MONDAY AFTERNOON, MARCH 31, 1969

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

Grand Ballroom

11. Aortic Valve Replacement: Long Term Results

Robert D. Bloodwell,* J. Edward Okies,* Grady L. Hallman, Jr.,

and Denton A. Cooley, Houston, Texas

Total excision and prosthetic replacement has become the most satisfactory method of treatment of advanced acquired aortic valvular disease. Overall hospital mortality among 799 patients undergoing aortic valve replacement during the past six years was 12 per cent. Current mortality's eight per cent despite denying no patient because of severity of cardiac disability. Late deaths have brought the cumulative mortality to 29 per cent. Despite reduced risk of valve replacement, late complications have not been eliminated. Late thrombpembolic complications have occurred in patients who had remained clinically improved for long periods after operation providing an overall incidence of 12.2 per cent. Half of the emboli occurred over one year after operation. While ball variance occurred in early ball and seat valves, none has occurred in modified ball valves used during the past three years. Ninety percent follow-up is available for patients operated upon over one year ago. Clinical trial of yarious types of prostheses used permits comparison of mechanical complications, throm-boemboh, and late mortality. Low hospital mortality, salvage of many extremely ill patients, functional and clinical improvement in most patients, and a low incidence of late complications and valve malfunction provide a basis for continued use of prosthetic aortic valve replacement.

12. Biological Factors Affecting Long-term Results of Valvular Heterografts

Alain Carpentier,* and Charles DuBost,* Paris, France

Sponsored by Frank Gerbope

The use of valvular heterografts raises two sorts of problems: technical and biological. Having been subjected to a great deal of work, the technical problems seem to be solved, whereas the biological problems still remain relatively unknown, although they play a great part in the long term results of this kind of graft. Since September 1965, date of the first successful valvular heterograft in human, we have used this method in aortic, mitral or tricuspid position sixty-one times, using different methods of preservation of the graft (freeze drying, chemical sterilization, formaldehyde, neta-periodate, ethylenglycol and glutaraldehyde). Analysis of these results shows that the method of preservation used is the essential factor in the long-term durability of the grafts. In the light of this clinical experience and biochemical studies the criteria of efficiency of a method of preservation have been defined as follows: 1. Guaranteed sterilization. 2. Elimination of the antigenic components previously defined in laboratory, i.e, soluble proteins, glycoprotems, mucppolysacharides, cells. 3. Prevention of the collagen and elastin denaturation. 4. Protection against the cellular ingrowth. When the method used respects all these criteria the long term fate of the grafted valves becomes excellent.

13. Tricuspid Insufficiency in Patients Undergoing Mitral Valve Replacement: Conservative Management, Annuloplasty, or Replacement?

James R. Pluth,* Robert L. Frye,* and F. Henry Ellis, Jr.,

Rochester, Minn.

Severe mitral valve disease may be accompanied by tricuspid insufficiency of variable magnitude. Opinions vary as to whether or not the insufficiency should be surgically corrected at the time of mitral valve replacement and, if so, by what means. This review concerns 148 mitral valve replacement procedures carried out between January, 1963, and January, 1968, on patients with associated tricuspid insufficiency. Twenty-two had intrinsic disease of the tricuspid valve with combined stenosis and insufficiency. Pure tricuspid insufficiency was present in the rest. The overall hospital mortality was 18 per cent. In 89 patients no procedure was performed on the tricuspid valve; tricuspid annuloplasty was done in 34 and tricuspid valve replacement in 25. Follow-up study, including cardiac catheterization, in some instances suggests that pure tricuspid insufficiency secondary to mitral valve disease and right heart failure does not always regress after mitral valve replacement, nor is tricuspid annuloplasty always effective. Tricuspid valve replacement is usually required in the presence of combined mitral and tricuspid valve disease, and when pure tricuspid insufficiency of severe degree is present.

