TUESDAY MORNING, MAY 4, 1982
8:30 a.m. Scientific Session - Assembly
Hall
19. High
Frequency Ventilation With A Single Lumen Tube For Intrathoracic Surgery
NABIL EL-BAZ*,
WAYNEH. WELSHER*,
ABDEL EL-GANZOURI*.
ANTHONY IVANKOVICH*,
C. FREDERICK KITTLE,
L. PENFIELD FABER
and ROBERT J. JENSIK
Chicago, Illinois
One lung anesthesia has proved a valuable
adjunct for many intrathoracic operations. The use of a single lumen (8 mm ID)
long (35 cm) cuffed endo-bronchial tube placed in the main bronchus of the dependent
lung with high frequency ventilation (HFV-60 to 600/minute) has been studied in
29 patients. These have had a variety of procedures (segmentectomy, lob-ectomy,
pneumonectomy, and esophagectomy). The tube was placed using the fiberoptic
bronchoscope. HFV at a frequency of 250/minute with an inspriatory time
percentage of 40%, a driving gas pressure of 20 psi, and 100% O2
were used. Arterial blood gases were measured at 10 minute intervals.
All patients maintained a PaO2 of
150-500 mm Hg and a PaCO2 of 20-50 mm Hg without appreciable pH
changes.
The single lumen smaller tube avoids the
occasional traumatic complications associated with a double lumen tube and is
more easily placed. HFV maintains full expansion of the dependent lung without
mediastinal shift and with adequate oxygenation. The collapsed atelectatic lung
facilitates dissection for various procedures.
*By invitation
20. Exsanguinating Hemoptysis
ANTONIO A. GARZON,
MARCIAL M. CERRUTI*
and MICHAEL R.
GOLDING*
Stolen Island and Brooklyn, New York
Massive hemoptysis (600 ml/24h) treated
conservatively carries a mortality of more than 50%. We have performed 74
pulmonary resections in patients with massive hemoptysis in the last fifteen
years with a mortality of less than 15%. The mortality rate correlated with the
speed and the amount of recorded blood lost before the operation. Those
patients that required single lung anesthesia to control aspiration during
operation had a mortality that was almost double the total group (25%).
From our experience, we have identified a
sub-group of patients with such large hemoptysis that life was threatened by
exsanguination. Twenty-four of our patients bled more than 1000 ml. and at a
rate of at least 150 ml/h. before the pulmonary resection was performed. The
bleeding site was always identified by bronchoscopy. Several methods were used
to avoid the patient drowning during the operation. In four patients, double
lumen endotracheal tube was used; two died of suffocation during the procedure.
In eight patients, a single lung ventilation with endotracheal tube in the
nonbleeding lung was used; two of them died of hypoxia and respiratory failure
due to aspiration. In another ten patients, a bronchial blocker (#10 Fogarty
balloon catheter) was used to stop the bleeding; two died of renal failure and
G.I. bleeding but none had aspiration problems.
Our experience indicates that blocking of the
bleeding bronchus under direct vision is the safer and more effective procedure
to control aspiration and bleeding in massive hemoptysis. Thoracic surgeons
managing massive hemoptysis must be familiar with the techniques to control
bleeding under these difficult circumstances. Since massive pulmonary bleeding
is not common, we believe the presentation of our experience and technique will
be valuable.
*By invitation
21. Surgical Treatment of Pleural Mesothelioma
PATRICIA M.
McCORMACK*, FUMINO NAGASAKI*,
BASIL S. HILARIS*
and NAEL MARTINI
New York, New York
From 1939 through 1980, 155 patients were seen
and treated for pleural mesothelioma. 19 of these were benign, and were treated
by resection without recurrence. 136 were malignant tumors, 20% (27/136) were
fibrosar-comatous and were resected with clear surgical margins where possible
and with additional postoperative radiation therapy where adequate margins
could not be attained. 80% (109/136) were diffuse malignant epithelial
mesothelioma with involvement of parietal and visceral pleura as well as
pericardia! and diaphragmatic surfaces.
Surgery, radiation therapy and chemotherapy
have been used singly or in combination in the treatment of malignant
mesothelioma. In fibro-sarcomatous mesothelioma, complete resection is
possible, and offers significant chance of long survival. In epithelial
mesothelioma where the disease is diffuse and often associated with effusion,
complete resection is not possible. In an earlier report by us on 39 patients,
better survival was obtained where pleurectomy, with resection of bulky
disease, was combined with external radiation therapy and chemotherapy. No
benefit was noted from sacrificing pulmonary tissue.
We have since seen and treated in a similar
manner 70 additional patients with malignant epithelial mesothelioma. We have
continued to preserve functioning lung tissue by performing a subtotal pleurectomy,
but have since 1977 modified our technique of delivering radiation therapy by
combining interstitial and external irradiation.
All patients with disease confined to one hemithorax are first
surgically explored. A pleurectomy and pericardiectomy are carried out to
remove as much tumor as possible. Bulky, non-resectable masses are implanted
with radio-iodine sources. The superior mediastinum and the diaphragm, areas of
high risk for recurrence, are treated with a removable Iridium-192 implant. Postoperatively,
external radiation therapy is given in a technique that allows treatment of the
entire pleural surface while sparing underlying lung and spinal cord. 32
patients have been treated in this manner from January 1977 to September 1981.
25 patients had malignant epithelial mesotheliomas, 4 had fibrosarcomatous
generalized tumors and 3 were of the mixed type. There was no operative
mortality. All the patients were able to complete the radiation therapy with
minimal morbidity. Chemotherapy was initiated upon completion of the
radiotherapy. The median survival of this group of patients is currently 17.3
months with a range of follow-up of 2-34 months. Survival with radiation
therapy and chemotherapy without surgery is considerably less in most reported series.
