AATS: Monday Morning, March 31, 1969

Monday Morning, March 31, 1969

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MONDAY MORNING, MARCH 31, 1969

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

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

1. Human Cardiac Transplantation: Clinical Experience

M. E. DeBakey, E. B. Diethrich,* G. P. Noon,* W. Butler,*

S. A. Kinard,* J. M. Lewis,* J. E. Liddicoat,* and D. K. Brooks,*

Houston, Texas

Cardiac transplantation as a form of treatment for end-stage heart disease has met with a degree of early success and certainly warrants further investigation. This report deals with our accumulative experience including a discussion of operative technique and donor-recipient selection with specific emphasis on the role of tissue typing and immunosuppressive therapy in these cases. The postoperative course will be reviewed with reference to clinical and laboratory signs and symptoms of rejection and the treatment used for its prevention and control. Special studies regarding the effectiveness of antilymphocytic globulin and suggested dosages and route of administration will be discussed. Results obtained in these cases with postoperative hemodynamic and angiographic studies will be included.

2. Function of the Transplanted Human Heart

Grady L. Hazlman, Louis L. Leatherman,* Robert D. Leachman,*

Donald G. Rochelle,* Donald L. Bricker,* Robert D. Bloodwell,*

and Denton A Cooley, Houston, Texas

The transplanted heart is a denervated organ Experience with cardiac transplantation in 12 patients has permitted us to make physiologic observations of the human heart under these conditions. All transplanted hearts resumed activity soon after removal of vascular clamps, some in sinus rhythm, some in ventricular fibrillation. Fibrillation was easily converted with direct current countershock. Both recipient and donor sinus nodes remained intact and produced P waves in the electrocardiogram, but only the impulse from the donor node was associated with ventricular contraction. Cardiac output was measured in 6 patients before, during, and after exercise at intervals following operation. Resting outputs were normal and increased with exercise in a variable fashion utilizing both intrinsic and humoral mechanisms. Heart rate and systemic arterial pressure were observed during the Valsalva maneuver. The usual change in heart rate did not occur because of denervation, but response of the systemic arterial pressure was normal. Reflex control of the recipient's own SA node remained intact as illustrated by slowing of the respective P wave in the electrocardiogram. This presentation will summarize the function of the transplanted heart at rest and its response to exercise, Valsalva maneuver, cold, pain, and various drugs.

3. Cardiac Transplantation in Man. II: Immunnosuppressive Therapy

Edward B. Stinson,* Eugene Dong, Jr.,* and Norman E. Shumway,

Palo Alto, Calif.

The Stanford program of immunnpsuppressive management for cardiac transplantation was developed from clinical experience in renal and hepatic transplantation, from our past experience with canine cardiac transplantation, and from the progress of our first seven clinical cases. Protocol: Patients accepted for transplantation are given azathioprine 1 mg per kilogram per day until the day of surgery. Immediately preoperatively the patients are given a loading dose of azathioprine 4 mg/kg orally and the first dose of antilymphocyte globulin administered intramuscularly. During surgery, methylprednisolone is infused intravenously for a total dose of 5 mg/kg. On the first postoperative day maintenance immunnosuppressive therapy is begun consisting of azathioprine 2-3 mg/kg per day, prednisone 2-3 mg/kg per day, and daily antilymphocyte globulin. Prednisone and anti-lymphocyte globulin are tapered gradually after the first two postoperative weeks. Of the seven patients, rejection was not identified in four. In the three remaining patients, four episodes of rejection were well documented by electrocardiographic, hemodynamic, enzymatic, and general systemic indicators. Three rejection crises were reversed successfully by combined therapy consisting of massive intravenous infusions of methylprednisolone given rapidly and actinomycin D as well as systemic heparinization. One patient died six weeks postoperatively of inadequate treatment. None of the four surviving patients has evidence of residual cardiac impairment.

