TUESDAY MORNING, April 26, 1983

6:45-8:15 a.m. Simultaneous Breakfast Sessions**

A. Interventional Therapy (Thrombolytic/Angioplasty) for Acute Myocardial Ischemia and Infarction

MODERATOR: Ellis L. Jones, Atlanta, Georgia

B. Surgical Problems of Aortic Arch

MODERATOR: E. Stanley Crawford, Houston, Texas

C. Controversies in the Surgical Management of Advanced Non-Small Cell and Limited Small Cell Carcinoma of the Lung

MODERATOR: E. Carmack Holmes, Los Angeles, California

8:30 a.m. Scientific Session - Grand Ballroom

19. Immediate Coronary Artery Re-Perfusion for Evolving Myocardial Infarction

STEVEN J. PHILLIPS*,

CHAMNAHN KONGTAHWORN*, JAMES R. SKINNER*

and ROBERT H. ZEFF*

Des Moines, Iowa

Sponsored by: RALPH A. DORNER, Des Moines, Iowa

Between 1975 and 1981, 339 patients underwent emergency coronary artery re-perfusion (CR) for treatment of evolving myocardial infarction (EMI). Group I (181 patients) had saphenous vein bypass graft (SVBG). Group II (112 patients) had CR with intercoronary streptokinase (SK). Group III (46 patients) had re-perfusion with a combination of intercoronary SK and percutaneous transluminal coronary angioplasty (PTCA). Twenty Group II patients and one Group III patient had emergency SVBG as SK and PTCA were unsuccessful and significant myocardium remained at risk due to residual stenosis in the EMI artery. Group I had successful thrombectomy of the infarcted artery in 79% of cases, and 17% of these patients had no observable lesion on restudy. There were eight early, and two late deaths in the surgical patients. Group II had four deaths, and Group III patients had no deaths. Patients with an EMI should be treated via re-perfusion of the EMI vessel by one of the above mentioned techniques. With single vessel involvement, streptokinase lysis of the intercoronary thrombosis should be attempted. If this is successful and there is a significant residual stenotic lesion, it should undergo balloon angioplasty at that time. If PTCA is unsuccessful, then SVBG should be done. When significant multiple vessel disease exists in conjunction with an acute myocardial infarction, the patient should have emergency saphenous vein bypass graft as the treatment of choice.

*By Invitation

**No advance registration. Attendance by ticket only. Tickets must be purchased at registration desk by 2:00 p.m. on Monday, April 26. Price of ticket covers attendance at session and breakfast.

20. Combined Carotid Coronary Surgery - When is it Necessary

ELLIS L. JONES, RICHARD E. MICHALIK*,

JOE M. GRAVER, ROBERT A. GUYTON*,

CHARLES R. HATCHER, JR. and

NORMAN REICHWALD*

Atlanta, Georgia

Numerous centers have reported that simultaneous carotid-coronary surgery (C/CS) can be performed safely; few have discussed whether it is always necessary. To answer this question three groups of patients were analyzed: Group I (N = 111) having C/CS, Group II (N = 51) having postop stroke (POS) after isolated coronary artery bypass (CAB) and Group III (N = 169) having CAB alone, but with preop findings of either asymptomatic cervical bruit (ACB), positive ischemic neurological history (NH) or prior carotid endartectomy (CE). There was no significant difference between Group I patients and a control group having CAB alone with regard to anginal pattern, vessel disease, ventricular functin, grafts performed or peri-operative complications (hospital mortality 2.7% vs. 0, inotropic need 8% vs 7%,IABP 1.8% vs. 1.5%, and POS 2% vs. 0%, respectively). The incidence of POS in Group II was 0.9% (51/5676). Group II patients were characterized by: diabetes (27%), + neurologic history (20%), carotid bruit (20%) and diseased ascending aorta (33%). There were no differences in extra-cranial arteriographic findings (ECAF) for patients in Group III with ACB, + NH (TIA/stroke) or prior CE. In patients with ACB (N = 60), ECAF were normal in 38% and revealed significant unilateral or bilateral carotid stenosis in 41%. POS rate in patients with ACB, + NH and CE (Group III) was 3.3%, 8.6% and 5.1%, respectfully compared to 2% in patients having C/CS (p = NS). This study suggests that although C/CS can be performed safely under ideal conditions, the combined approach is not mandatory, and in patients with unstable angina the ACB or positive NH can be ignored and CAB performed alone with acceptable incidence of POS. It is probable that POS after isolated CAB is most often caused by conditions other than known or occult carotid vascular obstruction.

