WEDNESDAY AFTERNOON, APRIL 2, 1969

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

Grand Ballroom

50. Bronchoplastic Procedures for Bronchogenic Carcinoma

Donald L. Paulson, Harold G. Urschel, Jr., J. Judson McNamara,*

and Robert R. Shaw, Dallas, Texas

Bronchoplastic procedures in combination with radical lobectomy have been used for bronchogenic carcinoma in 52 patients since 1952, 6 per cent of all resections. The procedure is feasible and applicable for the localized hilar carcinoma, preferably without nodal involvement, but it may be used also as a compromise with pneumonectomy for the more extensive lesion. Preoperative irradiation has been used for 20 patients to attain better localization. The site of greatest usefulness for this procedure is the localized epidermoid carcinoma involving the right upper lobe bronchial orifice (35 patients). Wide sleeve resection of the right main bronchus combined with right upper lobectomy, thorough mediastinal nodal dissection, and anastomosis of the intermediate bronchus to the stump of the main bronchus accomplishes the same ends as a pneumonectomy, with the advantage of preservation of the middle and lower lobes. The results to date, calculated by the life table method, indicate a 40 per cent overall 5-year survival rate, 50 per cent in the group of patients in whom the procedure was done deliberately as an adequate operation for the particular carcinoma concerned and 20 per cent for those in whom it was done as a compromise with pneumonectomy.

51. Preoperative X-ray Therapy as an Adjuvant in the Treatment of Bronchogenic Carcinoma

T. W. Shields, Chicago, Ill., G. A. Higgins, Jr.,* R. L. Lawton,*

A. Heibrum,* and R. J. Keehn,* Washington, D.C.

A randomized study of preoperative X-ray therapy in patients with bronchogenic carcinoma was carried out by VA Surgical Adjuvant Cancer Chemotherapy Study group. One hundred sixty-seven patients were randomized for preoperative X-ray therapy and 165 as controls. An X-ray dose of 4,000 r to 5,000 r was given in 4 to 6 weeks followed by operation within 4 to 6 weeks. The control patients were operated upon shortly after randomization. Eighty-six of the treated patients and 90 of the control patients were resected. Twenty X-ray patients and 63 controls underwent thoracotomy only. No operative procedure was performed in the remaining patients. The 30-day mortality and morbidity were essentially the same in both groups. The last patient was accepted for study 10 months ago and the last operation was performed 7 months ago. A marked difference in survival, six months following clinically curative surgery was seen: 44.6% for preoperative X-ray patients and 81.7% for controls, P<0.01 The reasons for the poor survival in patients treated with X-ray therapy are obscure, but does not appear to be related to delay in performing surgery. Routine preoperative X-ray therapy in patients with bronchogenic cancer appears of little benefit and actually may exert a harmful effect resulting in a substantially reduced survival following curative resection.

52. Abdominal Exploration in the Evaluation of Patients with Carcinoma of the Thoracic Esophagus

James M. Guernsey,* and D. Frederick Knudsen,* Stanford, Calif.

Sponsored by James B. D. Mark

Five year survival is uncommon for patients with carcinoma of the thoracic esophagus. In an attempt to select patients who would benefit from preoperative x-ray therapy, forty patients with carcinoma of the thoracic esophagus in whom no metastatic carcinoma could be found by conventional means, were subjected to exploratory laparotomy prior to embarking on this treatment plan. At abdominal exploration, sixteen of the forty patients had metastatic squamous cell carcinoma from the esophagus in the celiac lymph nodes. No patient had tumor outside of these lymph nodes. All patients were then subjected to 6,600 rads of 6 MeV radiation to the primary lesion and to the celiac lymph nodes if they were involved with tumor. Four weeks later, total esophagectomy with simultaneous reconstruction was carried out when possible. All sixteen patients with metastatic carcinoma of the celiac lymph nodes are dead of their disease within eleven months of the beginning of treatment. Of the twenty-four patients with negative celiac lymph node biopsies, only ten have died of their disease. Our experience demonstrates that patients with metastatic esophageal carcinoma in the celiac lymph nodes are not candidates for radical radiation therapy or surgery.

53. Spontaneous Rupture of the Esophagus: A Review of a Large Series and Comments on a New Method of Treatment

Osler A. Abbott, William D. Logan, Jr., Charles R. Hatcher,

and Panagiotis N. Symbas,* Atlanta, Ga.