Details of the surgical and radiation techniques involved in the
treatment of these patients will be presented.
9:30 a.m. Intermission - Visit Exhibits
*By invitation
10:15 a.m. Scientific Session - Assembly Hall
22. Use of Operative Transluminal Coronary
Angioplasty as an Adjunct To Coronary Artery Bypass
EUGENE WALLSH,
ANDREW J. FRANZONE*,
ANDRE CLAVEL*,
GERALD S. WEINSTEIN*
and SIMON H.
STERTZER*
New York, New York
Intraoperative transluminal coronary
angioplasly (OTCA) was used lo improve cornonary ariery bypass graft (CABG)
runoff in patients having complex segmcntal and diffuse coronary artery
obstructions.
OTCA was performed during CABG through the bypass arteriotomy on 63
arteries in 58 patients, employing an angioplasty system specifically designed
for intraoperative use.
Elective restudy was performed on 29 dilated
arteries in 27 patients: 21 between 8 and 21 days (mean 16) and 8 between 4 and
31 months (mean 21.4). Overall patency was 83% (16/21 studied early, 8/8
studied late).
Three perforations (4.8%) occurred and were
repaired without sequelae. One operative death (1.7%) occurred in a patient
with preoperativc refractory cardiogenic shock. There were 7 pcrio-operative
infarctions (12.1%), of which 3 were in the distribution of the coronary artery
undergoing OTCA.
We conclude that OTCA is a useful adjunct in
the operative treatment of patients with complex proximal and diffuse distal
coronary obstruction.
*By invitation
23. Coronary Athero-Embolism Causes Peri-Operative
Myocardial Infaction - A Hazard at Reoperation
WILBERT J. KEON and
H. ALEXANDER HEGGTVEIT*
Ottawa, Ontario
We have demonstrated a
phenomenon occurring during coronary artery bypass grafting (CABG) which has
not been previously described. Thirteen instances of fatal peri-operative
myocardial infarction following CABG were associated with intra-operative
atheromatous embolization in the coronary microcirculation. In five cases the
emboli originated from ulcerative atherosclerotic lesions in the aortic root at
the site of the vein graft ostia, two cases likely emanated from coronary
endarterectomy sites and two cases from mechanical disruption of plaques in the
major epicardial coronary arteries during surgery. The above 9 cases occurred
during initial revascularization procedures. We have performed 4,095 initial
cases of CABG and this represents a risk of 0.22%. A further 4 cases occurred
during repeat CABG procedures and resulted from manipulative disruption of
atheroma in old vein grafts. Our total number of CABG's is 175; a 2.29% risk at
reoperation representing a tenfold increase in risk for this complication at
reoperation. Inadequate histological sampling of the myocardium at autopsy will
necessarily result in underestimation of the incidence of this phenomenon.
Analysis of angiograms prior to repeat CABG
can identify patients at increased risk who have severe graft atherosclerosis
as opposed to myointimal hyperplasia. To reduce the incidence of atheroembolism
at reoperation we strongly advocate ligation of the vein graft at the level of
the distal anastomosis as early as possible during dissection reopening the
chest.
*By invitation
24. Idiopathic Hypertrophic Subaortic Stenosis and
Coronary Atherosclerosis; Results of Coronary Artery Bypass Alone and
Myomectomy Combined with Coronary Artery Bypass Surgery
CARL C. GILL*,
ANDREW M. DUDA*,
HIDEMASA KITAZUME*,
JOHN R. KRAMER*
and FLOYD D. LOOP
Cleveland, Ohio
Twenty-one patients with
combined coronary artery disease (CAD) and idiopathic hypertrophic subaortic
stenoses (1HSS) have had coronary artery bypass grafting (CABG) alone (group I,
n = 7) or combined with ventricular septal myomectomy (LVM) (group II, n = 14).
There were no operative deaths. Follow-up is current for all patients. Patient
data for both groups is summarized below:
|
|
Mean age
|
Sex
|
Multivessel CAD (%)
|
Peak pre-op subvalvular gradient (mmHg.)
|
Grafts/ patient
|
Mean follow-up (months)
|
|
|
|
M
|
F
|
|
|
Group
|
|
|
|
|
|
|
|
|
|
1
|
56.1
|
5
|
2
|
64
|
69.1
|
2.3
|
82
|
|
|
(n = 7)
|
± 6.1
|
|
|
|
± 19
|
± 76
|
|
|
|
Group
|
|
|
|
|
|
|
|
|
|
11
|
60.6
|
9
|
5
|
85
|
83.9
|
2.0
|
21
|
|
|
(n = 14)
|
± 8.3
|
|
|
|
± 39.6
|
± 1.2
|
|
|
In group I there has been one sudden death 16 months postoperatively;
five other patients in group I have undergone recatheterization. The
subvalvular gradient was unchanged in all except one, who experienced graft
occlusion and inferior myocardial infarction; he now has no subvalvular
gradient 7 years after initial surgery. Another patient in group 1 had
progressive angina and mitral insufficiency requiring mitral valve replacement
25 months after initial CABG. The functional class of the 5 other group 1
patients is unchanged or worse after CABG alone. In contrast group 11 patients
are markedly improved (12 NYHA class 1? 1 NYHA class 11) except one
patient who experienced recurrent angina pectoris 16 months postoperatively.
CABG alone is ineffective in relieving symptoms in patients with IHSS and CAD.
LVM combined with CABG provides safe and effective relief of symptoms for these
difficult patients.
11:30 a.m. Address of Honored Speaker
Achievements In The Study and
Control of Cancer of The Esophagus - 1940 - 1980
WU YING-KAI Beijing, China
12:15 p.m. Cardiothoracic Residents Luncheon -
Flagstaff Room
*By invitation
