American Association for

Thoracic Surgery

65TH ANNUAL MEETING

Scientific Program

MONDAY MORNING, April 29, 1985

8:30 a.m. Business Session (Limited to Members)

8:45 a.m. Scientific Session - Grand Ballroom

1. Experiences with the Carpentier Techniques of Mitral Valve Reconstruction in 89 Patients

FRANK C. SPENCER, STEPHEN B. COLVIN*

And O. WAYNE ISOM

New York, New York

During the past 4 years (May 1980-August 1984) 89 patients have had some type of Carpentier reconstruction performed for mitral insufficiency. There were two hospital deaths, unrelated to the operative technique. No late deaths or major thromboembolic episodes occurred. All patients are clinically well. Doppler studies in 71 found no insufficiency in 60 patients, a trace in 10, and moderate insufficiency in one. Catheterization performed one to three years after operation in 15 patients found no signs of insufficiency. Valve replacement was later necessary in two patients for unrelated infections (heroin addiction).

The basic disease was rheumatic in 9, prolapse in 27, ruptured chordae and prolapse in 45, endocarditis in 2, coronary disease in 6. Two patients had severe annular calcification. Annuloplasty alone was adequate in only 16. Fifty-one had resection of two or more cm of mitral leaflet combined with annuloplasty. In 22 aortic lesions, chordae transposition or shortening was used.

The absence of recurrent insufficiency fully supports the durability of the reconstructive techniques. Multiple abnormalities were present in most patients, explaining the limited role of annuloplasty alone. With present techniques of myocardial preservation, probably the vast majority of non-rheumatic, non-calcified valves can be repaired. A much wider use of these techniques is indicated.

*By Invitation

2. Late Thrombosis of the Tricuspid Bjork-Shiley Tilting Disc Valve: Thrombolytic Treatment with Streptokinase

DEJAN BOSKOVIC*, IVO ELEZOVIC*

and DARINKA BOSKOVIC*

Beograd, Yugoslavia

Sponsored by: W. DUDLEY JOHNSON

Milwaukee, Wisconsin

The main complication after implantation of tricuspid Bjork-Shiley tilting disc valve is late thrombotic obstruction. Of 28 patients with tricuspid valve replacement (12 MVR + TVR and 16 MVR + AYR + TVR) (mean follow-up of 4.7 years), six (21.4%) developed thrombosis of tricuspid prosthesis, an incidence of 4.6 valve thromboses per 100 patient years. Thrombosis occurred 46, 43, 33, 35, 78 and 88 months after operation.

Clinical deterioration presented with signs of congestive heart failure. In all patients, the click of the tricuspid prosthesis was not heard and new systolic or diastolic murmurs were audible. The diagnosis was confirmed with bi-dimensional echocardiography (immobile disc, diminished opening angle of the disc).

Thrombolytic therapy with Streptokinase was used in all six patients. Treatment consisted of Streptokinase (initial loading dose of 250,000 IU then 150,000 IU/h) for 12 hours in two patients and 24 hours in four patients. Thrombolytic therapy was always monitored with thrombin time.

Complete regression of clinical, echocardiographic and radiological signs of thrombosis was seen in all six patients during the first 24 hours of thrombolytic treatment. There were no bleeding complications. In one patient, clinical signs of mild pulmonary embolism occurred and were confirmed with chest radiography.

Follow-up extends between 4-24 months, mean 13 months. In four patients, long-term results are excellent: There have been no clinical, radiological, or echocardiographic signs of thrombosis of tricuspid prosthesis.

Rethrombosis of tricuspid prosthesis was observed in two patients four and seven months after initial treatment with Streptokinase. Repeat thrombolytic treatment with Streptokinase was performed with success in both patients.

Summary: Fibrinolytic treatment with steptokinase seems to be treatment of choice for thombosis of tricuspid Bjork-Shiley valve and should always be tried before reoperation.