4. Dissecting Aneurysms of the Aorta: Treatment and Results in 54 Patients

M. W. Wheat, Jr., Gainesville, Fla, P. D. Harris,* J. R. Malm,

G. Kaiser,* F. O. Bowman, Jr.,* New York, N.Y., and

R. F. Palmer,* Gainesville, Fla.

During the past 4 ½ years, 54 patients with acute dissecting aneurysms of the aorta have been treated on two separate thoracic surgical services, one in New York City and the other in Gainesville, Florida. Twelve of these underwent surgical correction with a mortality rate of 25 per cent. Forty-two patients were treated with drugs during the acute phase with a mortality rate of 10 per cent. In the group of 42 patients treated with drugs, 48 per cent were seen within 24 hours, 90 per cent within one week and all within two weeks of the onset of symptoms. Forty-eight per cent originated in the descending aorta and 52 per cent involved either ascending aorta, arch of the aorta, or both. The diagnosis was confirmed by aortography in 51, autopsy in one, and clinical impression in two cases. The indications for surgical approach to the aneurysm itself have been significant aortic valve insufficiency, poor response to drugs, or progression of the dissection. Contrary to recently published "Reservations," absence of hypertension, ischemic limbs, and paraplegia are not contraindications to successful drug therapy. This study validates further the concept of the use of drug therapy in most patients with acute dissecting aneurysms of the aorta.

5. Complications of Prophylactic Digitalization in Thoracic Surgical Patients

Edward A. Stemmer, Long Beach, Calif., George L. Juler,*

and John E. Connolly, Irvine, Calif.

Because of the increased incidence of cardiac arrhythmias in thoracic surgical patients, many surgeons employ prophylactic preoperative digitalization. Our experience with 564 patients undergoing thoracotomy for non-cardiac lesions does not support this policy Prophylactic digitalization was not employed from 1954 to 1959. The incidence of postoperative arrhythmias in 295 patients was 6 5%. Thirteen of these patients, or 4.4% of the entire group, died as a result of arrhythmia. After 1960, prophylactic digitalization was employed in 169 unselected patients and omitted in an additional 100 patients. Thirty-eight (23%) of the 169 digitalized patients developed cardiac arrhythmias postoperatively Eleven of these patients, or 7.0% of the 169, died as a result of the arrhythmia The incidence of arrhythmias in the 100 patients without prophylactic digitalization was 8 0% with a 4 0% postoperative mortality due to the arrhythmia. It was apparent that a patient's chance of surviving a post-thoracotomy arrhythmia was better (70% vs 55%) if he had been prophylactically digitalized However, the greatly increased incidence of arrhythmias in digitalized patients resulted in a post-thoracotomy mortality of almost twice that of patients who had not been prophylactically digitalized. The advantages of prophylactic digitalization of noncardiac surgical patients are more apparent than real.

6. Heart Block in Children: Treatment with a Radiofrequency Pacemaker

William W. L. Glenn, Natalie DeLeuchtenberg,*

Daniel W. Van Heeckeren,* Genichi Sato,* and Wade G. Holcomb,*

New Haven, Conn.

A transthoracic radio-frequency (R-F) pacemaker has been implanted in 9 children at Yale since 1961. In three, aged ½, 1 and 4 years, heart block was congenital. In six, aged 6-10, block followed repair of a vetricular septal defect. One patient died 2 months after implantation, and one reverted to normal sinus rhythm enabling discontinuation of pacing. In the remaining 7 patients the average duration of pacemaker function is 2/4 years (29 months), ranging from 16 to 37 months. In four patients a dysfunctioning of implanted radio-receiver required replacement, twice in one case. The same defect, found in all receivers, has been corrected. To allow for growth of the child, a loop of the myocardial electrode (cathode) is coiled in a teflon bag and placed in the subcutaneous tissue of the chest wall. Experiments with young pigs have shown that the wire will uncoil as the subject grows. Observations on cardiac output at various heart rates, in two patients aged 2 and 6 years demonstrate a parallel increase in output with rates up to 120 per minute. Advantages of the R-F pacemaker for children with heart block are small size, externally controlled rate and power source and the infrequent (if ever) need for reoperation.

