American Association for

Thoracic Surgery

53rd Annual Meeting

Scientific Program

MONDAY MORNING, APRIL 16, 1973

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

8:45 A.M. Scientific Session: Regency Ballroom

1. Tubed Gastric Pedicle for Esophageal Replacement in placement in Children

KATHRYN D. ANDERSON* and JUDSON G. RANDOLPH,

Washington, D.C.

The standard operation for esophageal replacement in children has been interposition of the colon. A favorable response in a child treated with gastric tube after failure of colon bypass, and the recent report by Stephens and Burrington, led us to adopt this operation as the primary approach for esophageal reconstruction. The tubed gastric pedicle has been evaluated in seven children. The patients include four children with extensive lye strictures and three infants with esophageal atresia without fistula. Age range of the patients at the time of surgery was eight months to four years. Patients have been followed from six months to five years.

Results: There have been no deaths or serious complications. Three patients developed mild strictures at the cervical anastomosis requiring several dilatations. No gastric tube has required revision. One patient developed an ulcer in the tube which responded to conservative therapy. All tubes have functioned satisfactorily to meet the nutritional needs of growing children. On the basis of this experience, a wider clinical trial of this procedure seems justified in children who need esophageal replacement.

*By invitation

2. Intrauterine Production of Coarctation of the Aorta: Operative Technique and Newborn Hemodynamic Studies

J. ALEX HALLER, JR., I. J. SHAKER,* ROBERT GINGELL*

and CHARLES HO,* Baltimore, Maryland

Clinical studies of coarctation of the aorta have contributed greatly to our understanding of this anomaly, but the high mortality of preductal versus postductal coarctation remains unexplained. Creation of these abnormalities in fetal lambs has provided an excellent opportunity to study the factors which affect survival, before and after birth, as well as the comparative differences in hemodynamic alterations.

Thirty ewes between 90-115/145 days gestation were operated upon and the fetal lamb was partially marsupialized to minimize amniotic fluid loss. Through a left thoracotomy, postductal coarctation was created in 13 lambs, and preductal in 17. Sixteen lambs were born alive either spontaneously or by C-section. The majority were studied angiographically to verify the site of coarctation and to demonstrate the extent of collateral circulation. Selected lambs received complete cardiac catheterization to assess the status of the ductus arteriosus and to measure the pressure gradient across the coarcted segment.

Operative techniques and data will be presented to show that intrauterine creation of preductal and postductal coarctation is possible with prolonged survival. Collateral circulation was remarkably similar in both groups and newborn survival was not affected by the location of the coarctation. We believe this is a useful model for definitive studies of altered hemodynamics in pre and postductal coarctation.

*By invitation

3. Surgical Repair of Single Ventricle

RICHARD N. EDIE,* KENT ELLIS,* WELTON GERSONY,*

FREDERICK O. BOWMAN, Jr., and JAMES R. MALM,

New York, New York

Single ventricle may occur with absence of the ventricular septum and two separate atrial ventricular valves associated with rotational variation in the origin of the great vessels. Four patients have successfully undergone repair of such an anomaly, two associated with Tetralogy of Fallot anatomy, one with double outlet in combination with pulmonary stenosis and one with D transposition and a pulmonary stenosis secondary to a pulmonary band. A technique of repair has been utilized to minimize residual shunting within the ventricle. The bundle of His is at risk in repair of this defect and direct mapping of its course has facilitated repair of the anomaly. The technique of His mapping will be presented in relation to single ventricle. Post operative studies are available on all patients. These demonstrate the complete prosthetic replacement of the ventricular septum can be carried out with near normal cardiac function post operatively.

*By invitation

4. The Fate of Reconstruction of the Right Ventricular Outflow Tract

SAMUEL KAPLAN,* JAMES A. HELMSWORTH,

GEORGE BENZING, III,* DAVID C. SCHWARTZ* and

J. TRACY SCHREIBER," Cincinnati, Ohio

One hundred and thirty-eight patients with tetralogy of Fallot have been followed for 1-15 years after surgical correction. Reconstruction of the right ventricular outflow was accomplished with a pericardial patch in 45 patients and in another 11 instances an aortic homograft was used. In the remaining 82 patients, relief of obstruction was achieved by infundibulectomy alone with or without pulmonary valvotomy. Aneurysms of the right ventricular outflow developed in 19 patients, 18 of whom had pericardial patches. In all patients who developed aneurysms, residual significant defects were present. These consisted of (1) persistence of right ventricular hypertension because of inadequate relief of pulmonic stenosis or significant pulmonary arterial branch stenosis and/or (2) persistence of left to right shunt across the ventricular defect. It is concluded that right ventricular outflow patches or aortic homografts are well tolerated for many years after surgery (even in the presence of pulmonary valve incompetence) provided that the obstruction to right ventricular outflow has been relieved and the ventricular septal defect is closed.

