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

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

1.     Frame Mounted Homografts for Mitral Valve Replacement

S. C. Lennox* (Evarts A. Graham Traveling Fellow,  1964-65),

A. Blesovsky* (Evarts A. Graham Traveling Fellow,  1965-66),

V. P. Chang,* W. P. Cleland,* and P. E. Ghadiali,* London, England

Sponsored by Herbert Sloan

The fate of frame mounted homografts in the mitral area has not been fully established. To simplify the assessment we have selected only those patients who had a lone mitral valve replacement. Since October 1968 there have been 100 such patients, 65 women and 35 men. Their ages ranged from 14 to 69 with a mean of 46. Twenty-seven patients had from one to four previous mitral operations. Although experience led to minor modifications essentially four different types of valve were used. These were (1) formalin preserved aortic homografts (2) formalin preserved pulmonary homografts (3) aortic homografts stored in antibiotic solution at low temperature and (4) pulmonary homografts similarly prepared. The homografts were mounted on a dacron covered titantium frame. Initial results were good. The hospital mortality was 7% and there have been no known embolic episodes despite the absence of anticoagulants. A detailed follow-up of these patients will be given including some post-operative haemodynamic studies and the results will be correlated with the type of valve used. So far 41 patients have shown valve dysfunction ranging from symptomless systolic murmurs to severe mitral regurgitation requiring re-operation. The lesions of the excised valves which include thinning, tears, perforations and detachment of the cusps will be described in detail.

2.     A Five Year Experience with the Cutter-Smeloff Mitral Prosthesis

Benson B. Roe, L. Henry Edmunds, Jr., Noel H. Fishman,*

and J. C. Hutchinson,* San Francisco, California

A 6 month to 5 year review of 119 consecutive adult patients who had mitral valve replacement with the Cutter-Smeloff prosthesis reveals a 10% operative mortality and a 12% late mortality. Of 62 patients over 3 years postoperative, 46 (75%) remain well. Thromboembolic complications of which 15 were cerebral vascular occlusion preceded operation in 44 (37%) patients. In 3508 patient-months of follow-up 10 patients have reported neurological symptoms of which 5 were transient. One late death was due to cerebral occlusion. All patients were anticoagulated, but recommended doses were frequently not maintained. Neither valve dysfunction, atrial thrombus nor peripheral emboli were found at autopsy in 12 of 14 late deaths. Paravalvular leak was demonstrated in 3 patients: twice clinically and once at autopsy. Possibly this experience compares favorably with other reports because of superiority of the prosthesis itself. During this study 21 patients had mitral replacement with Davila, Kay-Shiley, or Wada prostheses resulting in higher morbidity and mortality. Subannular placement of the prosthetic cuff may contribute to the low incidence of thromboembolic complications and paravalvular leak in patients with Cutter-Smeloff mitral valve prostheses.

3.     Closed Valvulotomy for Calcific Mitral Stenosis

Gordon N. Olixger,* Fred W. Rio,* and James V. Maloxey, Jr.,

Los Angeles, California

It is the consensus among cardiac surgeons that mitral stenosis with moderate or heavy calcification should be treated by prosthetic replacement of the valve by the open operative technique. It is the purpose of this presentation to provide objective evidence that this widely held view may be incorrect. Twenty-three patients with moderate or heavy calcification were operated upon by the closed method, and followed an average of 5.5 years (2 to 14). The results have been compared with all data available in the literature (2000 cases) on patients with prosthetic replacement. The closed method had a hospital mortality of 0% vs. 19%; probability of four year survival 0.89 vs. 0.60; and a lower incidence embolism and perivalvular insufficiency. Three patients who developed restenosis in the 7th, 9th, and 14th years have had a second valvulotomy by the closed method and are living and well (one other patient had a prosthetic valve replacement elsewhere in the 11th postoperative year). It is concluded that if the calcified, autogenous mitral valve can be made to function by the closed valvulotomy method, the immediate and long-term results are superior to those achieved by replacement with a prosthetic valve.

