8:30 A.M. ScientificSession

Ballroom

17. LeftVentricular and Unidirectional Intra-Aortic Balloon Pumping: Effects onHemodynamics in Canine Cardiogenic Shock

DAVID BREGMAN, EDUARDO PARODI,*

and JAMES R. MALM, New York, N.Y.

Intra-aortic balloon pumping (IABP) is currently the supportivetreatment of choice for the management of refractory left ventricular powerfailure. However, in the extremely low output state, IABP may behemodynamically ineffective and a more direct left-ventricular assist would bedesirable. Left ventricular balloon pumping (LVBP) has emerged as an effectivecardiac assist device in the low output state. A spherical balloon is insertedthrough the left ventricular apex, and, by its inflation during systole, iteffectively augments cardiac output and left ventricular emptying. To evaluateLVBP, 46 experiments were performed in dogs with cardiogenic shock induced withpropranolol 1.5% mg/kg and LAD coronary ligation. A unidirectionaldual-chambered intra-aortic balloon was positioned in the descending thoracicaorta and a left ventricular balloon was inserted directly into the leftventricular cavity of the same animal. Two assist consoles were synchronized tothe ECG. LVBP was initially instituted and when the animal becamehemodynamically stable, IABP was additionally begun. Results tabulated aspercentage change are shown in the following table:

The results indicate that LVBP markedly improved cardiacoutput and left ventricular hemodynamics, while the addition of IABPeffectively served as a transition in temporary cardiac support which wasinitiated with LVBP.

18. ClinicalExperience with Heparinless Veno-Arterial Bypass without Oxygenation for theTreatment of Acute Cardiogenic Shock

AKIO WAKABAYASHI,* Irvine, Calif., EDWARDA. STEMMER,

Long Beach, Calif., YOSHIMASA NAKAMURA,*and

JOHN E. CONNOLLY, Irvine, Calif.

A new circulatory support system using a plastic circuitcoated with non-thrombogenic polyurethane-polyvinyl-graphite for heparinlessveno-arterial bypass (HL-VAB) has been developed in our laboratory. Venousblood of up to one-third cardiac output is returned to a peripheral arterywithout oxygenation using a roller pump. The experimental results noted were(1) immediate hemodynamic improvement in all animals with acute cardiogenicshock (BP <60 mm Hg), (2) rapid recovery and survival of these animals, and(3) maintenance of normal blood gases by ventilatory support with 40% oxygen inspite of venous admixing.

Based on these data HL-VAB was employed in six patients tosupport the failing circulation both before and after emergent correctivecardiac surgery. In one patient in cardiogenic shock HL-VAB was instituted 40hours before surgery including support during coronary arteriography andemployed again for 48 hours in the post-operative period. In all patientshypotension associated with cardiogenic shock and anesthesia was corrected byHL-VAB. In five patients HL-VAB was employed to assist the circulationimmediately after completion of the cardiac procedure, while in the sixth patientit was initiated eight hours after surgery. Although the multiple operativeprocedures involved in each case necessitated prolonged use of cardiopulmonarybypass, good hemostasis was achieved with reversal of heparinization byprotamine while the patient was supported with HL-VAB.

Conclusion: HL-VAB without oxygenation appears to be a simple,safe, and practical method of mechanical circulatory assistance for cardiogenicshock.

19. Repair of Coarctation of the Thoracic Aorta byPatch Graft Aortoplasty

GEORGE J. REUL, JR.,* SAMI S. KABBANI,*FRANK M.

SANDIFORD,* DON C. WUKASCH,* and

DENTON A. COOLEY, Houston, Texas

Because of the avoidance of aconstricting circular anastomosis, we believe excision of the coarctationmembrane and Dacron patch gralt aortoplasty is the procedure of choice forcorrection of most types of coarctation of the thoracic aorta especially in theinfant and adolescent age groups. To support this viewpoint, the early and lateresults in 70 patients were evaluated from 6months to 12 years after patch graftaortoplasty for coarctation. There were 42 males and 28 females ranging in agefrom two days to 65 years with a mean of 12.4 years. Nineteen patients underthe age of two were considered separately from 51 patients who were over theage of two. The primary indication for surgery in the younger age group wascongestive heart failure. Over half of these patients had pulmonaryhypertension and only three patients had no associated congenital heart defect.Of the five patients under the age of two who expired in the postoperativeperiod, all had severe pulmonary hypertension secondary to a large ventricularseptal defect. Of the 51 patients over the age of two, nine patients hadcongestive heart failure and five had pulmonary hypertension. Only two patientsexpired in the older age group and both had severe associated cardiac defects.Clinically significant recurrent coarctation was not found in either groupduring the 12 years of follow-up. The actual surgical technique, the long termresults including cardiac catheterization data and the selection of patientswill be discussed.

