MONDAY AFTERNOON, APRIL 17, 1967

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

Imperial Ballroom

8. Fascia Lata Replacement of Aortic Valves

Ake Sennino,* Zurich, Switzerland.

Sponsored by John W. Kirklin

Since 1962 diseased aortic valves have been replaced with autologous fascia lata. The technical aspects of this operative method will be discussed. The clinical experience with this technique in the first ninety cases of aortic stenosis or incompetence will be presented. Hemodynamic improvement was assessed by pre-and postoperative catheter studies. Special attention will be paid to the occurrence of late complications (endocarditis and insufficiency) during a follow-up period of 4 ½ years.

9. An Evaluation of Aortic Valve Homografts Sterilized by Electron Beam Energy

James R. Malm, Frederick O. Bowman, Jr.,* Paul D. Harris,* and

A. T. W. Kowalik,* New York, N. Y.

Aortic valve replacement has been reported utilizing human grafts sterilized by immersion in 1% beta-propiolactone. Subsequent storage by freeze-drying or nutrient medium has modified valve consistency and limited the safe preservation time prior to implantation. A technique of freezing (-70 degrees centigrade) for preservation and high energy radiation (2 megarads) for sterilization has provided a soft pliable graft with a prolonged utilization time. Comparative tensile strengths of identical specimens of aortic grafts show 1) no change in untreated grafts (control) 6-24 hours after death; 2) a decrease up to 40% with 1% beta-propiolactone; 3) no change by freeze irradiation technique; and 4) strength varies with age and sex of donor, i.e. for comparable age, grafts from females are stronger than males. Techniques for valve harvesting, sterilization and implantation will be presented. Among eleven patients with homograft implantations, there has been 1) no operative mortality; 2) maintenance of normal blood pressure; 3) no post-operative anticoagulation used; and 4) no post-operative emboli. Only one patient has an aortic diastolic murmur noted immediately postoperatively. The relationship of late aortic insufficiency, previously reported in 44% of transplanted aortic valves, to methods of graft preservation and technique of implantation will be discussed.

10. The Problem of Insufficiency Following Homograft Replacement of the Aortic Valve

W. G. Bigelow, A. S. Trimble,* H. E. aldridge,* and

P. Bedard,* Toronto, Ontario.

The development of a technique to insert homograft aortic valves in the subcoronary position has given cardiac surgeons an alternative to the plastic ball valve. There are perhaps three reasons why the homograft technique has not been generally accepted: (1) the technical difficulty of the procedure, (2) the problem of acquiring and storing valves, and (3) the presence of a post-operative aortic diastolic murmur in a large percentage of cases in all the reported series. The first two problems can be solved. This report is an attempt to assess the problem of post-operative insufficiency. Twenty-three patients have undergone homograft replacement of the aortic valve. There were five hospital deaths. The clinical results have been good, with no post-operative thrombosis, embolism, or infection, and no anticoagulant therapy with its attendant complications. Seventy percent have an aortic diastolic murmur, some of which have appeared after leaving hospital. Thus far eleven patients have had hemodynamic and angiographic assessment four to 18 months after surgery. A second assessment is planned for some, to assess any change. An attempt will be made to correlate the degree of insufficiency with: (1) the murmur, (2) the original aortic valve pathology, (3) the selection and storage of valves, and (4) the experience of the team.

11. Valve Replacement in Active Aortic Insufficiency Due to Endocarditis

G. C. Kaiser, V. L. Willman, M. Thurmann,* and C. R. Hanlon,

St. Louis, Mo.

Infection superimposed upon an artificial valve is attended by such high mortality that some have considered it futile to attempt correction of these defects. Bacterial endocarditis of the normal aortic valve, usually acute, may result in sudden medically unmanageable aortic insufficiency. This hemodynamic crisis may preclude survival long enough for definitive bacterial treatment. We have recently observed five male patients with acute aortic insufficiency secondary to bacterial endocarditis. Ages ranged from 17 to 68 years. The organisms involved were staphylococcus (2), pneumococcus (1), alpha streptococcus (1), enterococcus (1). Two patients died of uncontrolled heart failure without operative intervention. In three patients, aortic valve replacement was accomplished (2 Starr-Edwards, 1 McGovem-Cromie). Two patients died; a 65 year old man succumbed to staphylococcal pneumonia on the fifth post-operative day, the other, age 37, died of pseudomonas and aerobacter pneumonia on the eighteenth post-operative day. A 17 year old boy is alive fourteen months after an initial operation, having required two additional operations at three weeks and eight months to close leaks around the aortic annulus. This experience prompts us to advise early aortic valve replacement in acute aortic insufficiency due to endocarditis when hemodynamic impact of the lesion precludes survival for the period necessary to complete antibacterial treatment and medical management.