14. Aortic Arch Atresia and Aortic Arch Interruption: Operative Experience with 11 Children

R. L. Tawes, Jr.,* P. Panaoopoulos,* E. Aberdeen,* D. J. Waterson,*

and R. E. Bonham-Carter,* London, England

Sponsored by H. Brodie Stephens

Aortic arch atresia and interruption are rare anomalies which are usually fatal in early infancy. Only 18 of the 111 reported cases were living children and only 12 underwent operation. Our 11 cases were preopera-tively diagnosed by angiocardiography and cardiac catheterization in five, and by thoracotomy in six. Nine had aortic arch atresia, two had interruption. Operation corrects or palliates the triad of cardiac defects that usually exist with this anomaly: atresia or interruption, patent ductus arteriosus, and ventricular septal defect. The patent ductus was ligated, the atresia resected, and the aorta anastomosed end to end in three cases. In five others with atresia a hypoplastic arch precluded this anastomosis, therefore the left subclavian artery was anastomosed to the descending aorta in four, and to the aortic arch in one. One infant died before any definitive operative procedure. The pulmonary artery was banded in two of these infants. In the two infants with aortic arch interruption, only pulmonary artery constriction was attempted. Four of the nine children with aortic arch atresia survived operation and left the hospital. The five deaths were in infants less than six months of age The two neonates with aortic arch interruption died at operation.

15. Neurologic Abnormalities Following Open Heart Surgery

Hushang Javid, Henry M. Tufo,* Hassan Najafi, William S. Dye,*

James A. Hunter, and Ormand C. Julian, Chicago, Ill.

While numerous reports of central nervous system disturbances following open heart surgery have appeared in the literature, the precise incidence, natural course and causes of these disturbances remain unknown. The following longitudinal study of 100 consecutive patients undergoing open heart surgery was developed to answer the following questions: (1) What is the incidence, magnitude and reversibility of central nervous system dysfunction following open heart surgery? (2) What factors are related to the occurrence of these disorders? Preoperative studies consisted of tape recorded interviews designed to elicit medical and psychological information in addition to complete neurological examination, standardized mental status evaluation and five psychometric tests. The following results were observed. Half of the sample had one or more neurological signs present at the time of the first postoperative examination. Fourteen of 15 operative deaths had evidence of focal or diffuse cerebral damage. Neurological abnormalities remained at the time of discharge in 12 patients. Of the survivors, one-third exhibited one or more of the following: disorientation, memory disturbance, bizarre motor restlessness, visual hallucinations and depressed intellectual function. Several factors appeared to be important in the genesis of these changes: severe preoperative depression, advanced age, and a prolonged period of persistent low mean arterial pressure during bypass.

16. Pericardial Tamponade Following Open Heart Surgery

Russell M. Nelson, Conrad B. Jenson,* and

Wendell M. Smoot III,* Salt Lake City, Utah

The occurrence of pericardial tamponade in the postoperative period can produce severe hemodynamic alterations. The differential diagnosis from low cardiac output syndrome due to other causes becomes important considering the necessity for reoperation for the relief of significant tamponade. Therefore, a retrospective study has been done to analyze the records of 422 patients subjected to open heart surgery in a ten year period from 1959 to July of 1968. Significant pericardial tamponade was diagnosed in sixteen of these patients, and confirmed in 14. Two patients had myocardial insufficiency found at the time of re-exploration The incidence was greatest among patients having open operations on the aortic and mitral valves, and least among the congenital abnormalities. Low arterial pressure, high venous pressure and a paradoxical pulse occurred most commonly as expected. Abnormal chest X-rays, electrocardiograms, or muffled heart tones were present in less than half of the cases. The average_< amount of thoracostomy drainage was 1200 ml. in the tamponade group, similar to the amount drajned from the control group of patients subjected to open heart surgery without pericardial tamponade. Seventy-five per cent of the patients with pericardial tamponade developed this problem within the first two days following surgery. At reoperation, a specific site of bleeding was not found in 50% of the patients. Patients with primary myocardial insufficiency exhibited the same hemodynamic abnormalities, but their thoracostomy drainage was significantly less. Differential diagnosis and proper treatment programs for postoperative pericardial tamponade will be presented.

17. Pericardectomy in Non-Tuberculous Pericarditis

Donald G. Mullen,* Marcus L. Dillon, W. Glenn Young, Jr.,

and Will G. Sealy, Durham, N.C.

