SUNDAY MORNING, APRIL 25, 1976

8:30 A.M. Scientific Session

Los Angeles Ballroom

23. Management of Concomitant Carotid and Coronary Artery Occlusive Disease

HAROLD C. URSCHEL, MARUF A. RAZZUK and DONALD L. PAULSON,

Dallas, Texas

The combination of concomitant severe occlusive disease of the carotid and coronary arteries, particularly the left main, is potentially a lethal lesion and requires careful therapeutic timing and management.

This series includes 27 cases. Eight had left main coronary artery lesions with cerebral symptoms, three of whom had over 85% stenosis of both internal carotids (1C); one who had total occlusion of left 1C and over 75% stenosis of right 1C; four had 75% lesion of either left or right 1C. Nineteen had either functional left main or combination of coronary vessel disease, three of whom had ulcerated carotid plaques, one of left 1C with previous stroke; the second had bilateral plaques and the third had plaque of left 1C. The latter two patients had only visual symptoms. Seven of the 19 had 75% stenosis of either one or both carotids with significant cerebral symptoms, but stable angina; nine had 75% stenosis of one or both carotids, but no cerebral symptoms, and carotid angiograms were done because of neck bruits.

The patients with marked carotid artery obstruction and severe angina had concomitant revascularization of the coronary arteries and one carotid artery endarterectomy. Cases with bilateral carotid lesions had the side with no crossover repaired. If crossover were bilateral, the nondominant side was repaired first. In patients who had severe angina and less than 75% carotid stenosis, revascularization was staged, with the coronary artery surgery performed first. Patients with stable angina, but with severe carotid artery disease had carotid endarterectomy first and subsequent revascularization of the coronary arteries.

There was no operative mortality or significant morbidity.

24. Use of the Augmented Ejection Fraction to Select Patients with Severe Left Ventricular Dysfunction for Coronary Revascularization

LAWRENCE H. COHN, JOHN J. COLLINS, JR. and

PETER F. COHN*, Boston, Massachusetts

Some patients with coronary artery disease and severe left ventricular dysfunction have significant improvement in both angina and failure symptoms following myocardial revascularization, suggesting that left ventricular dysfunction can be the result of ischemia rather than fibrosis. This study was initiated to see whether a diagnostic discriminate could be developed to separate those patients with acceptable operative risk and high expectation for improvement from those with high operative risk and little hope of longterm improvement.

Thirty-three patients with angina (31 male, 2 female, 33-68 years, 52) who had signs and symptoms of left ventricular dysfunction were evaluated. All had multiple vessel coronary disease and at least 1 prior myocardial infarction. Cardiac catheterization in all patients demonstrated abnormally-elevated LVEDP, low cardiac output and depressed resting biplane systolic ejection fraction (BSEF) ranging from 18-45%, 31%. To evaluate residual myocardial function, a premature ventricular contraction (PVC) was introduced during the ventriculogram and the BSEF of the post-extrasystolic potentiated beat calculated and compared to a sinus beat BSEF. Patients could be separated into 2 groups based on the increase in BSEF, those with > 0.10 augmentation (24 patients) and those < 0.10 augmentation (9 patients).

Coronary revascularization was carried out with at least 2 bypass grafts in each patient. The operative mortality in those with > 10% BSEF augmentation was 9% (2/24), late mortality 5% (1/22) and 20/21 became Class I or II in the follow-up period, 6-48 mos. (18). Operative mortality in those with BSEF augmentation of < 10% was 3/9 (33%), late mortality 1/6 and only 1/5 achieved Class I status.

These data suggest that significant augmentation of BSEF by a PVC is a simple and useful indicator to aid in selection of patients with left ventricular dysfunction for coronary revascularization.

*By invitation

25. The Bad Left Ventricle: Results of Coronary Surgery and Effect on Late Survival

W. DUDLEY JOHNSON, JACK C. MANLEY*, JAMES F. KING*

and HOWARD J. ZEFT*, Milwaukee, Wisconsin

Between 1968 and 1971, 252 patients with severe ventricular malfunction underwent revascularization surgery. Using single plane ventriculography, the ventricle was divided into six segments, three anteriorly and three inferiorly, and ejection fractions (EF) were calculated. Patients were classified into four groups.

