WEDNESDAY AFTERNOON, April 27, 1983

2:00 p.m. Scientific Sessions - Grand Ballroom

41. Complement and the Possibly Damaging Effects of Cardio-pulmonary Bypass

JAMES K. KIRKLIN*, EUGENE H. BLACKSTONE*,

JOHN W. KIRKLIN, DENNIS E. CHENOWETH*,

ALBERTO. PACIFICO and STEVE WESTABY*

Birmingham, Alabama; LaJolla, California; London, England

The existence of a damaging effect from cardiopulmonary bypass (CPB) per se, especially in infants, and its possible mechanisms and prevention remain controversial. Therefore, a prospective clinical study was made of the blood levels of C3a (a product of complement activation), the usual clinical laboratory tests, and a number of clinical events which were carefully recorded and categorized for severity, in all patients undergoing open (n = 116) and closed (n = 12) cardiac operations on two surgical services in a 6 week period. C3a levels were normal (160-220 ng/ml) in the closed cases, and in the open cases were 1170 ng/ml (± 660-2050, p for difference from closed cases <0.0001), 870 (± 500-1510, p<0.0001), and 280 (± 160-490, p = 0.4) at the end of CPB, 3 hours later, and 20 hrs. later, respectively. By multivariate analysis, only the C3a levels 3 hours after CPB, young age, and longer CPB times increased the probability of postoperative bleeding diathesis (p = 0.08, 0.06, 0.004 respectively), importantly impaired cardiac performance (p = 0.02, <0.0001, 0.02) important pulmonary dysfunction (p = 0.01, <0.0001, 0.03), and important renal dysfunction (p = 0.02, <0.0001, >0.2). Only the same three variables were related to the probability of important morbidity (all of the above events combined, p = 0.008, <0.0001, 0.0002). The nature of the relations were such that C3a levels above 1750 ng/ml tended to be associated with a high probability (≥ 30%) of morbidity, the tendency increasing exponentially with younger ages (particularly rapidly <1 yr) and longer CPB times (particularly >120 minutes). The hypothesis that results is that a damaging effect in the form of a whole body inflammatory reaction, with complement activation, results from even short periods of CPB; that very small patients are particularly vulnerable; and that long CPB times add further damage. Many techniques allow considerable suppression of these risk factors and good results, but more knowledge is required for their complete neutralization.

*By Invitation

42. Management of Intracardiac Fungal Masses in Premature Infants

JOHN E. FOKER*, THEODORER. THOMPSON*,

JOHN L. BASS*, JOHN A. TILLELI*

and DANA E. JOHNSON*

Minneapolis, Minnesota

Sponsored by: ROBERT W. ANDERSON,

Minneapolis, Minnesota

Intracardiac fungal masses can develop following episodes of candidemia in premature infants with indwelling right atrial lines. Previously, this diagnosis had only been made at autopsy in the cases described in the literature. We report here the diagnosis and first successful surgical removal of Candida-containing intracardiac masses in three premature infants. Over the past four years, six premature newborns developed condidemia despite oral nystatin prophylaxis. The right atrial lines were removed and the infants treated with amphotericin B and 5-flucytosine. Echocardiograms revealed that three (50%) had developed intracardiac masses. In two, a pedunculated solitary mass was found within the right atrium. In these two patients the antifungal therapy over the next 21-42 days controlled the Candida sepsis. By echocardiography, however, the intracardiac masses did not decrease in size and became quite mobile. In the third infant, masses were present from the right atrium to the main pulmonary artery and surgical removal was recommended four days after beginning antifungal therapy. In all three patients, the masses were nearly the size of the main pulmonary artery and presumably contained viable organisms. Because of concern for the risk of pulmonary embolism, surgical removal was undertaken and two were removed using cardiopulmonary bypass (CPB). One infant, however, weighed only 1300 grams and CPB seemed too hazardous. In the latter case, the intraatrial mass was easily removed using inflow stasis of 30 seconds duration. In all three patients removal was grossly complete and the masses were filled with Candida mycelia. All patients tolerated the operation well and have been discharged home with a minimum follow-up of six months without evidence of recurrent Candida infection. In summary, this report documents that: (1) Echocardiography provides a noninvasive method of diagnosing the development of intracardiac fungal masses and should be performed in all infants who have had condidemia and a central venous line. (2) The intracardiac masses do not appear to resolve even with prolonged systemic antifungal therapy. (3) The masses can be safely removed even in the premature infant, using either inflow stasis or CPB. (4) Surgical removal seems to be an effective component of the management of these infants by eliminating the acute threat of a large septic embolism and contributing to the elimination of the focus of infection.

