WEDNESDAY MORNING, May 10, 1989
7:30 a.m. SYMPOSIUM I - AORTIC DISSECTION
MODERATOR: Randall B. Griepp, M.D., New York, NY
PANELISTS: E. Stanley Crawford, M.D., Houston,
TX
M. Arisan Ergin, M.D., New York,
NY
Nicholas Kouchoukos, M.D., St.
Louis, MO
D. Craig Miller, M.D., Stanford,
CA
7:30 a.m. SYMPOSIUM II - SURGERY OF EMPHYSEMA
MODERATOR: Jean DesLauriers, M.D., Sainte-Foy,
Quebec, Canada
SURGICAL APPROACH TO BULLOUS
EMPHYSEMA
Edward A. Gaensler, M.D., Boston,
MA
OPERATIVE STRATEGIES AND
RESULTS OF SURGERY
Jean-Paul Whitz, M.D., Strasbourg,
France
ROLE OF SURGERY IN DYSPLASTIC
TRACHEA
Mr. H. Hsrzog, Basel, Switzerland
NEW PERSPECTIVES IN SURGERY FOR
DIFFUSE NON BULLOUS EMPHYSEMA
Marcel Dahan, M.D., Toulouse,
France
9:00 a.m. SCIENTIFIC SESSION - HYNES BALLROOM
26. 30 Year Follow-Up of Superior Vena
Cava-Pulmonary Artery Shunts
GARY S. KOPF*.
HILLEL LAKS,
HORACE C. STANSEL,
WILLIAM E. HELLENBRAND*,
CHARLES S.
KLEINMANN* and NORMAN S. TALNER*
New Haven,
Connecticut
Superior vena cava-pulmonary artery shunt
(SVC-PAS), (Glenn shunt) as first performed clinically at our institution in
1958. From then through September 1988, 91 patients have undergone SVC-PAS. We
here report the follow up data available on all patients.
Patients' age ranged from 1 month to 46 years
(mean 6.8 yrs). Diagnoses were: tricuspid atresia 27, single ventricle 22,
tetralogy of Fallot 14, D-TGA +VSD + PS 9, TGA 5, Ebstein's anomaly 4, PA +
intact septum 4, others 6. Hospital mortality was 7.7% (1 death in the last 53
patients 1.9%); 5 of the patients who died were 4 months of age or younger.
Arterio-venous fistula formation (AVF)
occurred in 18 patients (19.7%), 6 of whom have undergone therapeutic
embolization with improvement in saturation. The incidence of AVF increased
with time post shunt. Desatura-tion due to venous collaterals occurred in 2
patients, and a patent SVC-RA connection in 1. No shunt thrombosis or
obstruction due to stricture formation occurred following discharge from the
hospital. Improvement in saturation was obtained following SVC-PAS in 8
inoperable patients by creation of a right axillary arterio-venous fistula up
to 12 years following shunt placement. Three patients had conversion of a right
Blalock-Taussig shunt to a SVC-PAS to decrease the volume load on a failing
ventricle and to improve saturation. Thirty patients underwent physiological
repair (Fontan procedure or modification in 26 and biventricular repair in 4,
with 4 deaths (13.3%). In 3 instances, the SVC-PAS was taken down to provide
continuity between the left and right pulmonary arteries; otherwise the shunt
was left intact. Compared to patients without prior SVC-PAS, hospital mortality
was not significantly different. Thirty years following SVC-PAS, the first
patient in this series is married and working full time, having undergone a
modified Fontan procedure (RA-LPA connection) in 1981.
We conclude that SVC-PAS, usually with
supplemental procedures to enhance oxygenation, has provided excellent
physiologic palliation with low mortality up to thirty years with no late
thrombosis or stricture formation. Pulmonary A-V fistula formation increases
with embolization. Physiological repair following SVC-PAS carries a low
mortality with good long term survival. Although currently used infrequently,
SVC-PAS, particularly with end-to-side anastomosis, remains a useful method of
palliation in selected patients.
*By Invitation
27. The Bi-Directional Cavopulmonary Shunts
JOHN J. LAMBERTI,
ROBERT L. SPICER*,
TODD M. GREHL* and
J. DEANE WALDMAN*
San Diego, California
The bi-directional cavopulmonary shunt (CPS)
improves systemic arterial oxygen saturation without increasing ventricular
work or pulmonary vascular resistance. A CPS is ideal palliation for patients
destined for a right atrium to pulmonary artery connection (RH-PAC). Since
1983, 15 patients have undergone CPS (5 primary operations, 10 secondary
operations). Diagnoses were: asplenia; 2, single ventricle; 2, pulmonary
atresia and intact ventricular septum; 6, tricuspid atresia; 3, hypoplastic
left heart; 1, TGA with hypoplastic LV; 1. Age at primary operation ranged from
3.5 to 30 months (median = 6 mos.). Weight ranged from 3.5 kg. to 9.7 kg. Age
at secondary operation ranged from 10 mos. to 14 yrs. (median = 15 mos.). Six
CPS were performed through a right thoracotomy utilizing a temporary shunt.