Gp I--3 akinetic segments, average EF = 0.31

Gp II--4 akinetic segments, average EF = 0.26

Gp III--5 akinetic segments, average EF = 0.19

Gp IV--6 akinetic segments, average EF = 0.15

Results were assessed in regard to relief of angina (ROA), graft patency status (GPS), surgical mortality (SM), and survival as determined by actuarial life-table analysis. This was then compared to overall Milwaukee medical and surgical experience (MSB) as well as other reported medical series of treatment for similar degrees of CAD and impairment of LVF. No significant differences were found between this surgical and overall MSE with regard to ROA (88%) and GPS (82%), though SM was higher (10-25%) and 5 yr. survival lower (73-35%). Comparison between this surgical and medical series suggests improved survival and improved quality of life in the surgical series. These findings become even more dramatic considering the present SM (1973-1975) has fallen to a range between 2.0 and 9.3% in dealing with similar degrees of impairment of LVF.

Thus, many of these "hopeless" patients with severe ventricular malfunction, especially if associated with angina, can be reasonably considered surgical candidates.

*By invitation

26. Experience with 44 Repeat Myocardial Revasculariza-tion Procedures

QUENTIN R. STILES, GEORGE G. LINDESMITH, BERNARD L. TUCKER*,

RICHARD K. HUGHES, GEORGE STEFANIK*, ROGER J. STRINGER*

and BERT W. MEYER, Los Angeles, California

We have performed 44 coronary bypass reoperations for 43 patients. Thirty-eight had previous coronary bypass grafts and 6 had previous Vineberg implants. The reasons leading to the second procedure were occluded or stenotic grafts in 22 patients, an inadequate number of grafts at the first procedure in 11 patients, both an inadequate number and obstructed grafts in 13, and progression of the arteriosclerotic process in the patient's coronary vessels in four. A total of 67 new vein grafts were fashioned and 7 functioning but stenotic old vein grafts were revised. Mediastinal and pericardial adhesions increased the technical difficulties and the operative risk. Five patients died from the operation, an 11.3% mortality rate. This is compared to our 2.6% postoperative mortality rate for 2028 initial revascularization operations.

In 35 of the 44 reoperations, myocardial revascularization was accomplished as planned. Because of the epicardial scarring, however, the angiographically demonstrated targets could not always be found. At 5 reoperations, one less than the planned number of grafts was accomplished. In two reoperations, two targets could not be found. During all repeat operations, at least one new graft was constructed. At reoperations, 4 functioning coronary bypass grafts were damaged during sternal opening. All were repaired. One functioning internal mammary graft was damaged and had to be replaced with a vein graft.

Seven patients with 9 new vein grafts have had coronary angiograms an average of 14 months after repeat operation. Eight of the 9 new grafts were patent. None of the grafts placed at the initial revascularization were occluded on the angiogram after the second operation.

Although repeat operation is technically more difficult and somewhat more risky than initial revascularization, we currently believe the benefits derived warrant continued application in carefully selected cases. Our indications for the procedure are the same as for initial revascularization, bearing in mind the increased risks.

*By invitation

27. Surgery of Congenital Mitral Valvular Disease in Children

A. CARPENTIER*, B. BRANCHING, E. ASFAOU*,

J. C. COUR*, A. DELOCHE*, J. RELLAND*,

L. PARENZAN* and G. BROM, Paris, France

Since 1970, a cooperative study of congenital mitral valve lesions has been in progress by the Cardiac Surgery Departments of Broussais Hospital (Paris), Academisch Ziekenhuis (Leiden) and Ospedale Maggiore (Bergamo). An attempt was made to undertake systematic repair of the mitral valve by developing and using various techniques adapted to the abnormalities encountered.

Clinical material consisted of 42 children between the ages of 5 months and 12 years (average 5 years - 3 months). Valvular lesions were classified into 4 groups: ostium primum and A.V. canal were exluded from the study: Group A = mitral insufficiency due to valvular lesions (14 patients): distension of the annulus (8), mural leaflet agenesis (2), cleft (4). Group B = mitral insufficiency with sub-valvular lesions (13 patients): elongated papillary muscle (1), elongated chordae (4), retracted chordae (4), chordae agenesis (1), abnormal papillary muscle insertion (3). Group C = mitral insufficiency combined with stenosis (7 patients): commissural malformation (3), concentric stenosis (3), "hemiparachute" valve (1). Group D = mitral stenosis (8 patients): "sling" valve (2), parachute valve (4), funnel shaped valve (2).

