WEDNESDAY AFTERNOON, MAY 3, 1972

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

Los Angeles Ballroom

43. Perforation of the Esophagus: A Thirty Year Review

B. EUGENE BERRY* and JOHN L. OCHSNER, New Orleans, Louisiana

Thirty-two cases of esophageal perforation were collected since the inception of the Ochsner Clinic in 1942. During this thirty-year period the incidence steadily increased, paralleling the frequency of endoscopic examinations which accounted for over 75% of perforations. The prevention of endoscopic injuries as well as diagnostic and treatment modalities are of prime importance in this distressing complication. Predisposing conditions to instrumental perforation in our series included benign and malignant strictures, esophageal rings, achalasia, hiatus hernia, and "lipping" of the anterior cervical spine. These patients constituted a high risk group who must be evaluated carefully before endoscopy.

Diagnosis was usually made with the history of endoscopy or trauma, subcutaneous air on physical examination, and free air visible on chest or abdominal roentgenograms. Esophagram confirmed the diagnosis and localized the site of perforation. Prompt diagnosis and treatment is essential. Our experience indicates that some patients can be managed conservatively, however, in the majority, surgical treatment appears most advantageous. Simple drainage of cervical esophageal perforations was sufficient. Suture closure and drainage are recommended for perforations of the intrathoracic esophagus. Concomitant correction of pre-existing pathology is possible when surgical treatment is instituted early following perforation. The overall mortality in this series was 15%.

*By Invitation

44. Surgical Management of Lymphatic Tumors of the Mediastinum in Children

STEPHEN LA FRANCHI* and ERIC W. FONKALSRUD,

Los Angeles, California

Thymic and lymph node tumors constitute the most common neoplasms of the antenor and middle mediastinum in infants and children.

Thirty-four patients less than 20 years of age underwent resection or biopsy of lymphatic tumors of the mediastinum at the UCLA Hospital during the past 15 years. Sixteen had malignant neoplasms of the lymph nodes, including Hodgkins, disease, lymphosarcoma, reticulum cell sarcoma, and acute lymphatic leukemia. There were 18 thymic tumors of which 14 were benign, the majority being thymic hyperplasia. Three children had malignant thy mo mas and one had a granulomatous thymoma.

Cervical or scalene lymph node biopsies provided the diagnosis in 13 of 14 lymph node tumors, whereas bone marrow examination gave a diagnosis in only 4 patients.

Only one of the lymph node tumors was resectable. The remainder were treated with a combination of irradiation and chemotherapy. Four patients are alive an average of 3½ years after diagnosis, 9 are dead, and 3 were lost to followup.

Thymectomy was performed for each of the thymic tumors. Two of the 3 children with malignant thymomas are alive. Twelve of 14 patients with thymic hyperplasia had myasthenia gravis, and all but one are alive an average of 7 years postoperatively. Each of these patients experienced improvement in their myasthenic symptoms postoperatively.

*By Invitation

45. Longterm Evaluation of Aortic Valvuloplasty for Aortic Insufficiency and Ventricular Septal Defect

FRANK C. SPENCER, EUGENIE F. DOYLE*, DELORES A.

DANILOWICZ*, N.Y., N.Y., HENRY T. BAHNSON, Pittsburgh, Pa.,

and CLARENCE S. WELDON, St Louis, Missouri.

In 1961 a technique of aortic valvuloplasty used in 3 patients for aortic insufficiency with ventricular septal defect was reported. The technique has not been generally adopted, however, and prosthetic valve replacement has been found necessary in many centers. The 2 patients surviving operation 10 years ago remain well with minimal diastolic murmurs. A total of 16 patients have subsequently been operated upon and treated in three different institutions. Prolapsing aortic cusps were repaired in 15 of these with excellent results in 14. Several have mild hemodynamically insignificant diastolic murmurs, but there have been no changes in physical signs of aortic insufficiency after the first few postoperative weeks. One asymptomatic patient had moderate regurgitation. The one postoperative death followed fascia lata replacement of the prolapsed cusp. Followup is now longer than 2 years in 10 patients. Techniques of valvuloplasty have varied with the pathologic findings, and a recent important modification developed by one of the authors (C.S.W.) will be described in detail.

Several crucial principles of technique will be presented. These experiences indicate that aortic valve replacement is rarely needed for this disease.

*By Invitation

46. The Pulmonary Artery After Debanding

ANTHONY R. C. DOBELL, DAVID A. MURPHY*, NORMAN L.

POIRIER* and JAMES E. GIBBONS*, Montreal, Quebec, Canada

Thirty-two pulmonary artery bands were partially or completely removed at the time of VSD closure. Three children with complex abnormalities died postoperatively.

Eight children have been re-catheterized some time after debanding. Four had persistence of their VSD and RV systolic pressures were dose to 100 mm. Hg. in three of them, with pulmonary flow about twice systemic and normal pulmonary artery pressures.

Four children without residual VSD have been re-studied and resting gradients up to 56 mm. Hg. have been found. We intend to study most of the remaining patients in the next few months. Five children have had a second intracardiac procedure to reconstruct the PA and close the persistent VSD if present. Fibrosis about the pulmonary artery in some of them has been appalling and the reconstruction has been difficult and unsatisfactory in some cases despite attempts to excise scar widely and interpose patches or do transverse arterial repair.

The indications for pulmonary artery banding should be narrowed because of permanent deformity of the pulmonary artery after debanding. Intracardiac repair should be considered in those infants with VSD who continue to deteriorate despite aggressive medical treatment. Banding should be reserved for dying babies deemed unsuitable for intracardiac repair.