7. Hemodynamic Consequences of Respiratory Insufficiency Following Trauma

Donald B. Doty,* Roger V. Moseley,* and Basil A. Pruitt,*

Washington, D.C.

Sponsored by Judson G. Randolph

Ability to maintain an increased cardiac output to supply increased tissue oxygen demand following tissue trauma may be the determining factor in the recovery or death of the injured patient. Concomitant respiratory insufficiency with incomplete ability to oxygenate the blood may place further work requirements on the heart sufficient to exceed its reserve pumping capability and result in high cardiac output failure. A uniform group of previously healthy soldiers were studied following battle injury in Vietnam to determine the hemodynamic consequences of trauma with associated respiratory insufficiency. There were 27 patients who had arterial hypoxemia (pO₂ < 80 mm Hg) in whom serial hemodynamic studies were performed. The mean cardiac index was 4.1 L/min.M² with 75% of the values above accepted resting normal of 3.0 L/min./M². Highest cardiac output values were associated with marked physiologic intra-pulmonary shunting of blood (venous admixture). Such high levels of cardiac output were usually well tolerated by these young patients. Five patients were observed to have increasing cardiac output until death occurred presumably as a result of increasing hypoxemia. Clinical course of these patients will be detailed. A low cardiac output was found only with concomitant severe hypovolemia documented by blood volume studies.

8. Diagnosis and Management of Mediastinal Masses in Children

J. Alex Haller, Jr., David Mazur,* and William W. Morgan, Jr.,*

Baltimore, Md.

Mediastinal masses in children represent a wide variety of conditions which present numerous problems in management. To give factual, clinical perspective to therapy we have reviewed records of eighty children treated for mediastinal masses in The Johns Hopkins Hospital between 1933 and 1968. Arbitrary division of the mediastinum into anterior, middle and posterior compartments was most useful for diagnosis and management. Thymic hyperplasia and teratomas were the commonest masses of the anterior mediastinum, lymph node neoplasms and infection were predominant lesions of the middle mediastinum and neurogenic tumors and duplication cysts formed the overwhelming majority of posterior masses. Forty per cent of all mediastinal masses were malignant with a 65% mortality. Except in infants with hyperplasia of the thymus in whom steroids were both therapeutic and diagnostic, operative intervention was necessary to establish the diagnosis and in most cases to excise the mass. Combined Cobalt-60 irradiation and drug therapy were used for primary lymph node tumors and undifferentiated stem cell tumors. X-ray features of different masses will be discussed as well as the drug regimens for malignant lesions. Technical features of several unusual congenital anomalies of die mediastinum will be stressed.

9. The Effects of Pneumonectomy in Children

Quentin R. Stiles,* Bert W. Meyer, George G. Lindesmith,

and John C. Jones, Los Angeles, Calif.

During the past 25 years, 22 total pneumonectomies have been done at the Childrens Hospital of Los Angeles. The reason for most of these was a destroyed lung from chronic suppuration, but 6 were done for neoplasm. The age ranges were from one month to seventeen years. Followup on most of these has been for many years and has included a period of life when the post-pneumonectomy patient still has a considerable period of expected body growth. A pneumonectomy is well tolerated by the child in the immediate postoperative period. There was one death during this time in this group. The long term followup shows that these children continue to grow and develop normally An attempt is made to evaluate objectively the effects of pneumonectomy upon future growth and development and upon the prognosis for a normal life expectancy in children who must have an entire lung removed.

10. Superior Mediastinotomy: An Improved Modification of Previous Approaches to the Diagnosis and Evaluation of Chest Disease Without Palpable Nodes

John Arthur Jacobey,* Denver, Colo.