MONDAY AFTERNOON, April 29, 1985

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

7. Complications of Tracheal Reconstruction - Incidence, Treatment and Prevention

HERMES C. GRILLO, PIERO ZANNINI*

and FABRIZIO MICHELASSI*

Boston, Massachusetts, Milan, Italy and Chicago, Illinois

Complications were analyzed in 365 consecutive patients who underwent tracheal resection and primary reconstruction for tumors and post-intubation stenosis between 1962 and 1982. Complications included: (I) those due to incomplete diagnosis, (II) technique and (III) miscellaneous. In I were: glottic incompetence (2), malacia (3), extent of lesion. In II were: granulation (28), anastomotic separation (4), stenosis (21), hemorrhage (2), laryngeal nerve injury (5). In III were: wound infection (6), laryngeal edema (1), respiratory failure (2), pneumonia (2).

Treatment included removal of granulations and steroid injection, re-suture of acute separation, tube stenting of delayed separation or stenosis and later resection, innominate artery repair or resection, T-tube by-pass for TEF with later repair, conservative management of cord palsy.

Prevention, as demonstrated by lesser incidence of complications in the second half of the series, includes use of absorbable sutures to avoid granulations, total removal of inflammatory lesions to avoid re-stenosis, avoidance of separation and stenosis due to excessive anastomotic tension, pre-operative definition of laryngeal incompetence and extensive malacia; peri-tracheal dissection to avoid innominate hemorrhage, peri-operative antibiotics and meticulous dissection, avoidance of devascularization, use of temporizing measures such as T-tube splinting and intralumenal excision of tumor to allow selection of optimal conditions for operation.

*By Invitation

8. Effects of Coronary Revascularization on Left Ventricular Function in Ischemic Heart Disease

J. SCOTT RANKIN*, GLENN E. NEWMAN*,

LAWRENCE H. MUHLBAIER*, VICTOR S. BEHAR*.

HARRY R. PHILLIPS* and DAVID C. SABISTON, JR.

Durham, North Carolina

Analysis of regional wall motion (RWM) during reperfusion of acute myocardial infarction has demonstrated reversibility of ischemic dysfunction in many cases. However, similar data about changes in RWM after coronary revascularization in broader categories of ischemic heart disease have not been available. Using conventional or digital subtraction techniques, 100 patients underwent coronary arteriography and biplane left ventriculography before and 7-14 days after coronary bypass grafting. RWM was assessed by the 100 segment method of Sheehan and Dodge, and a perioperative change in shortening of greater than 2 S.D. of normal variability in 20 or more adjacent segments was considered significant. 51 patients had stable or progressive angina (SA), 49 had medically refractory unstable angina (UA), 89 were NYHA class IV, and 20 had a preoperative left ventricular (LV) ejection fraction (EF) of less than 0.4. Myocardial integrity was preserved with crystalloid cardioplegia and topical hypothermia. 438 bypass grafts were performed (323 vein grafts and 115 mammary artery grafts), and 8 patients underwent concomitant LV aneu-rysmectomy. Overall postoperative graft patency was 95% (93% for vein grafts and 100% for mammary arteries). Only one patient had a decrement in RWM, and 46 had significant postoperative improvement (26 in UA and 20 in SA); of the patients with improved RWM, EF increased by an average of 0.18 (P<0.01). EF also improved in all patients undergoing aneu-rysmectomy (avg. of + 0.11; P<0.05), and the increment seemed to result from both a reduction in end-diastolic volume and improved RWM. Thus, reversible eschemic myocardial dysfunction appears to be common in the general population of patients undergoing coronary artery bypass grafting; 51% of UA and 39% of SA patients can be expected to improve RWM after successful revascularization. Finally, ventricular aneurysm resection significantly enhances LV performance as assessed by ventriculographic EF.

*By Invitation

9. Intraoperative Color Flow Mapping By Real-Time Two-Dimensional Doppler Echocardiography for Evaluation of the Valvular and the Congenital Heart Diseases, and the Vascular Diseases

