American Association

for Thoracic Surgery

70TH ANNUAL MEETING

MAY 7-9, 1990

Scientific Program

MONDAY MORNING, May 7, 1990

8:30 a.m. BUSINESS SESSION (Limited to Members)

8:45 a.m. SCIENTIFIC SESSION - Sheraton Ballroom

1. Valvuloplasty for Aortic Insufficiency

DELOS M. COSGROVE, ELIOT R. ROSENKRANZ*,

WILLIAM J. STEWART* and WILLIAM G. HENDREN*

Cleveland, Ohio

Aortic valvuloplasty has been less successful than reparative procedures on the atrioventricular valves and has been employed mainly to alleviate aortic stenosis. To evaluate the efficiency of aortic valvuloplasty to eliminate insufficiency, 21 consecutive patients who underwent a new method of aortic valvuloplasty including annular plication at the commissures and triangular leaflet resection were reviewed.

Nineteen (90.5%) were males. Mean age was 56 ± 16.7 years (range 22-82). Ten valves (47.6% were bicuspid and 11 (52.4%) were tricuspid. Aortic valvuloplasty was the only procedure in 11 (52.4%) cases; 10 patients had associated procedures. Aortic valvuloplasty included annular plication at the commissures in all cases and a triangular leaflet resection in 13 (61.9%).

The amount of aortic insufficiency was documented by angiography and echo Doppler preoperatively and by echo Doppler on two occasions postoperatively. Aortic insufficiency was graded on a scale of 0-4 +.

Postoperatively, the maximum instantaneous gradient across the valve determined by echo Doppler was 18.5 ± 9.9 mmHg.

There was one non valve-related hospital mortality (4.8%) and no late deaths. At a mean follow-up of ± 4.9 months, 19 patients were New York Heart Association Functional Class I and one was NYHAFC II. There were no postoperative cardiac or valve-related events.

Aortic valve repair is an attractive alternative for aortic insufficiency with leaflet resection and annular plication at the commissures and 1) eliminates aortic insufficiency without causing aortic stenosis, and 2) results in excellent functional status without evidence of postoperative insufficiency.

*By invitation

2. Valvular Extension With Autologous Pericardium Preserved With Glutaraldehyde. Results in Mitral Valve Repair

SYLVAIN M. CHAUVAUD*, J. CARLOS CHACHQUES*,

SERBAN MIHAILEANU*, ERIC ARNAUD-CROZA T*,

FRANCINE LECA * and ALAIN CARPENTIER

Paris, France

Autologous pericardium has already been used in the past for mitral valve extension. This technique, however, has been abandoned because of either patch shrinkage or distension.

Experimental studies in our laboratory have shown that preservation of autologous pericardium with Glutaraldehyde prevents late deterioration and calcification.

From 1986 to 1989, 35 patients operated upon for mitral valve insufficiency required a patch extension of the posterior leaflet. Age ranged from 2.5 to 58 years (mean 16 ± 14). The posterior leaflet was fibrotic in 29 cases (rheumatic fever), hypoplastic in 6 cases (congenital). A large, losangic, Glutaraldehyde preserved autologous patch was placed on the posterior leaflet in order to enlarge the surface area. The autologous patch has been previously placed in a 0.62% Glutaraldehyde solution for 10 minutes and rinsed in saline for an additional 10 minutes. Associated lesions of the mitral valve, namely leaflet prolapse, present in 20 cases were treated according to techniques previously described. A Carpentier ring was mandatory in 30 of the 35 cases because of annulus deformation. Associated lesions of the aortic valves, present in 10 cases were treated by valve repair.

There was no operative death. Two patients (6%) were reoperated upon, for annulus distention in one (primary repair without prosthetic ring) and patch detachment in the other. In both cases, the pericardial patch was pliable without thickening or calcification and a second valve repair was possible.

Follow up is available in all the patients for a period comprised between 0.5 to 3 years (mean 2.1). Mitral valve function was assessed by bidimention-nal echo and color echo Doppler. Mitral valve insufficiency was trivial or absent in 28 cases (80%) and mild in the remaining cases. The motion of the pericardial patch was normal in 27 cases (77%) billowing in 6 (17%) and restricted in 2 (6%).

We conclude that:

1) Mitral valve extension is a simple and reliable technique to treat posterior leaflet restricted motion or to increase surface area in children requiring a prosthetic ring.