Nine CPS were performed on cardiopulmonary bypass (CPB). All CPB patients had
additional procedures: Takedown modified Blalock-Taussig shunt, 7; revise right
ventricular outflow tract, 4; reconstruct pulmonary arteries, 4; tricuspid
valvuloplasty, 1. There was no operative mortality. One patient required early
revision. Follow-up ranges from 1 to 53 months. Twelve of 15 had a good to
excellent late result. Two patients died late (pulmonary vascular disease, 1 pt.,
pulmonary A-V malformations, 1 pt.). There was one late failure (converted to
Glenn). The CPS is an excellent palliative procedure when RA-PAC must be
deferred because of age, weight or anatomic considerations. In addition, at the
time of RA-PAC (modified Fontan) the CPS approach may optimize the anatomic
connection (8 additional patients).
*By Invitation
28. Unifocalization and Complete Repair of
Patients with Pulmonary Atresia, Ventricular Septal Defect and Systemic
Collaterals
FRANCISCO J. PUGA, FRANCO
E. LEONI*,
PAUL R. JULSRUD* and
DOUGLAS D. MAIR*
Rochester, Minnesota
and Edmonton, Alberta, Canada
Arborization abnormalities of the peripheral
pulmonary arterial tree in patients with pulmonary atresia and ventricular
septal defect have limited the success of attempts at complete surgical repair.
Techniques at surgical Unifocalization have allowed disconnection of pulmonary
arterial branches from systemic collateral arteries with concomitant
anastomosis to other branches and creation of centrally accessible sources of
pulmonary arterial blood flow. Thus, an anatomic situation is created which
permits complete correction of the anomaly. From 1982-1988 we have operated 115
patients in whom 60 unifocalizations were performed. All patients had pulmonary
atresia, ventricular septal defects, and systemic collateral arteries supplying
the majority of pulmonary arterial segments. A total of 93 extrapericardial
anastomoses were performed and 80 systemic collaterals interrupted. Procedures
included: direct pulmonary arterial branch anastomosis (Type I),
in-terpulmonary conduit interposition (Type II), patch angioplasty of
communicating pulmonary arterial branches (Type III), and establishment of
in-trapericardial pulmonary confluence (Type IV). There were 3 deaths resulting
from the Unifocalization procedure (5%). Twenty-five patients have completed
bilateral Unifocalization procedures. Two of these have been rejected for
complete repair due to persistent restriction in pulmonary arterial runoff. One
patient has been accepted for complete repair and is waiting for surgical
correction. Twenty-two patients have undergone complete repair (elimination of
extracardiac sources of pulmonary arterial blood flow, closure of septal
defects, and insertion of valved conduit between the right ventricle and the
pulmonary arteries). There were 21 survivors. Intraoperative, post-repair peak
systolic pressure ratio between the right and left ventricles ranged from 0.4
to 0.85 (mean = 0.60, SD 0.25). We conclude that, in selected patients, staged
reconstruction of peripheral arterial confluence may correct arborization
problems sufficiently to allow complete surgical repair of patients formerly
considered unrepairable.