Valve repair was carried out in 37 (89%) patients whereas valve replacement was necessary in 5 patients: 2 parachute valves, 2 mitral insufficiencies, 1 abnormal papillary muscle insertion. Associated lesions: VSD, ASD, Aortic stenosis, coarctation, were present in 28 patients and were corrected during the same operation.

There were 3 operative deaths (8%) and no late deaths in the valve repair group, 2 operative deaths (2/5) and 2 late deaths (2/5) in the valve replacement group.

Thirty-two out of 34 surviving patients following mitral valve repair were improved. No anticoagulation therapy was used and no thromboembolic complications were observed. Post-operative catheterization studies were performed in 17 patients.

*By invitation

28. Tricuspid Regurgitation: A Comparison of Nonoperative Management, Tricuspid Annuloplasty, and Tricuspid Valve Replacement

R. H. BREYER*, J. H. McCLENATHAN*, L. L. MICHAELIS*,

C. L. McINTOSH* and A. G. MORROW, Bethesda, Maryland

During the years 1972-1974,146 patients underwent mitral valve replacement, isolated or combined with aortic valve replacement. In 118 patients an intra-operative assessment of tricuspid valvular competence was made by digital palpation of the valve prior to the institution of cardiopulmonary bypass. In 76 of the 118 patients tricuspid regurgitation of variable degree was evident.

In 21 patients, tricuspid regurgitation was judged to be mild, and no operative procedure on the tricuspid valve was carried out. Thirty patients were considered to have moderate tricuspid regurgitation and underwent suture annuloplasty of the tricuspid valve. The remaining 25 patients had severe tricuspid regurgitation and/or tricuspid stenosis; in them the tricuspid valve was replaced with a Hancock porcine xenograft. Fourteen of the 76 patients (18%) died within 30 days of operation. Early mortality was highest among patients undergoing tricuspid annuloplasty (27%), 12% among patients undergoing tricuspid valve replacement, and 14% in patients in whom the valve was not treated operatively.

Mean length of follow-up has been 13 months. Forty-nine of the 76 patients underwent cardiac catheterization six months postoperatively; there were no significant differences among the three groups in mean right atrial or pulmonary arterial systolic pressure. However, a good clinical result (Functional Class I-II) was achieved in significantly more patients undergoing tricuspid valve replacement (80%) than in patients undergoing tricuspid annuloplasty (50%). Conservative management is justified in the patient with mild, presumably functional tricuspid regurgitation. In ,our experience, suture annuloplasty has not been effective in correction of tricuspid valvular regurgitation, and valve replacement with the Hancock porcine xenograft is now advocated when moderate or severe tricuspid regurgitation is evident when the valve is palpated.

INTERMISSION - VISIT EXHIBITS

*By invitation

29. Left Ventricular Rupture Complicating Mitral Valve Replacement-Surgical Experience of Six Cases and Review of the Literature

VIKING O. BJORK, AXEL HENZE* and LUIS RODRIGUEZ*,

Stockholm, Sweden

We are not the first to attempt repair of left ventricular rupture complicating mitral valve replacement, as 18 analogous cases have been reported earlier. Our personal experience comprises 6 patients. Four of them survived and two died. The rupture occurred either as a laceration in the posterior atrioventricular groove (type I, 14/24 patients) or as a perforation of the midportion of the left ventricle (type II, 10/24 patients). Intra-operative rupture (16/24 patients) was, as a rule, appreciated on termination of bypass, while delayed rupture (8/24 patients) occurred in the recovery room. The mortality rate was about 50% for the intra-operative type, while no patient survived a delayed rupture. The prognosis appeared to be most favorable in intra-operative type II lesions.

The main factors affecting the prognosis were (1) instant reinstitution of extracorporeal circulation and (2) avoidance of the descending branch of the circumflex coronary artery during repair of type I lesions located close to the antero-lateral mitral commissure. Attempts to suture a ventricular rupture on the pressure loaded beating heart were always unsuccessful and frequently extended the laceration. Patients with the delayed type of rupture died of hemorrhage before they were replaced on bypass.

