Emerald Room

29. Surgical Treatment of Pulmonary Embolism

Dennis M. L. Rosenberg, (and by invitation)

Charles Pearce, and John McNulty, New Orleans, La.

During the past fifty years or so, there has been no remarkable change in the treatment of thromboembolism. Pulmonary embolism continues to be a complex disease and a threat to life. One hundred records of autopsied cases occurring at Charity Hospital and Touro Infirmary in New Orleans have been studied. Of significance in this group were 29 patients who survived for two hours after the onset of severe symptoms and 12 patients who lived more than 12 hours. For certain patients in this group who specifically develop sustained hypotension and progressive deterioration the authors propose a more direct approach, suggesting pulmonary embolectomy with the aid of extracorporeal circulation. Experience with two such cases is outlined. Details of pre-operative study and diagnosis are presented, together with the technique of surgery and suggestions for the use of rapidly available, portable and disposable pump-oxygenator units. This approach has been used successfully twice and suggests strongly that early diagnosis and treatment by embolectomy may reduce the still appalling figure of approximately 3,000 deaths each year in the United States from pulmonary embolism. Emphasis is made on cognizance of the disease, aids to earlier recognition, and energetic medical or surgical treatment.

30. Tricuspid Atresia: A Step Towards Corrective Treatment

Sir Russell Brock, London, England

Tricuspid atresia is the Cinderella of the surgery of congenital heart disease. This is because it is one element in a whole range of abnormalities, some so complex as to be untreatable. Operation has consisted of a shunt procedure, an excellent palliative in very ill children; the immediate results have been reasonably good, but the late results are less so. In one group the essential lesion is atresia of the inflow tract of the right ventricle but with adequate development of the outflow tract and of the pulmonary artery. In these an associated valvar or infundibular stenosis can be relieved with great improvement. A more important lesion, however, is stenosis (or small-ness) of the ventricular septal defect through which all blood to the lungs must pass. A logical treatment is deliberate enlargement of the defect by an open operation. An example of such an operation is reported. In this case the condition of the right ventricle prevented a total cure which would have involved closure of the atrial and ventricular communications and insertion of a valve between the right atrium and right ventricle. This could be a feasible procedure for which surgeons should be alert.

31. Hypertrophic Subaortic Stenosis: Evolution of a Surgical Technique

A.R.C. Dobell, and H. J. Scott (both by invitation),

Montreal, Canada

Sponsored by Lloyd D. Maclean

We have operated upon four patients with severe hypertrophic subaortic stenosis. With each experience our surgical technique was modified and our understanding of this perplexing disease broadened. In the first operation we learned the importance of maintaining the cardiac beat in order to understand the dynamic outflow tract constriction. At the second we learned that simple incision of the involved muscle would not relieve the obstruction. For this reason muscle was resected in the third operation with a cutting current applied to a wire loop passed into the left ventricle from the aorta. Only in the fourth operation were ideal conditions achieved. Here the exposure was by way of the left atrium with bisection of the aortic leaflet of the mitral valve. Excellent exposure of the entire ventricular septum was provided and four grams of muscle was resected from the outflow tract with a wire loop. The pressure gradient was abolished. The patient was recatheterized four months later. Our understanding of hypertrophic subaortic stenosis is by no means complete. Nevertheless the advantages of the transatrial approach justify its description in detail.

32. Stenosis of the Branches of the Pulmonary Artery

Milton Weinberg, Jr , Magnus H. Agustsson (by invitation),

Ivan D'Cruz (by invitation), Juan P. Bicoff (by invitation),

Majid Behravesh (by invitation), John Raffensperger (by invitation),

and Egbert H. Fell, Chicago, Ill.

Stenoses of single or multiple branches of the pulmonary artery are frequently unrecognized and have received little attention in regard to the surgical treatment of congenital heart disease. These are, however, relatively common anomalies which may be of critical importance in patients undergoing heart surgery. Cardiac catheterization studies and angiocardiograms have demonstrated stenoses of one or more branches of the pulmonary artery in 88 patients. In 27 of these, the lesions were not accompanied by other defects. In 61 patients, the stenoses were associated with a wide variety of cardiac anomalies, the most common being ventricular septal defect (20), pulmonary valvular stenosis (16), patent ductus arteriosus (7), and tetralogy of Fallot (5). In the majority of this group of patients undergoing operation, usually for the associated anomalies, the pulmonary artery branch stenoses were either mild or limited to the branches of one lung. In eight patients, however, three of whom died, the high degree of obstruction to pulmonary blood flow resulted in persistence of severe right ventricular hypertension after correction of the associated defects. Cardiac catheterization data and angiocardiograms demonstrating the stenoses are presented, and the anatomic variations are discussed in relation to surgical significance.

