WEDNESDAY MORNING, April 27, 1983

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

33. Intrathoracic Transposition of Extrathoracic Skeletal Muscle

PETER C. PAIROLERO*, PHILLIP G. ARNOLD* and

JEFFREY M. PIEHLER*

Rochester, Minnesota

Sponsored by: DWIGHT C. MCGOON, Rochester, Minnesota

During the past five years, 25 patients (16 male and 9 female) with life-threatening intrathoracic infections were treated by transposing an extrathoracic skeletal muscle into the pleural cavity or mediastinum. Indications for muscle transposition included bronchopleural fistula (BPF) following irradiation and/or infection (11 patients), postpneumonectomy empyema with BPF (8 patients), infected false aneurysm of the heart and great vessels (4 patients), and esophageal perforation (2 patients). Ages ranged from 16 to 79 years with a mean of 57.6 years. Thirty-seven muscles were transposed, including 16 latissimus dorsi, 15 pectoralis major, 3 pectoralis minor, 2 serratus anterior, and 1 rectus abdominis. Eleven patients had multiple muscle transpositions (7 concurrently and 4 staged). Thirty-day operative mortality was 12% (3 patients). Follow-up ranged from 2 to 66 months with a mean of 17 months. Eighteen patients had no further signs or symptoms of the original infection. Infection recurred in 4 patients, resulting in death in 3 (BPF in 2 and tracheoaortic fistula in 1). The fourth patient had a recurrent BPF which was successfully treated with further muscle transposition.

Nineteen patients (76%) were successful long-term survivors. These included 88% of patients (7/8) with postpenumonectomy empyema and BPF, 75% of patients (3/4) with infections of the heart and great vessels, 73% of patients (8/11) with BPF, and 50% (1/2) with perforated esophagus. Three patients eventually died from other causes (myocardial infarction in 2 and recurrent cancer in 1). We conclude that intrathoracic transposition of an extrathoracic skeletal muscle is an excellent method of treatment of persistent, life-threatening intrathoracic infection.

*By Invitation

34. Open Window Thoracostomy in the Management of Post-Pneumonectomy Empyema With or Without Bronchopleural Fistula

FARID M. SHAMJI*, ROBERT J. GINSBERG,

JOEL D. COOPER, ERNEST H. SPRATT*,

MELVYN GOLDBERG*, PAUL F. WATERS*,

RIIVO ILVES*, THOMAS R. TODD* and

E. GRIFFITH PEARSON

Toronto, Ontario

The management of chronic post-pheumonectomy empyema with or without bronchopleural fistula (BPF) continues to plague thoracic surgeons. Total thoracoplasty is successful but mutilating. Large myovascular bundles are useful if the empyema cavity is relatively small. Clagett introduced the concept of open window thoracostomy, daily irrigation with an antiseptic solution and eventual closure of the window as an alternative. This method could be utilized with empyemas associated with BPF only if these fistulae were to close spontaneously or by operative intervention.

We report our experience with thoracostomy window for the mangement of post-pneumonectomy empyema with or without BPF in 31 patients. The pneumonectomies were performed for primary bronchogenic carcinoma (21), inflammatory conditions (9) and invasive, malignant thymoma (1). Empyema with BPF occurred in 24 cases and empyema alone in 7 cases.

In all cases, initial treatment was tube thoracostomy followed by open window thoracostomy by the method of Clagett. Daily irrigations were begun, awaiting bronchopleural fistula closure if present, hoping to attempt eventual closure of the thoracostomy window.

In the 7 patients with empyema alone, 3 completed the total Clagett procedure. In 2 cases, it was successful without re-infection. In 3 patients, death from metastatic disease ensued prior to closure of the window. There are 2 patients alive with the window present.

In those patients with associated BPF, the fistula healed spontaneously in 8, required operative closure in 9, and did not close before their demise from metastatic disease in 7. Of 17 patients with closed fisulae, 5 completed the Clagett procedure, and only 1 was successful. Re-infection occurred in the 4 other attempts, necessitating re-opening of the window. In 5 further patients, the persisting space was closed either by limited thoracoplasty (2) or myovascular bundle (3). The remaining 7 patients are alive up to 7 years with persisting open thoracostomies, and tolerating them well.

We conclude that open thoracostomy window provides adequate drainage and excellent interim treatment of an empyema space. In those patients with associated BPF, spontaneous healing of the fisula can occur (8 of 24). In our hands, successful completion of the Clagett procedure is rare when associated with BPF. However, with open thoracostomy, the residual cavity does reduce markedly in size and allows for the use of a myovascular bundle or a more limited thoracoplasty, to close the space.