10:00 a.m. Intermission - Visit Exhibits
*By Invitation
10:45 a.m. SCIENTIFIC SESSION - HYNES BALLROOM
29. The Size
of the Pulmonary Arteries and the Results of the Fontan Type Repair
FRANCIS FONTAN, GUY
FERNANDEZ*,
FRANCISCO COSTA*,
DAVID NAFTEL*,
FRANCESCO TRITTO*,
EUGENE BLACKSTONE
and JOHN W. KIRKLIN
Pessac-Bordeaux,
France, Curitiba, Brazil
and Birmingham,
Alabama
Among the 334 patients undergoing a Fontan
type repair for congenital heart disease (between 1968 and August 1, 1988) in
two widely separated institutions, cineangiograms were available in 234 patients
(median age 7.0 years, range 8/12 to 38 years) for measurements of the McGoon
ratio:
diameter of right pulmonary artery + diameter
of left pulmonary artery
diameter of descending aorta at diaphragm
Fifty-five patients (24%) died or had a
takedown of the repair within two months of the operation (the event). 124
patients had tricuspid atresia (20 events) and 110 had other cardiac
malformations, most commonly double inlet left ventricle (35 events) (P =
.005). The new atrial connection was to the right ventricle in 73 patients (8
events) and to the pulmonary arteries in 161 (47 events) (P = .002). The median
value of the McGoon ratio was 2.3. A smaller McGoon ratio was a risk factor
(logistic multivariate analysis) for death or takedown within two months of the
Fontan-type repair (P<.001) with increments being added by young age
(P<.001), termination of the new right atrial connection on the pulmonary
artery (rather than right ventricle) (P<.007) and the presence of mitral
atresia (P = .03). The risk factors were identical when the event was analyzed
in a time-related manner (hazard function). Solution of the multivariate
equation, in a patient aged 5 years, without mitral atresia, and with a right
atrial to right ventricular connection, predicted a 14%, 22%, and 41%
prevalence of the event when the McGoon ratio was 2.0, 1.6 and 1.2
respectively; and when the connection was directly to the pulmonary arteries,
the prevalence was 36%, 49% and 71% respectively.
To enhance usefulness in considering early
takedown of the Fontan repair, an additional multivariate analysis was made
incorporating the early postoperative right atrial pressure (PRA)- This considerably refined the risk
factors, such that in the patient described, with a connection to the right
ventricle and with a McGoon ratio of 2.0, the prevalence of the event varied
from 5% (PRA 13 mmHg)
to 15% (PRA17 mmHg)
to 38% (PRA 21mm Hg); with a McGoon ratio of 1.6 the prevalence of
the event varied from 10% (PRA
13 mmHg) to 27% (PRA 17
mmHg) to 56% (PRA21 mmHg);
and with a McGoon ratio of 1.2 the prevalence of the event varied from 27% (PRA
13 mmHg) to 55% (PRA 17 mmHg) to 81% (PRA21 mmHg). (These combinations were all
represented in the experience.)
Therefore, the size of the right and left
pulmonary arteries, as determined by preoperative cineangiography, is an
important risk factor for surgical failure, but its effect can be modified by
other risk factors.
*By Invitation
30. Modified Fontan Procedure Reconstructive
Surgery for Single or Dominant Right Ventricle
JOHN D. PIGOTT*,
ALVIN J. CHIN*,
JOHN D. MURPHY* and
WILLIAM I. NORWOOD
Philadelphia,
Pennsylvania
Since January, 1984, 105 patients with a
single or dominant right ventricle have undergone application of Fontan's
procedure for definitive palliation. Diagnosis included hypoplastic left heart
syndrome (60), heterotaxy syndrome (23), solitary right ventricle (4), other
(18). Age at Fontan's procedure ranged from 4.5 months to 23 years (median 20
months). Surgery included baffling pulmonary venous return in 15 patients,
closure of an ASD and atriopulmonary anastomosis in 6 patients, and baffling
systemic venous return to the pulmonary arteries in 84 patients. Extensive
pulmonary arterial augmentation using pulmonary artery homograft was performed
in the last 85 patients. There were 26 early deaths. Suspected causes of early
mortality include ventricular diastolic dysfunction (10), residual pulmonary
arterial stenosis (4), pulmonary venous hypertension (3), elevated pulmonary
vascular resistance (2), hemorrhage and infection (3 each) and hepatic
dysfunction (1). Thirty-five patients had 37 nonfatal complications, including
prolonged pleural and pericardial effusions (30), complete heart block (3),
prolonged ventilation and atrial arrhythmias (2 each). Early reoperation was
undertaken in 13 patients: pulmonary artery angioplasty (4), change pulmonary
venous to systemic venous baffle (3), pacemaker (2), others (6). Five of 26
early deaths occurred in patients undergoing early reoperation. There were 8 late
deaths. Suspected causes of late mortality include persistent pleural and
pericardial effusions (4), ventricular diastolic dysfunction (2), irreversible
cerebral injury (1), elevated pulmonary vascular resistance (1). Patients with
single or dominant right ventricles have structural issues not present in
patients with single left ventricles. The thrust of this work has been to
develop a systematic means to apply Fontan's principle to all patients with
single ventricle, including those with unusual pulmonary and systemic venous
return and right atrioventricular valve dysfunction. Important elements for
improved survival in this series include: wide augmentation of branch pulmonary
arteries and baffling of systemic venous rather than pulmonary venous return at
initial operation as well as scrupulous avoidance of elevations in ventricular
end diastolic pressure in the early postoperative period.