A study of 41 cases of spontaneous rupture of the esophagus is presented. These have resulted from the usual causes; i.e. posterior fossa brain surgery, alcoholism, pre-existing lower esophageal disease, and some idiopathic cases. Comparison of the result of 22 cases treated without open thoracotomy versus a more aggressive approach is made, especially those in which a positive diagnosis was made within 48 hours of onset. Special emphasis is placed on nine (9) patients diagnosed after 24 hours who are treated by a special "T-tube" method. Survival in this group was remarkably high, especially when compared to a similar group of equally late diagnoses in whom direct surgical repair was performed. Certain errors in application of the "T-tube" method were noted in all such cases which did not survive or had major complications. In those patients wherein this type of treatment was applied correctly, we experienced no deaths, major complications or strictures. Certain diagnostic points are emphasized which should lead to earlier recognition of this disease.

54. Clinical and Hemodynamic Assessments of Fabric-Covered Starr-Edwards Prosthetic Valves

Robert L. Reis,* D. Luke Clancy,* Kevin O'brien,*

Stephen E. Epstein,* and Andrew G. Morrow, Bethesda, Md.

Fabric-covered Starr-Edwards prostheses (Model 2300 aortic, models 6300 and 6300c mitral) were utilized in 96 patients. None of 13 early deaths was related to valve function. No late deaths occurred in 33 patients surviving isolated aortic replacement; 3 have had cerebral emboli, and 2 have severe hemolytic anemia. Thirty-five patients survived isolated mitral replacement; 4 have had systemic emboli, 2 of which were fatal. Three of 15 patients living after multiple replacements have died late (valve unrelated), and 2 others have had emboli. In 22 patients with aortic prostheses resting peak systolic gradients, measured 6 months post-operatively, averaged 43 mm. Hg (12-75); aortic areas averaged 0.60 cm.²/M.² (0.35-1.07). In 28 patients with mitral prostheses, mean left atrial pressure averaged 16 mm. Hg (6-28) at rest, and 28 mm. Hg (20-40) during exercise; orifice areas averaged 1.03 cm.²/M² (067-1.43) for 2M, and 1.18 cm.²/M.² (0.82-1.69) for 3M valves. Nine of the 77 surviving patients remain severely symptomatic (class III or IV), all have poor hemodynamic results, and one mitral prosthesis has been replaced. Serial hemodynamic assessments, now in progress, will indicate whether the valves are stenotic at insertion or become so from tissue ingrowth. Valves of these designs are no longer employed in this clinic.

55. Early Clinical Results with Cloth-Covered Prosthetic Cardiac Valves

F. C. Spencer, R. H. Clauss, G. E. Reed, and D. A. Tice,

New York, N.Y.

Cloth-covered, steel-ball prosthetic valves were recently developed to decrease thromboembolism and ball variance. In the 12 month period ending September, 1968, 119 such prostheses were inserted as single or double valvular replacements, with 16 deaths within one month after operation. Anticoagulant therapy was begun 4 to 7 days after operation and continued indefinitely. Only one embolus has occurred (incidence approximately 1 per cent), a massive fatal one 15 days after operation. In an earlier reported series of 66 mitral replacements, the frequency of thromboembolism was 12 per cent. Prosthetic valve function has been excellent to date, with no recognized occurrence of late stenosis of the cloth-covered prostheses. A detailed clinical comparison of the new prostheses with over 430 previous ones (Starr-Edwards, disc, Magovern) will be presented.

56. The Experimental and Clinical Results of a Modified Cage Disc Mitral Prosthesis

G. J. Magovern, F. R. Begg,* E. M. Kent, W. B. Gushing,*

M. L. Gerber,* and D. L. Fisher,* Pittsburgh, Pa.

The process of tissue encapsulation of heart valve prostheses has been effective in reducing thromboembolic complications but has introduced additional functional problems. This paper describes our experimental results following several modifications of a cage disc mitral prosthesis designed to prevent the complications specific to cloth covering a valvular prosthesis, and describes the clinical results in thirty patients in whom the most favorable design was ultimately employed. There were four hospital deaths and one late death, and the remaining twenty-five patients are well. Anticcagulation was maintained for three to six months and then discontinued and there have been no early or late thromboembolic complications, one month to twelve months following insertion. We feel this prosthesis has several advantages: 1. Total Dacron cloth covering to permit encapsulation. 2. A vertical cuff sewing ring to facilitate placement and prevent inflow orifice tissue impingement. 3. A hypobaric metallic disc which as yet has not caused cloth distinction. Follow-up results and postoperative catheterization data will be presented on all survivors. The results show that the design of the fixation ring, the method of covering the cage, the type of material employed, the design of the disc and the fixation position, all have a bearing on the ultimate result.

