WEDNESDAY AFTERNOON, May 9, 1984

1:30 p.m. Scientific Session - Grand Ballroom - Third Floor

38. Bronchoscopy After Cardiopulmonary Transplantation

JOHN C. BALDWIN*, STUART W. JAMIESON*,

PHILIP E. OVER*, EDWARD B. STINSON*,

NORMAN E. SHUMWAY and JAMES B.D. MARK

Stanford, California

Fifteen combined heart and lung transplants were performed between March, 1981 and August, 1983. The technical aspects of this operation, including the use of continuous polypropylene anastomoses, has been described. Six of these patients have undergone bronchoscopy at varying intervals after transplantation; five of these procedures were done for specific clinical indications; one was done incidentally during another surgical procedure requiring general anesthesia. We report the endoscopic and pathologic findings in these patients.

All patients had intact, healing tracheal anastomotic suture lines; there were no instances of tracheal stenosis. One patient had minimal granulation tissue along the suture line. The distal tracheobronchial tree appeared endoscopically normal in the transplanted lungs, except in areas of known infiltrates. Four of the patients had endobronchial biopsies, and all showed evidence of chronic inflammation in the submucosa. Eosinophilic pro-teinaceous exudate was noted in the alveolar air spaces in three of the four patients biopsied. No patient was bronchoscoped during a period of cardiac rejection documented by endomyocardial biopsy.

Controversy exists as to the optimal technique for tracheal anastomosis, but in the case of the steroid-treated, immunosuppressed transplant patient, the technique of continuous anastomosis with polypropylene yielded satisfactory results, free of recognized potential complications of early leakage, failure of healing, stenosis, and development of suture-related granulation tissue. Trans-bronchoscopic endobronchial biopsy may not be helpful in diagnosing pulmonary rejection. All patients in this group who were biopsied showed submucosal chronic mononuclear cellular infiltrates, and most had intra-alveolar eosinophilic exudates. These findings were not associated with evidence of cardiac rejection in these patients.

*By Invitation

39. Bronchial Carcinoids: A Review of 111 Cases

BRIAN C. McCAUGHAN*, NAEL MARTINI

and MANJIT S. BAINS*

New York, New York

The medical records of 111 patients with bronchial carcinoids seen between 1949 and 1983 were reviewed. There were 59 females and 52 males. The age range was 12 to 82 years (median 55 years).

Ten of the tumors were incidental pathologic findings at autopsy or surgery. These were excluded from survival data determinations. At the time of diagnosis 87 patients had disease localized to one hemithorax, 14 had distant metastases. The latter were more commonly male and smokers and their tumors had a more malignant histologic appearance compared to the patients with localized disease. Those with distant disease were treated with external radiation and/or chemotherapy and their median survival was 6 months.

Of the 87 with localized disease endobronchial resection was performed in 5 and pulmonary resection in 82 (pneumonectomy 11, bilobectomy 8, lobec-tomy 45, sleeve resection 3, segmentectomy 15). Disease free actuarial survival (Kaplan-Meier) following pulmonary resection was 91% at 5 years and 81% at 10 years. Factors predisposing to recurrence were central location of the tumor, a more malignant histologic appearance and regional lymph node metastases. Disease free survival at 5 and 10 years in 12 patients who had regional lymphatic metastases was 63% and 48% compared with 96% and 88% in those without lymphatic metastases (p = .003).

Complete resection of tumor and involved lymph nodes was associated with long term disease free survival in 4 of these 12 patients. Recurrence following endobronchial resection was observed in 3 of 5 patients.

We conclude that a) carcinoid tumors are malignant and 10% present with metastases and b) for those with clinically localized tumors, the prognosis is determined by the status of the regional lymph nodes which must be assessed at thoracotomy.

*By Invitation

40. Management of Recalcitrant Median Sternotomy Wounds

PETER C. PAIROLERO* and PHILLIP G. ARNOLD*

Rochester, Minnesota

Sponsored by: GORDON K. DANIELSON

Rochester, Minnesota

During the past 7 years, 35 patients (30 males and 5 females) had repair of a chronically infected median sternotomy wound. Ages ranged from 13 to 73 years (mean 54.4 years). Sternotomy was performed for cardiac disease in 32 patients and for tumor in 3. Four patients had prior mediastinal radiation. Infection had been present a mean of 7.3 months (range 1 to 78 months). Skin pathogens were the most frequently cultured organisms; 3 patients had fungal infections; 9 patients had associated costochondritis.