*By Invitation

21. Coronary Artery Bypass Grafting in Patients with Ejection Fractions Below 40%: Early and Late Results in 466 Patients

MARK S. HOCHBERG*. VICTOR PARSONNET,

ISAAC GIELCHINSKY, RONALD M. ABEL and

S. MANSOOR HUSSAIN*

Newark, New Jersey

The outcome of patients undergoing coronary artery bypass grafting with preoperative ejection fractions (E.F.) below 40% was evaluated to determine if a specific level of ventricular dysfunction resulted in an unacceptably low short-term or long-term result. Ejection fractions were broken down into groups of five percentage points starting with 35-39% and progressing down to 10-14%. In evaluating the six ejection fraction groupings between 10 and 39%, there was no significant difference between the groups in the number of vessels bypassed, the number of previous myocardial infarctions, age, preoperative NYHA class, or the length of time of intra-operative ischemic arrest. From 1976 through 1981, 466 patients were distributed among these groups, all having ejection fractions below 40% (average 30 ± .32).

There was a significant difference (p= .001) in the hospital and long-term survival of patients with pre-operative ejection fractions from 20-39% (425 patients) as compared to those with pre-operative ejection fractions from 10-19% (41 patients). Hospital survival was 89% for patients with ejection fractions from 20%-39%, but only 63% for patients with ejection fractions below 20%. At three years, patients with ejection fractions of 20-39% had an average survival of 60% as compared to an average survival of 15% for those with ejection fractions below 20%. The pre-operative LVEDP did not significantly predict the survival except at the lowest ejection fraction (10-14%). NYHA class decreased an average of 3.00 to 1.25 in surviving cases following CABG.

It is concluded that ejection fraction is an excellent predictor of short-term and long-term survival following coronary artery bypass grafting. Patients with ejection fractions of 10-14% and 15-19% have a significantly reduced short- and long-term survival as compared to patients with ejection fractions ≥20%.

*By Invitation

22. Technique and Results of Operative Transluminal Angioplasty in 60 Consecutive Patients

NOEL MILLS, JOHN L. OCHSNER, DANIEL P. DOYLE*

and WILLIAM P. KALCHOFF*

New Orleans, Louisiana; Montreal, Quebec;

Houston, Texas

Sixty consecutive patients with distal multivessel coronary artery disease had attempted operative transluminal angioplasty at the time of coronary bypass surgery. Lesions chosen for angioplasty were those in coronary arteries that otherwise would not be bypassed because of size and/or location. A guidewire-tipped catheter with a 2 mm. balloon was found to be most satisfactory of the two devices used. Seventy lesions in 60 patients had attempted dilatation. Thirty-eight lesions were in primary coronary arteries with distal disease, 16 lesions were obstructing flow to branches not large enough for grafting, and 16 lesions were tandem lesions that otherwise would not warrant two grafts. The distal left anterior descending lesion was the most common attempted (55%). A dilatation was classified "successful" when a 1.5 or 2 mm. dilator could be passed across the lesion postdilatation. This was achieved with 58 lesions (83%). Ten unsuccessful dilatations occurred due to inability to traverse the lesions with the catheter.

Postoperative angiography performed in 21 patients to study 23 lesions was carried out 10 days to 6 months postoperatively. In 16 of 21 successfully dilated lesions (76%), the stenoses were completely alleviated. Three lesions were found unimproved and in one the coronary artery was occluded distally. Two bypass grafts were closed involving two lesions with extensive dilatation. One patient suffered an asymptomatic perioperative myocardial infarction and there were no deaths in this series. Calcification of lesions did not bear upon operative or late angiographic success, whereas length of the lesion was indirectly proportional to a successful dilatation. Operative dilatation of short coronary distal lesions is safe, has a high percentage of success, and offers a larger distal runoff for coronary bypass grafts. Areas of normal coronary arteries should not be dilated. Careful attention to detail, and proper selection of lesions to be dilated is required. The technique should be used only to dilate arteries that otherwise would not accept a bypass graft.