*By Invitation

43. Prospective Evaluation of Patients with Chronic Respiratory Signs and Symptoms for the Presence of Occult Esophageal Disease

TOM R. DEMEESTER, CLEMENTE IASCONE*

and DAVID B. SKINNER

Chicago, Illinois

Seventy-seven patients with chronic respiratory signs and symptoms of unknown etiology (18 chronic cough, 20 recurrent pneumonia, 10 pulmonary fibrosis and 29 wheezing) were evaluated with a careful clinical history, esophageal manometry and 24-hour esophageal pH monitoring for the presence of esophageal disease. Symptoms of heartburn, regurgitation or dysphagia were mild or absent in 90% of the patients. Fifty-four of the 77 patients had abnormal esophageal acid exposure on 24-hour pH monitoring and the severity of acid exposure was similar in all groups with the exception of those who wheezed. They had less acid exposure, mainly in the supine position (p<.05). The lower esophageal sphincter pressure and length of abdominal esophagus were similar in each group, but significantly less than normal. The 54 patients who refluxed were divided into four groups depending on the severity of their respiratory symptoms as manifested by the presence of one or more of the following complaints: morning cough, nocturnal cough, recurrent pneumonia and wheezing spells. Group I had only one symptom; group II had two symptoms, etc. Both the incidence of dysmotility of the body of the esophagus and the occurrence of a respiratory symptom immediately preceeding or following a reflux episode increased as the severity of their respiratory complaints increased, suggesting that dysmotility may predispose to aspiration in those who have abnormal acid exposure (Table I). Twelve patients were suspected aspirators on the basis of respiratory symptoms occurring during or following an reflux episode. This was commonly seen in patients complaining of only one respiratory symptom suggesting that the esophageal disease was primary. Patients with wheezing during or after a reflux episode had less acid exposure suggesting that wheezing spells were not due to aspiration, but to a reflex bronchial constriction triggered by the reflux episode. Seventeen patients were operated on, and the results are shown on Table II.

Table 1
Severity of Respiratory Symptoms:
Relationship with Esophageal Body Dysmotility and Reflux Episodes
				Reflux Episodes
Severity of				Following or preceding
Respiratory symptoms		Dysmotility		Respiratory symptoms
# patients		# patients	%	# patients	%
Group 1	19	6	31.6	5	26.3
Group 2	12	5	41.7	5	41.7
Group 3	13	7	53.7	7	53.7
Group 4	10	7	70	6	60

Table 2
Results of Anti-Reflux Surgery For Respiratory Symptoms
	Pre-Op Presence	Post-Op Improvement
Recurrent Pneumonia	9/17	7/9 78%
Wheezing	12/17	6/12 50%
Nocturnal Cough	14/17	12/14 86%
Morning Cough	10/17	8/10 80%

*By invitation

44. Treatment of Malignant Disease in Trachea and Main Stem Bronchi by Carbon Dioxide Laser

RICHARD B. MCELVEIN and GEORGE ZORN*

Birmingham, Alabama

The use of a carbon dioxide laser to erradicate intralumenal malignant lesions of the trachea and main stem bronchi is described.

Forty-three patients, 28 males and 15 females ranging from 36 to 78 years have received from one to five laser treatments to provide an improved airway with relief of major respiratory tract obstruction. There has been one in-traoperative death and two immediate postoperative deaths.

Improvement in respiratory status has been accomplished in all surviving patients persisting from 1 to 14 months. The carbon dioxide laser treatment does not cure cancer but does provide an improved airway with low risk so other treatment can be used.

