Monday Afternoon, April 16, 1962

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

Khorassan Room

7. Surgical Treatment and Follow-up of 140 Cases with Correction of Tetralogy of Fallot

Henry T. Bahnson, Baltimore, Md., Frank C. Spencer,

Lexington, Ky., Catherine A. Neill (by invitation), and

Helen B. Taussig (by invitation), Baltimore, Md.

Since 1956 correction of the tetralogy of Fallot has been performed during cardiopulmonary bypass on 140 patients. In most cases this has been done with normal flow, normothermia, and with patching of the ventricular defect. The right ventricular outflow tract or pulmonary artery has also been patched when necessary to relieve the obstruction. Seventy-three per cent of the patients survived operation and have been followed. Important determinants of operative risk have included: coronary arteries which arise anomalously and cross the outflow tract or which have a major septal branch passing through the area of infundibular resection; pulmonary hypertension in association with a previous shunt; young age. A shunt operation had been done previously in most cases, but this added little to the risk of operation unless the anastomosis had been end-to-end or of aortic-pulmonary type. Selection of patients for operation, points in operative technique and postoperative care, and follow-up will be discussed.

8. Pulmonary Valvotomy and Infundibulotomy in Infants

M. Weinbero, Jr., J. P. Bicoff (by invitation),

H. G. Bucheleres (by invitation), M. H. Agustsson (by invitation),

M. Behravesh (by invitation), J. D. Anderson (by invitation),

E H. Fell, and B M. Gasul (by invitation),

Chicago, Ill.

The results of closed transventricular pulmonary valvotomy and in-fundibulotomy (Brock operation) performed upon severely ill infants from three days to one year of age are presented. The defects in this group include pulmonary valve stenosis, pulmonary valve atresia, tetralogy of Fallot, transposition of the great vessels with pulmonary stenosis, tri-cuspid atresia, and tricuspid stenosis. In all instances operation upon these infants was considered urgent because of congestive heart failure or severe symptoms of hypoxia. The anatomic variations in the entities listed are discussed and demonstrated in relation to operative treatment Of particular importance in the use of this procedure is the fact that it does not interfere with the later performance of a corrective operation or a shunt for palliation after the child has been enabled to attain the age and size to make these procedures more easily performed with a low mortality. In the case of tetralogy of Fallot, the results obtained here are such that the Brock operation is considered by us to be the procedure of choice in small infants with severe symptoms, even though in some cases a second palliative operation may become necessary before a corrective operation is undertaken.

9. Corrected Transposition: The Surgical Features and Associated Anomalies

H. Sayed, W. P. Cleland, H. H. Bentall, D. G. Melrose,

M. B. Bishop, and J. Morgan (all by invitation),

London, England

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

The experience with sixteen cases of corrected transposition is presented, seven of whom were operated on under bypass. The condition is defined and the anatomy is briefly described. The associated cardiac anomalies are discussed correlating the incidence of conduction defects with the abnormal course of the conducting tissue. The clinical, cardiographic, radiographic and haemodynamic aspects of these cases are mentioned underlining the diagnostic points. Brief description of the pathological material will include three cases that died following surgery, and one case that died during investigation. The operative details of seven cases are presented with special emphasis on the surgical difficulties. Complete heart block which is the most important hazard following surgery is underlined and the significance of mitral valve lesion is discussed. Criteria for choosing cases with corrected transposition for surgery are suggested and a technique to minimize the surgical hazards is described.

10. Open Heart Surgery in Infants

Herbert Sloan, Joe D. Morris, James Mackenzie (by invitation), and

Aaron Stern (by invitation), Ann Arbor, Mich.

Correction of intracardiac defects in infants has been accompanied by a high mortality rate which has been the result in part of difficulties in the use of extracorporeal circulation. Most present day equipment is too large and the volume of the extracorporeal circuit is too great to permit accurately balanced perfusions in infants weighing less than ten kilograms. An entire extracorporeal circuit and accessories designed for perfusions in infants has been developed. The priming volume has been reduced and all parts have been miniaturized. The equipment has been employed with a standard pumping unit. Experience in the use of extracorporeal circulation to repair intracardiac defects in more than 50 infants two years of age or less will be reported. The trials and tribulations of their care will be stressed. The improvement which results from increased experience and proper perfusion equipment will be cited.