During the last fifteen years we have performed pericardectomies on twenty-four patients who had non-tuberculous pericarditis. This review is concerned with the indications for surgical therapy, the course following the operation, and the long-term follow-up of these patients. Particular emphasis will be placed on those patients who had recurrent episodes of pain, and those in whom the pericardectomy was done for prevention of constriction. The cause of the pericarditis was trauma in two patients, rheumatoid disease, one patient; unsuspected tumor, four patients; and, presumably a virus in 17. The indications for operation included diagnosis, constriction, prevention of recurrent episodes of pain or tamponade, and recurrent fluid accumulation. It is concluded from this study that an aggressive approach is indicated in patients with non-tuberculous pericarditis who demonstrate persistence or recurrence of symptoms, and in whom there is evidence from the character of the fluid that constriction will likely occur. Early removal of the anterior pericardium will prevent some of the more serious complications of this disorder.

18. Partial Cardiopulmonary Bypass, Hypothermia, and Total Circulatory Arrest: A Life Saving Technique in Certain Complicated Situations

G. Walton Lillehei, and Robert J. Ellis,* New York, N.Y.

Six years ago we were presented with a patient bleeding from a hole in the ascending aorta exposed in the depths of an infected sternotomy who had had two open heart procedures and at this time had a staphylococcus septicemia. With manual aorta compression, operation was instituted by peripheral cannulation, partial bypass, and total body hypothermia. At 21°C the pump oxygenator was shut off and the blood drained into the oxy-genator. During circulatory arrest of 21 minutes the hole was closed and an uneventful early and late recovery followed. Since then, we have used this method as an emergency (occasionally electively) in 30 patients with a variety of complicated situations many of which would have been impossible by any other approach. These included most frequently infected sternotomy wounds with massive hemorrhage. Other occasional indications were adult tetralogies with massive bronchial flow, aortic-innominate vein arteriovenous fistulas, ruptured acute myocardial infarctions, unusual tears in inferior cava or arch of the aorta, large coronary arteriovenous fistula into the posterior right ventricle. Twenty-three (75%) have been successful. Conversations with others indicate that the value and simplicity of this technique, which will be presented in detail, is not generally recognized.

19. A New Operation for Correction of Transposition of the Great Arteries, Ventricular Septal Defect, and Pulmonary Stenosis

G. G. Rastelli,* Robert B. Wallace, and Dwight C. McGoon,

Rochester, Minn.

Hospital mortality rate for complete correction of transposition associated with ventricular septal defect (VSD) and subvalvular pulmonary stenosis (SPS) by creating transposition of venous return has been 61% (8 of 13 patients) at the Mayo Clinic. The location and variable nature of the SPS prevent adequate surgical relief, and this is probably responsible for high surgical mortality. A new "anatomic" correction for this type of transposition was devised in which SPS was relieved without a direct approach to it. This repair consists of (1) division of the main pulmonary artery, the cardiac end of which is oversewn, (2) construction of an intracardiac tunnel between the VSD and the aorta, and (3) construction of a new right ventricular outflow by anatomosing a homograft of ascending aorta, including the aortic valve, between the distal end of the pulmonary artery and the right ventricle. This repair may achieve better correction than would transposition of venous return, because the left ventricle is made to eject into the aorta and the right ventricle to eject into the pulmonary artery. Two patients 14 and 15 years were successfully operated on with this technique. Cardiac catheterization and angiocardiographic findings before and after operation will be presented.

20. Ebstein's Anomaly: Further Experience with Definitive Repair

Kenneth L. Hardy,* and Benson B. Roe, San Francisco, Calif.

A functional concept of the altered cardiodynamics in Ebstein's anomaly and a reconstructive operation to correct them was described before this Association by one of us (KLH) in 1964. The patient reported at that time, now five years postoperative, remains clinically well and active, in a functional Class 1 status. While the relative rarity of this lesion does not provide an opportunity for extensive experience, we have now treated a total of six patients by the operation originally described with satisfactory functional correction in every case. There has been one death, not related to the method of repair. This experience supports the original belief that the procedure is effective and provides a more desirable alternative to the presence of a mechanical device in the low pressure side of the heart with its commitment to lifelong anticoagulation and the threat of repeated pulmonary emboli. In this consecutive series, it was feasible to correct the dysfunction without having to consider the need for a prosthetic valve or foreign tissue. Further observations about the anatomical constants and variables in the Ebstein heart will be demonstrated to facilitate operative evaluation and repair of the abnormality. Minor technical refinements of the basic technique have evolved from this experience and will be described.

*By Invitation