4.     Open Mitral Commissurotomy: Results of 100 Consecutive Cases

Sohrab Gerami,* Bruno J. Messmer,* Grady L. Hallmax

and Dentox A. Cooley, Houston, Texas

The morbidity and mortality associated with early years of open heart surgery discouraged the use of mitral commissurotomy under direct vision, even though it was otherwise preferable to transventricular instrumental dilatation, which necessitated blind manipulation inside the heart. In a recent series of 100 consecutive cases of open mitral commissurotomy we had few complications and no deaths. Patients ranged in age from seven to 67 years. Thirty-six were functional class II, 62 were class III, and two were class IV. Fifty-one patients had calcification of the mitral valve, seven had thrombus in the left atrium, and six had fibrinous material on the valve. Operations were conducted at normothermia using disposable plastic bubble oxygenators primed with five percent dextrose in water. Only 13 patients received blood transfusion during operation (500 ml each). Average hospital stay was 12.6 days. Although follow-up has not been long, results are encouraging. Of 34 patients who have been followed two years or more, 32 are well and free of symptoms. We believe that "closed" techniques should be discontinued and that all mitral operations should be done under direct vision using temporary cardiopulmonary bypass.

5.     Pericardiectomy for Recurrent Pericarditis

Charles R. Hatcher, Jr., William D. Logan, Jr., P. N. Symbas,

R. Brucf. Logue,* and Osler A. Abbott, Atlanta, Georgia

Pericardiectomy is reserved traditionally for patients with constrictive pericarditis. In certain patients who exhibit episodes of recurrent pericarditis characterized by fever, pain, and recurrent pericardial effusion, pericardiectomy is indicated prior to the development of constriction. In the period 1963-1970, twenty-one patients underwent pericardiectomy for recurrent pericarditis at Emory University. During this interval pericardiectomy was performed in nineteen patients with constrictive pericarditis. This report details the etiology, previous medical therapy, indications for surgery, surgical technique, and follow up results obtained by pericardiectomy for recurrent pericarditis. Eighteen patients have had no further symptoms following pericardiectomy. Two patients have continued to manifest minor episodes of chest pain and fever responsive to steroids and in one patient the clinical course was unchanged by resection of diseased pericardium. A comparison is made with the operative and postoperative courses of patients in whom pericardiectomy was delayed until constriction had developed. Total pericardiectomy is a safe and effective treatment for recurrent pericarditis and in selected cases avoids the morbidity and mortality related to subsequent constriction.

6.     Surgical Treatment of Mediastinal Tumors: A 40-Year Experience

Adam R. Wychtlis,* W. Spencer Payne, O. Theron Clagett, and

Lewis B. Woolner,* Rochester, Minnesota

In the 40-year period, 1928 through 1968, 1,064 patients have undergone exploratory thoracotomy for the diagnosis and treatment of mediastinal tumor at the Mayo Clinic. Approximately 60% of the patients were found to have one of the commoner neoplasms: neurogenic (212), thymoma (206), or benign cysts (196). Another 30% were found to have malignant lymphoma (107), teratoma 99), granulomas (67), or intrathoracic goiter (56). The remaining 10% of the tumors proved to be some type of benign or malignant mesenchymal tumor, benign lymph node or thymic hyperplasia, meningocele, chemodectoma, parathyroid tumor, mesothelioma, or apparent primary mediastinal carcinoma. Approximately 75% of the mediastinal tumors were benign and were readily and permanently removed at operation. However, 25% of the tumors were malignant: lymphoma (107), thymoma (61), primary mediastinal carcinoma (25), neurogenic (14), mesenchymal (33), and teratoma (13). With the exception of patients with stage I (localized or unifocal) lymphoma, those with malignant mediastinal tumors had an almost universally poor prognosis. An analysis of tumors by decades indicates a progressive reduction in the size of the neoplasm encountered in more recent eras and a diminution in morbidity from huge benign neoplasms.

