Tuesday Morning, May 8, 1984

TUESDAY MORNING, May 8, 1984

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

A. Surgical Management of Myocardial Infarction

MODERATOR: Floyd D. Loop, Cleveland, Ohio

B. Congenital left Ventricular Outflow Tract Obstruction

MODERATOR: John W. Kirklin, Birmingham, Alabama

C. Carcinoma of the Esophagus

MODERATOR: Earle W. Wilkins, Jr., Boston, Massachusetts

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

16. Late Results of Repair of Ruptured Chordae

THOMAS A. ORSZULAK*, HARTZELL V. SCHAFF*,

GORDON K. DANIELSON, JEFFREY M. PJEHLER*,

JAMES R. PLUTH, FRANCISCO J. PUGA*,

D WIGHT C. McGOON and ROBERT L. FRYE*

Rochester, Minnesota

Between 1958 and 1980, 131 patients came to operation for repair of ruptured chordae of the mitral valve (82 males and 49 females: median age 57, ranging 5 to 70 years; 79% in New York Heart Association Class III and IV preoperatively). The leaflet involved was the anterior in 44 patients (33.5%), posterior in 85 (64.8%), and both leaflets in 2. Most frequently associated valve abnormalities were annular dilatation (60%), leaflet prolapse (21%), and leaflet cleft (15%). Mitral valve repair was effected by plication in 116 patients, wedge resection of the leaflet in 6, Ivalon sponge buttress of the posterior leaflet in 3 patients, chordal repair in 2 patients, and isolated annular procedures in the remaining 4 patients. Annuloplasty was included in repair in 115 patients. Early mortality was 6.1% (9% for anterior leaflet repair, 4.7% for posterior leaflet repair). Late follow-up (2 to 19 years, 10 years median) included 98% of patients and demonstrated an overall survival of 88% at 5 years and 75% at 10 years. Patient age, additional operative procedures, and presence of atrial fibrillation did not influence late survival. Actuarial survival curves were similar in patients with repair of ruptured chordae to the posterior leaflet and anterior leaflet. Twenty-eight patients (22.7%) ultimately came to reoperation at a mean of 5 years, 25% of the anterior leaflet patients, and 22.2% of the posterior. One patient had re-repair, the others mitral valve replacement. Overall patient survival (88 vs. 72% at 5 years) was significantly better in these patients undergoing mitral valve repair for ruptured chordae compared to patients having mitral valve replacement for ruptured chordae during the same time period. Our data support valve repair for mitral regurgitation due to ruptured chordae including those patients with ruptured chordae to the anterior leaflet.

*By invitation

**No advance registration. Attendance by ticket only. Tickets must be purchased at registration desk by 2:00 p.m. on Monday, May 7, 1984. Price of ticket covers attendance at session and breakfast.

17. Early and Late Risk of Aortic Valve Replacement: An 11-Year Concomitant Comparison of the Porcine Bioprosthetic and Tilting Disc Prosthetic Aortic Valves

LAWRENCE H. COHN, ELIZABETH N. ALLRED*,

VERDI J. DiSESA *, RICHARD J. SHEMIN*

and JOHN J. COLLINS, JR.

Boston, Massachusetts

Results in 912 consecutive patients (614M/298F, 16-95, 61 yrs, 28 functional class (FC) 1-2, 533 FC 3, 351 FC 4) operated upon from 1/72 to 1/83 who received 663 porcine valves (PV) and 249 tilting disc valves (TDV) were analyzed. Age and sex were similar but there was a higher percent FC 4 for TDV. 657 patients had primarily aortic stenosis (AS) while 255 had primarily aortic regurgitation (AR). Associated procedures were done in 308 patients (33%). Overall operative mortality was 57/912 (6.3%), 29/640 (4.5%) for AYR alone, 20/228 (8.7%) for AVR + CABG and 8/44 (18%) for AVR + AAA. Overall operative mortality for AR was 19/255 (7.5%), 38/657 (6%) for AS; mortality for PV was 28/663 (4.2%), and 29/249 (11.5%) for TDV.