57. Internal Thoracic (Mammary) Arteriography: A Questionable Index of Myocardial "Revascularization"

Y. Kato,* C. H. Dart, Jr.,* R. G. Fish,* W. M. Nelson,*

S. M. Scott, and T. Takaro, Oteen, N. G.

Internal thoracic (mammary) arteripgrams performed on 139 patients one to five years after implant operations showed that 31% of implants could opacify coronary arteries well, 55% poorly or not at all, and in 7% implants were occluded. Nevertheless, late mortality, incidence of infarction, and relief of symptoms were similar in all three groups. There was striking variation in coronary opacification, depending on position of catheter tip. The significance of this variation was studied in 140 implant arterio-grams in nine previously operated animals. Arteriography itself almost always caused temporary elevation of implant flow. If the volume of contrast medium was kept constant, the number of opacified vessels and the intensity of opacification varied directly with injection pressure and measured flow in the implant induced during arteriography. In some patients, and in all animals in which arteriography produced increase in implant flow, the contrast medium instead of progressing distally in the usual manner, appeared to move back and forth in the opacified proximally occluded coronary, suggesting movement against intercpronary collateral flow. Since internal thoracic arteriography itself alters implant flow, this procedure cannot be used as a quantitative evaluation of myocardial revascularization. These observations help to explain the inconsistencies in the clinical results following internal thoracic artery implantation.

58. The Aggressive Surgical Approach to Coronary Disease

W. Dudley Johnson,* Harold Harding,* and Derward Lepley, Jr.,

Milwaukee, Wis.

The published criteria of acceptable risks for coronary artery surgery have often denied help to the patients most in need. For 20 months we have extended our criteria so that 192 of 197 patients presented have been accepted for surgery (advanced age, 3-vesseI disease and elevated end-diastolic pressure notwithstanding). Impressive results have been achieved using combinations of the following three basic procedures: (1) All ventricular aneurysms are excised (21 patients), (2) All avascular areas of the left ventricle are attacked using 4 to 9 separate arterial implants from a single internal mammary artery pedicle, and (3) Immediate improvement in coronary flow using vein grafts from the ascending aorta to any available coronary vessel (28 patients). Fifteen of the 28 vein grafts were placed to branches of the main coronary arteries. All those restudied to date show patent veins and improved coronary flow. The mortality has been 11% and is lower in the group with vein grafts. One hundred per cent clinical follow-up has been accomplished and only five of 192 patients are unimproved at two months or longer after surgery. A description of operative techniques and representative postoperative angiograms will be presented.

59. Left Ventricular Resection for the Poorly Functioning Heart with Coronary Artery Disease

Jerome Harold Kay, Edward F. Dunne,* Bernard G. Krohn,*

Harold K. Tsuji,* John V. Redington,* Adolfo Mendez,*

and Oscar Magidson,* Los Angeles, Calif.

Large portions of the left ventricle distal to the papillary muscles have been removed from thirteen patients with pronounced coronary artery disease, revealed by selective coronary arteriography. Portions of the ventricular septum have been removed also. In four more patients, the non-functioning posterior portion of the left ventricle has been plicated. In fourteen patients, revascularization was also performed. Preoperatively, a forward left ventriculogram in all patients revealed a noncontractile distal % to % of the left ventricle or nonfunctioning posterior portion of the left ventricle. Before surgery, the left ventricle in these patients ejected only 20 to 53% of the end-diastolic volume (normal 70%). After surgery, ventriculographic studies in ten patients revealed the ejection fractions to be normal or significantly improved. Removing the noncontractile distal % to % of the left ventricle or plication of the posterior portion of the left ventricle significantly improved the cardiac function. These areas are not aneurysms and differ in that the involved areas have muscle with fibrous involvement.

*By Invitation