Wednesday Afternoon, March 31, 1965

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

International Room

44. Endocarditis Associated with Intracardiac Prostheses: Diagnosis, Management and Prophylaxis

Raymond A. Amoury*, Frederick O. Bowman, Jr.*,

and James R. Malm, New York, N. Y.

Intracardiac prostheses were utilized in 340 patients in a series of 550 open heart operations, with 12 instances of post-operative endocarditis. There were 220 patients with congenital heart disease in whom correction required an intracardiac patch. Infection occurred in only one of this group, and, was due to a species of aspergillus. Valve replacement was carried out in 122 patients, with insertion of 141 prostheses of various types. Infection occurred in 1 of 73 mitral valve replacements, and developed in 10 cases following 68 aortic valve procedures. The predominant organism encountered was a coagulase negative staphylococcus. The means of establishing the diagnosis of post-operative endocarditis are analyzed. The methods of management are presented. Four patients survived. One required excision of the infected prosthesis, and implantation of a suture-less valve. One has been bacteriologically sterilized. Two are satisfactorily controlled by chronic, suppressive antibiotic therapy. A modification of the pre- and post-operative antibiotic program has eliminated endocarditis during the past 12 months.

45. The Place of Surgery in Hypertrophic Obstructive Cardio-myopathy (Idiopathic Hypertrophic Subaortic Stenosis)

Hugh H. Bentall*, London, England

Sponsored by A. G. Morrow

Since the original description by Brock of functional obstruction of the left ventricle, many reports of the surgical treatment of hypertrophic obstructive cardiomyopathy, variously called also hypertrophic or muscular subaortic stenosis, have appeared. The present paper reports experience at Hammersmith Hospital, London, with fifteen patients treated surgically between the years 1958 and 1964 and amplifies our original reports by means of postoperative haemodynamic studies. A brief description is given of the methods of operation used and of the dangers inherent in operating in this condition. The symptomatic, haemodynamic and electrocardiographic results are given and the results correlated where possible. The mechanisms revealed by this study taken in conjunction with the histo-chemical and electron microscopy studies of Pearse, make it clear that this is a disorder in which there is widespread disorganization of the heart muscle and that surgical treatment is more unlikely to effect any radical cure, but that surgery should be regarded as a method of limited but important value in the treatment of patients with severe obstruction who are in danger of sudden death or who are severely and distressingly incapacitated.

46. Right Ventricular Outflow Obstruction Due to Anomalous Muscle Bundles

Herbert E. Warden*, Morgantown, W. Va.,

Russell V. Lucas, Jr.*, and Richard L. Varco,

Minneapolis, Minn.

Significant right ventricular outflow obstruction may be caused by large anomalous muscle bundles traversing the right ventricular cavity. This type of obstruction is distinguishable from the more common types of infundibular stenosis and may occur with an intact septum and without associated intracardiac pathology. This report concerns 11 patients with intact septa in whom the diagnosis of anomalous muscle bundle obstruction to right ventricular outflow was established by catheterization and angiocardiography. In 6 patients, the anomalous muscle bundles represented the only cardiac abnormality and was the sole cause of obstruction to blood flow through the right ventricle, while in the remaining 5 patients, there was an associated pulmonary valvular stenosis. To date, 8 patients have undergone operation and all are now asymptomatic with essentially normal hemodynamics. Experience with the above group of patients has suggested certain features of anomalous muscle bundle obstruction of the right ventricle which this presentation will attempt to emphasize: 1) this type of obstruction is a distinct entity which may occur independently and may produce significant right ventricular hypertension, 2) there are associated diagnostic characteristics which make its pre-operative recognition possible, and 3) normal hemodynamics may be restored by corrective surgery.

47. Surgical Treatment of Lutembacher's Syndrome

William H. Muller, Jr., James B. Littlefield, and

Julian R. Beckwith*, Charlottesville, Va.