*By Invitation

3. Experience with 110 Consecutive Patients Undergoing Surgery for the Wolff-Parkinson-White Syndrome

JAMES L. COX, JOHN J. GALLAGHER*

and MICHAEL E. CAIN*

St. Louis, Missouri and Charlotte, North Carolina

Between July 1, 1980 and October 1, 1984, 110 patients underwent surgery for correction of the Wolff-Parkinson-White (WPW) syndrome by the senior author. There were 67 males and 43 females with ages ranging from 9 months to 70 years (mean, 28 ± 6 yrs). The major indications for surgery were medical refractoriness or drug intolerance (79%) and previous cardiac arrest (13%). Associated abnormalities included Ebstein's anomaly (8%), other arrhythmias (36%), coronary artery disease (5%), cardiomyopathy (6%), and other congenital heart disease (24%). Two patients had undergone WPW surgery previously at other institutions. Twenty percent of patients had multiple (2-4) accessory pathways, a total of 138 pathways being present in the 110 patients. Distribution of the accessory pathways was: 56% left free-wall, 24% posterior septal, 14% right free-wall, and 6% anterior septal. The surgical technique employed previously for the WPW syndrome was modified in August, 1981 to include: 1) 2.5 power optical magnification, 2) exclusive use of the endocardia! approach under cardioplegic arrest, 3) wider margins of surgical excision, 4) sharp dissection of the involved valve annulus,

5) division of only the ventricular insertion of the accessory pathway, and

6) internal identification of the ventricular epicardial peel in all regions of dissection. Using these modifications, 137 of 138 accessory pathways were divided successfully in the 110 patients. In comparison to our initial 200 patients previously reported, the modified surgical technique resulted in an increase in the success rate from 86% to 99.3%, a decrease in the reoperation rate from 19.5% to 0%, and a decrease in the incidence of heart block from 10.5% to 0.9%. The mortality rate was 5.5% in the entire series but only one death occurred following elective surgery in the absence of associated cardiac anomalies. The present surgical technique and attendant results suggest that surgery is the conservative alternative to a lifetime of medical therapy in young, otherwise healthy patients suffering from the WPW syndrome.

*By Invitation

4. Twelve Year Experience with Internal Mammary Artery for Coronary Artery Bypass

HENDRICK B. BARNER, JOHN W. STANDEVEN*

and JEFFRY REESE*

St. Louis, Missouri

From January 1972 to January 1984 1000 patients have had primary coronary reconstruction with one or two (100 patients operated between 6/72 and 6/74) internal mammary arteries (IMA). Patients having associated procedures such as valve replacement or aneurysmectomy were excluded. Prior to 6/74, patients were not selected and subsequently they were. Overall operative mortality was 1.3% but eight deaths occurred in the 100 patients having bilateral IMA bypass and all but one death occurred in the first 500 patients. Survival at five years is 89% and at 10 years 76%.

One or more postoperative cardiac catheterizations have been done in 485 patients; 345 of these were operated from 1972 through 1975 and 30% of them have had three postoperative studies. Patency for IMA grafts at one year is 94%, at five years 90% and at 10 years 88%. Patency for saphenous vein grafts in these same patients is 92% at one year, 81% at five years and 67% at 10 years. We have not recognized progressive graft atherosclerosis leading to IMA closure.

Although the durability of the IMA has been established this has not been firmly translated into enhanced survival. The right IMA was usually placed to the right coronary artery at the acute margin and did not bypass all disease so that follow up angiograms frequently revealed a patient IMA into a distally diseased or occluded vessel. More appropriate use of the right IMA is to the obtuse marginal artery, usually as an in situ graft, or to the posterior descending artery, usually as a free graft. It is hoped that use of bilateral IMA grafts, with sequential grafting when appropriate, will be associated with enhanced survival and a reduced need for reoperation.

10:00 a.m. Intermission - Visit Exhibits - Grand Salon

Complimentary Coffee

*By Invitation

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

5. Electron Microscopy in Selection of Patients with Small Cell Carcinoma of the Lung for Medical Versus Surgical Therapy

J. DIRK IGLEHART*, WALTER G. WOLFE,

WALTER B. VERNON*, ROBIN T. VOLLMER*,

JOHN D. SHELBURNE* and DAVID C. SABISTON, JR.