12. Treatment of Massive Hemorrhage in Pulmonary Tuberculosis

Chin B. Yeoh,* Rafik T. Hubaytar,* Joseph M. Ford, and

Robert H. Wylie, New York, N. Y.

Hemoptysis caused by pulmonary tuberculosis transmits the disease to other portions of the lung, and in massive volumes can prove fatal. From 1959-1966, studies were made on 56 patients who bled more than 200 cc. per day during their stay in the hospital. Evaluation is based on age, sex, race, single or multiple episodes of hemoptysis, bacteriological studies, and new or retreated cases. Of the 43 patients who received conservative treatment, 10 died. Conservative therapy is outlined. The 10 who died are discussed in terms of their clinical courses and the probability of surgical intervention. Criteria governing selection of potential surgical candidates are given. Thirteen patients underwent emergency surgical resections; 11 had lobectomies and 2 had pneumonectomies. Complications following surgery include: (1) spread of disease, (2) respiratory insufficiency, and (3) reactivation and recurrent bleeding from a quiescent site. The 2 operative deaths are reviewed with regard to cause, prevention, and error in management.

13. Pleural Tuberculosis

Hiram T. Langston, Walter L. Barker,* and Allan L. Graham,*

Chicago, Ill.

Familiarity with empyema is today an uncommon gift and pleural disease of tuberculosis etiology is conspicuously absent from most current surgical practices. Our experience in this field seems to justify review. In twelve and one-half years 190 patients with significant pleural disease were admitted to the Chicago State Tuberculosis Sanitarium. These were classified as being of tuberculous etiology on the basis of usual criteria. Initial management has consisted of chemotherapy, appropriate antibiotics, and thoracenteses as required. Failure of adequate response as manifested by radiographically persistent pleural or parenchymal disease necessitated surgical intervention 115 times. This was accomplished with an overall morbidity rate of 23% and a mortality rate of 10%. Morbidity and mortality rates are proportional to the complexity of the surgical problem and will be analyzed. There were 35 decortications, and 39 decortications combined with partial pulmonary resection. In 41 cases a pleuropneumonectomy was required. Of particular interest will be the management of those cases wherein a bronchopleural fistula was present preoperatively with respect to establishment of preliminary drainage. The criteria for selection of surgical candidates including the methods of preoperative assessment will be discussed in relation to the timing and modality of surgical maneuver.

14. Radioactive Lung Scanning in the Diagnosis and Management of Pulmonary and Cardiac Disorders

David C. Sabiston, Jr., and Robert H. Jones,* Durham, N. C.

Pulmonary scanning with radioactive macro-aggregated human serum albumin was first reported in 1964 and is now available for general use. Although originally employed in the diagnosis of pulmonary embolism, recent experience has emphasized its usefulness in a variety of additional disorders. Analysis of the scan data provides important evidence of regional pulmonary function as well as demonstrating defects in perfusion. Recent experimental data has shown that count densities of lung scans provide an accurate quantitation of regional pulmonary flow. The present study evaluates the use of lung scanning in more than 200 patients with localized pulmonary disease and certain cardiac disorders. The magnitude of the pulmonary perfusion deficit has been determined in patients with carcinoma of the lung, congenital lobar emphysema, pulmonary tuberculosis, cystic lung disease, sequestration and agenesis of the lung, systemic-pulmonary shunts for congenital heart disease, and other cardiac disorders. These data correlate with the perfusion of the area observed at operation and with the pathologic anatomy of the pulmonary vasculature in excised tissue. In summary, lung scanning quantitates regional pulmonary blood flow in a variety of pulmonary and cardiac disorders. It has been shown to be of considerable importance in the preoperative evaluation, surgical management and ultimate prognosis of patients with such conditions.

*By invitation