WEDNESDAY AFTERNOON - MAY 13, 1981

2:00 P.M. Scientific Session - International Ballroom

41. Pulmonary Fungus Infections: Survey of 140 Cases With Surgical Aspects

JAMES D. HARDY and BARRY D. NEWSOM*,

Jackson, Mississippi

Fungus diseases of the lungs usually regress spontaneously or respond to drug therapy. However, in a significant number of patients some type of sugical intervention is required for either diagnosis or management. We have reviewed the 140 patients treated in the University Hospital. Exclusive of OB-GYN, the hospital populations of white vs. blacks, and of men vs. women, are approximately equal. There were 66 cases of blastomycosis (46 ♂ and 20 ♀; 50 black abd 16 white), 30 cases of histoplasmosis proven by tissue or culture (18d ♂, 12♀; 20 white, 10 black), 17 cases of aspergillosis (8 fungus balls), 13 cases cryptococcosis, 8 cases nocardosis, 6 cases ac-tinomycosis. Of course, the diagnosis of histoplasmosis had been assigned to a rather larger number of patients who exhibited the widespread pulmonary calcifications so often seen in our region secondary to this disease, but these cases were excluded from this study unless the diagnosis was supported by tissue or culture. Instances of coccidioidomycosis, mucormycosis, and sporotricosis were met in our adjacent V.A. Hospital but the substantial number of cases in that institution was not analyzed in detail. Epidemiology and pulmonary fungal infections in immunodepress-ed patients were of special interest.

Operative intervention was required for diagnosis, chronic unresponsive infiltrate, cavitation, decortication, hemorrhage or bronchopleural fistula, variously, in 18 blactomycosis and 20 histoplasmosis patients, among others. Operations required were pneumonectomy (2), lobectomy (7), seg-mental resection (7), with wedge resection, open biopsy, decortication and closure of bronchopleural fistula the rest. Drugs included Kl, Stilbamidine and Amphotericin B. Treatment problems and results with different fungi will be presented.

Conclusions: Blastomycosis constituted the major pulmonary fungal challenge in our area. When drug therapy was not curative for fungus disease, surgical treatment was generally satisfactory and usually without complications.

*By invitation

42. The Role of Bronchoplastic Procedures in the Surgical Management of Benign and Malignant Pulmonary Lesions

JAMES E. LOWE*, ALBERT H. BRIDGMAN* and

DAVID C. SABISTON, JR., Durham and Ashville,

North Carolina

Conventional resectional procedures such as segmentectomy, lobectomy or pneumonectomy represent the appropriate surgical treatment for the majority of pulmonary lesions requiring operation. However, a small but definite number of patients with carcinoma and perhaps the majority of patients with benign endobronchial neoplasms in the proximal airways should be considered as candidates for conservative resectional procedures. The term conservative is used to indicate that normal lung is preserved by these operations. A variety of terms have been applied to these procedures relating to the amount of lung actually removed, but most commonly these operations are referred to as "sleeve resections." As this term indicates, a portion of bronchus is removed with or without lobectomy and a primary bronchial reanastomosis is performed in order to preserve the remaining distal airway and subsequent ventilatory function.

Bronchoplastic techniques are applicable to traumatic airway injuries, benign strictures such as tuberculous bronchostenosis, benign endobronchial lesions as well as tumors of low malignant potential such as bronchial adenomas and a select group of patients with carcinoma of the lung. From 1947 to 1980, 565 bronchoplastic procedures have been reported in the literature as follows:

Our series of bronchoplastic procedures consists of 28 patients undergoing operation with no mortality and with minimal morbidity. The pathological diagnoses were carcinoma 20, adenoma 6, hamartoma 1, and 1 post-traumatic. Four patients had prolonged atelectasis requiring repeated bronchoscopy and one had a bronchopleural fistula. The remainder of these patients have done well.

In summary, bronchoplastic procedures represent appropriate surgical therapy for benign endobronchial tumors and for correction of traumatic airway injuries. They are also applicable to a select group of patients with carcinoma and in such patients long term survival is comparable to the results achieved by pneumonectomy. When properly performed these procedures are safe and perhaps used too seldom.