*By Invitation

35. Aortic Valve Homografts in the Surgical Treatment of Complex Cardiac Malformations

FRANCIS M. FONTAN, ALAIN CHOUSSAT*,

CLAUDE DEVILLE*, CHRISTIAN DOUTREMEPUICH*,

JOSEPH COUPILLAUD* and CARLO VOSA *

Bordeaux, France

From April 1968 to September 1982, the surgical treatment of complex congenital cardiac malformations requiring a conduit for their correction was performed with Aortic Valve Homograft (AVH) or Aortic Valved Homograft Conduits (AVHC), prepared sterilized and preserved in our hospital. Our experience concerns 91 patients (pts) in whom a total of 101 AVH with a diameter ranging from 14 to 26 mm were implanted. Since March 1981, it was possible to match recipient and donor ABO Blood group and Rhesus in 10 pts. The pts ranged in age from 5 months to 37 years (mean 12.1 years). The AVH or the AVHC were implanted according to one of the five following situations:

1. AVHC between Right Ventricle (RV) and Pulmonary Artery (PA) in 32 pts: Pulmonary Atresia 14, extreme Fallot 7, Transposition of the Great Vessels 8, Truncus Arteriosus 1, Double Outlet Right Ventricle 2.

2. AVH between right atrium (RA) and PA in 21 cases of Tricuspid Atresia (TA) and in 19 cases of Single Ventricle.

3. AVH between RA and RV - Outlet Chamber - in 9 cases of T.A. and 2 cases of hypoplastic right heart.

4. AVH in the pulmonary valve site in 4 pts: pulmonary valve agenesia in 2, severe pulmonary valve incompetence in 2.

5. AVH for vena cava valvulation in 12 pts: Inferior vena cava in 11 pts and both venae cavae in one.

There was a hospital mortality of 21 pts (23%) ranging from 0 to 100% and a late mortality of 6 pts (6.6%), in none the death can be related to the AVH. The clinical follow-up of the survivors (1 to 172 months, mean 55.1) evidenced neither dysfunction of the AVH, nor thromboembolism or hemolysis. Control cardiac catheterization was performed postoperatively in 42 pts at a mean delay of 8.1. months and a second control in 5 of them at a mean delay of 62 months. A gradient was found in 10 pts with a AVHC between RV and PA. In 4 of them it was lower than 5 mm Hg and in the others respectively 6, 9, 11, 15, 15 and 30 mm Hg. It was not possible to locate the precise level of the gradient: AVH or proximal or distal anastomosis. These results lead us to conclude that at the present time AVH is the best material for the surgical treatment of complex cardiac congenital malformations requiring valved connexions or valved conduits.

*By Invitation

36. Systemic-Pulmonary Shunts in Infants and Children: Early and Late Results

JOHN J. LAMBERTI, JAMES R. CARLISLE*,

FREDERICK A. LODGE* and J. DEANE WALDMAN*

San Diego, California

We reviewed our recent experience with systemic to pulmonary artery (PA) shunts to compare four techniques currently in use. From September 1978 to September 1982, 53 shunts were performed in 41 consecutive patients. Age ranged from 18 hours to 4 years, mean age = 0.66 years, with 25 patients (25/53=47%) ≤1 month at operation. Weight ranged from 1.7 kg to 13.2 kg, mean = 5.7 kg, with 25 patients (25/53 = 47%) ≤4.0 kg at operation. There were 14 classical Blalock-Taussig (BT), 5 central polytetrafluoroethylene prosthetic (PTFE), and 34 BT type interposition PTFE shunts (8 end of subclavian artery to end of PTFE [IBT], 26 side of subclavian artery to end of PTFE "Great Ormond Street" [GOBT]; all 34 were distal end of PTFE to side of PA). No direct aorta to PA anastomoses were performed. There was one operative death (1/53= 1.9%) (GOBT) in a 1.7 kg neonate with a patent shunt. Three patients required reoperation for shunt revision (one banding of a GOBT, one kinked but patent IBT, and one patent BT anastomosed to ductal tissue in an interrupted PA patient) and there was one reoperation for conversion of a clotted central shunt to an IBT.

Ten of 53 procedures represented a second palliative procedure 12 to 36 months after initial operation. Initial shunts in these 10 cases were: 4 BT, 4 IBT, 1 central, and 1 GOBT. Two late deaths were possibly shunt related, (1 BT; 1 central). All survivors had shunt patency confirmed by angiography or 2-D echo with Doppler plus clinical criteria. Excellent palliation was afforded by all four types of shunt for 12 to 36 months.