20. Cardiac Valve Replacement in Children

B. EUGENE BERRY,* DWIGHT C. McGOON,

ROBERT B. WALLACE, DONALD G. RITTER,* and

GORDON K. DANIELSON, Rochester, Minn.

From 1962 through 1972, cardiac valves were replaced in 56children aged 1 year to 16 years (median 10 years). The aortic valve wasreplaced in 20 patients, the mitral valve in 28, the tricuspid valve in 4, andthe left atrioventricular valve in 4 patients with corrected transposition. AStarr-Edwards valve was the most commonly used prosthesis in all locations,though aortic-valve homografts were used in eight aortic and two tricuspidreplacements. Overall, the operative (30-day) mortality was 25%. These deathswere related primarily to low cardiac output (8 cases), cerebral infarction(4), and acute myocardial infarction (2). In the last 5 years, the operativemortality was 10% (3 in 29 cases).

All surviving patients have been followedup, the maximum period being 9 years and the mean 3.3. There were seven latedeaths, due to subacute bacterial endocarditis (2), valve dehiscence (1),congestive heart failure (1), accident (1), and unknown cause (2). There werefour thromboembolic complications, of which three occurred in the earlypostoperative period (accounting for two of the operative deaths). Severeaortic insufficiency necessitated replacement of one homograft valve. Inretrospect, six of the operative deaths could be considered preventable by presenttechniques and knowledge, including improved myocardial protection, avoidanceof heart block, and nonprosthetic repair of Ebstein's anomaly. We continue toavoid cardiac valve replacement in children when possible. If valve replacementis necessary, however, the lowered mortality rate and satisfactory late resultsoffer considerable encouragement for successful management of this difficultgroup of patients.

21. Total Anomalous Pulmonary Venous DrainageBelow the Diaphragm

STANLEY M. HIGASHINO,* Oakland, Calif.

GUY G. SHAW,* Chesapeake, Virginia,

IVAN A. MAY and ROGER R. ECKER, Oakland,Calif.

Although the surgical repair of both supra andinfra-diaphragmatic total anomalous pulmonary venous drainage (TAPVD) isessentially the same, the reported successful results in the infradiaphragmaticgroup have been much less than in the supradiaphragmatic group. The invariablesevere pulmonary venous obstruction in the infradiaphragmatic group leading toearly and rapid deterioration demands aggressive management. Six such patientscomprise this report.

The age of referral ranged from 17 hoursto 14 days. All had signs of congestive heart failure, five had cyanosis, andall had radiological evidence of pulmonary venous obstruction. Cardiaccatheterization with angiocardiography was performed in all six and uniformlyshowed higher pulmonary than systemic systolic pressures, equal mean right andleft atrial pressures, and low oxygen saturation in all chambers.Angiocardiograms in five of six were diagnostic of infra-diaphragmatic TAPVD.

All six patients were operated upon.Three survive to date with a good result. Deaths occurred in one operated uponwithout cardiopulmonary bypass, one with a late diagnosis, and one with anincomplete diagnosis.

From this experience we conclude that the successful managementof infradiaphragmatic TAPVD requires:

1. Early recognition, referral, and definitivediagnostic studies;

2. Early complete surgical repair usingcardiopulmonary bypass via a left thoracotomy, ligation of the ductusarteriosus, cannulation of the right atrium and ascending aorta, moderatehypothermia, closure of the atrial septal defect thru the left atrium withtemporary circulatory arrest, and wide anastomosis of the common pulmonary veinto both the left atrium and left atrial appendage;

3. Intensive perioperative care.

22. Open-Heart Surgery During First Three Monthsof Life

ALDO R. CASTANEDA, JOHN LAMBERTI.* ROBERT M. SADE,*

ROBERTA WILLIAMS,* and ALEXANDER S. NADAS, Boston, Mass.

Approximately 50 percent of all infantsborn with a congenital cardiac defect die within the first three months oflife, unless treated. Primary correction of complex intracardiac lesions earlyafter birth seems therefore desirable. Since January 1, 1973, 17 critically illinfants, ranging in age from one to 90 days were operated upon, utilizingprofound hypothermia and circulatory arrest technique (combined surface coolingand extracorporeal cooling and rewarming).

