Monday Afternoon, March 29, 1965

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

International Room

8. Changing Concepts in the Surgical Treatment of Pulsion Diverticula of the Lower Esophagus

Thomas H. Allen*, Birmingham, Ala., and O. Theron Clagett,

Rochester, Minn.

A review of twenty years experience at the Mayo Clinic in the surgical treatment of lower esophageal (epiphrenic) pulsion diverticula shows a rather distinct contrast between therapeutic concepts employed and morbidity observed during the first ten years and the clinical experience during the latter period. The importance of associated hiatal and other esophageal abnormalities is discussed and the incidence is recorded. The salient features of surgical management are outlined and illustrated stressing careful pre-operative evaluation and preparation, the use of a left thoracotomy approach, two-layer closure of the esophagus following diverticulectomy, esophagomyotomy, and correction of associated lesions. Two cases illustrating the severe complications resulting from conventional diverticulectomy only in the presence of associated lesions are briefly reviewed.

9. Hiatal Hernia and Reflux Esophagitis in Children

Irvin L. Heimburger*, Indianapolis, Ind., William C. Alford, Jr.*,

Geoffrey H. Wooler*, and John A. Aylwin*, Leeds, England

Sponsored by Harris B Shumacker, Jr.

Hiatal hernia, a significant cause of vomiting during infancy, is frequently complicated by severe peptic esophagitis. Sixty-one infants and children with hernias have been seen at the Leeds infirmary. Three-fourths exhibited peptic esophagitis and over half of these had strictures. Treatment of the strictures by repeated dilatations proved entirely unsatisfactory, most of these children eventually requiring esophageal resection. Thirty children were satisfactorily treated by hernia repair. A thoracoabdominal repair has been developed which has eliminated the recurrences originally encountered with the earlier transthoracic repairs Sixteen resections have been performed during the past eleven years. Ten had jejunal loop reconstruction. These have proven very successful and have not been affected by the child's growth or by peptic erosion. The unique method employed to preserve adequate circulation to this loop is described. The high incidence of stricture following esophagogastrostomy in the other six has made this clearly an undesirable procedure. Several of the fifteen patients not treated surgically died as the result of complications that can occur when this abnormality is not corrected. The definite role of early diagnosis and intensive medical management is also discussed.

10. The Preoperative Detection of Left Atrial Thrombi

Don L. Fisher*, Lawrence B. Brent*, Edward M. Kent, and

George J. Magovern, Pittsburgh, Pa.

Left atriography by direct injection is shown to be accurate and safe in the preoperative diagnosis of left atrial thrombosis. Routine preoperative use of the test is advised in mitral stenosis, especially if atrial fibrillation is present, or if embolization has occurred. During transatrial septal left heart catheterization, an 8½ F left atrial catheter is placed. 21 ml sodium iothalamate 80% is injected in 1½ sec. A single 1/30 sec P.A. x-ray film exposure is taken at the end of injection, using a grid cassette. An additional film in the R.A.O. view is usually done. Use of a cassette changer is optional. 35 mm cinecardiographic films were found to be inferior to standard sized films. In 378 patients tested, 99 showed thrombi in left atrium or appendage (26%). 56 of the 99 were explored surgically, and no diagnostic errors were found. Only one embolization occurred during testing, and no other major complications. Massive thrombosis was treated by complete removal during open heart mitral repair. Lesser thrombi were treated by closed mitral stenosis repair, leaving intact the thrombi of the main chamber, but removing those of the appendage. Anticoagulant drugs and electrical defibrillation were given during convalescence.

11. Aortic Valve Replacement Utilizing the Sutureless (Ma-govern) Prosthesis

C. Walton Lillehei, Richard C. Lillehei, and

Randolph M. Ferlic*, Minneapolis, Minn.

Extensive experience with open reconstruction techniques for acquired aortic valve disease disclosed initial good, but poor long term palliation. This led to development of techniques for successful total valve replacement in 1958 utilizing a silastic flap valve (patient still alive). In the period 1961-1964, the Starr-Edwards valve was employed in 59 patients with 17 hospital deaths (28%) and 2 late deaths to date. More recently, we adopted use of the sutureless aortic valve, and in a series of 35 consecutive cases have been impressed by reduction of hospital mortality to 9%. To date there have been no late deaths, embolic complications, nor valve migration. This mortality reduction has been particularly evident in poor risk patients of older ages (7th and 8th decades) and those needing multiple procedures (10 of this series). Total body perfusion was carried out at moderate hypothermia (30°C) with Rheomacrodex-mannitol prime (16 to 20 cc/kg.), and perfusion of both coronaries. No venting of the heart is utilized. The sutureless valve is larger in diameter than the comparative sutured valve, but this has been compensated for by development of a simple technique (to be described) for inserting a larger sutureless valve without cardiac damage.

