MONDAY AFTERNOON, APRIL 26, 1971

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

Phoenix Ballroom

10. The Simple Approach to Direct Coronary Artery Surgery: Cleveland Clinic Experience

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

Cleveland, Ohio

Between May 1967 and October 1970, 1,310 patients have been treated by revascularization surgery: (1) 611 patients received vein grafts to the right coronary artery (hospital mortality rate 3.8%), (2) 434 patients received bypass grafts to left coronary artery (hospital mortality rate 3.1%) and, (3) 265 patients received multiple vein grafts (hospital mortality rate 3.6%); in category (3), 42 triple vein graft procedures were performed with one hospital death. Vein graft patency rates have risen from 80% in the first 220 vein grafts to a current figure of 90%. The following factors contribute to decreasing mortality and improved results: (1) High-quality coronary arteriography. (2) Methoxyflurane anesthesia.(3) Extracorporeal circulation with hemodilution technic at normothermic level. 4) Standardization of operative techniques: incisions, cannulations and methods that provide an ideal surgical field will be described in detail. Regional hypothermia and coronary arterial perfusion are not employed. (5) Coronary vasodilators are utilized during and after surgery. (6) Postoperative management emphasizes controlled ventilation, adequate sedation, prevention or correction of hypokalemia, rapid digitalization when indicated and simple monitoring procedures. Blood volume is controlled by central venous pressure and left atrial pressure. Continuous improvement in direct revascularization results depends upon standardization and simplification of methods employed.

11. The Safety of Ischemic Cardiac Arrest in Distal Coronary Artery Bypass

George J. Reul,* George C. Morris, Jr., J. F. Howell,*

E. Stanley Crawford, Frank M Sandiford,*

and Don C. Wukasch, Houston, Texas

Ischemic cardiac arrest accomplished by occlusion of the ascending aorta during total cardiopulmonary bypass was not utilized in 30 of the first 60 patients undergoing aorta to coronary artery bypass grafts. Significant differences in the clinical course, operative mortality, postoperative electrocardiogram, and enzyme levels were not seen. Early graft patency levels in the non-ischemic arrest group, however, was less satisfactory (4 of 30 occluded). Providing the advantage of a dry immobile operative field, aortic occlusion for periods of 12 to 107 minutes was utilized in the next 400 patients. Comparison of the two groups has revealed little difference. Operative mortality due to "pump failure" has remained less than 3%, and early fatal myocardial infarction has occurred in about three percent of each group. Even though postoperative electrocardiogram patterns diagnostic of acute myocardial infarction were present in about 11% of both groups, actual clinical manifestations of non-fatal myocardial infarction occurred in only 4% of both groups. Myocardial failure or infarction could not be related to aortic occlusion time (if less than 60 minutes), or severity of coronary artery, involvement The techniques to safely accomplishing this procedure and further comparison of the two groups will be discussed.

12. Emergency Myocardial Revascularization for Impending Infarctions and Arrhythmias

Cary J. Lambert,* Maurice Adam,* Gerald Geisler,*

Eduardo Verzosa,* Manucher Nazarian,*

and Ben F Mitchel, Jr., Dallas, Texas

An analysis of 250 patients undergoing aorto-coronary vein bypass grafts revealed that 45 of these operations had been performed as semi-emergency operations. Forty-two patients were operated for "impending infarctions"; three because of uncontrollable arrhythmias; in four other patients, a combination of uncontrollable arrhythmia and impending infarction constituted the indication. Sixteen patients had single vessel disease, ten had two vessel disease and nineteen had triple vessel disease. Ventricular function was judged as good in 35 patients, fair in eight and poor in two. There was one cardiac death and one central nervous system death. One late death was due to pulmonary embolus. Thirty-six patients (80%) are asymptomatic. Six patients are considered failures; 1-overt infarction; 1-residual angina with patent vein grafts; 1-EKG changes but without symptoms; 1-RC open, LAD closed; 1-failure, redone with good results and 1-late failure at 6 months. We conclude that: (1) cineangiography can be done safely in this group of patients; (2) semi-emergency surgery has not been associated with added mortality in our hands; (3) the "preinfarctional syndrome" can be abruptly and favorably terminated by appropriate revascularization.