*By Invitation
31. Primary Repair of Tetralogy of Fallot in
Infancy
GILLES D. TOUATI*,
PASCAL R. VOUHE*,
PHILIPPE POUARD*,
FRANCINE LECA*,
ANTONIO AMODEO* and JEAN-YVES NEVEUX*
Paris, France
Sponsored by: Aldo
R. Castaneda, Boston, Massachusetts
From June 1983 to April 1988, 100 consecutive
symptomatic infants with Tetralogy of Fallot (without pulmonary atresia) were
operated upon. Age ranged from 0.5 to 12 months (mean = 7.3 ± 3.7). Twenty
patients were 0.5 to 3 months, 21 were 3 to 6 months and 59 were 6 to 12 months
of age. Mean weight was 6.5 Kg ± 1.7.
Seventy patients received a transannular
patch. Only 16 patients had hypothermic circulatory arrest, all others had
conventional cardiopulmonary bypass.
Hospital mortality was 3%; there were no late
deaths; cummulative follow-up was 186 patients/years. Causes of deaths include:
hypoplastic pulmonary arteries (4 and 5 months old) and right ventricular
failure (4 months old).
The last 48 patients were operated on without
mortality; during this period, operative management differed in: 1.) blood
cardioplegia repeated every 20 minutes and 2.) ultrafiltration was added to bypass.
The predicted 30-day survivorship after repair
was 96-98% (CL 70%) and was 90-99% (CL 95%). No ventricular arrythmias have so
far been detected after repair (mean of follow-up = 21.6 months) and
echocardiographic ventricular diameter ratios were: 0.60 ± 0.10.
These early results encourage continued
primary repair of symptomatic infants with Tetralogy of Fallot thanks to
improved surgical and anesthetic management.
*By Invitation
32. Neonatal Aortic Stenosis
KEVIN TURLEY, EDWARD
L. BOVE,
JOSEPH J. AMATO,
MARK IANNETTONI*
and JOHN YEH*
San Francisco,
California, Ann Arbor, Michigan
and Newark, New
Jersey
Aortic stenosis in the neonate has in the past
been associated with a high surgical mortality. As a result, in the era of
percutaneous balloon valvuloplasty, the optimal mode of therapy remains
controversial. An approach of metabolic stabilization using cardiopulmonary
bypass (CPB) followed by relief of left ventricular outflow tract obstruction
(LVOTO) was employed by three institutions, and the results are presented.
During the period 1983-1988 (the valvuloplasty
era), 33 neonates with isolated aortic stenosis, patent ductus arteriosus,
and/or coarctation of the aortic underwent operative repair. Ages ranged from 1
to 30 days, median 11 days including 16 in the first week of life. There were
25 males and 8 females; and weights ranged from 2.5 to 5.5 kg., mean 3.7 kg.
Preoperative conditions included: congestive heart failure in 32, mitral
regurgitation in 14, and left ventricular/aortic gradients ranged from 15 to
130 mmHg. Operative therapy included the use of CPB to provide metabolic
stabilization in all thirty-three prior to relief of LVOTO. There were 25 open
valvulotomies and eight transventricular dilatations. Hospital survival was 85%
(28/33) with n.s. difference between the methods (7/8, 21/25). There have been
four reoperations with one late death (MVR-Apical-Aortic conduit) and one late
sudden death.
The use of CPB for resuscitation of neonates
with critical aortic stenosis combined with relief of LVOTO can result in a
high operative and late survival. These results support the concept that this
technique provides a milieu in which the nenonatal myocardium can optimally
respond to relief of obstruction. The results of this technique are a standard
against which closed methods such as percutaneous valvuloplasty should be
compared.
12:00 p.m. Adjourn for Lunch
*By Invitation
1:30 p.m. SCIENTIFIC SESSION - HYNES BALLROOM
33. Aortic Valve Replacement with Stentless
Porcine Aortic Bioprosthesis
TIRONE E. DAVID,
CHARLES POLLICK*
and JOANNE BOS*
Toronto, Ontario,
Canada
Fatigue tests indicate that the best stent for
the aortic valve leaflets is the aortic root. That is probably why hand-sewn
aortic valve homografts are more durable than stent-mounted homografts used for
aortic valve replacement. Artificial stents not only shorten the durability of
aortic valve bioprostheses but also impair their hemodynamic performance.