We conclude that the GOBT is the optimal shunt due to low operative risk, ease of performance, predictable patency (100% in this series), non-distortion of PA, and ease of takedown. These advantages far outweigh the minor disadvantage of the need for complete repair or a second shunt at 12-18 months in some patients.

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

(Galleria) - Complimentary Coffee

*By Invitation

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

37. Intelligence Quotient and Development Following Use of Profound Hypothermia and Circulatory Arrest for the Repair of Congential Heart Defects in Infants and Young Children

CHRISTOPHER LINCOLN*, FRANK WELLS*,

STEPHEN COGHILL* and DAVID NAFTEL*

London, England

Sponsored by: JOHN W. KIRKLIN, Birmingham, Alabama

Published works on intelligence quotient (IQ) and development following the use of profound hypothermia and circulatory arrest (PHCA) suggests little or no impairment when used to repair congenital heart defects (CHD) in infants and young children. IQ and other development aspects, cognitive, memory, perceptual, quantitative and verbal, (McCarthy's scale of children's abilities, mean score 100, SD 16) were measured 5 years following surgery which was performed between 1973-1976, in 31 patients using PHCA. These patients were compared with three control groups. (1) 19 patients (pts) with similar defects but using moderate hypothermia and continuous cardiopulmonary bypass (CPB), (2) The siblings of those PHCA pts-16, and (3) Siblings of the CPB pts-14. The hypothermia temperature reached within each technique was closely clustered around 15°C in the PHCA group (GP) and 28°C in the CPB gp. PHCA time ranged from 22-71 minutes. Statistical analysis, T-test, Chi-square test of association and Wilcoxon Test showed the only base-line characteristic difference between the two pt gps in respect of preoperative and age variables, diagnosis, level of cyanosis, oxygen saturation, hemoglobin concentration, age at operation, was weight p = 0.03. The mean intelligence score 93 ± 5.7 (mean±SE) of the PHCA pt gp was significantly lower (p = 0.002) than their siblings 106 ± 4.1. The CPB pts score 98 ± 6.0 was not demonstrably different than their siblings, 96 ± 5.9. Degree of cyanosis, oxygen saturation and hemoglobin concentration was not significantly related to the IQ score in either patient gps. The sibling and pt (PHCA) IQ differences are associated with length of arrest time in verbal p = 0.06, quantitative p = 0.07, and general cognitive p = 0.003 scores. A decrease of 0.53 points per minute of arrest time was estimated for the entire group of 31 pts; or, for the 19 with siblings, for each minute increase in circulatory arrest time the pts dropped 0.69 IQ points below their siblings. These and analysis of other published data do not support the generally accepted view that PHCA can be used entirely without penalty and questions the accepted safe estimates of duration of circulatory arrest of 60 minutes.

*By Invitation

38. Subclavian Flap Repair of Coarctation of the Aorta in Neonates - Realization of Growth Potential

ANTHONY L. MOULTON*, JANET E. BURNS*,

JOEL I. BRENNER* and MICHAEL A. BERMAN*

Baltimore, Maryland

Sponsored by: JOSEPH S. MCLAUGHLIN, Baltimore, Maryland

The subclavian flap repair for coarctation of the aorta (CoA) allows potential for growth by utilizing autogenous tissue. Though well-documented in young children, its promise in the tiny neonate warrants further evaluation. Since 8/79, 27 patients have undergone subclavian flap repair. Nineteen were less than 1 month of age and 13 were less than 10 days. Weights ranged from 1.4 to 5 kg (means 3.0 kg). All had associated severe intracardiac defects and were in severe congestive failure. Fourteen received preoperative prostaglandin.

There was 1 intraoperative death among the 6 patients who underwent simultaneous pulmonary artery banding (PAB). One patient with a small VSD and severe mitral stenosis, acidotic and seizuring preop, died in low output 36 hours after repair and PAB. Another premature baby with mid-septal VSD's died from pneumonia and sepsis 2 weeks after CoA repair and PAB. One newborn whose CoA was repaired at 2 days of age underwent emergency open aortic valvotomy at 5 days, had a smooth immediate postop course and died suddenly 1 day after the open procedure. There was 1 late death, 6 months after satisfactory CoA repair, in a baby with a hypoplastic left ventricle.

