WEDNESDAY AFTERNOON, APRIL 24, 1968

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

Ballrooms 1 and 2

44. The Therapy of Cavitary Pulmonary Histoplasmosis

Changwoo Ahn,* James W. Kilman,* John S. Vasko,*

and Neil C. Andrews, Columbus, Ohio

Chronic cavitary pulmonary histoplasmosis is usually progressive and may result in death from pulmonary insufficiency if untreated. A critical analysis of the treatment of 42 patients with chronic cavitary pulmonary histoplasmosis has been done. The forty-two patients have been divided into groups, according to their treatment. Sixteen patients received either no treatment or incomplete treatment with Amphotericin B. All sixteen had open cavitary disease at the time of discharge with a follow-up period between 6 months and 4 years. Fourteen patients received over two grams of Amphotericin B treatment without surgical resection. Eight of these patients have cavitary pulmonary disease by x-ray and the follow-up period has been from three months to two years. Two recurrences of the disease and a 14% mortality in this group. Twelve patients received surgical resection for cavitary disease. Seven of these cases were given preoperative and postoperative adequate treatment with Amphotericin B therapy and there has been no recurrence of the disease in this group. A review of the literature reveals 120 surgical resections for cavitary pulmonary histoplasmosis. Only eight of these cases in addition to our seven cases have been treated with preoperative and postoperative Amphotericin B therapy. The mortality and morbidity rate of this group is much improved over the group having surgical resection alone. We strongly feel that the best therapy at the present time for chronic cavitary histoplasmosis is the use of preoperative and postoperative Amphotericin B and surgical resection of the cavitary lesion.

45. The Management of Benign Intrathoracic Tracheal Stenosis

Hermes C. Grillo, Boston, Mass.

Stenosis of the intrathoracic trachea is a formidable complication of assisted ventilation through a tracheostomy and is of increasing clinical importance with growing effectiveness of respiratory care units. Histologic studies show pathogenesis of the lesion to be destructive erosion, with attempted healing by cicatrization, at a point several centimeters below the tracheostomy site, at a level where the tip of the tracheostomy tube lay. Conservative treatment is ineffective in management of fully developed lesions. Definitive treatment requires resection of the stenosis and reconstruction. Thirteen patients with benign stenosis of the intrathoracic trachea are included in the present study. Eleven were explored; ten underwent resection and reconstruction - nine successfully. In eight patients reconstruction was accomplished by mediastinal tracheal mobilization with primary anastomosis (with or without adjunctive thoracotomy). Cervico-mediastinal or cervico-thoracic approach was selected in accord with level and length of stenosis. Intrapleural mobilization of the right hilus was necessary to obtain maximum length for primary repair of longer stenotic segments. In one patient who had suffered extensive loss of trachea from prior efforts at repair, reconstruction required fashioning of a cutaneous tube interstitially splinted with special plastic rings.

46. Surgical Repair of Tetralogy of Fallot with a Functioning Potts Aorticopulmonary Anastomosis

Robert E. Gross, S. Bert Litwin,* and William F. Bernhard,

Boston, Mass.

Since 1960, 48 patients with Tetralogy of Fallot and a functioning Potts anastomosis underwent total surgical repair. Transpleural ligation of the shunt was carried out prior to cardiopulmonary by-pass in 7 (Group I). In the remaining 41 cases (Group II), direct suture closure of the anastomosis was performed (via left pulmonary arteriotomy during circulatory arrest at 20°C.). In Group I, there was 1 post-operative death related to Potts shunt closure (persistent Potts and hemorrhage into chest) and 1 unrelated (residual outflow obstruction). One patient died at 3 years (patent Potts anastomosis and endocarditis). Four patients are alive 4 to 7 years post-operatively. In Group II, there were 2 immediate post-operative deaths from air embolization. Three other early deaths and 5 late ones were unrelated to the Potts anastomosis or closure of same. Thirty-one patients are well ½ to 3½ years post-surgery. Other results in this series of patients will be presented. Technical steps in closing the Potts anastomosis (via left pulmonary arteriotomy )and conditions influencing the ease or difficulty of such will be emphasized.

47. Atrioventricularis Communis: Recatheterization Results in 40 Patients Following Intracardiac Repair

Raymond C. Bonnabeau, Jr ,* Ray C. Anderson,* Randolph M.