We have initiated a clinical trial on aortic
valve replacement using a Stentless porcine aortic valve which is processed in
the same manner as the Hancock II bioprosthesis (fixed with glutaraldehyde
under very low pressure and treated with sodium dodecyl sulphate to retard
calcification). This bioprosthesis has been implanted in 20 patients. To
evaluate its hemodynamic performance, these 20 patients were matched for age,
valve lesion, body surface area and bioprosthetic size with 20 cohorts who
underwent aortic valve replacement with Hancock II bioprosthesis. The
hemodynamic performance of the bioprostheses was assessed by Doppler
echocardiography. The results were the following:
|
Valve Size (mm)
|
Number of Patients
|
Peak Systolic Gradient
(mmHg)
|
Aortic Valve Orifice
(cm.sq.)
|
Stentless
|
Hancock II
|
Stentless
|
Hancock II
|
|
21
|
4
|
7.2 + /- 6.0
|
18 + /- 5.8
|
1.58 + /- 0.36
|
1.26 + /- 0.11
|
|
23
|
4
|
7.5 + /- 6.6
|
22 + /- 6.5
|
1.72 + /- 0.12
|
1.38 + /- 0.14
|
|
25
|
5
|
10.4 + /- 7.0
|
23 + /- 5.2
|
1.80 + /- 0.24
|
1.43 + /- 0.05
|
|
27
|
4
|
0.0 + /- 0.0
|
14 + /- 3.4
|
1.89 + /- 0.19
|
1.56 + /- 0.16
|
|
29
|
3
|
0.0 + /- 0.0
|
16 + /- 1.5
|
1.96 + /- 0.41
|
1.62 + /- 0.18
|
This Stentless porcine aortic valve has lower
peak systolic gradient and greater effective orifice than its stented version
in every bioprosthetic size. The steneless porcine aortic valves, like the
hand-sewn aortic valve homografts, are expected to be more durable than the
stended porcine aortic bioprostheses.
*By Invitation
34. Prosthetic Ring Mitral Valve Repair: The
Second Decade
ALAIN DeLOCHE*,
VICTOR A. JEBARA*,
PATRICK M. PERIER*,
JOHN Y. M. R ELL AND*,
GILLES D. DREYFUS*
and ALAIN F. CARPENTIER
Paris, France and
Beirut, Lebanon
The 195 consecutive patients (pts) having
undergone prosthetic ring mitral valve repair (PRMVR) between 1972 and 1979 in
our institution were reviewed in order to assess long term function of this
method of repair.
Patients age ranged from 18 years to 79 years
(mean age 48.7 years). There were 107 (55%) males and 88 (45%) females. Mitral
valve incompetence was secondary to degenerative valvular diseases in 113 cases
(58%), rheumatic disease in 74 cases (38%), ischemia and various other causes
in 8 cases (4%). 188 patients (97%) were in NYHA class III and class IV
preoperatively and 94 (48%) had atrial fibrillation. The patients were divided
into 3 functional groups:
|
- Type I
|
(Normal leaflet
motion)
|
35 patients (18%)
|
|
- Type II
|
(Leaflet prolapse)
|
147 patients (75%)
|
|
- Type III
|
(Restricted leaflet
motion)
|
13 patients (7%)
|
The techniques used include prosthetic ring
annuloplasty (187), partial leaflet resection (158), chordae shortening (89),
leaflet mobilization (10) and papillary muscle reimplantation {1). Long term
follow-up was available in 189 patients (96.8%) for a rate of 2316
patients/year. The actuarial survival at 15 years was 72.2 ± 4.4%. The
occurrence of complications were analyzed in linear and actuarial terms:
|
Event
|
% Free
|
%/Pts/Year
|
|
- Valve related
death
|
82.4 ± 3.9
|
1.2
|
|
- Reoperation
|
88.4 ± 5.3
|
1.0
|
|
- Thromboembolism
|
94 ± 6.8
|
0.4
|
|
- Endocarditis
|
96.6 ± 7. 8
|
0.2
|
|
- Anticoagulant
hemorrhage
|
95.3 ± 7.5
|
0.3
|
Half of the reoperations were necessary in the
first postoperative year and were proved to be due to technical errors. Among
the 157 survivors, 117 (74%) were in NYHA class I and class II and 105 (66%)
were in sinus rhythm. Risk factor analysis did not show any statistically
significant difference in the long term results with regards to age, etiologies
and functional groups and lesions.
We conclude that PRMVR is associated with a
low risk of complications and mortality when compared to other alternatives.
The technique is reliable and provides stable long term results.
*By Invitation
35. Comparative Clinical Assessment of Mitral
Valve Replacement With and Without Chordal Preservation
HANI A. HENNEIN*,
JULLE A. SWAIN*,
CHARLES L.