*By invitation

43. Bullet Wounds of the Trachea

PANAGIOTIS N. SYMBAS, CHARLES R. HATCHER, JR.

and SUE E. VLASIS*, Atlanta, Georgia

During the last ten years, 18 patients, 16 male and 2 female with ages ranging from 15 to 60 years were admitted to Grady Memorial Hospital with gunshot wound of the trachea. Thirteen of them had wounds of the cervical trachea and five had wounds of the intrathoracic trachea. In addition to the tracheal injuries, four patients had injuries to major vessels and six patients, three of whom had tracheoesophageal fistula, had esophageal injury. The diagnosis of tracheal injury was suspected because of the site of the wound and the clinical manifestations; hemoptysis, air escaping from the cutaneous wound, subcutaneous emphysema, etc. This was confirmed by tracheoscopy in 7 patients or at the time of surgery in 11 patients.

The treatment of the tracheal injury was dependent upon the magnitude of the tracheal wound and the presence of injury to adjacent organs. Seven patients underwent primary repair of the tracheal wound, two patients had primary repair with reinforcement of the suture line with pleural flaps, three patients had repair of the tracheal wound and tracheostomy, one patient underwent tracheocutaneous stoma construction, 2 patients had temporary orotracheal intubation for 24-48 hours, and 3 patients were observed. Seventeen patients recovered from the injuries and 1 patient died from respiratory insufficiency.

This study suggests that the management of bullet wounds of the trachea should be individualized according to the magnitude of the wound and the presence of other organ injury. Primary repair can be accomplished in the majority of civilian victims with gratifying results.

*By invitation

44. The Relationship of Whole Body Oxygen Consumption to Perfusion Flow Rate During Hypothermic Cardiopulmonary Bypass

LAWRENCE S. FOX*, EUGENE H. BLACKSTONE*,

JOHN W. KIRKLIN, ROBERT W. STEWART* and

PAUL N. SAMUELSON*, Birmingham, Alabama

Whole body oxygen consumption (VO₂) and its relationship to arterial perfusion flow rate (Q) were determined in 17 adult patients undergoing routine coronary artery bypass grafting. The patients were cooled (t = 21.3 ± 0.47 °C) by the perfusate after which Q's of 0.25, 0.5, 1.0, 1.5, or 2.0 1-min" -m" were selected by randomization. After Q of 10 minutes, blood samples were obtained, a new Q selected, and he process repeated. The median number of Q per patient was 4. The results were (mean one standard deviation):

VO₂ increased markedly as perfusion flow rate was increased (p< 0.001), but the increase was progressively smaller at higher flow rates. The relation of Q and VO₂ at 20 °C is expressed by a hyperbolic equation, from which is obtained the asymptote maximal (VO₂ = 38 ml-min" -m"), and the % of this at various Q's. Mixed venous oxygen saturation was strongly correlated with perfusion flow rates below a Q of about 1.3 (r = 0.9, p< 0.0001), but were less strongly correlated (r = 0.4) at higher flow rates. Internal jugular venous oxygen saturation was lower than mixed venous oxygen levels, and remained strongly correlated with flow rate throughout the range of flows studied. Thus despite the effect on metabolism of hypothermia during cardiopulmonary bypass, the oxygen demands are not fully met at flows used clinically.

*By invitation

45. Longterm Survival with Partial Left Heart Bypass Following Peri-operative Myocardial Infarction and Shock

DANIEL M. ROSE*, STEVEN B. COLVIN*,

ALFRED T. CULLIFORD*, JOSEPH N. CUNNINGHAM,

O. WAYNE ISOM and FRANC C. SPENCER,

New York, New York

In the last 24 months a partial left heart bypass (LHD), (modified from the technique originally described by Litwak), and an intra-aortic balloon pump (IABP), were used in 11 seriously ill patients who could not be weaned from cardiopulmonary bypass with inotropic agents and IABP alone. Venous cannulation was done with a 28-32 French venous cannula inserted into the left atrial appendage and arterial cannulation with a 5-6mm Roe cannula inserted into the ascending aorta and advanced beyond the left subclavian artery. The cannulae were connected with silastic tubing through a roller pump. Flow rates up to 3500ml/min. could be obtained. The activated clotting time was kept in the range of 120-150 seconds, requiring only small amounts of heparin.

Five of the 11 patients survived. One died from cardiac arrest four months later, while four are well, six, nine, 14, and 17 months after discharge.

Two of the six deaths were in patients with severe aortic stenosis and triple vessel coronary artery disease. Severe coronary disease was present in three of the six who died and four of the five who recovered. All deaths were characterized by progressive failure of myocardial function. All survivors, by contrast, had significant improvement in ventricular function following 12-24 hours of partial LHB, which was stopped after 20-52 hours. IABP was stopped 2-7 days after insertion.