*By invitation

30. Bacterial Endocarditis-An Analysis of 44 Operated Cases

ARTHUR D. BOYD, FRANK C. SPENCER, OTTIS W. ISOM*,

JOSEPH N. CUNNINGHAM, JR.* and RANDOLPH M. CHASE, JR.*,

New York, New York

Prosthetic valve replacement was performed for 47 patients with bacterial endocarditis at New York University Medical Center between January 1970 and July 1975. The infecting organism was a staphylococcus in 25 patients, a fungus in 5, and a variety of organisms in the remainder. The involved cardiac valve was: aortic valve 24, mitral 6, tricuspid 6, aortic and mitral 5, prosthetic valve 6. Operation was performed for progressive heart failure in 20 patients, uncontrolled sepsis in 14, and emboli in 13. When antibiotic therapy was effective in controlling infection before operation, (27 patients), results were good: 15% mortality (4/27). In sharp contrast, when operation was reluctantly undertaken after prolonged ineffective antibiotic therapy, mortality was 50% (10/20 patients). In 5 of the 10 operative deaths, operation was probably futile as the patients were moribund and expired within 48 hours. An analysis of the high mortality group indicates that prolonged ineffective antibiotic therapy not only did not decrease mortality, but actually increased it, both from generalized sepsis as well as local destruction of the valve annulus with complicating fistulae. Future improvement with therapy should come by performing operation as soon as appropriate antibiotic therapy appears ineffective.

*By invitation

31. Pericardium Xenograft Valve Replacement; Five Years Experience

MARIAN I. IONESCU*, DAVID A. S. MARY* and

ABDELFETTAH ABID*, Leeds, England

Sponsored by Dwight C. McGoon, Rochester, Minnesota.

Glutaraldehyde preserved, stented pericardium xenografts were used during the past 5 years for isolated valve replacement in 198 patients (136 aortic and 62 mitral). The 182 operative survivors were followed-up from 6 to 60 months. The cumulative follow-up totals 5760 months.

Actuarial analysis indicated an expected survival rate at 5 years of 97.9% for patients with aortic replacement. 98.1% were free of thromboembolism, 97.65% free of infection and 90.5% without murmurs. In the mitral group the survival rate was 87%. 96% were free of infection, 91.6% free of thromboembolism and 89.2% without murmurs. Only one of the 6 late deaths was valve related.

There have been 0.63 embolic episodes per 100 patient years in the aortic and 2.5 episodes per 100 patient years in the mitral series. All 6 emboli occurred during the first 45 postoperative days and none left sequelae. No anticoagulants were used.

The murmurs appeared very early postoperatively, were of trivial intensity and have not progressed with the passage of time.

There have not been valve failures.

The glutaraldehyde preserved pericardium xenograft provides a heart valve substitute with superior haemodynamic characteristics and very low thrombogenicity without anticaogulants. The unimpaired durability of the pericardium xenograft up to 5 years follow-up compares very favourably with all available prostheses and tissue valves.

*By invitation

32. Selection of Tissue or Prosthetic Valve: A Five Year Prospective Randomized Comparison

WILLIAM W. ANGELL and ROBERT D. WUERFLEIN*,

San Jose, California

Even after considerable experience, controversy persists between the selection of tissue or prosthetic valves. In order to provide a non-biased comparison, a prospective randomized study was designed in September 1970. One hundred consecutive patients with isolated primary single valve replacement were randomized to tissue or prosthetic valves. The Tissue Bank supplied homografts either mounted for mitral replacement or as free grafts for patients with small aortic roots. Starr-Edwards cloth covered prostheses were used for comparison.

There was an even distribution of patients by age, sex, valve lesion, and New York heart classification attesting to the accuracy of the random selection. Anticoagulants were used in 33 patients who had operative or embolic evidence of atrial clot, or history of thromboembolism. Thirty-five patients have undergone postoperative catheterization.

	Aortic		Mitral
	Homo	SE	Homo	SE
Operative death	1	1	1	1
Late death	0	7	2	5
Reoperation	4	3	8	3
# of patients	24	27	22	26
Mean age (years)	54.3	55.4	48.7	51.0

Causes of death and valve failure will be presented on an actuarial basis. Death in the Starr-Edwards patient group was sudden or due to fabric wear with subsequent thromboembolism, hemorrhage, or infection.

We must conclude that over a five year interval the tissue valve can be found to be a safer choice for valve replacement than was the most popular prosthetic device available at the time of this study.