All patients required sternal debridement; 7 had full thickness resection. Sternal rewiring was performed in 12 patients. Prosthetic material was not utilized. Reconstruction was with muscle transposition in 31 patients, omen-tal transposition in 2, and both in 2. The pectoralis major muscle was transposed in 30 patients; 25 had simultaneous bilateral transpositions. The number of operations (including debridement) to reconstruct the sternum ranged from 1 to 6 (mean 2.7). The wound was closed at the time of muscle transposition in 26 patients. There were no operative deaths or immediate postoperative wound infections. Mean hospitalization was 18.4 days (range 5 to 44 days).

Follow-up ranged from 2 to 65 months (mean 22.9 months). There were 4 late deaths, none related to wound reconstruction. Two patients developed recurrent sternal infections; both responded to further debridement and reutilization of the previously transposed muscle. One patient developed a subphrenic abscess. All 35 patients eventually had a healed, stable wound. We conclude that muscle transposition is an excellent method of management for recalcitrant median sternotomy wounds.

*By Invitation

41. Encircling Endocardia! Resection With Complete Removal of Endocardial Scar Without Intraoperative Mapping for the Ablation of Drug Resistant Ventricular Tachycardia

RODERICK W. LANDYMORE*, CECIL E. KINLEY*,

MARTIN J. GARDNER* and DAVID A. MURPHY

Halifax, Nova Scotia

Although localized endocardial resection (LER) guided by intraoperative mapping has proven superior to simple aneurysmectomy for drug resistant ventricular tachycardia (VT) LER fails to ablate reentrent ventricular arrhythmias in 15 to 20% of patients. Recently, we have employed encircling endocardial resection (EER) with complete removal of endocardial scar in 10 patients without intraoperative mapping. Reproduceable sustained VT was induced in all patients preoperatively with programmed electrical stimulation (PES). PES was performed at twice the diastolic threshold with single and double premature extra stimuli. All 10 patients had failed a trial of conventional antiarrhythmics; 7 patients required frequent cardioversion and 3 patients required overdrive suppression with transvenous pacing. Ejection fraction, estimated by bi-plane angiography, ranged between 20 - 56% (X 31), cardiac index ranged between 1.5 - 2.7 1/m² (X 2.4) and left ventricular end diastolic pressure at rest ranged between 15-32 mmHg (X 22). EER was performed in all patients with complete removal of endocardial scar. EER required reimplantation of the mitral apparatus in 9 patients. 8 patients underwent aneurysmectomy and 9 patients_required concommitant aortocoronary bypass receiving a total of 13 grafts (X 1.3 grafts per patient). There were no spontaneous postoperative arrhythmias. PES was carried out following EER with single, double and triple premature extra stimuli; only 1 patient without postoperative clinical arrhythmias who had required daily preoperative cardioversion had induceable VT with postoperative PES but not after loading with Procainamide. Mean follow-up is 8.9 months. 8 patients are alive and well. There were 2 late deaths. 1 patient died with recurrent ventricular septal defects 2.5 months following extensive septal EER and 1 patient with massive pulmonary embolus and right heart failure at 4 months. This early experience suggests that EER with complete removal of endocardial scar successfully ablates reentrent VT. We feel that EER will prove to be more effective than LER because EER removes all ventricular sites that have the potential to generate reentrent VT. This data also indicates that ventricular septal defects are a potential hazhard of extensive septal endocardial resection and has resulted in the use of a prophylactic septal patch in the last 2 patients.

*By Invitation

42. Cardiac Surgery in Patients with Functioning Renal Allografts

R. MORTON BOLMAN, III*, ROBERT W. ANDERSON,

J. ERNESTO MOLINA, JEFFREY S. SCHWARTZ*,

BARRY LEVINE*, RICHARD L. SIMMONS*

and JOHN S. NAJARIAN*

Minneapolis, Minnesota

The Transplant Service at the University of Minnesota Hospitals has performed nearly 2000 kidney transplants. Fourteen of these patients have developed cardiac conditions necessitating surgical intervention at intervals of 9 to 120 months (average 54 months) following their transplant. These patients had a mean age of 42 years and 5 (36%) were diabetic. All patients had functioning renal allografts with preoperative serum creatinines ranging from 1.0 to 3.2 mg/100 ml (average 1.4 mg/100 ml). All patients were receiving azathioprine and prednisone as their immunosuppressive therapy except two, whose immunosuppression had been discontinued due to life-threatening infection.

Ten patients underwent aorto-coronary saphenous vein bypass grafting (ACBP). One patient underwent two vessel ACBP and concomitant left ventricular aneurysmectomy. Two patients underwent surgery for native valvular endocarditis. One had tricuspid valve debridement for fungal endocarditis, and the other aortic valve replacement (AYR) for bacterial endocarditis. The final patient had calcific aortic stenosis and coronary artery disease (CAD), necessitating AYR and ACBP x 2.