During LHB thrombocytopenia (platelet counts of 30-60 x 10³mm³) required platelet transfusions, but none of the survivors had serious bleeding. There was no significant pulmonary or renal injury. These data indicate that some patients with peri-operative cardiogenic shock can survive with the prompt use of the left bypass if IABP is ineffective. The fact that in surviving patients cardiac function improved markedly after 12-24 hours of LHB suggests that benefit resulted from preventing the progression of myocardial edema to extensive myocardial infarction.

*By invitation

46. Improved Results for Dissecting Aneurysms with Intraluminal Sutureless Prosthesis

GERALD M. LEMOLE, MICHAEL D. STRONG*,

PASCHAL M. SPAGNA * and PETER KARMELOWEICZ*,

Browns Mills, New Jersey and Philadelphia, Pennsylvania

Surgery for dissection of the thoracic aorta has had a high mortality rate. This has been due in part to hemorrhage from the prosthesis and the suture lines. A method of treatment has been developed utilizing an intraluminal prosthesis that requires no end-to-end anastomosis. We have used this method in 14 patients of whom 8 had acute thoracic aortic dissections and 6 had chronic dissections. We asembled our own prosthesis in the first 5 patients. More recently we have utilized an intraluminal prosthesis provided by USCI. Eight of the patients had Type I dissection of whom 5 required concommitant aortic valve replacement, and 3 coronary artery bypass grafting; 1 had a Type II dissection and 5 had a Type III dissection. The age range was 31 to 71 years with a mean of 58. There were 12 males and 2 females. There were no intraoperative mortalities, however, one patient died 10 days postoperatively of a perforated ulcer and 1 patient died at 6 months with empyema. Follow-up has been from 2 to 45 months with a mean of 14 months. There has been no evidence of compromise of the aortic lumen, and no prosthetic problems such as erosion, migration or thrombisis. This technique provides a safe and simple way to repair dissecting aneurysms of the thoracic aorta and has proven to have long term reliability. We have subsequently used this graft for 3 patients with aneurysm of the aorta without dissection with favorable results. We presently recommend this technique for dissecting, atherosclerotic and Marfanoid aneurysm of the thoracic aorta.

Adjourn

*By invitation

A1 Hemodynamic Comparison of Dopamine and Dobutamine in the Postoperative Volume Loaded, Pressure Loaded, and Normal Ventricle

VERDI J. DiSESA*, EDWARD BROWN*,

GILBERT H. MUDGE*, JOHN J. COLLINS, JR. and

LAWRENCE H. COHN, Boston, Massachusetts

Though improved myocardial protection techniques have reduced the use of postoperative pressor support, when catecholamines are indicated selection of an agent should be predicated on its hemodynamic as well as myocardial effects. We compared the hemodynamic effects of Dopamine and Dobutamine in 17 postoperative patients evaluating both drugs in a randomized crossover study using each patient as his own control; 6 had valve replacement for mitral or aortic insufficiency (volume-loaded ventricle), 5 had valve replacement for aortic stenosis (pressure-loaded ventricle), and 6 had coronary bypass (normal ventricle). Heart rate (HR), right atrial (RAP), left atrial (LAP), pulmonary artery (PAP) and systemic arterial (SAP) pressures were monitored. Thermodilution cardiac output, pulmonary vascular resistance (PVR), systemic vascular resistance (SVR), and cardiac index (Cl) were calculated. Data were collected 24 hours postoperatively before and during elective infusion of Dopamine and Dobutamine at 2.5 and 5.0 ug/kg/min. A 60-minute infusion of the first drug was followed by a 60-minute control period followed by a 60-minute infusion of the second drug. Control values before each drug, control period versus peak response at 5.0 ug/kg/min, and the absolute values and the mean percent changes from control were compared statistically.

In the volume-loaded ventricle Dopamine and Dobutamine equally augment heart rate and cardiac output but Dobutamine reduces left ventricular afterload significantly more than Dopamine. In the normal ventricle, Dobutamine is more chronotropic, causes a greater increase in cardiac output and a greater reduction in SVR and PVR. Neither agent produces significant hemodynamic changes in the pressure-loaded ventricle although likewise there is a trend toward greater reduction of left ventricular afterload with Dobutamine.

*By Invitation

A1 - Alternate Paper