*By invitation

5. Early Correction of Congenital Heart Disease with Surface Induced Deep Hypothermia and Circulatory Arrest

P. VENUGOPAL,* J. OLSZOWKA,* H. WAGNER,* P. VLAD,*

E. LAMBERT* and S. SUBRAMANIAN* Buffalo, New York

Sponsored by John W. Kirklin

In the past three years we have done open correction of congenital heart defects in 110 children using the Kyoto technique which consists of surface cooling with ice packs, a short period of perfusion followed by exsanguination and circulatory arrest. Core rewarming was done after surgical correction. Thirty-seven infants were below six months of age, 29 were between 7 and 12 months, 26 patients between 1 and 2 years and 18 were over 2 years. Eighty-nine weighed less than 10 kg and 43 infants were below 5 kg in weight.

The lesions included:

a. Transposition-57 patients; 34 uncomplicated with 29 survivors. Twenty-three complex Transpositions with 15 survivors.

b. Twenty-four children had VSD and associated anomalies and in 15 infants with isolated VSD there were no deaths.

c. Tetralogy of Fallot in 10 infants with 2 deaths.

d. Nine infants with Total Anomalous Pulmonary Venous Drainage with 5 survivors.

The use of this technique has permitted us to carry out complete correction successfully as early as 7 days of age. Surgical palliation is performed at this institution only in exceptional circumstances.

*By invitation

6. Surgical Correction of the Transposition Complex in Infancy

JAMES W. KILMAN, THOMAS E. WILLIAMS, JR.,*

GERARD S. KAKOS,* JOSEPHA CRAENEN* and

DON M. HOSIER,* Columbus, Ohio

Twenty-five patients with transposition of the great vessels have had total correction of this anomaly using an intra-atrial baffle and a triangular patch to enlarge the new left atrium. Only one death has occurred in this series resulting in a mortality of 4.0% (1/25). Associated defects included seven ventricular septal defects and five patients with pulmonary stenosis. These twelve defects have all been corrected at the same surgical procedure. Surgery was done using normothermic, high flow cardiopulmonary bypass with a standard disposable bubble oxygenator. The mean body weight of these patients is 8.9 kilograms. Fourteen patients were under 10 kilograms and no deaths have occurred in this group. The mean preop PaO2 was 42 mm Hg. and the mean postop PaO2 in room air was 76 mm Hg. Arrhythmias have not been a serious problem with this modified Mustard repair. A new maneuver for the exposure and closure of the ventricular septal defect has been used. It is felt that after this experience that transposition of the great vessels can be surgically corrected with only minimal risk in infancy.

*By invitation

7. Repair of Ventricular Septal Defect with Aortic Insufficiency

G. A. TRUSLER, Toronto, Ontario, Canada

Over the past five years, 16 children with ventricular septal defect (VSD) and aortic insufficiency (AI) have been treated by repair of the VSD and valvuloplasty of the affected aortic valve leaflet. The valvuloplasty transforms the elongated prolapsed leaflet into a competent leaflet with a free margin identical in length to that of the other aortic leaflets. Success hinges on precise measurement of the leaflet margin, secure fixation of the excess prolapsed leaflet to the aortic wall and reconstruction of the adjacent commissure.

Three of the 16 children had only slight to moderate relief of AI because the technique was inappropriate due to a bicuspid aortic valve in two and dilatation of the aortic ring in the third.

The other 13 children had a typical prolapsed leaflet (right 11, left 1 and non-coronary 1). The VSD was subcristal in 10 children and supracristal in 3.

Excellent results with no diastolic murmur, normal pulse pressure and decreasing heart size were obtained in 7 children. The other 6 children were improved but with mild to moderate aortic insufficiency.

Late studies, including angiocardiography, up to 4'/2 years after repair, show that improvement is maintained. AI due to a prolapsed valve leaflet can be safely and effectively repaired by this technique.

*By invitation

8. Progress and Problems in the Surgical Management of Congenital Aortic Stenosis

WILLIAM F. BERNHARD, DONALD C. FYLER,* KENNETH E.

FELLOWS* and ROBERT E. GROSS, Boston, Massachusetts

During, a fourteen year interval, 194 patients with valvar, subvalvar and supravalvar aortic stenosis were operated upon. One hundred forty-six underwent valvotomy, including 33 infants (under one year). Although there were 11 infant deaths, twenty of the last 24 babies survived. Two deaths occurred among the remaining 113 children. Among the survivors, 80 had no significant aortic regurgitation (AR); however, AR was severe in ten, and mild to moderate in 43 patients. Follow-up LV-aortic pressures (available in SO patients) revealed gradients less than 40 mmHg in 35. Of the remaining 15, two died with residual stenosis and five had successful valve replacement.

Forty children underwent partial resection of a subvalvar ring (five deaths). Sixteen survivors were recatherterized: gradients less than 40 mmHg were found in 14; nine had appreciable aortic or mitral incompetence.

Eight patients presented with supravalvar AS (four with discrete lesions). The latter improved following operation; however, three with a hypoplastic ascending aorta and aortic annulus expired.

Conclusions: Valvotomy provides effective palliation in children with severe stenosis (including infants). Valve replacement was necessary in only five. Finally, left ventricular hypertension can be relieved in most patients with discrete obstructions below or above the valve.

11:15 A.M. Presidential Address

Frank Gerbode, San Francisco, California

COMPUTERIZED MONITORING IN THE

SERIOUSLY ILL PATIENT

*By invitation