11. A Two Stage Operation for Total Anomalous Pulmonary Venous Drainage in Childhood

W. T. Mustard, and J. D. Keith (by invitation), Toronto, Canada

Thirty-five children with total anomalous pulmonary venous drainage have been operated upon at the Hospital for Sick Children, Toronto, in the past ten years. Twenty-one were of the supracardiac type with 1 into the right superior vena cava and the remainder into the left superior vena cava. In 6 children the drainage was into the coronary sinus, in 4 into the right atrium, and in 4 the drainage was mixed cardiac and supracardiac drainage. Seventeen of the children operated upon were in the first year of life and the majority of these under 6 months of age The presence of an atrial septal defect is mandatory for sustaining life. When the atrial septal defect or patent foramen ovale is small, death may occur in the first few weeks or months of life. If the atrial defect is large the child may survive a number of years. The larger the right to left shunt the greater the development of the left side of the heart. The infant who gets into trouble early in life has an inadequate right to left shunt, and, therefore, an underdeveloped left heart unable to meet the strain of total correction and the new load placed on the left ventricle. Our experience with total anomalous pulmonary vein drainage leading into the left superior vena cava following surgical anastomosis of the common vein to the left atrium, suggests it is better to leave the left superior vena cava patent and ligate it several months or a year or two later, after the left ventricle has developed sufficiently to accept the new load. In the adult such a two stage procedure may not be as necessary.

12. Renal Toxicity of Polybrene in Open Heart Operations

J. Alex Haller, Jr. (by invitation), Herbert T. Ransdell, Jr., and

W. Fielding Rubel (by invitation), Louisville, Ky.

Oliguria and occasionally acute renal shutdown are included in the complications of most series of open heart procedures In most instances this renal dysfunction is vaguely attributed to inadequate perfusion or blood reactions. In our experience at the Louisville Children's Hospital, there has been a striking correlation between this oliguria, rising BUN, and renal shutdown and the relative amount of undiluted Polybrene used in the operating room and subsequently in the recovery room. In the four patients who died of renal shutdown, distinctive renal lesions were noted at autopsy and all received greater than average doses of Polybrene To test this hypothesis 10 dogs were given graded doses of undiluted Polybrene to counteract comparable clinical Heparin doses. Varying degrees of uremia were produced and were again directly related to the increasing Polybrene dosages. This apparent Polybrene toxicity to the renal parenchyma will be discussed in relationship to the experimental and clinical findings.

13. Respiratory Insufficiency as a Factor in Postoperative Gastrointestinal Bleeding

William S. Blakemore, and Sidney K. Wolfson, Jr.

(by invitation), Philadelphia, Pa

Among 3,000 patients who had a craniotomy or thoracotomy between 1951-1959, 14 patients (4 after craniotomy, 10 after thoracotomy) without prior history of peptic ulcer had massive upper gastrointestinal bleeding. When blood CO₂ measurements were recorded, the venous contents and/or arterial tensions were elevated (59-80 mmHg). Nineteen patients without gastric, thoracic or intracranial lesions were studied. Free and total gastric acid was measured in aliquots obtained by continuous suction at 15' intervals during control periods of breathing air followed by breathing 5% CO₂ and 20% oxygen in nitrogen for one hour via an open circuit mask. A second one hour period of breathing air followed. Gastric acid (meq/min) increased in all subjects during the period of breathing the CO₂ gas mixture. Arterial pCO₂ and pH, and volume of the collected gastric sample were measured. From these data there appears to be a correlation between elevation of arterial pCO₂ and gastric acidity and postoperative upper gastrointestinal hemorrhage Respiratory insufficiency commonly associated with thoracotomy or craniotomy may be a common etiological factor and emphasizes the need for the measurement of arterial pCO₂ in these patients. Therapy to prevent or reverse these changes will be discussed.