Twenty-two survivors continue to do well up to 3 years postop. All have normal weight gain, but no patient has a measured arm-to-leg gradient greater than 10 mmHg. In 1 patient the VSD spontaneously closed, and open VSD closure was uneventfully performed in 2 others at 1 and 5 months of age. Another underwent a successful Mustard procedure at 3 months. Five patients have undergone repeat catheterization, and all demonstrated satisfactory growth of the subclavian flap segment of repair. We therefore continue to utilize this technique for the treatment of CoA even in tiny neonates.

*By Invitation

39. Reparative Surgery for Interrupted Aortic Arch

WILLIAM I. NORWOOD, ALDO R. CASTANEDA,

FLORENS VERSTEEGH* and THOMAS J. HOUGEN*

Boston, Massachusetts

From January 1975 through September 1982, 24 infants underwent primary or staged repair of interrupted aortic arch (IAA) with ventricular septal defect (VSD). Excluded are 10 infants with associated truncus arteriosus (5), single ventricle (3), Taussig-Bing anomaly (1), or aortic atresia (1). Seven of 24 had Type A and 17 had Type B IAA. Eleven infants, median age 5 days, underwent staged surgery while 13, median age 6 days, underwent primary repair. Palliation was by tube graft interposition (6), subclavian aortic anastomosis (3), left carotid aortic anastomosis (1), and end-to-side aortic anastomosis (1) combined with pulmonary artery banding (8) or early ventricular septal defect closure (3). There were 3/11 (27%) early and 1/8 (13%) late deaths with palliation. Delayed repair at 5 days to 14 months (median 7 months) incurred 3/7 (43%) early and no late deaths. Primary repair consisted of ventricular septal defect closure combined with graft interposition (12) or end-to-side aortic anastomosis (1) with 3/13 (23%) early and no late deaths. Four (17%) patients had or developed severe subaortic stenosis. In 3 with long segment obstruction, a ventricular apico-aortic conduit was placed at 5 and 7 days and at 15 months with no mortality. The other had resection of fibrous subaortic stenosis at age 3 years. Of note, 9 (38%) infants had perioperative hypocalcemia and of these, 3 had DiGeorge's syndrome diagnosed by absence of T-cells.

Nine of 14 survivors had hemodynamic evaluation by catheterization 1 to 3 years following repair. None had residual VSD or pressure gradients between the ascending and thoracic aorta. Six had subaortic stenosis; 4 mild (gradient < 20 mm Hg) and 2 severe (gradient > 70 mm Hg) requiring surgery.

Results of surgery in neonates with interrupted aortic arch continue to improve. Essential in management is an awareness that subaortic stenosis and hypocalcemia may be accompaniments of this anomaly. Based on these data, we prefer primary repair for interrupted aortic arch with VSD.

*By Invitation

40. Individualized Surgical Management of Complete Atrioventricular Canal

WILLIS H. WILLIAMS*, ROBERT A. GUYTON*,

RICHARD E. MICHALIK*, ELLIS L. JONES,

KYOO H. RHEE*, WILLIAM H. PLAUTH, JR.*

and CHARLES R. HATCHER, JR.

Atlanta, Georgia

In a five year interval (10/1/77-9/31/82), 51 children with complete atrioventricular canal required operation. Group A (31 children) underwent correction; Group B (20 children) received surgical palliation.

Group A ranged in age from 4 months to 14.6 years (mean 4.2 years), 14 being less than one year old. Weights ranged from 4.1 kg to 39 kg (mean 13.6 kg), 14 weighing less than 10 kg. Ten had undergone previous surgical palliation (7 by pulmonary arterial band; 3 by systemic-to-pulmonary arterial shunt). There were no early deaths and one late death. One infant required mitral valve replacement at total correction; two required subsequent mitral valve replacement, successful in both cases.

Group B ranged in age from 8 days to 4.5 years (mean 8.4 months), 17 being less than one year old. Weights ranged from 2.5 kg to 11.2 kg (mean 4.8 kg), 19 weighing less than 10 kg. Operations included pulmonary arterial banding in 14 and shunt creation in 5. One child underwent pericardial enlargement of the right ventricular outflow tract without closure of VSD to promote growth of small pulmonary arteries. Subsequent correction was successful. One death occurred five days after operation in an infant with unrecognized coarctation. One late death occurred several months after the creation of a second shunt in a child with severe associated tetralogy of Fallot.

Of the 51 children, 48 (94%) are alive now. Postoperative cardiac catheterizations and clinical courses will be described.

Even though universal primary total correction of complete atrioventricular canal in infancy is now widely advised, we believe the outcome in these 51 patients managed by selective palliation and/or total correction supports individualized choice of initial operation based upon clinical condition, weight, pathophysiology, associated anomalies, and intracardiac anatomic details.

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

*By Invitation