33. Clinical Experience with Local Hypothermia in Elective Cardiac Arrest

Edward J. Hurley, Richard R. Lower, Eugene Dong, Jr.,

R. Cree Pillsbury (all by invitation), and Norman

E. Shumway, Palo Alto, Calif.

Prolongation of the safe period of myocardial anoxia is easily and innocuously achieved by the introduction of isotonic saline at 0-4° C. into the pericardial cradle about the heart. Experimentally, simple immersion of the heart within such a solution permits resuscitation after 7 hours of myocardial anoxia. Among the initial 210 patients operated upon consecutively at the Stanford Medical Center for congenital or acquired heart disease during cardiopulmonary bypass, 98 underwent elective anoxic cardiac arrest to facilitate repair. Lesions encountered in this group of patients included 26 ventricular septal defects, 23 Fallot's anomaly, 48 aortic valvular lesions, and one sinus of Valsalva fistula. The age range was 19 months to 65 years. Utilizing a disc oxygenator without heat exchanger, periods up to 58 minutes of anoxic cardiac arrest were tolerated with the myocardium protected by topical hypothermia. An effective heart beat was established in every instance. There were three deaths in the 98 patients, none of which was related to the method of elective cardiac arrest. The purpose of this paper is to describe the technique of myocardial protection by topical hypothermia and the results obtained.

34. Comparative Merits and Results of Blood Primes and 5% Dextrose in Water Primes of Heart-Lung Machines: Analysis of 250 Patients

Nazih Zuhdi, John Carey, William Sheldon (all by invitation),

and Allen Greek, Oklahoma City, Okla.

Two series of consecutive patients had open heart surgery using moderate internal hypothermia (28-30 °C as measured in the mid esophagus) and low flow rates (20 ml per kilogram of body weight per minute). In 43 patients, the double helical reservoir bubble oxygenator was primed with blood. In 207 patients, it was definitively primed with 5% dextrose in water (using the formula: weight in kilograms x 16 ml.) producing true hemodilution. The latter series is subdivided into two groups. In the first group, banked citrated blood was used to replace the measured loss from the surgical field as it occurred. In the second group, banked citrated blood was used only if blood loss from the surgical field was excessive and then preferably administered after the termination of the cardiopulmonary bypass; establishing the fact that total cardiopulmonary bypass, per se, is safely conducted without any blood. The basic principles involved will be discussed, the relative merits outlined, and the results tabulated.

35. Renal Complications of Open Heart Surgery: Predisposing Factors, Prevention and Management

Thomas J. Yeh, Edwin L. Brackney, David P. Hall (all by invitation),

and Robert G. Ellison Augusta, Ga.

One hundred and fifty-three consecutive cases of open heart surgery were analyzed for renal complications. While over 80% had abnormal microscopic urinary findings postoperatively, only 16 developed serious renal complications; 6 of these were classified as having renal tubular acidosis (high output renal failure) and 10 as acute renal failure. Statistical analysis indicates that hemolysis in excess of 200 mgm %, perfusion over one hours duration, flow rate less than 1.8 L/M²/min with or without hypothermia, and use of Magnesium-Egglugate preserved blood for priming, singly or in combination predisposed to renal damage. There were no cases of serious renal complication among 51 patients in whom flow rates were greater than 2.2 L/M²/min regardless of other factors, suggesting that renal damage may be completely preventable with use of high flow rates. Prophylactic Mannitol has been used in 30 consecutive cases with eminently good results. All 16 cases of serious renal complications were managed conservatively with or without ion exchange resin. Artificial renal dialysis was required in only one case of renal failure with survival. There was only one renal death in this series.

36. Endarterectomy in the Treatment of Coronary Artery Disease

Donald B. Effler, Laurence K. Groves, (and by invitation)

F. Mason Sones, Jr., and Earl Shirey, Cleveland, Ohio

Endarterectomy has been advocated for definitive treatment of arterial disease. At present, we believe that this direct approach has limited application and should be reserved for those patients who demonstrate localized obstruction of the main arteries. Selection of the candidate for coronary endarterectomy requires precise evaluation of the coronary vessels and their disease patterns. This evaluation is accomplished by Sone's method of selective coronary arteriography. The arteries are opacined by direct injection of contrast medium; selective filling of each vessel is recorded by cine-photography. Our experience is limited to operations upon four patients who presented segmental occlusion of a main coronary artery. The area of occlusion represented at least 75% reduction in normal vessel caliber and each patient was incapacitated by angina pectoris. The operations utilized total body perfusion and cardioplegia induced by regional hypothermia. Endarterectomy was performed under direct vision and the vessel reconstructed with vein patch graft. Coronary endarterectomy is a major surgical undertaking and limits of its application are emphasized. One patient failed to survive operation; postmortem dissection demonstrated distal dissection of the intima. Follow-up study in three survivors by postoperative arteriograms is presented.