SHINICHI TAKAMOTO*, SHUNEI KYO*,

YUJI YOKOTE* and RYOZO OMOTO*

Saitama, Japan

Sponsored by: MORTIMER J. BUCKLEY

Boston, Massachusetts

No accurate methods for intraoperative evaluation of the valvular and the congenital heart diseases, and the vascular diseases in the dynamic state have existed. We have newly developed real-time two-dimensional Doppler echocardiography (2-D Doppler) which displays real-time color flow mapping on B-mode echocardiogram. Flow towards the transducer is displayed by red color and flow away from it by blue color. Velocity of the flow is displayed in direct proportion to the brightness of the color. This study was performed to examine the clinical usefulness of intraoperative 2-D Doppler in the valvular and the congenital heart diseases and the vascular diseases. Intraoperative 2-D Doppler was performed in 17 patients. 6 valvular (MS 1, TR 1, AR 2, other 2) and 5 congenital heart diseases (VSD 2, ASD + MR 1, d-TGA 1, other 1) and 8 vascular diseases (Dissecting Aortic Aneurysm 8). In valvular diseases status of regurgitation after mitral commissurotomy and repair of the valve, and that of untouched valve were evaluated in the beating state and necessity of valve replacement was checked. In congenital heart diseases pre-operative diagnoses were confirmed, location of VSD was precisely determined and post-repair states were evaluated. 2-D Doppler guided blade atriosep-tostomy in d-TGA was performed successfully. In the dissecting aortic aneurysms sites and size of even small entry and re-entry, flow dynamics in the true and false lumens were displayed and the precise operative procedures were determined. And the post-operative flow status in the graft anastomosis, the residual dissection and the major aortic branches were evaluated.

In conclusion intraoperative 2-D Doppler can display clearly and easily the intra-cardiac and vascular abnormality of not only the structure but also flow dynamics in a short time. Intraoperative 2-D Doppler is very effective in evaluating pre- and post-operative states and determining the precise operative procedures in the cardiovascular diseases.

3:00 p.m. Intermission - Visit Exhibits - Grand Salon

Complimentary Coffee and Soft Drinks

*By Invitation

3:45 p.m. Forum Session - Grand Ballroom

10. Retained Intracardiac Air: Transesophageal Echo-cardiography for Definition of Incidence and Monitoring Removal by Improved Techniques

YASU OKA *, TETSUHIDE INOUE*, YONG HONG*,

DONATO A. SISTO*, JOEL A. STROM*

and ROBERT W.M. PRATER

The Bronx and New York, New York

Retained intracardiac air is a continued hazard for cardiopulmonary bypass (CPB). M-mode TEE of LA, LV & Ao is a highly sensitive method for detecting retained intracardiac air bubbles. In 15 valve surgery (VS) and 18 coronary bypass (CABG) patients - M-mode TEE was used to record air bubble presence during and for 15 minutes after bypass. Routine air cleaning methods were: ascending Ao needle aspiration (VS & CABG), LA & LV & Ao aspiration after careful passive chamber filling (VS).

12/15 (79%) VS patients and 2/18 (11%) CABG patients had air detected. One with Ao air had visible R coronary air embolism. Three patients with positive echograms had transient CNS disturbances. In a further eleven (11) VS patients, Asc. Ao to Venous shunt were instituted before discontinuing bypass but air continued to be present in the LA. Finally, in 7 patients, positive chamber filling with echo demonstration of LA stretching, vigorous chamber ballottement, specific echo directed chamber aspiration and maintenance of CPB until TEE was negative for retained air were added to the routine. Although small amounts of atrial air could still be detected for a minute or two in some patients, this technique appears finally to have eliminated significant retained air and its consequences.

A sensitive technique for intracardiac air detection reveals retained air surprisingly often post CPB. There are both possible and probable adverse consequences of this air. After VS, LA air is the most difficult to eliminate. The essential elements of air removal are: 1) Mobilization of the air: positive chamber filling, stretching the atrial wall and ballottement are critical. 2) Removal of mobilized air: continuous Asc. Ao to venous shunting and non-suction LA venting are very important. 3) Proof of elimination prior to ending CPB: TEE is vital for this.

*By Invitation

11. Cryoprecipitate-Topical Thrombin Glue: Initial Experience in Cardiac Surgery Patients

FLAVIAN M. LUPINETTI*, WILLIAM S. STONEY,

WILLIAM C. ALFORD, JR., GEORGE R. BURRUS*,

DAVID M. GLASSFORD, JR.*,

MICHAEL R. PETRACEK* and

CLARENCE S. THOMAS, JR.