7.     Management of Persistent Bronchopleural Fistulas

Walter L. Barker, L. Pen Field Faber, William E. Ostermillkr, Jr.,*

Hiram T. Langston, Chicago, Illinois

Persistent bronchopleural fistulas still represent a surgical catastrophe and therapeutic challenge. Although the incidence remains small, the morbidity and inordinate hospitalization associated with this problem demand a more aggressive approach when conventional measures have failed. The present report concerns 18 cases of persistent bronchopleural fistulas closed with pedicled muscle grafts. We feel that it is important to re-emphasize this technique as a means to close persistent leaks, to obviate the necessity of drainage tubes, to remove portals of infection, and to restore more adequate ventilatory function. The principles involved in muscle grafting are primarily control of active infection and reduction in size of the empyema space. The former is accomplished with adequate drainage and antibiotics; the latter, with appropriate timing and thoracoplasty when necessary. Preoperative evaluation and the technique of muscle grafting will be illustrated. The postoperative follow-up extends from one to ten years. Permanent closure of the fistula has been obtained in fifteen of eighteen cases. Improvement in ventilatory function and resumption of normal activities has been noted.

8.     The Contribution of Cuff Volume and Pressure in Tracheostomy Tube Damage

Nathaniel P. Ching,* Stephen M. Ayres,* Roland P. Paeole,*

and Thomas F. Neai.on, Jr., New York. New York

Postmortem examination of the tracheas of 54 patients who died in our hospital following prolonged continuous ventilatory support demonstrated substantial tracheal damage in all cases. In several instances the damage was sufficient to have directly contributed to the death of the patient. Other authors have reported serious long-term complications following tracheal intubation with cuffed tubes. The first part of the study included laboratory models and in vivo dog studies. Using conventional readily available types of cuffed tracheostomy and endotracheal tubes the pressure within the cuff and the pressure exerted by the cuff against the lateral tracheal wall were measured following the insertion of different volumes of air into the cuffs using a wide range of tube sizes. These demonstrated considerable differences between the pressures in the cuffed tube and the pressure actually exerted against the lateral tracheal wall. Every second day the tracheas of patients being ventilated continuously have their tracheas measured and photographed. The findings are assessed in the light of the pressures exerted and the type of management of the tracheostomy tube. It would appear that a high volume-low pressure cuff minimally disturbed is the more desirable method of occluding the trachea about the tube.

9.     Surgical Implications of Pulmonary Aspergilloma (Fungus Ball)

Robert W. Solit,* John J. McKewn, Jr., Stanton N. Smullens,*

and William Fraimow, Philadelphia. Pennsylvania

The surgical significance of an intracavitary "fungus ball" or mycetoma due to Aspergillosis is emphasized because of the high incidence of massive and often fatal hemoptysis in these patients. Thirty-two patients diagnosed with this entity have been followed at Jefferson Medical College Hospital. Of this group, 19 had pulmonary tuberculosis as their underlying disease, eight had sarcoidosis. In addition, there was one case each of chronic pyogenic lung abscess, bronchial cyst, lymphoma, and chronic pneumonitis. Hemoptysis was present in 69 per cent of the patients. Operation, usually a lobectomy, was performed in 13 patients, 10 with hemoptysis, without mortality and only minor morbidity. In the group of 19 non-operative cases, there were seven deaths. Five were due to massive hemoptysis and two due to progression of primary disease. Seven of the remaining 13 non-operative cases have had hemoptysis but due to medical reasons or patient's refusal have not had operation. Because of this high incidence of massive and frequently fatal bleeding, awareness of this entity in all forms of chronic cavitary lung disease, particularly tuberculosis and sarcoidosis, is stressed. In addition, prompt operative intervention is advised before the occurrence of hemoptysis whenever a mycetoma is recognized.

* By Invitation