McINTOSH*, CHRISTOPHER D. STONE*,
ROBERT O. BONOW* and
RICHARD E. CLARK
Bethesda, Maryland
Left ventricular (LV) function often
deteriorates both acutely and chronically after mitral valve replacement (MVR)
for pure mitral regurgitation (MR). Disruption of the mitral apparatus at
operation has been proposed as a major cause of postoperative dysfunction. The
hypothesis tested in this clinical study was that MVR with chordal preservation
results in more favorable postoperative LV function. Forty-eight consecutive
patients with pure MR were studied before and six months after operation by
treadmill exercise testing, catheterizations, echocardiography, and
radionuclide angiography. Thirteen patients underwent MVR with St. Jude and
Biopros-thesis with preservation of chordae tendineae, and the remaining 35 had
MVR without chordal preservation. Preoperatively, there were no differences in
age, gender, New York Heart Association functional class, exercise capacity,
cardiac index, rest EF, exercise EF, fractional shortening, mean arterial
pressures, or cardiac index the two groups. There were three operative and six
late deaths among the 35 patients with chordal resection, but no early or late
deaths in patients who had MVR with chordal preservation (P = 0.05). In
patients whose chordae were excised, exercise capacity was unchanged after MVR
and left ventricular function deteriorated with a reduction in resting EF (49 ±
11% to 34 ± 13%, PC 0.001), exercise EF (51 ± 14% to 38 ± 16%, PC 0.01), and
fractional shortening (34 ± 10% to 23 ± 18%, p = 0.005). In contrast, exercise
capacity increased after MVR in patients whose chordae were preserved (by 5.9 ±
2.2 minutes, PC 0.005) and function was maintained, with no charges in resting
EF (45 ± 13% to 47 ± 11%,P = NS), exercise EF (47 ± 12% to 51 ± 14%, P = NS),
and a decrease in LV end systolic dimension (from 40 ± 8% to 35 ± 6%, P <
0.05). Both group of patients demonstrated improvement in pulmonary artery
pressure, mean left atrial pressure, LV end diastolic pressure, cardiac index,
with no statistical differences between groups. These data demonstrate that
patients who undergo MVR with chordal preservation have improved postoperative
survival, exercise capacity, and LV function compared to patients in whom the
chordae were excised.
*By Invitation
36. Mitral Valve Repair: Results and Decision
Making Process of the Reconstruction
ARRIGO LESSANA*,
CARMINE CARBONE*.
MAURO ROMANO*,
EVELYNE PALSKY*,
YU HONG QUAN* and
GENEVIEVE LUTFALLA*
Aubervilliers and
Paris, France and Beijin, China
From 1975 to 1988, 266 patients (pts)
underwent mitral valve repair (MVR) procedures for pure or predominant mitral
regurgitation (MR). The cause of MR was rheumatic in 176 pts (mean age: 28.4 ±
1.2, x ± SEM) and degenerative in 78 pts (mean age: 54.2± 1.6).
Fifty-five percent of the pts were in NYHA class III and IV prior to surgery.
Intraoperative assessment of the MV led us to identify 3 major mechanisms of
MR: 1) Restriction of leaflet motion by fibrosis (56 pts, Group I); 2)
Enhancement of leaflet motion by leaflet and chordae extension and prolapse
(137 pts, Group II) and 3) Combination of both (65 pts, Group III). Only 8 pts
had isolated dilatation of the annulus. One hundred and forty-nine pts had
isolated MR and 117 had associated aortic and/or tricuspid valve or coronary
disease. To illustrate more comprehensively how surgical procedures were
selected according to the type of valve disease, a 7-min motion pictures has
been prepared and will illustrate the different steps of the decision-making
process and the subsequent surgical maneuvers. Hospital mortality was 3.8% ±
2.2. Follow-up was 95.9% complete and totaled 1,182.86 patient-years. The
postop assessment included clinical examination, and echodoppler study. At
13-year follow-up, survival was 91.9% in Group I, 89.2% in Group II and 96.5%
in Group III. The percent freedom from reoperation was 69.8% in Group I, 81.6%
in Group II and 64.2% in Group III; the percent freedom from emboli was 97.2%,
97.6%, and 92.5%, respectively. In the group of pts with isolated MR, the
results were as follows:
|
LINEARIZED RATE (expressed as percent/pt-yr)
|
|
Event
|
Group 1 (n=25)
|
Group II (n=82)
|
Group III (n=34)
|
|
Emboli
|
0.0
|
|
0.3
|
|
0.0
|
|
Reoperation
|
0.9
|
|
0.0
|
|
1.5
|
|
Persistent MR
|
0.0
|
|
0.3
|
|
1.0
|
|
Recurrent MR
|
2.6
|
←P<0.05→
|
0.3
|
|
1.0
|
|
Recurrent rheumatic
fever
|
2.6
|
←p<0.05→
|
0.3
|
|
1.0
|
|
Endocarditis
|
0.0
|
|
0.0
|
|
0.0
|
|
Late death
|
0.9
|
|
0.3
|
|
0.0
|
|
Cumulative
morbidity
|
2.6
|
←p<0.05→
|
1.0
|
←p<0.05→
|
2.0
|
|
|
|
|
|
|
|
|
These results suggest that conservative
surgery should be used with caution in Group I and III pts. In contrast MVR
should be extended in Group II pts. This finding is clinically relevant, since,
in Western countries, valve prolapse tends to be a major cause of MR.