Circulatory arrest time averaged 50minutes (30 - 60 min.). Transient early postoperative seizures occurred in twoinfants.

Operative mortality for correctable lesions proved, in general,lower than the combined risk of early palliation with later correction. Latehemodynamic follow-up and larger numbers are necessary to evaluate the eventuallong term benefit of this approach.

23. Transpositionof the Great Vessels with Ventricular Septal Defect: Surgical and AnatomicalConsiderations

F. S. IDRISS, Chicago, Illinois, JOSEAUBERT,* Marseille, France,

MILTON PAUL,* H. NIKAIDOH,* and MAURICELEV,*

Chicago, Ill.

Closure of a large ventricular septaldefect (VSD) at the time of correction of transposition of the great vessels(TGV) by the Mustard technique presents certain technical problems. A study ofthe location of the VSD in 94 autopsied hearts with TGV and its relationship tothe atrioventricular valve revealed that: (a) 84% of these defects were relatedto the tricuspid valve, and (b) the majority of the defects can be closedthrough the tricuspid orifice rather than through a ventriculotomy.

These pathologic observations wereconfirmed by our clinical experiences with 14 patients with TGV and a large VSDin a series of 72 Mustard operations performed at the Children's MemorialHospital since 1968. There was one operative death in an infant with Grade IVpulmonary vascular disease in this group of 14 patients. In addition to theVSD, 8 patients had pulmonary stenosis, 2 patients had a previous pulmonaryartery banding and 2 patients had a previous Baffes procedure. In 2 patientswith severe pulmonary vascular disease the VSD was not closed and only apalliative total venous switch of Mustard was performed. All the remaining 12patients had the VSD closed through the tricuspid orifice at the time of thevenous switch. Pulmonary stenosis was resected retrograde through the pulmonaryartery.

This surgical series indicated thatmidmuscular, anterior muscular, membranous and high conal VSD with absentcrista could be well-visualized and repaired with direct suture or patchthrough the tricuspid valve, and there has been no clinical evidence ofinterference with tricuspid function.

When severe pulmonary vascular disease, Grade IV or over, ispresent the Mustard procedure without closure of the VSD gives satisfactoryresults and palliation to these patients.

24. Obstruction toSystemic Venous Return Following Mustard's Operation for Transposition of theGreat Arteries

JAROSLAV STARK,* ERIC D. SILOVE,* JAMESF. N. TAYLOR,*

and GERALD R. GRAHAM,* London, England

Sponsored by J. W. Kirklin, Birmingham,Alabama

Obstruction of the systemic venous pathways may be a fatalcomplication of Mustard's operation. For various reasons 70 of 241 survivors(279 Mustard's operations) were reinvestigated two days to six years afteroperation, 10 of them twice. There were 61 cardiac catheterizations withangiocardiography and 19 venous angiograms to demonstrate vena caval pathways.

Pressure measurements in the superior and inferiorvenae cavae (SVC and IVC) and systemic venous atrium (SVA) were available in 42patients. Eight had clinical features of obstruction of both the SVC and IVC,one of the IVC alone and and 10 of SVC alone. In these 19, the mean pressure inthe SVC or IVC was at least 5 ram. Hg higher than the mean SVA pressure; in 10more than 15 mm. Hg higher. Angiography confirmed the clinical diagnosis ineach case; four with SVC pathway obstruction also had shunts from the SVC intothe pulmonary venous atrium. Systemic venous pathway obstruction warrantedreoperation in 21 of the 241 survivors. A Dacron patch had been used for theoriginal repair in 17 and a pericardia! patch in four. Thirteen survived thereoperation.

In order to minimize the incidence ofobstructive complications, we used a "trouser-shaped (Brom)" pericardial patch,measured SVC, IVC and SVA pressures intraoperatively and performed SVCangiograms within 48 hours of surgery. In 25 survivors of the last 26operations, the mean SVC-SVA gradient was more than 2 mm. Hg in four (i.e. inthree of 12 patients with a standard shape patch but in only one of 14 with a"trouser-shape" patch). None of the 25 patients have developed clinical orangiographic signs of obstruction, but the postoperative period of observationis only one to six months.

11:15 A.M. Address of Honored Speaker

ShigeruSakakibara, M.D.

Directorof The Heart Institute of Japan

Professorof Surgery

TokyoWomen's Medical College, Tokyo, Japan

EXPERIENCESWITH CONGENITAL ANOMALIES OF

THEHEART IN JAPAN

*By invitation