13. Coronary Artery Bypass Grafts for Congestive Heart Failure

Frank C. Spencer, George E. Green,* David A. Tice,

and Ephraim Glassman,* New York, New York

Numerous reports have shown the early benefits from coronary bypass grafts for angina pectoris, but the value and hazards of such grafts for congestive heart failure are uncertain. In a group of 200 patients with bypass grafts inserted for coronary arterial disease (operative mortality 9%) 21 were operated upon for congestive failure; angina was minimal or absent. Ventriculography showed impaired contractility, elevated end diastolic pressure (20-40 mm Hg), and localized aneurysms. Mitral insufficiency, pulmonary hypertension, and hepatomegaly were present in some patients. Operative procedures included double bypass grafts, excision of paradoxical myocardial scars, and correction of mitral insufficiency. Three deaths occurred, at operation, five days, and seven weeks respectively. Moderate improvement consistently resulted but many patients remain with some disability. One late death resulted from cerebral thrombosis. Catheterization two to four months after operation in five patients found patent grafts but continued impairment in ventricular function (contractility, cardiac output, and ejection fraction). These data indicate that bypass grafting may be done for congestive heart failure without a high operative risk and with immediate symptomatic improvement. However, the long term influence on cardiac function and longevity is uncertain and remains an important consideration in evaluating indications and contraindications for bypass grafting.

14. Assessment of Myocardial Contractility after Coronary Bypass Grafts

James R Jude, Richard M. Rubinson,* David D. Michie,*

Hooshang Bolooki,* and Kathleen Bocabella,* Miami, Florida

In 6 patients with severe occlusive disease of the right and left coronary arteries, myocardial contractility as expressed by the extrapolated maximal velocity of contractile elements (Vmax) and the calculated contractile element velocity at end diastolic pressure (VCE/EDP) were obtained during surgery using a catheter tip pressure transducer. The VCE was calculated from the isometric segment of the left ventricular pressure curve and its first derivative (dp/dt KP, K = 28). The studies were done prior to, during and after occlusion of the bypass grafts. Within one hour after the bypass graft in 3 patients Vmax increased an average of 20% over the preoperative value. The 3 patients with VCE/EDP value of less than 1.0 circumference/second prior to grafting did not show any postoperative improvement in Vmax and VCE/EDP. During temporary occlusion (3-5 min.) of the graft, there was a significant decrease in Vmax (P<0.05) and VCE/EDP (P<0.025) as compared to control (the measurements made prior to occlusion.) The largest decline was noted in patients with VCE value greater than 1.1 circ/sec. After return of blood flow through the graft these parameters returned to or exceeded the control levels. No appreciable changes in the left ventricular end diastolic pressure was observed during the time of these measurements. The method provides immediate evaluation of effect on myocardial function of the operation.

15. Selectivity in the Surgical Treatment of Bronchogenic Carcinoma

Donald L. Paulson and Harold C. Urschel, Jr., Dallas, Texas

The results of surgical treatment of bronchogenic carcinoma are predetermined largely by the natural history, the stage and the extent of the lesion and less on the procedure performed. The importance of complete pretreatment assessment of prognosis is illustrated in a review of the results of treatment in 2087 cases divided approximately equally into two ten year periods, 1950-59 and 1960-69. Improved selection of patients based on location, cell type, stage and extent of the lesion, particularly by means of mediastinal exploration, resulted in a reduction of the operability rate from 49% in the fifties to 45% in the sixties, but an increase of the resectability rate from 37% to 41% of the total cases (from 75% to 91% of operated cases). Exploratory thoracotomy rate fell from 25% of those operated upon to 9% (12% of the total cases to 4%). Operative mortality remained about the same, 5%. Survival at 5 years for the operable cases including exploratory thoracotomy increased from 18% in the fifties to 35% in the sixties. Total salvage for all cases increased from 9% to 16% in the latter period.

16. Coincident Active Pulmonary Tuberculosis and Carcinoma of the Lung

William Tunell,* and Paul C. Adkins, Washington, D.C.