*By Invitation
37. Five Hundred and Thirty Patients Undergoing
Tricuspid Valve Surgery: 25 Year Assessment Early and Late Phase Hazards and
Events
LYNN B. McGRATH*,
LORENZO GONZALEZ-LAVIN,
BRIDGETM. BAILEY*,
GARY P. GRUNKEMEIR*,
JAVIER FERNANDEZ,
FRANCIS P. SUTTER*
and GLENN W. LAUB*
Browns Mills, New
Jersey
From January 1, 1961 through December 31,
1987, 530 patients underwent an intracardiac repair which included tricuspid
valve surgery. Three hundred fifty-one patients had tricuspid valve repair
(66.2%) and 179 had tricuspid valve replacement (33.8%). Mean age at repair was
56.9 years, range 10 years to 79 years. Two hundred and fifty-six patients
(48.3%) had undergone previous cardiac surgery. Preoperative variables
predicting the requirement for tricuspid valve replacement included: ascites (p
= 0.02), hepatomegaly (p = 0.002), pulsatile liver (p = 0.01), peripheral edema
(p = 0.01), tricuspid stenosis (p = 0.001), previous cardiac operation (p =
0.001), increasing right atrial pressure (p = 0.0001), increasing preoperative
angiographic severity of tricuspid valve incompetence (p = 0.003), concomitant
mitral valve replacement (p = 0.002), and higher functional class (p = 0.07).
There were 76 hospital deaths (14.3%). Incremental risk factors for the event
hospital death included male gender (p = 0.003), higher functional class (p =
0.07), hepatomegaly (p = 0.02), ascites (p = 0.04), previous operation (p =
0.009), total cardiopulmonary bypass time (p = 0.00001), total aortic occlusion
time (p = 0.03), and the use of an annuloplasty ring in the tricuspid valve
repair group (p = 0.05). Ninety-seven percent of the patients were followed, at
a mean of 50.6 months, range 0 to 315 months. There were 250 late deaths
(55.1%). Actuarial survival was 33.5% at 120 months and 13.1% at 180 months.
Seventy-eight patients (17.2%) had at least one reoperation. Actuarial freedom
from reoperation was 83.1 % at 60 months and 29.3% at 180 months. There was no
difference in reoperation rates (p = 0.10), nor actuarial survival (p = 0.40)
according to the type of tricuspid valve procedure performed. Hazard function
analysis for reoperation revealed early, intermediate, and late phase events.
We conclude that preoperative variables may
predict the requirement for tricuspid valve replacement. As there is no
difference in hospital nor late survival in patients undergoing tricuspid valve
repair (versus replacement), and as there is an increased incidence of valve
related events in the replacement group, we recommend tricuspid valve repair,
without annuloplasty ring, whenever possible.
*By Invitation
38. The Operative Treatment of Patients with
Hypertrophic Cardiomyopathy and Pulmonary Hypertension
CHRISTOPHER D.
STONE*, HANI A. HENNEIN*,
CHARLES L.