Long-term follow-up was analyzed for 511 PV and 191 TDV patients operated upon from 1/1/72 to 1/1/82, providing a minimum 12 mo. follow-up, 48 mos. Actuarial survival at 120 mos excluding no deaths was 61 ± 3%; for AS it was 64 ± 4% and for AR, 55 ±8% (p<0.01); probability of survival was 65 ± 5% for PV and 57 ± 5% for TDV (p<.02). Survival at 108 mos for AVR alone was 72 ± 4%, for AVR ± 11 (p< .01) and for AVR + AAA 45 ± 11 (p<.01). Survival probability for FC 1-3 was 70 ± 5, and 50±5 for FC 4 (p< .001). At 120 mos the probability of thromboembolism (TE) overall was 88 ± 2, for PV 88 ± 2 and 89 ± 3 for TDV (p = NS). Emboli/pt year were 1.8 for PV, 1.3 for TDV (p = NS). For PV in atrial fibrillation TE was 77 ± 5 vs 91 ± 3 for sinus rhythm (p< .002). Only 10% of PV patients (in AF) were on anticoagulation (A/C) while all TDV patients were on A/C; there were 6 major hemorrhages in TDV patients (3%, 0.6/pt yr). 4 TDV patients had total thrombosis (off A/C) and one in the PV group.

Primary valve dysfunction did not occur with TDV but did in 13/511 patients with PV (2.5%) (p< .006); freedom from valve dysfunction at 120 mos with PV was 88 ±7%. There were no differences in age groups for PV dysfunction. Perivalvar leak necessitated reoperation in 7 patients (6 PV, 1 TDV) (7%); freedom from PVL was 98 ± 1 at 120 mos. Late endocarditis oc-cured in 10 patients; probability free from SEE was 97 ± 1% in PV at 120 mos and 99% in TDV (p<.05).

The overall operative risk for AYR is now about 5%. Late survival reflects preoperative FC and associated cardiovascular disease. TE, valve thrombosis and A/C hemorrhage are major risks of TDV. Valve failure, primary or infectious, is the major risk factor of PV.

* By Invitation

18. Five-Year Experience with the St. Jude Valve Prosthesis

AURELIO CHAUX*, RICHARD J. GRAY*,

LAWRENCE S.C. CZER*, MICHELE A. DeROBERTIS*

and JACK M. MATLOFF

Los Angeles, California

Our 5-year experience with the bileaflet, St. Jude cardiac valve prosthesis has been analyzed. To ensure a minimum follow-up of one year, 198 patients (pts) receiving only St. Jude prostheses, between March 1978 and June 1982, were reviewed. All pts (mean age 63 yrs, range 6 to 84) were followed, for a total of 4896 pt months (mean 25 months). Mitral valve replacement (MVR) was performed in 90, aortic valve replacement (AYR) in 73, and MVR + AYR (DVR) in 35. Concomitant coronary bypass was performed in 101 (51%), with additional cardiac procedures in 22 (11%). There were 13 (6.5%) early and 30 (16.0%) late mortalities. One pt died one day after surgery due to prosthetic erosion into the atrioventricular groove. Two pts subsequently developed perivalvular leaks, both due to SBE. One-hundred seventy-six were anticoagulated with warfarin sodium and 9 were not. Nine thromboem-bolic episodes (TE) occured (2.5/100 pt years): 4 after MVR (2.3/100 pt years), 2 after AYR (1.3/100 pt years) and 3 after DVR (3.7/100 pt years). No episode of TE was fatal, but one pt experienced a residual right hemiparesis, and one had successful reoperation for a thrombosed aortic valve. There were no structural failures at any time. Thus, the total valve-related complication rate from all causes (TE, SBE-perivalvular leak, valve erosion, valve-related death) was 2.9/100 pt years (12 events). Of the surviving pts, 139 (90%) were improved by at least one NYHA class. No evidence of clinically-significant hemolysis or anemia was found in 50 pts studied a minimum of 2.5 years after surgery.

In summary, 5 years of pt follow-up after St. Jude cardiac valve replacement reveals: 1) structural valve failure has not occurred; 2) the TE rate is low (2.5/100 pt years) in properly-anticaogulated pts; 3) no clinical evidence of hemolysis has occurred; 4) the all-inclusive valve-related complication rate has been low (2.9/100 pt years).

These intermediate results, taken in concert with prior demonstration of excellent hemodynamic function, support the continued use of this cardiac valve prosthesis.