12. Chronic Hemolysis in Patients with Ball-Valve Prostheses

Murray N. Andersen, Elemer Gabrieli*, and Joseph A. Zizzi*,

Buffalo, N. Y.

The occurrence of anemia in certain patients who had previously undergone mitral or aortic valve replacement with a ball-valve prosthesis has led to a study of the degree of chronic hemolysis occurring in such patients. Studies were performed six months to two years after valve replacement in ten patients with prosthetic mitral valves and six patients with prosthetic aortic valves. Chronic hemolysis was evaluated by three principal methods which provide sensitive indices of intra-vascular hemolysis: serum haptoglobin levels, serum lactic dehydrogenase levels (total and fractionated for specific isozymes) and free plasma hemoglobin. Red cell survival times, measured by Cr₅₁ tagging, were determined in most patients. Reticulocyte counts and routine hematocrits were also obtained. All patients studied had evidence of significant chronic hemolysis with total, or near-total, depletion of serum haptoglobin and persistent elevation of lactic dehydrogenase in the fractions associated with red blood cell lysis. Elevation of free plasma hemoglobin was unusual in patients with mitral valve pros-theses but frequent in the patients with aortic prostheses, indicating more severe hemolysis following aortic valve replacement. The loss of the protective mechanism provided by haptoglobin against free plasma hemoglobin may be of particular significance and the implications of these findings, particularly in relation to renal damage, will be discussed.

13. The Treatment of Coronary Occlusive Disease by Endar-terectomy

Ralph B. Dilley*, Jack A. Cannon*, Albert A. Kattus*,

Rex N. Macalpin*, and William P. Longmire, Jr.,

Los Angeles, Calif.

Of twenty-five patients undergoing coronary endarterectomy for localized occlusive arteriosclerosis between 1957 and 1964 at the University of California Medical Center at Los Angeles, nineteen have survived the operative procedure. There have been five early postoperative deaths from thrombosis of the endarterectomized vessel and four late deaths from five months to six years following operation. In one of these an unusual circumferential scarring of the endarterectomized vessel was demonstrated. In another, death occurred after re-operation for a localized process in the right coronary artery six years following a left anterior descending endarterectomy which had remained patent. Detailed follow-up data is available in six of the ten surviving patients at present. Selective cineangiography has demonstrated re-occlusion of the endarterectomized vessel in three patients, and excellent patency in three patients - two, four and six years postoperatively. Operative techniques have included direct open endarterectomy, closed endarterectomy through the aortic root, release of external constricting bands, and internal mammary bypass. Our current indications for operation as well as a detailed analysis of operative techniques employed will be presented. In addition, the causes of the immediate and late deaths plus details of follow-up information in surviving patients will be discussed.

14. Myocardial Revascularization by Vineberg's Internal Mammary Implant: Evaluation of Postoperative Results

Donald B. Effler, F. Mason Sones, Jr.*, L. K. Groves,

and Ernesto Suarez*, Cleveland, Ohio

Seventy-eight internal mammary implants were performed at the Cleveland Clinic Hospital between April 1962 and December 1963. An objective report of results is based upon: (1) patient survival, and (2) restudy with coronary and internal mammary arteriography (Sones' Technic). (1) Survival: 73 Patients are alive. 3 Immediate and 1 late fatality are recorded, each death attributable to coronary artery disease. A 7 months' survivor died of lymphosarcoma; autopsy revealed a viable implant. (2) Arteriography: 44 Patients have been restudied to date. The best arteriograms are obtained 9 to 12 months after operation. Direct opacification of the implanted vessel shows: (a) 31 patients demonstrate working implants, (b) 6 patients have occluded implants, and (c) 7 patients have inconclusive results because of early or inadequate study. Sones' Technic provides logical selection of candidates, an objective method of assessing results, and a means of determining progress of disease. A film, utilizing stop-frame technic, proves conclusively that myocardial revascularization may occur. The revascularization may be accomplished by: (a) new vessel formation, and (b) direct arteriolar-to-arteriolar anastomoses with preexisting coronary vessels. Arteriograms of the "ideal candidate" are included.

*By Invitation