A major advantage of this form of treatment is decreased bleeding and the ability to provide an improved airway. The disadvantages are the necessity for general anesthesia and expense of the equipment.

45. Thymoma - Ten Year Experience

JOEL D. COOPER, FARID SHAMJI*,

FREDERICK G. PEARSON, THOMAS R.J. TODD*,

RIIVO ILVES* and ROBERT J. GINSBERG

Toronto, Ontario

Between 1970 and 1980, 53 patients with a thymoma were seen at the Toronto General Hospital. Two patients were inoperable at the time of admission and the remaining 51 patients underwent surgical resection. The results in these 51 patients, all of whom had a complete resection, forms the basis of this report. Treatment consisted of resection alone in 30, resection with preoperative radiation in 11, resection with postoperative radiation in 8, and resection combined with preoperative and postoperative radiation in 2.

Twenty-three patients had invasive tumours and 28 had non-invasive tumours. Myasthenia gravis was present in 25 patients (10 with invasive tumours and 15 with non-invasive tumours). Current information is available on 46 of the 51 patients with a mean follow-up of 5.4 years.

Results

Of the 23 patients with invasive tumour, 7 patients are dead, 3 of unrelated causes, 2 from tumour recurrence, and 2 from complications associated with radiotherapy. In addition 2 patients are alive with tumour recurrence (2 years and 10 years). One patient is lost to follow-up.

Of the 21 patients with non-invasive tumours, 3 patients are dead, all of unrelated causes. No patient has developed recurrent tumour, 4 patients are lost to follow-up.

Contrary to earlier experience, the presence of myasthenia gravis did not alter the prognosis: of 23 patients with invasive tumours, there were 3 deaths in the 10 patients with myasthenia gravis and 4 deaths in the 13 patients without myasthenia gravis. The mean survival time was not affected by the presence of myasthenia gravis and no patient had died of myasthenia.

We conclude that surgical excision for thymoma is associated with a very favourable prognosis and that the long term survival is not significantly affected by the presence of myasthenia gravis.

*By Invitation

46. Surgical Treatment of Aneurysm of the Ascending Aorta with Aortic Insufficiency - A Selective Approach

DOUGLAS P. GREY*, DAVID A. OTT*

and DENTON A. COOLEY

Jacksonville, Florida; Houston, Texas

The selection of an appropriate surgical technique for repair of aneurysm of the ascending aorta with aortic insufficiency (AATA-AVR) is unsettled. Placement of a supra-coronary graft is a compromise if the coronary ostia are displaced cephalad by the aneurysm; whereas, insertion of a valved conduit is difficult and unnecessary if the coronary ostia are normally placed.

From June 1979 to May 1982, 123 patients underwent repair of AATA-AVR. Mean age was 46.4 years. Annuloaortic ectasia was the most common indication for repair (44/123, 35.8%), followed by acute and chronic dissection (39/123, 31.7%). Twelve patients had previous operations on the ascending aorta or aortic valve, and five patients had undergone prior AATA-AVR using conventional methods (separate valve and supra-coronary graft). Seventy-two patients (58.5%) underwent composite replacement with coronary reimplantation, and fifty-one patients had repair using the conventional technique. Cardiopulmonary bypass methods, times, and postoperative complications were comparable between the two groups.

Hospital mortality for the whole series was 7.4% (9/122), with 4.2% (3/71) in patients having composite replacement and 11.8% (6/51) in patients having a conventional repair (p = N.S.). Five Jehovah's Witness patients survived. One patient committed suicide on the third post-operative day and was eliminated from subsequent calculations. Of sixty patients who have been followed locally for a total of 1183 patient-months, three died: two new dissections (6 weeks, 14 months) and one death without autopsy (2 months). Notably, no patient has required reoperation for conduit malfunction or required repair of aneurysm below a supra-coronary graft. Clinical anatomic assessment at operation should determine the technique of repair employed, based on the degree of displacement of the coronary ostia relative to the aortic annulus.

4:00 p.m. Adjournment

*By Invitation