Intraoperative management consisted of routine narcotic anesthesia combined with infusion of a mixture of furosemide in mannitol sufficient to maintain urine output of at least 50-100 ml/hour. Mean arterial pressure was maintained at 70 mmHg or greater during cardiopulmonary bypass to assure adequate perfusion of the renal graft. Myocardial protection consisted of moderate systemic hypothermia (28°C) combined with cold potassium car-dioplegia for periods of ischemia.

Two patients (14%) expired perioperatively. One was a young juvenile onset diabetic with markedly unstable angina who expired suddenly several days after surgery and at autopsy was found to have an occluded right ACBP and extensive infarction. The other was a 51-year-old lady with calcific aortic stenosis and CAD with unstable angina who expired in surgery from uncontrollable arrhythmias. There was one late death (7%) from non-cardiac related causes. The remaining 11 patients are alive and well at intervals of 3 to 82 (mean 25 months) after surgery. Postoperative serum creatinines averaged 1.4 mg/100 ml, unchanged from preoperative levels. Cardiac surgery can be performed safely in patients with functioning renal allografts. Patient survival was acceptable and preservation of renal function was uniformly successful in this group of patients.

*By Invitation

43. Myocardial Surgical Revascularization Following Streptokinase Treatment for Acute Myocardial Infarction

JACQUES GEORGES LOSMAN*,

GUILLERMO C. DACUMOS*,

CHRISTOPHER R. JONES*, DOUGLAS NAGLE*,

ALLAN S. WILENSKY*, R. NEWELL FINCHUM*,

ROBERT G. MARTIN*, MARTIN T. BAILEY*

and DONALD R. KAHN

Birmingham, Alabama

Sixty-one patients (pts) admitted with acute myocardial infarction (MI) were treated with intra-coronary (ICOR, 39 pts) or intravenous (IV, 22 pts) Streptokinase (STR). There were no STR related complications. Group I, 25 ICOR-STR pts and Group II 14, IV-STR pts underwent coronary artery bypass grafting (CABG). Group I included 19 males (ages 40 to 69 years, mean = 54 ± 9) and 6 females (ages 38 to 70 years, mean = 58 ± 11). Admission ECG evidenced antero-lateral MI in 17 pts and inferior MI in 8. Peak CPK ranged from 190 U to 9000 U (mean = 2466 ± 2237, median = 2150). MB fraction ranged from 2% to 46% (mean = 26 ± 11, median = 26). Time from onset of symptoms to ICOR-STR was 290 ± 55 min. Fibrinogen blood levels decreased to 27% of control values 0.61 ± 0.2 mg/L versus 2.23 ± 0.2 mg/L). In 6 pts ICOR-STR failed to re-open the obstructed coronary artery (COR). All 6 developed severe hypokinesia (hypok) in that COR supplied area. Re-canalization occurred in 19 pts, the residual stenosis ranged from 80% to 99%. Severe hypok developed in the supplied area in 4 pts (one apical aneurysm). Five pts developed mild to moderate hypok and 11 (58%) had no myocardial damage. Group II included 12 males (ages 37 to 71, mean = 56 ± 10) and 2 females ages 62 and 72. Admission ECG evidenced antero-lateral Mi's in 4 pts and inferior Mi's in 10 pts. Peak CPK ranged from 230 U to 8100 U (mean = 2187 ± 2008, median = 1700), MB fraction ranged from 1% to 29% (mean = 16% ± 7, median = 15%). Time from onset of symptoms to IV-STR was 163 ± 89 min., with symptoms relieved in 13/14 pts after 43 ± 29 min. In 4 pts IV-STR failed to re-open the COR. Severe hypok of the supplied area developed in 3 (one apical aneurysm), and moderate hypok in one. In 10 pts (71%) IV-STR re-opened the COR. One pt developed severe and 2 pts moderate hypok in the COR supplied area. Group I and II did not differ significantly for any of the parameters analyzed. In Group I, 10 pts (40%) and in Group II, 7 pts (50%), had no evidence of muscle damage on ventriculography or on direct inspection at surgery. CABG (3.3 ± 0.9 graft/pt) were performed without operative or early postoperative mortality. In conclusion, STR appears to be a useful agent to salvage myocardium and JV-STR may be as effective as ICOR-STR. IV-STR has advantages of earlier administration, (p<0.05), no invasive procedure and lesser cost.

3:30 p.m. Adjourn

*By Invitation