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