*By Invitation

19. Mitral Valve Replacement for Mitral Regurgitation With and Without Preservation of Chordae Tendinae

TIRONE E. DAVID*, MAURICE M. DRUCK*

and ROBERT J. BURNS*

Toronto, Ontario

PAUL A. EBERT

San Francisco, California

The operation of septation of the single ventricle has always appeared to be a more physiologic and desirable approach to patients with such conditions providing the AV valves functioned independently. The present experience related to four patients who had a staged partitioning of their single ventricle anomolies. The patients were identified to have a single ventricle of a common chamber type with increased pulmonary blood flow and a posterior position pulmonary artery that was in approximation to the tricuspid annulus. Their ages at the time of the first stage operation were three, six, nine and ten months. At this time, one patch was placed at the apex of the ventricle and a second patch at the superior portion of the ventricle between the AV valves. This was accomplished through the tricuspid orifice and a band was placed on the pulmonary artery. The time of second stage repair ranged from six to eighteen months. At this time the pulmonary artery band was removed and the pulmonary artery enlarged. A third patch was placed in the central portion of the ventricle to close the "large VSD". All four patients have survived. One child developed infundibular pulmonary stenosis two years after his second stage procedure. This subsequently required a right ventricle to pulmonary artery conduit. All four are in sinus rhythm and remain in general good health. Staging allows the apical and base patches to stiffen and avoids paradoxical motion of the artificial septum at the time of closure of the remaining "VSD".

*By Invitation

21. Reoperation for Obstructed Right Ventricle-Pulmonary Artery Conduits: Early and Late Results

HARTZELL V. SCHAFF*, ROBERTO M. DiDONATO*,

GORDON K. DANIELSON, FRANCISCO J. PUGA*,

DONALD G. RITTER* and DWIGHT C. McGOON

Rochester, Minnesota and Rome, Italy

Obstruction of right ventricle-pulmonary artery (RV-PA) conduits can result from neointimal peel formation and/or valvular degeneration and calcification. To determine the risks and outcome of reoperation, we have reviewed 100 consecutive patients (pts) who had replacement of severely stenotic RV-PA conduits between 10/16/72 and 5/25/83. Original reparative surgery was performed for transposition of the great arteries with ventricular septal defect (VSD) (37%), pulmonary atresia with VSD (26%), truncus arteriosus (24%), and other complex malformations (13%). At reoperation the 70 boys and 30 girls had a mean age of 13.3 ± 4.8 years (± SD). Seventy-three pts had fatigability or symptoms of right ventricular failure; in the remaining pts, conduit obstruction was diagnosed at routine examination. Associated cardiac defects were identified in 47 pts including: residual VSD (28); truncal, aortic, or tricuspid valve insufficiency (17); and hypoplasia or stenosis of the proximal right or left pulmonary arteries (22). During surgery 37 homografts, 61 Dacron grafts with integral porcine valves, and 3 other conduits were replaced with valved (83) or non-valved (17) pro-stheses. The mean RV-PA pressure gradient fell from 81 ± 6 preoperatively to 7 ± 8 mm Hg postoperatively (p<0.01). Concomitant cardiac valve replacement was performed in 7 pts, and residual VSD closure was accomplished in 26 pts. Operative (< 30 days) mortality was 7%, and all deaths occurred in pts who had additional operative procedures. There was no mortality among the 47 pts who only had replacement of the stenotic extracardiac conduit. At 3 and 5 years postoperatively, probability of survival among pts dismissed from the hospital was 94 ± 3% and 86 ± 6%, respectively. Conduit obstruction may produce serious late morbidity in children who have had otherwise successful repair of complex congenital heart disease, but in our experience risk of reoperation for conduit obstruction alone is low, thus minimizing the effect of graft failure on overall survival.

11:30 a.m. Address by Honored Speaker -

Left Ventricular Aneurysmectomy: Resection or Reconstruction?

ADIB D. JATENE, Sao Paulo Brazil

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

12:15 p.m. Cardiothoracic Residents' Luncheon - Trianon Ballroom

*By Invitation

MODERATOR: Floyd D. Loop, Cleveland, Ohio

Rochester, Minnesota

Boston, Massachusetts

Sponsored by: RICHARD D. WEISEL

PAUL A. EBERT