*By Invitation

47. Spontaneous Breathing With Continuous Positive Airway Pressure (CPAP) After Open Intracardiac Operations in Infants

SCOTT STEWART, III*, L. HENRY EDMUNDS, JR.

and JOHN W. KIRKLIN, Birmingham, Alabama

We have performed intracardiac correction in 14 infants using profound hypothermia and circulatory arrest, and have managed their pulmonary subsystem during the postoperative period with the technique of spontaneous breathing and CPAP. 6 patients had transposition of the great arteries, 3 ventricular septal defect, 2 total anomalous pulmonary venous connection, 2 tetralogy of Fallot, and 1 truncus arteriosus Type I. The ages ranged from 5 weeks to 30 months, and weights from 2.9 to 13 kilograms. One death occurred, in an 8 month old child with ventricular septal defect.

Postoperatively the endotracheal tube has been left in place, the babies have breathed spontaneously, and the system of CPAP described by Gregory has been used. This was discontinued between 18 and 96 hours postoperatively, and the patients extubated. No respiratory complications have occurred, although 1 baby did not tolerate the system and required use of a ventilator. Tracheostomy has not been needed, and no baby has required reintubation. The combination of control of the CPAP and of the F_iO₂ has allowed ideal control of arterial pO₂. Arterial pCO₂ has been normal in all babies.

This technique has provided respiratory care which is superior to any we have used previously, ranging from immediate early extubation to prolonged use of volume regulated ventilators.

*By Invitation

48. Total Correction of Tetralogy of Fallot in Infancy

ALBERT STARR, LAWRENCE I. BONCHEK*

and CECILLE O. SUNDERLAND*, Portland, Oregon

We have performed total correction of tetralogy without prior shunts in 19 patients under two years (including 12 under one year) with two deaths. Seventeen survivors are asymptomatic, take no medications, and are developing normally. Only one required tracheostomy, and none have heart block. Of 12 shunts in this period, there were five deaths.

The most important criterion in selecting patients for correction is the size of the pulmonary artery, severe hypoplasia precludes successful correction in infancy. Preoperative clinical evaluation usually correlates with angiographic findings. Intermittent or mild cyanosis at rest with frequent "spells" often occurs in this age group and usually indicates dynamic, muscular right ventricular outflow tract obstruction without severe pulmonary hypoplasia. This can usually be relieved by infundibular resection alone, and only two of 11 patients in this clinical category required patches across the pulmonary annulus.

The high incidence of good anatomical candidates for total correction in infancy indicates that right ventricular outflow obstruction can be progressive, due to increasing fibrosis of the infundibulum and undergrowth of the pulmonary artery. The policy of early total correction should permit more satisfactory anatomic correction, with less pulmonary insufficiency.

Discussion will include catheterization findings up to four years postoperatively.

*By Invitation

49. Open-Heart Surgery in the First Year of Life

IAIN M. BRECKENRIDGE*. HELLMUT OELERT*, GERALD R. GRAHAM*,

JAROSLAV STARK*, DAVID J. WATERSTON* and

RICHARD E. BONHAM CARTER*, London, England

Sponsored by John W. Kirklin

120 infants under 12 months of age have undergone intracardiac surgery using cardiopulmonary bypass at the Hospital for Sick Children, Great Ormond Street, London, between February 1963 and October 1971. Half the series dates from the beginning of 1970. Mean age of all patients was 5.6 months (youngest 4 days), and mean weight 5.5 kg. (range 2.5 to 10 kg.). A disc oxygenator primed with blood was used in most cases, but lately circulatory arrest with perfusion cooling to 22°C. has been successfully employed. Principal diagnostic groups were total anomalous pulmonary venous drainage (TAPVD) (54 cases), transposition of the great arteries (TGA) (39), aortic stenosis (6), V.S.D. (4) and cardiac tumours (3). All were emergency operations, except for the increasing use of elective Mustard procedures for infant T.G.A.'s. Of the 120 children, 62 (51%) have survived, 23 from the first 60 and 39 from the second. The youngest survivor followed aortic valvotomy at 10 days, while another survived emergency Mustard operation at 7 weeks. Of 37 under 3 months, only 8 survived, and all were operated on in 1971. Further details of this clinical experience will be presented.

*By Invitation

50. The Rastelli Operation: Its Indications and Results

DWIGHT C. McGOON, ROBERT B. WALLACE

and GORDON K. DANIELSON, Rochester, Minnesota

The results of the first 100 Rastelli operations performed by the authors are reviewed. The procedure, which involves connection of the right ventricle to the pulmonary artery by a homograft aorta and valve, is applicable for truncus artenosus, transposition of the great arteries (with pulmonary stenosis), and pulmonary arterial atresia, listed in the order of descending frequency.

Although one fourth of the procedures have not been successful, the experience has identified an optimal age range for operation (5 to 12 years, 11% mortality rate), the acceptable degree of pulmonary vascular obstructive disease (Rp/Rs < 0.65), and certain anatomic prerequisites.

Numerous associated anomalies, including absence of a pulmonary artery, interrupted aortic arch, pulmonary arterial banding, anomalous drainage of the right pulmonary veins below the diaphragm, and previous Baffes procedure have posed interesting technical challenges but have not adversely affected results. One patient required subtotal sternectomy to allow room for the graft. Homograft valvular insufficiency is occasionally noted early after operation. Homograft calcification has not resulted in discernible ill effect. Only one late death has occurred (3 months).

The procedure promises to remain a valuable addition to the operations useful in the treatment of congenital heart disease.

*By Invitation