Nashville, Tennessee

The use of fibrin glues as topical hemostatic agents is reported in numerous clinical series in the European literature. We have composed a fibrin glue in our operating rooms from cryoprecipitate and topical thrombin (5000 units/5 ml saline) in equal volumes applied directly to the site of bleeding. This report describes our initial experience using cryo-precipitate-topical thrombin (CTT) in 26 patients undergoing open-heart operations. Severe bleeding not responding to usual methods of control was encountered during or after CAB (n= 17), valve replacement (n = 3), CAB + valve replacement (n = 5), or repair of post-infarction VSD (n = 1). Five patients were operated on emergently and 4 were undergoing their second open-heart operation. CTT was used in 4 patients while on bypass and fully heparinized and in 17 patients who continued to bleed after separation from bypass and administration of protamine. Hemostasis was achieved in all cases and none required reexploration for bleeding. In 5 patients who were reexplored for postoperative hemorrhage (none having received CTT during the initial operation), CTT provided hemostasis when other measures failed, and no additional reexplorations were needed. No patient developed hypersensitivity, fibrinolysis, or coagulopathy following the use of CTT. In 18 patients surviving and discharged from the hospital, no hepatitis has occurred over a follow-up period of 3 to 6 months. The highly concentrated fibrinogen in cryoprecipitate is activated by thrombin to form fibrin and bring about rapid hemostasis. CTT is a readily available, reliable, and inexpensive topical hemostatic agent in the cardiac surgery patient.

*By Invitation

12. Externally Stented PTFE Valved Conduits for Right Heart Reconstruction: An Experimental Comparison with Dacron Valved Conduits

JOHN W. BROWN, MICHAEL P. HALPIN*,

FRED J. RESCORLA*, BRUCE W. VANNATTA*,

ANDREW C. FIORE*, GARY D. SHIPLEY*,

MOGES BIZUNEH*, RANDY BILLS*

and BRUCE WALLER*

Indianapolis, Indiana

Valve containing conduits have made possible the repair of many congenital anomalies which involve right ventricular to pulmonary artery (RV-PA) discontinuity. The distressing problem of neointimal peal (NP) formation with eventual conduit obstruction in clinical series of Dacron valved conduits (DVC) has led to the need for premature replacement in many patients. Externally stented polytetrafloroethelene (ES-PTFE) has demonstrated superior patency in the venous system experimentally and clinically and may offer advantages when compared to Dacron for the development of NP. The purpose of this study was to compare the trans-conduit resistance and the thickness of NP in RV-PA valved conduits constructed of ES-PTFE with those of woven Dacron.

Nineteen millimeter ES-PTFE conduits (Impra) containing a porcine valve (Hancock-Extracorporeal) were implanted in six adult mongrel dogs followed by proximal PA occlusion. In six additional animals a DVC of similar size and length was inserted. Cardiac Output (CO), transconduit gradient (G) and resistance (G/CO) were measured at operation and at 3 months. All conduits were subsequently explanted, opened longitudinally and the thickness of the NP (excluding suture lines) measured. Groups were compared statistically using a T test.

Cardiac output and resistance were not significantly different between the two groups (P<.09). The NP was four-fold greater in DVC (P<.01). ES-PTFE conduits had a thin, uniform NP with normal opening valves, while DVC had a thick NP which extended into the valve cusps limiting leaflet excursion.

This study demonstrated: (1) the early hemodynamic performance of ES-PTFE conduits was comparable to that of DVC; (2) DVC demonstrated an accelerated rate of NP formation which affected cusp mobility; and (3) ES-PTFE conduits formed a thin neo-intima and valve leaflet motion was preserved.

These data suggest that right heart conduits constructed of externally stented PTFE offer advantages over Dacron valve conduits and warrant careful clinical trial.

