MONDAY MORNING, APRIL 17, 1967

8:30 A.M. Business Session (Limited to Members)

Imperial Ballroom

8:45 A.M. Scientific Session: REGULAR PROGRAM

Imperial Ballroom

1. Abnormalities of the Sinus of Valsalva: Diagnosis and Treatment

Michael E. DeBakey, Edward B. Diethrich,* John E. Liddicoat,*

Samuel A. Kinard,* H. Edward Garrett, and James F. Howell,*

Houston, Texas.

Twenty-six patients with abnormalities of the sinuses of valsalva have been treated at the Methodist Hospital within the last three years. These abnormalities were classified as aneurysms (22 cases), fistulae (2 cases), and aneurysms associated with fistulae (2 cases). In the group of 22 patients with aneurysms, 20 had 3 sinus involvement and 2 had single sinus involvement. In the group of patients with fistulae, two were from the left coronary sinus to the left atrium, and one each from the right coronary sinus to the right atrium and the right ventricular outflow tract. The history, physical examination, electrocardiogram and plain chest films were nonspecific. Positive diagnosis was established in each case preoperatively by retrograde aortic catheterization and aortic root injection. All the aneurysms were associated with aortic incompetence requiring aortic valve replacement in conjunction with resection of the aneurysm and graft replacement. The aortic valve was normal in three patients with fistulae and the treatment consisted of fistula ligation. The diagnostic features, operative techniques and results in this group of interesting patients with sinus of valsalva abnormalities will be discussed.

2. Mitral Replacement: A Review of Six Years Experience

Albert Starr, Rodney H. Herr,* and James A. Wood*

Portland, Ore.

This report reviews our total experience with 263 patients undergoing mitral valve replacement with a ball valve prosthesis from September, 1960 to September, 1966. 145 patients had isolated mitral valve replacement, 75 had mitral and aortic valve replacement, 14 had mitral and tricuspid replacement, and 29 had triple valve replacement. The overall operative and late mortality of 15% and 10% respectively were roughly comparable in each of the groups without regard to the number of valves involved. Advances in our thinking with regard to the selection of patients for surgery, improvements in operative approach and technique, management of associated valvular heart disease, modifications of valve design, and certain features of postoperative care have greatly decreased operative morbidity and mortality. Attention is directed to the various causes of late morbidity and mortality such as thromboembolism, myocardial fibrosis, and recurrent regurgitation. The encouragement of encapsulation of the attached portion of the mitral prosthesis, first introduced in March, 1965 with the extended cloth design, has resulted in a decrease in embolic complications from 38% to 4% in the isolated mitral series. Further experiences with totally encapsulated prostheses and other recent innovations in valve design will be discussed.

3. Myocardial Revascularization by Internal Mammary Implant Procedures: Clinical Experience

Rene G. Favaloro,* Donald B. Effler, Laurence K. Groves, and

F. Mason Sones, Jr.,* Cleveland, Ohio.

7,300 selective coronary arteriograms (Sones' technique) have been made in the Cleveland Clinic. 786 patients, so studied, received surgical treatment for coronary artery disease or its sequelae (January, 1961 to October 31, 1966). Internal mammary implantation has the broadest application of all revascularization operations and may supplement coronary perfusion in any part, or all, of left ventricle. 587 patients underwent some form of mammary implantation between April, 1961, and October 31, 1966. The Vineberg procedure, used initially, was followed by the Sewell pedicle implant. Overall hospital mortality is 4.7%; the last 178 operations carried a 2.2% mortality. One year follow-up in 78 patients reveals 90.4% implant patency. Comparative statistics between the Vineberg series and the Sewell series will be presented. Results of implantation are improved by long tunnels beneath major branches of the anterior descending and the circumflex arteries. Current technique (Vinberg-Sewell AP implant) places a trimmed pedicle through two connecting tunnels which traverse the anterolateral and the diaphragmatic aspects of the left ventricle. For patients with severe diffuse disease a double implant is used - the right artery is placed in the anterior left ventricle and the left artery is placed posteriorly. Operative techniques of both procedures will be described - arteriographic evidence of revascularization will be shown.

4. Experience with the Cytologic Detection, Localization and Treatment of Radiographically Undemonstrable Bronchial Carcinoma

F. G. Pearson,* D. W Thompson,* and N. C. Delarue,

Toronto, Ontario.