McINTOSH*, ARSHED A. QUYYUMI*
and RICHARD E. CLARK
Bethesda, Maryland
The clinical course and hemodynamic results in
patients undergoing operation for obstructive hypertrophic cardiomyopathy (HCM)
with preoperative pulmonary artery hypertension (PHT) was unknown. The
hypothesis tested in this retrospective study was that operative relief of left
ventricular outflow tract obstruction results in a substantial reduction in
pulmonary artery pressures and mitral regurgitation (MR) without necessitating
mitral valve replacement (MVR). Patients were included if their preoperative
pulmonary systolic pressure was > 35 mmHg, and were, with the exception of
MR, without concomitant cardiac pathology. Since 1962, 49 pts. who fit our
criteria underwent left ventricular myotomy and myectomy (LVM&M) with 98%
follow up. Mean follow up was 7.9 ± 4.5 (mean ± 1 S.D.) years with a range of
.8 to 18.4 years. Early hospital mortality was 12% (N ± 6), 2 (4%) from low
C.O. and 4 (8%) from arrhythmia. There were 43 (84%) hospital survivors and 19
late deaths; 4 (9%) from arrhythmia or sudden death, 5 (12%) from CHF, 3 (7%)
died at repeat cardiac procedure, and 4 (9%) from other causes. Actuarial
survival was 74 ± 6.5% (N = 31) at five years and 46 ± 8.4% (N = 8) at ten
years. Three patients had late MVR. Of the 43 survivors 39 (91%) returned 7.7 ±
4.5 months later for follow up evaluation including cardiac catheterization.
The majority (82%) experienced New York Heart Association functional class one
or two status postoperatively. Cardiac catheterization indicated a fall in PA
systolic pressure from 62 ± 17.4 (range = 36 to 105) to 38.5 ± 11.7 (range = 17
to 68) mmHg (p = .0001) with no difference in right atrial pressure or cardiac
output. Pulmonary capillary wedge mean pressure decreased from 23.6 ±6.4 to
16.1 ± 5.3 mmHg (p = .0002) and, preoperative MR improved or was abolished in
85% of patients studied (N = 13). Rest and maximum provocable left ventricular
outflow tract gradients decreased from 80.5 ± 45.4 and 103.4 ± 26.2 to 13.8 ±
19.2 and 46 ± 43 respectively (p = .0001). Analysis of the above pts. operated
upon since 1982 and comparison to an age and functionally matched group with
PHT and HCM treated with MVR showed no statistical difference in mortality,
morbidity, hemodynamic or functional outcome with two years of mean follow up.
We conclude that a consistent, significant reduction (mean =42% ± 18%) in
preoperative pulmonary hypertension, clinical symptoms and mitral regurgitation
occurs with relief of outflow tract obstruction by LVM&M and that MR and
PHT are not indications for MVR in these patients.
*By Invitation
SCIENTIFIC SESSION - ALTERNATE
Hypoplastic Left Heart Syndrome: Palliation Without
Cardiopulmonary Bypass
WILLIAM Y. TUCKER*,
ROBERT C. McKONE*,
KENNETH M. WEESNER*
and NEAL D. KON*
Winston-Salem, North
Carolina
Sponsored by: A.
Robert Cordell, Winston-Salem,
North Carolina
Hypoplastic left heart syndrome (HLH)
continues to be a surgical challenge. Mortality with a first stage palliative
repair utilizing car-diopulmonary bypass (CPB) is high. Cardiac transplantation
in neonates with HLH has severe limits of time, donor avilability and patient
management.
Our 100% mortality with first stage HLH repair
using CPB led us to a procedure not requiring CPB. In 9 consecutive patients,
after medical stabilization, a left thoracotomy was performed and an 8 mm woven
Dacron graft placed from the main pulmonary artery to the descending thoracic
aorta. The patent ductus arteriosus was ligated and the main pulmonary artery
banded distal to the graft and proximal to the bifurcation.
Age at surgery ranged from 2-6 days. Weights
were 2.3-3.7 kg (mean 3.2 kg). Pre-op diagnosis was made by ECHO in 4 patients
and by cath in 5. Caths were accompanied by balloon atrial septostomy. Two
patients diagnosed by ECHO underwent post-op cath and balloon septostomy prior
to discharge. Five patients were extubated within 4 days (range 1-4). Only low
dose Dopamine was needed for inotropic support. There were no bleeding
problems. Five patients were discharged 11-80 days postop (mean 38 days). There
were 4 hospital deaths; 1 from Candida sepsis at 81 days, 1 from low cardiac
output at 2 days, and 2 from a restrictive ASD at 3 and 5 days. Both of the
latter had pre-op ECHO with cath and balloon septostomy planned prior to
discharge. Patients followed up to 3 years have had normal growth and
development.
Palliation of HLH without CPB has allowed
hospital discharge in 5 of 9 patients and has decreased post-op hemodynamic,
respiratory and bleeding problems. We now do pre-op balloon septostomies on all
patients and feel that this will improve survival rate. This simpler initial
approach may allow for a staged Fontan or cardiac transplant at a later date
for more definitive treatment.
3:30 p.m. ADJOURN
*By Invitation