*By Invitation

13. Double Orifice Mitral Valve in AV Canal Defect: Surgical Experience in 25 Patients

CHUEN-NENG LEE*, GORDON K. DANIELSON,

HARTZELL V. SCHAFF*, FRANCISCO J. PUGA

and DOUGLAS D. MAIR*

Rochester, Minnesota

Double orifice mitral valve is an uncommon, but surgically important condition. Our surgical experience with 25 cases of double orifice mitral valve associated with atrioventricular (AV) canal defects (16 partial and 9 complete) was reviewed. This constituted 4.3% of the 581 cases of AV canal defects operated upon between 1961 and July 1984. Of the 24 cases in which the interconnecting tissue bridge was left intact, all survived surgery. The single operative death (4.0%) occurred in an early (1967) patient in whom the tissue bridge was severed, resulting in massive mitral regurgitation. The combined mitral orifice area ranged from 85% to 91% of normal in those valves sized intraoperatively. Two patients required mitral valve replacement for mitral regurgitation 3 and 11 yrs postoperatively, respectively. Of 23 patients with cleft mitral valves, 20 had partial or complete closure of the cleft. All patients had either none or only mild mitral stenosis at a mean follow-up of 6 yrs. Double orifice mitral valves without clefts are usually competent. Many of those valves with clefts are incompetent at the cleft. Complete closure of the cleft may cause hemo-dynamically signficant mitral stenosis. Repair should be made so that a minimum amount of mitral insufficiency and mitral stenosis remain. Measurement of valve orifice areas and comparison with standard tables, intraoperative valve testing, and post-repair double sampling dye curves improve accuracy of the repair. In most patients, an excellent repair can be accomplished with very low mortality.

*By Invitation

14. Saphenous Vein and Intraoperative Evaluation of the Coronary Arterial System Using Angioscopy in Cardiac Surgery

BENJAMIN WESTBROOK*, HAROLD L. LAZAR*,

JOHN R. McCORMICK*, TIMOTHY A. SANBORN*

JOERGEN RYGAARD* and ARTHUR J. ROBERTS*

Boston, Massachusetts

Sponsored by: IRVING MADOFF

Brookline, Massachusetts

Improvements in fiberoptic systems have permitted the development of clear photographic images processed through flexible 1.5 to 1.7 mm solid state catheters. Accordingly, intraoperative assessment of the luminal anatomy of the saphenous vein, native coronary arteries and anastomotic relationships between these structures were evaluated during coronary artery bypass graft surgery. In addition, changes in native coronary obstructions prior to and following intraoperative balloon catheter dilatation were visualized. Preliminary evaluation was performed in a group of patients during a period of cardioplegic arrest utilizing hypothermic crystalloid potassium cardioplegia. The fiberoptic catheter was inserted into the vascular system through a coronary arteriotomy or a previously completed distal coronary artery-saphenous vein anastomosis. Native coronary artery obstructions were identified by this process and semi-quantitative correlations with preoperative coronary angiograms showed reasonable correlations in terms of the extent of luminal narrowings. Coronary artery anastomoses showed a wide range of patency and, in some cases, intraluminal projections related to native vessel disease or imperfect coronary anastomoses were identified. Improvements in luminal diameter related to balloon catheter dilatations were also clearly discernible. There were no vessel dissections, coronary perforations, or mortalities associated with the use of this new and intriguing technique. Further evaluation is warranted and is presently in progress.

*By Invitation

15. Immediate Tricuspid Valve Replacement for Endocarditis: Indications and Results

HENRY J. STERN*, DON A TO A. SISTO*,

JOEL A. STROM*, RUY SOEIRO*, STEPHAN R. JONES*,

and ROBERT W.M. PRATER

New York, New York

Tricuspid valve excision is currently recommended for TE in addicts and purports to avoid 1) early and 2) late postoperative infection and 3) any severe hemodynamic cost to the patient. Three (3) patients had TV excision. All left with gross Tl and one was last seen in critical failure. We report the alternative policy of routine TVR with bioprostheses in 10 patients over 3½ years. Indications for surgery: Uncontrolled infection 10; Repeated pulmonary embolism 7; Valvular insufficiency 3. All 10 had Staphylococcus Aureus (SA) infection and 2 had additional other organisms. All had vegetations > 1 cm. in size on echo. Preoperative complications: Organ failure - Hepatic (2); Resp. (1) and Renal (4); Pericarditis (2); Empyema (2); Recurrent hemoptysis (1); Septic Arthritis (1); Anemia (8); Thrombocytopenia (6); Vasculitis (1). There was no in-hospital mortality and all patients left infection free. At least 3 patients returned to their addiction. One needed repeat TVR at 28 mos. One patient died at 5.5 mos. (perforated DU + torulopsosis). There was no evidence of prosthetic valve endocarditis at autopsy.

Indications: To put these findings in perspective - 22 consecutive patients with TE were studied in one year. Infecting agents: Staph A: 13 (8 vegs.>l cm.). Other organisms 9 (2 vegs.>l cm.). During the year 3 had TVR for uncontrolled infection. All had Staph infection with vegs.>1 cm. All 22 patients left hospital infection free.

Conclusions: TE rarely needs surgery. Failed antibiotic therapy occurs in Staph infection with large vegs. and is the likeliest cause for surgery. TVR is not accompanied by early reinfection and avoids congestive failure. Chronic addiction is a mortal disease with or without a tricuspid valve prosthesis.

*By Invitation