10:00 a.m. Intermission - Visit Exhibits - Lower Level

(Galleria) - Complimentary Coffee

*By Invitation

10:45 a.m. Scientific Session - Grand Ballroom

23. The Use of Transluminal Coronary Angioplasty in the Patient with Prior Bypass Surgery

GERALD DORROS*, W. DUDLEY JOHNSON,

ALFRED TECTOR and LYNNE JANKE*

Milwaukee, Wisconsin

Transluminal coronary angioplasty (TCA) has proved successful in treating patients (pts) with single vessel disease (SVD). TCA has been used in prior coronary bypass surgery (CABG) pts with a saphenous vein graft (SVG) and/or a native arterial (NA) stenosis. During 47 months, 50 pts (37 males, 13 females) underwent TCA with 84 attempts and 73 (87%) primary successes (PS). A PS was determined by a ≥20% decrease in the percent diameter stenoses coupled with an improved clinical response. 43 pts had 1 prior CABG; and 7 pts had 2 or more prior CABG's. SVD was present in 5 pts (10%), and multivessel disease (MVD) in 45 pts (90%). A SVG stenosis was dilated in 33 cases with a PS achieved in 27 (82%): with 20/25 PS's at an anastomotic site (80%) and 7/8 PS's in the body of the graft (88%). A NA stenosis was dilated in 51 cases with a PS achieved in 46 (90%) with 12/15 PS's in the left anterior descending (80%); 8/13 (62%), in the circumflex; 21/23 (91%), in the right coronary; and 5/5 (100%), in the left main. Complications included: emergency CABG in 1 pt (2.0%); a myocardial infarction (MI), in 2 pts (4.0%); and no related mortalities. Two pts died of arrhythmias, awaiting EL CABG. There were 11 failures with 8 pts having EL CABG, and 3 pts managed medically. There were 39 successful pts of which 15 had restenoses 5 of these had EL CABG, 9 had a second TCA (6 remained well, 3 restenosed and underwent EL CABG). There was one late death and one late MI. A restenosis occurred in 8 NA's (16%) and 10 (30%) SVG's: 5 NA and 4 SVG restenoses underwent a successful second TCA. Thus, there were 29 pts (58%) with late clinical success of which 28 pts (97%) had no or improved angina, and all had improved exercise treadmills. Thus, TCA is technically feasible in selected pts with prior CABG and can result in the avoidance of a subsequent higher risk surgical procedure in the majority of selected pts.

*By Invitation

24. Intracoronary 201-Thallium Scintigraphy - An Immediate Predictor of Salvaged Myocardium Following Intracoronary Thrombolysis

HANS J. KREBBER*, JOCHEN SCHOFER*,

DETLEF MATHEY*, RICHARD MONTZ*,

PETER KALMAR* and GEORG RODEWALD*

Hamburg, Federal Republic of Germany

Sponsored by: J. DONALD HILL, San Francisco, California

Since February of 1980, 140 patients having the symptoms of acute myocardial infarction for less than 3 hours, underwent intracoronary lysis (ICL). Thirty-eight patients required early aortocoronary revascularization. Surgery, however, was felt to be indicated only when ICL was successful and myocardium was salvaged. As left ventricular angiography proved unreliable in the assessment of the viability of the myocardium in the acute stage, we therefore from March of 1981, obtained intracoronary 201-Thallium scintigrams (i.e. TL 201) in 23 patients, before and after ICL. Patients who showed significant reduction (>50%) in their initial 201 TL defect (n = 12) were considered ideal candidates for surgery (Group 1). Patients with poor or unimproved 102 TL uptake after successful ICL (n = 6) were treated medically (Group 2), as were patients whose ICL had been unsuccessful (n = 5, Group 3). In order to validate this new approach we compared the change in the regional wall motion of the "infarcted area" as shown in the acute and follow-up left ventricular angiograms in all 3 groups. In the acute stage the mean regional EF was 20% in Group 1, 19% in Group 2 and 20% in Group 3. Only in Group 1 was there a significant increase in regional EF to a mean of 51%. The mean EF obtained at follow-up in Groups 2 and 3 was 17%.

Conclusion: 201-Thallium scintigraphy is a valuable predictor of the salvagability of myocardium immediately following ICL and, has been to date, the most valuable tool in assessing those patients suitable for early coronary revascularization.

11:30 a.m. Address by Honored Speaker

ALAIN CARPENTIER, Paris, France Valve Surgery: "The French Correction"

12:15 p.m. Adjourn for Lunch - Visit Exhibits

12:15 p.m. Cardiothoracic Residents' Luncheon

Dusseldorf & Lisbon Rooms

*By Invitation