Durham, North Carolina

Although most patients with small cell carcinoma of the lung (SCCL) are currently managed by a combination of chemotherapy and radiotherapy, controversy continues concerning indications for surgical treatment. A study was conducted to determine the role of electron microscopic sections (EM) in establishing a pathological diagnosis in patients with SCCL. The EM findings were correlated with the clinical pathological state and the prognosis. Forty-five patients with a pulmonary lesion demonstrated on chest film were evaluated. Twenty underwent thoracotomy and 12 had biopsy of a metastatic lesion. Light microscopy (LM) of the tissue in each of these patients was reviewed independently. All EM preparations were examined for features of squamous epithelial differentiation, for features of adenocarcinoma, and for those which were classic for SCCL. A postoperative "TNM" state was established and actuarial survival determined for each group. When examined by EM, 26 (59%)of the neoplasms appeared to be classical SCCL, whereas 19 (41%) displayed features of squamous differentiation (15) or of adenocarcinoma (4). There was no relationship between LM and EM characteristics. While the majority of patients with classic SCCL by EM presented with inoperable disease and underwent biopsy of a metastatic lesion, 14 of 19 patients with electron microscopic features of squamous differentiation presented with operable disease and a curative resection was possible in 9. The actuarial survival in patients with EM features of squamous differentiation exceeded 25% at 5 years and was comparable to figures for bona fide squamous carcinoma. In contrast, only one patient with classic SCCL survived longer than 22 months. This study has identified a special and sizable group of patients with SCCL who have a quite favorable prognosis and cannot be distinguished by LM alone. In view of the markedly improved results with surgical therapy in this group, preoperative anatomic staging and selective surgical resection followed by EM examination is recommended.

*By Invitation

6. Treatment of Bronchopleural Fistula After Pneumonectomy

JOHN C. BALDWIN* and JAMES B.D. MARK

Stanford, California

Disruption of the closure of a mainstem bronchus after pneumonectomy is frequently a catastrophic complication; those patients who survive frequently develop empyema and bronchopleural fistula. Management of these fistulae remains a formidable therapeutic challenge, which has been approached with a variety of surgical techniques. We report our experience with anterior transpericardial closure of bronchopleural fistulae, emphasizing the possibility of approaching either mainstem bronchus and the efficacy of in-continuity ligation of the bronchus.

Three patients are presented, who developed bronchopleural fistulae after pneumonectomy. The first patient had left pneumonectomy for complicated tuberculosis; the second had right pneumonectomy for neoplasm; and the third had right pneumonectomy for trauma. All patients were approached surgically using median sternotomy and transpericardial approach to the distal trachea, dividing the posterior pericardium between the superior vena cava and aorta. Simple in-continuity staple closure of the proximal mainstem bronchus was employed in all cases. All patients are clinically well at 16, 12, and 2 months after surgery.

In post-pneumonectomy bronchopleural fistula, the technique of anterior transpericardial approach to bronchial ligation carries the advantages of the well-tolerated median sternotomy incision, the avoidance of dealing directly with a devascularized bronchial stump and areas of post-surgical scarring, the avoidance of areas of chronic sepsis, and the avoidance of surgical deformity of the chest wall with associated compromise in pulmonary function. Our experience also indicates that either mainstem bronchus is accessbile using an approach between the superior vena cava and aorta without division of either pulmonary artery. In addition, since closure of a divided distal bronchial stump would increase the risk of mediastinal sepsis and still leave a blind stump, we propose that the procedure of in-continuity staple ligation is safer and no less satisfactory from the theoretical viewpoint.

11:30 a.m. Presidential Address - Grand Ballroom

Observations On The Coronary Circulation

DAVID C. SABISTON

12:15 p.m. Adjourn for lunch

*By Invitation