*By invitation

33. Long-Term Experience with Porcine Aortic Valve Xeno-grafts

EDWARD B. STINSON*, RANDALL B. GRIEPP* and

NORMAN E. SHUMWAY, Stanford, California

Between March, J971 and July, 1975 glutaraldehyde-preserved porcine aortic valve xenografts (Hancock) have been employed for replacement of aortic (AVR) or mitral (MVR) valves in 462 patients at this center. Combined procedures (e.g. coronary artery bypass grafting, replacement of ascending aorta, left ventricular resection) were performed in 43% of AVR patients, 34% of MVR patients, and 33% of AVR+MVR cases. Postoperatively, long-term anticoagulation was not given. This report focuses upon late postoperative performance of porcine xenografts, with particular attention to durability of this type of bioprosthesis. Postoperative thromboembolism was diagnosed categorically on the basis of any new neurological deficit (unless proved non-embolic) or peripheral embolism; xeno-graft dysfunction was assigned on the basis of valvular regurgitation and/or stenosis (including suspected periprosthetic leaks) and endocarditis. Current follow-up of 99.6% of patients have been obtained.

Selected aspects are summarized below:

	AVR	MVR	AVR+MVR
1. Total patients:	167	244	51
2. Operative mortality:	6%	8%	12%
3. Total duration of follow-up:	140 pt-yrs	338 pt-yrs	37 pt-yrs
4. Average duration of follow-up:	0.9 years	1.6 years	0.9 years
Range:	0.1-4 yrs.	0.1-4.4 yrs	0.1-2.4 yrs
5. Three year survival rate of operative survivors:	96 (± 1.7)%	85 (± 3.9)%	-
6. Linearized thromboembolism rate:	2.1%/pt-yr	5.3%/pt-yr	5.4%/pt-yr
7. Linearized xenograft dysfunction rate:	4.3%/pt-yr	2.4%/pt-yr	2.7%/pt-yr
8. Documented tissue (valve) failure:	0	2	0

These data support the use of glutaraldehyde-preserved porcine xenografts as superior valve substitutes that pose a low risk of thromboembolism without anticoagulation. The overall durability of such bioprostheses, within the restriction of a maximum current follow-up interval of 4.5 years, appears comparable to that of currently available mechanical prostheses.

*By invitation

34. A Thirteen Year Review of the Magovern-Cromie Aortic Valve in Four Hundred Patients

GEORGE J. MAGOVERN, GEORGE A. LIEBLER*,

WILLIAM J. CUSHING*, SANG B. PARK* and

JOHN A. BURKHOLDER*, Pittsburgh, Pennsylvania

In 1962 the senior author introduced the Mogovern-Cromie sutureless aortic valve prosthesis. This valve was initially received with great enthusiasm because of its method of rapid insertion and over the past thirteen years, approximately 7,000 of these valves were employed. We have continuously used the prosthesis with subsequent modifications and will present a thirteen year review of 400 patients who underwent aortic valve replacement from 1962 through 1974. All patients were Class III & IV (NYHA), eighteen to eighty-one years of age. The operative mortality (0-21 days) was 12%. There were only 5 patients who did not actually survive the operative procedure. There were 68 late deaths (17%) and 257 patients or 65% of the patients are living. There were 37 patients over the thirteen year period who had episodes of thromboembolism (9%). From 1971 to 1974 with the cloth covered modification only 2/106 patients (1.8%) had thromboembolic complications. All patients are anticoagulated. In this thirteen year review there were 10 cases of ball variance (2.5%) and seven patients had successful reoperation. There were 6 cases of perivalvular leak (1.5%) and two patients developed partial dehiscence of the valve requiring operation. In the total group, there was a 5% incidence of partial or complete heart block which required pacemaker implantation. All cases were done with cardiopulmonary bypass, moderate hypothermia (32°) without coronary perfusion. The average total cross-clamp time was 30 minutes. The only exception to using this valve is an aortic ring less than 2 cm in diameter. There are 102 patients (88%) living 1 to 2 years; 78% or 194 patients living 2 to 5 years; 85 patients or 57% living 6 to 10 years; 6 patients or 23% living 10 to 13 years. The data for the advantages of mechanical fixation in association with combined valvular and/or revascularization procedures will be presented.

1:00 P.M. Adjournment

*By invitation