benzanthracene) was instilled by bronchoscopy into a lower lobe bronchus in doses varying from 0 4 to 5 milligrams at approximately weekly intervals for 6 to 14 months in 11 dogs. After 13 months one animal was found to have an invasive squamous carcinoma at the distal anastomosis, and another animal had carcinoma in situ. This is believed to be the first bronchogenic carcinoma produced experimentally in the dog

21. Hematoporphyrin Derivative: A New Aid for the Endoscopic Detection of Malignancy

Richard L. Lipson (by invitation), Edward J. Baldes (by invitation),

and Arthur M. Olsen, Rochester, Minn

Extensive experimental investigation previously reported concluded that by utilizing an acetic acid-sulfuric acid derivative of hematoporphyrin, and proper filter systems for activating and viewing the fluorescence, malignant lesions could be detected. For clinical application, a bronchoscope or esophagoscope was especially modified to illuminate an area with either the usual white light or the wave lengths necessary to activate the hematoporphyrin derivative. Special glasses are used for viewing the red fluorescence. The procedure has been carried out on 15 patients - nine by bronchoscopy, five by esophagoscopy and one by both. In every case in which a malignant lesion was so located as to allow the activating light to reach it, the area of malignant involvement exhibited a brilliant red fluorescence as opposed to the normal tissue which ranged from grayish white to black in appearance. There were no false positive results. The various details of this experience will be given.

22. Lung Resection with Temporary Vascular and Bronchial Occlusion

F. John Lewis, Nicholas J. Demos (by invitation),

Peter J. Connaughton (by invitation), and Stuart Poticha (by invitation),

Chicago, Ill

Through occlusion of the lung root sub-lobar resections may be carried out in a bloodless, airless field. Experiments in 60 dogs taught us how to achieve a completely ischemic field. The dog lung can be ischemic for over an hour at normal temperature without injury; for six hours when cooled locally. A technique of closing the raw surface with electrocoagulation was developed. Fifteen patients have undergone lung resection for tuberculosis, other granulomas, or blebs using this technique.

23. Modified Non-Suture Anastomosis of Coronary and Internal Mammary Arteries in Dogs

George J. Magovern (by invitation), Edward M. Kent,

Bernard S. Levowitz (by invitation), Ram S. Ratan (by invitation),

John B. Lovette (by invitation), and

Sheldon O. Burman (by invitation), Pittsburgh, Pa.

To overcome the technical problems of direct suture anastomosis in small blood vessels, particularly the coronaries, we have developed a rapid non-suture anastomotic method. The left internal mammary artery is isolated to its origin and its branches are ligated and cut. The distal end of the internal mammary artery is then threaded through a stent, and the intima everted over it, thereby forming a cuff. The cuff is fixed with single 4-0 silk suture. The edge of the vessel is sutured to the flanges of the stent. The circumflex branch of the left coronary artery is isolated for about 4 cms. and is ligated near its origin and incised transversely The preformed cuff of the internal mammary artery is rapidly inserted and fixed with ligature, providing intima to intima approximation. Five animals so prepared have been followed 6 to 11 months. Angiograms have shown patency of the anastomosis. Temporary ligation of the internal mammary artery has resulted in serial electrocardiographic changes which indicate the myocardium to be dependent on this source of blood supply. The fate of another 31 animals utilized in the perfection of this technique is detailed.

24. Effects of Continuous Flow Through Implanted Mammary Artery and Myocardial Ischemia on Mammary-Coronary Communications

Mariano Lopez-Belio (by invitation), Luis Sanchez (by invitation),

Salvador Rodriguez (by invitation), and

Ormand C. Julian, Chicago, Ill.

A modification of the Vineberg mammary artery implantation was devised by removing the proximal end of the internal mammary to include a small flange of subclavian artery wall. The mammary artery, freed to the fifth intercostal segment, is otherwise left intact distally. The proximal end, after having been tunnelled through the left ventricular wall, is re-implanted end-to-side in the descending aorta. This preparation was compared to the Vineberg preparation with and without the prior induction of a significant degree of myocardial ischemia. A total of 80 preparations were studied 6 and 12 months after operation. These show that (1) development of effective mammary artery - coronary artery communications are strongly favored by maintained patency of the mammary artery over a significant period of time and by the presence of chronic myocardial ischemia; (2) the mammary artery implanted in such a fashion as to maintain its normal flow while it traverses a myocardial tunnel remains open in almost all animals in which the preparation is made, and therefore contributes to the development of desirable communications.

25. Surgical Correction of Coronary Arteriovenous Fistula

Osler A. Abbott, Carlos Rivarola (by invitation),

and R. Bruce Logue (by invitation), Atlanta, Ga.

Arteriovenous fistula may involve any area of the coronary vascular bed. The differential diagnosis between this lesion and persistent ductus arteriosus is often difficult. The technical details contributing to successful surgical correction of a large fistulous communication between the left common coronary artery and the coronary sinus are given. A short illustrative film demonstrates the valuable diagnostic contribution of cineangiography.

26. Total Mitral Valve Replacement: The Shielded Ball Valve Prosthesis

Albert Starr (by invitation), and M. Lowell Edwards

(by invitation), Portland, Ore.

Twenty dogs underwent mitral valve replacement with a shielded ball valve. Following implantation, removal of the shield retractor allows the silastic shield to snap into place, thereby covering the zone of injured endothelium and myocardium at the suture line. Results indicate a marked reduction in the incidence of thrombotic occlusion of the shielded prosthesis when compared to the unshielded valve. Long-term survival is possible without anticoagulant drugs. Postoperative studies of valve function by phonocardiography, cardiac catheterization, and cine techniques will be presented Experience in 4 patients is included.

27. Prolonged Survival after Total Replacement of the Mitral Valve in Dogs

Ara. V. Doumanian (by invitation), and F. Henry Ellis, Jr.,

Rochester, Minn.

Prolonged survival after total replacement of the mitral valve of the dog with a prosthesis has been unusual because of the development of thrombosis and its complications. At the time of the submission of this abstract, however, seven dogs are alive; three for periods of 2 to 3 months, two for periods of 1 to 2 months; two other dogs are alive 3 to 4 weeks after operation No episodes of embolism have been recognized. All have survived beyond the period in which according to our earlier experience, death from thrombosis would have occurred. An attempt is being made to determine which factor or factors have been most significant in achieving prolonged survival. Late physiologic studies of the function of prosthetic valves in vivo will now be possible and will be reported.

28. Total Excision of the Mitral Valve and Replacement with the Autologous Pulmonic Valve

Richard R. Lower (by invitation), Raymond C. Stofer (by invitation),

and Norman E. Shumway (by invitation),

San Francisco, Calif

Sponsored by Emile Holman, San Francisco, Calif.

Clinical and experimental evidence that the pulmonic valve may be expendable warrants its trial as an autologous valve transplant. In 26 animals the pulmonic valve with its annulus was excised intact and transplanted into the left atrium by suturing it to the mitral ring In 22 others, the pulmonic valve autotransplantation was carried out, as described above, and in addition, the animal's mitral valve was completely removed The 12 survivors in the first group (studied from 2 weeks to 6 months postoperatively) demonstrated that the free graft appeared to survive in a functional state. From the second series, eight valve grafts were studied grossly and microscopically between 7 and 66 days after operation. Ten animals are now alive and well 5 to 7 months postoperatively. Atrial pressure studies, photographs, and angiocardiograms will be presented to illustrate the functional status of these valve grafts. A movie will demonstrate the operative technique.