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