Lutembacher's syndrome (mitral stenosis and atrial septal defect) is a rare surgical lesion. The correction of the mitral valve deformity associated with this syndrome may prove difficult. The authors present their experience with 2 patients successfully treated for Lutembacher's syndrome who are now well 10 months following operation. Cardiac catheterization data and the technique used to correct the congenital deformity of the mitral valve are presented. The experience of others with the surgical correction of this syndrome will be summarized.

48. Incomplete Persistent Atrioventricular Canal: Operative Methods and the Results of Pre- and Postoperative Hemo-dynamic Assessments

Nina S. Braunwald, and Andrew G. Morrow,

Bethesda, Md.

Thirty patients are described in whom operative treatment of incomplete persistent atrioventricular canal was undertaken. In 11 patients an additional anomaly was present: common atrium 5, pulmonic stenosis 2, sub-aortic stenosis 1, and small ventricular septal defect 3. In all, the cleft mitral valve was repaired, the interatrial septum reconstituted with a prosthesis, and any associated malformation corrected. Four operative deaths occurred, from air embolism, aplastic anemia (chloramphemcol), recurrent shunt, or residual mitral regurgitation. Two patients died late, one from heart block and one from mitral regurgitation. Intraoperative dye curves were recorded in all patients and 17 have had detailed postoperative hemodynamic assessment. Pulmonary hypertension was abolished in 6 of the 7 patients in whom it was present preoperatively. Pulmonary capillary and right atrial pressures were normal postoperatively in all patients studied, indicating satisfactory mitral and tricuspid valve function. No circulatory shunt was evident in 22 patients and trivial ones, not necessitating reoperation, are present in the other 2. The operative methods utilized, and certain correlations between pre- and postoperative hemodynamic findings and the results of operation, will be presented.

49. Congestive Heart Failure in Children with Atrial Septal Defect

M. Weinberg, Jr., R. A. Miller*, A. R. Hastreiter*,

J. G. Raffensperger*, E. H. Fell, and H. G. Bucheleres*,

Chicago, Ill.

Atrial septal defects in infants and children, exclusive of endocardial cushion defects, generally are associated with few or no symptoms. Operation is recommended as an elective procedure to prevent complications in adult life. A distinct group is encountered, however, in which congestive heart failure and severe retardation of growth and development appear in infancy, and operation is mandatory at an early age. Although physical examination, cardiac catheterization, and angiocardiography demonstrate findings of only the isolated interatrial communication, associated anomalies should be suspected and may be encountered at operation. These include mitral stenosis and insufficiency, incomplete forms of triatrial heart, anomalous drainage of pulmonary veins, and fibroelastosis or hypoplasia of the left ventricle. At times no clear additional deformity is recognized. All of these variations have been encountered by the authors, and will be discussed. The presence of severe symptoms in a child with an atrial septal defect should constitute a special indication for careful inspection of the left atrium and ventricle, the pulmonary veins, and the mitral valve. Of overwhelming importance is the recognition that control of blood volume is unusually critical in these children. Pulmonary complications are frequent and demand exceptional attention.

50. Total Anomalous Pulmonary Venous Drainage: Surgical Treatment in 61 Patients

Denton A. Cooley, and Grady L. Hallman*,

Houston, Texas

Drainage of the entire pulmonary circulation into the right side of the heart may occur in numerous anatomic forms. Darling's classification which is based upon the site of entry for the pulmonary blood into the systemic venous blood describes four types: supracardiac, paracardiac, infracardiac, and mixed. Prognosis and age of onset of symptoms in this complex anomaly depend upon several factors including size of the foramen ovale, presence of obstruction in the venous trunk, patency of the ductus arteriosus, and others. This report is based upon a consecutive series of 61 patients operated upon between 1957 and 1964. Supracardiac drainage was demonstrated in 35 patients, and other types accounted for the remainder. Age of the patient influenced risk of operation, since among 33 infants less than one year of age there were 15 survivors and in the remaining 28 patients 26 survived complete surgical correction. This presentation will be concerned with technical considerations in repair of total anomalous pulmonary venous drainage. Methods will be proposed for reducing the mortality in small desperately ill infants including use of staged operations.

By Invitation