Sputum cytology can detect bronchial carcinoma in stages before the tumor becomes demonstrable in a chest radiograph. In 40 such patients seen at the Toronto General Hospital since 1960, the lesion has been located and histologically verified in 20. Follow-up observations indicate a greatly enhanced prognosis if the lesion is located and adequately treated in these early stages. In a recent sputum cytology screening program of an asymptomatic high risk group of 1,586 patients, with an average of only 1.4 sputum samples per patient, 13 had positive sputum cytology. Do date the lesion has been located in 3. 22 patients with symptoms suggestive of bronchial carcinoma but with no tumor demonstrable in chest radiographs had positive sputum cytology. Localization has been effected in 12. 5 patients presented with radiographic lesion which were found to be benign and unrelated to co-existent, radiographically invisible bronchial carcinoma. Of the 20 patients in whom the lesion was located, 13 were treated by resection and 5 by irradiation. 2 lesions were found at autopsy. Techniques and problems in localization, and follow-up data are presented. The follow-up search for an obscure lesion in a patient with positive sputum cytology is described.

5. Long Term Survival After Surgical Resection for Bronchogenic Carcinoma

John C. Jones, William H. Kern,* Niles D. Chapman,*

Bert W. Meyer, and George G. Lindesmith,* Los Angeles, Calif.

The authors review a series of 359 consecutive resections of bronchogenic carcinoma with 94 patients surviving five to twenty-two years. The results of the histological review of slides of every specimen in the series is presented in detail with some startling conclusions, particularly as regards survival time of some patients whose specimens were considered to be highly malignant. The location of the tumor in survivors is compared to that of the non-survivors. The various locations of the tumors in long term survivors is considered along with the cell type and size of these tumors. Of interest is the finding of long term survival in some patients with lymph node metastasis, extension of tumor to the margin of bronchial resection, invasion of pleura, and blood vessel invasion. To be considered is the fact that in review of the slides by five pathologists there is a variation in criteria which sometimes makes it difficult to compare results in various series, both in the survivors and non-survivors. These results of long term survival, and the knowledge that many of those who did not survive an initial five years died of unrelated causes, makes it more than ever imperative that these patients be found and submitted to surgery as early as possible.

6. Bronchogenic Carcinoma Involving the Thoracic Wall: Surgical Treatment and Prognostic Significance

Alexander S. Geha,* Philip E. Bernatz, and Lewis B. Woolner,*

Rochester, Minn.

Of 2,113 patients undergoing surgical exploration for lung cancer, 174 (8.2%) had extension into the thoracic wall with or without concomitant invasion of the mediastinum, pericardium, or major vessels. Of 158 with primary bronchogenic carcinoma in the latter group, 41 (26%) underwent en bloc resection, considered curative by the surgeon, with 1 operative death. Twelve of the 41 (32%) survived more than 5 years; the 5-year survival rate was 35% in squamous cell carcinoma, 60% in adenocarcinoma, and 10% in large cell undifferentiated carcinoma. With proper planning of treatment, the outlook for patients with bronchogenic carcinoma and associated invasion of the chest wall may be among the more favorable outlooks for patients with lung cancer.

7. Treatment of Multiple Lung Metastases in Children with Combined Therapy: Surgery and Chemotherapy and/or Irradiation

Eugene E. Cliffton,* and John L. Pool, New York, N. Y.

The results of surgical treatment of pulmonary metastases in children from 1946 to 1966 is to be reported. There were 20 children who had multiple pulmonary metastases treated with chemotherapy and/or x-ray therapy prior to surgery. Long term survival (5 years or more) was obtained in 5 of these patients. One patient had an osteogenic sarcoma, two had adenocarcinomas of the testicle, one a rhabomyosarcoma and one a Wilm's tumor. Two others are living and well at 26 and 39 months after surgery for the metastases. These both had Wilm's tumors. In 4 patients, bilateral resections were performed and of these, one patient is alive and well 8 years following surgery and a second is living without evidence of recurrence 26 months following surgery. This last patient had 7 tumor nodules removed. Two others are living and well less than one year. The total experience of recognized metastatic cancer in the lungs of children will be reported in the completed paper. This five year survival of 20% is surprising and would suggest a much more aggressive approach to the treatment of metastatic lung cancer in children, with chemotherapy and x-ray therapy followed by resectional treatment of those lesions which persist.

*By Invitation