Ferlic,* Minneapolis, Minn., and C. Walton Lillehei, New York, N.Y.

Between 1958 and 1967, 115 patients with the partial and complete forms of A.V. canal defect underwent intracardiac repair at the University of Minnesota Hospitals. During that same interval 40 patients, all clinically improved, have undergone postoperative cardiac catheterization. In this group, 4 (10%) had minimal left-to-right shunts, while only one (2.5%) had a significant 50% left-to-right shunt. None necessitated reoperation. Seven (17.5%) patients exhibited a trace to 1+ (maximum, 4+) degree of mitral valvular insufficiency, while one patient also had a trace of tricuspid valvular insufficiency. All other patients exhibited essentially normal cardio-vascular physiology. The preoperative and postoperative pulmonary resistances, pressures, and flows will be compared. We have used the degree of mitral valvular regurgitation demonstrated by preoperative cardiac angiography as our main indication for repair of the cleft in the mitral leaflet. We believe that the proper preoperative evaluation of this entity has contributed to the excellent results obtained in this series.

48. Complete Repair of Persistent Truncus Arteriosus Defects

Robert B. Wallace,* G. C. Rastelli,* Patrick A. Onoley,*

Jack L. Titus,* and Dwight C. McGoon, Rochester, Minn.

Complete surgical correction of a persistent truncus arteriosus (PTA) defect was performed in three children aged 3, 5, and 8 years. One had a type I PTA defect, one a type II defect, and one a type IV defect. Preoperative cardiac-catheterization studies suggested a favorable pulmonary vascular bed with a calculated pulmonary-to-systemic resistance ratio of less than 0.6 in each case. Surgical repair of the type I and type II defects consisted of (1) disconnection of the pulmonary arteries from the truncus and direct suture of the resulting defect in the truncus, (2) closure of the ventricular septal defect, and (3) use of a homograft of the ascending aorta including the aortic valve to reconstruct the pulmonary artery. The type IV defect was repaired similarly by anastomosing the homograft to the two large bronchial arteries supplying the lungs. All three children survived operation and were dismissed from the hospital. Postoperative catheterization studies carried out in one patient showed absence of gradients across the various anastomoses and competency of the grafted valve.

49. Hemodynamic Correction of Transposition of the Great Vessels in Infancy

A. R. C. Dobell, and J. E. Gibbons,* Montreal, Quebec

Hemodynamic correction (the Mustard operation) has been carried out on five infants ranging in weight from 4.8 to 7.8 Kilograms and in age from 5 to 18 months. Four of the children had required balloon septostomy in early life and three of these had had an atrial shunt constructed surgically some months later. Nevertheless, further deterioration necessitated hemodynamic correction. None of the children had high pulmonary vascular resistance and the operation was well tolerated in all. One child died several days later and the remainder have survived and are thriving. The advent of balloon septostomy permits selected infants to avoid a palliative operation prior to hemodynamic correction. In addition, early application of the intracardiac operation may be the most effective means of preventing the pulmonary vascular obliteration that occurs so commonly in this condition.

50. An Analysis of Operated and Non-Operated Patients with Documented Coronary Arterial Disease up to Five Years Following Myocardial Revascularization or Angiographic Study

Edward B. Diethrich,* John E. Liddicoat,* Edward W. Dennis,*

Samuel A. Kinard,* and Michael E. DeBakey, Houston, Texas

Selective right and left coronary arteriography has been employed in the evaluation of 500 patients with typical or atypical angina pectoris over the past five years. On the basis of these studies, 170 patients have undergone myocardial revascularization using either direct or indirect techniques. Revascularization was not performed in the remaining patients for a variety of reasons: too advanced coronary arterial disease for which operative treatment was not available, insignificant coronary arterial disease, associated valvular disease, congenital coronary anomalies, or patients refusal of operation. A comparison of the clinical status of operated and non-operated patients with comparable coronary disease patterns up to five years following study or operation has been made. This analysis provides information regarding the presence and severity of angina pectoris, current activity level, and the occurrence of myocardial infarction. Answers to several important questions regarding the progression of coronary arterial disease and the role of myocardial revascularization are available from these data. Such factors as the influence of revascularization on subsequent myocardial infarction and the fate of unoperated patients with documented coronary arterial disease will be discussed.

*By Invitation