Delays in the diagnosis of pulmonary carcinoma continue to contribute substantially to the poor prognosis of those patients whose carcinoma co-exists with active pulmonary tuberculosis. Forty cases of co-existing active pulmonary tuberculosis and carcinoma of the lung, seen during the years 1957 through 1966 at Glen Dale Hospital, the tuberculosis facility of the District of Columbia, were analyzed in an attempt to clarify the problem posed by these coincident conditions. The diagnosis of carcinoma was strikingly delayed when comparison was made between patients with carcinoma alone and those with co-existing tuberculosis and carcinoma (average 3.4 weeks versus 16.3 weeks). In addition, the 16.3 weeks diagnostic interval exceeded that (7.1 weeks) of a group of 14 patients admitted with a diagnosis of tuberculosis but found to have carcinoma and no tuberculosis. Excepting thoracotomy, no single diagnostic modality (Papanicolaou smears, bronchoscopy, bronchial biopsy and washing, and scalene node biopsy), delineated carcinoma in more than one-third of these patients. Diagnostic thoracotomy was performed in 14 patients. Carcinoma was diagnosed in all. This study suggests undue delays were caused by preliminary diagnostic studies and that more frequent, earlier diagnostic thoracotomy is most likely to improve the diagnosis and cure of carcinoma co-existing with tuberculosis.

17. Human Experience with Pulsatile Left Heart Bypass without Anticoagulation for Thoracic Aneurysms

John E. Connolly, Akio Wakabayashi,* Junichi Hirai,*

John C. German,* Edward A. Stemmer, and

Edward J. Serres,* Irvine, California

Recently we described animal experiments in which we employed a left heart bypass system for periods up to 30 hours without anticoagulation. It consists of a pulsatile bladder pump lined by dacron velour and employs xenograft aortic valves. It is connected to the patient with tubing coated with a nonthrombogenic material of graphite-polyurethane-polyvinyl. To date we have employed this pulsatile nonthrombogenic left heart bypass in nine patients undergoing resection of thoracic aortic aneurysms, including five fusiform, three dissecting, and one post-traumatic aneurysm. No heparin was used and bypasses were up to three hours in duration. Pressures in the proximal and distal aorta were easily equalized and the patients tolerated the procedure with dramatic operative hemostasis and absence of postoperative bleeding. In the immediate postoperative period there was no evidence of renal, neurological, or cardiac impairment. Successful clinical application of athrombogenic pulsatile left heart bypass as described appears to be safer and superior to currently used methods for surgery of the thoracic aorta.

18. Clinical Experience with the Unidirectional Dual-chambered Intra-aortic Balloon Assist

David Bregman,* Robert H. Goetz,* and

David State, Bronx, New York

Intra-aortic balloon pumping (IABP) presently appears to be the best temporary mechanical method of assisting the failing heart. A new unidirectional dual-chambered balloon has been developed which effects maximal central movement of blood in diastole producing a 66%-100% greater increment in coronary blood flow over that obtained with a single-chambered balloon of equal displacement. Four moribund, anuric patients in medically refractory cardiogenic shock with an average cardiac index of 1.03 L/M² have been assisted and hemodynamically studied to date: one has been discharged and is well for 1 year; one was successfully assisted for 15 hours but extended his infarct and succumbed; the third was assisted for 16 hours, became hemodynamically stable, but died of pulmonary and renal complications 2 days post-assist; the fourth was assisted for 11 hours, survived and was well for 1 week, but expired suddenly. In our comatose patients the sensorium cleared rapidly, central venous pressure fell promptly (average 10 cm H₂O), and the average free plasma hemoglobin was 2.7 mgs%. One additional terminal, oliguric patient with intractable left ventricular failure 2 weeks post-myocardial infarction was successfully assisted for 14 hours. Pumping produced a prompt diuresis and the cardiac output rose from an initial 3.5 L/min. to 5.3 L/min. After angiographic studies were obtained during balloon pumping, open heart surgery was performed with the resection of an extensive left ventricular aneurysm. We believe that IABP with the dual-chambered intra-aortic balloon is the supportive treatment of choice both in medically refractory cardiogenic shock and as an adjunct to the pre- and post-operative care of selected patients requiring open heart surgery or a myocardial revascularization procedure.

*By Invitation