2) Glutaraldehyde prevents mid term retraction and calcification of the autologous pericardium.

*By Invitation

3. Mitral Valve Repair With Replacement of Chordae Tendineae With Goretex® Sutures

TIRONE E. DAVID, JOANNE BOS* and

HARRY RAKOWSKI*

Toronto, Ontario, Canada

We have used 4-0 or 5-0 expanded tetrafluoroethylene (Goretex® ) sutures for replacement of diseased chordae tendineae during reconstructive procedures of the mitral valve (MV). A double-armed suture is passed twice through the papillary muscle head and tied down. Each arm of the suture is then brought up to the free margin of the leaflet and passed through the area where the native chorda was attached and, after adjusting their lengths, the ends are tied together.

Thirty-one pts have undergone MV repair with replacement of one or more chordae tendineae with Goretex sutures. There were 21 men and 10 women whose mean age was 53 years, range 27 to 74. Most pts (84%) were in NYHA class III or IV before operation. Twenty-four pts had mitral regurgitation (MR), 3 had a stenosis and 4 had mixed lesions. The MV pathology was degenerative disease in 21 pts, rheumatic in 8 and ischemic in 2. Eleven pts had had infective endocarditis of the MV. Chordal replacement was necessary because of rupture or elongation of flimsy chordae tendineae of the anterior leaflet (17 pts) or commissural areas (10 pts), or excessively fibrotic or calcified chordae (9 pts). In addition, many pts required shortening of other chordae tendineae, resection of portion of the posterior leaflet or com-missurotomy. A ring annuloplasty was performed in 28 pts. Other procedures included aortocoronary bypass in 3 pts, aortic valve replacement in 2 and tricuspid valve repair in 4.

There were no operative deaths and no serious postoperative complications. Patients have been followed from 2 to 54 months, mean of 10. All pts have had Doppler echocardiographic studies before surgery and at 2, 6, 12 months and annually thereafter. Twenty pts have no postoperative MR, 8 have mild MR and 3 have moderate MR. At 2 months after operation, the left atrial size decreased from 54 ± 6 mm preop to 43 ± 4 mm postop (p < 0.02), and the left ventricular end-diastolic diameter decreased from 60 ± 7 mm preop to 49 ± 6 mm postop (p < 0.01) in pts who had MR preoperatively. The echocardiographic excursion of the anterior leaflet appears normal and does not seem to change with time. One pt with Barlow's disease of the MV suffered 2 episodes of TIAs early after surgery in spite of adequate oral an-ticoagulation. There have been 2 late deaths, neither one was valve-related. All 29 survivors improved symptomatically and are in NYHA class I or II.

Replacement of chordae tendineae with Goretex sutures is simple and provides good functional results. This technique allows for reconstruction of the MV in many pts who would otherwise require MV replacement. We presently prefer this technique instead of chordal transfer in pts with MR secondary to ruptured chordae tendineae of the anterior leaflet.

*By Invitation

4. A Comparison of the Aortic Homograft and Pulmonary Autograft for Aortic Valve or Root Replacement in Children

GINO GEROSA *, ROXANE McKA Y*, JILL DAVIES* and

DONALD N. ROSS

London and Liverpool, England

In order to assess late results of aortic homograft and pulmonary autograft valves implanted into the left ventricular outflow tract of children, we have reviewed our experience of 122 patients 18 years of age or younger, who underwent aortic valve or root replacement between November 1964 and December 1988. Eighty-eight patients (mean age 11.9 ± 4 years) received an aortic homograft (Group I), while thirty-four patients (mean age 14.0 ±4 years) had their own pulmonary valve transferred to the aortic position (Group II). There were 44 valve and 44 root replacements in Group I, and 31 valve and 3 root replacements in Group II. Indications for operation were left ventricular outflow obstruction in 51 patients (42%), aortic regurgitation in 50 (41%), mixed valve disease in 14 (11%), prosthetic valve endocarditis in 4 (3%), prosthetic valve malfunction in 2 (2%), and homograft degeneration in 1 (1%). Fifty-three patients (43%) had undergone previous operations on the left ventricular outflow tract.

Hospital mortality was 13% (12 patients) in Group I and 12% (4 patients) in Group II. Survivors in Group I and Group II have been followed up for a total of 524 and 214 patient-years, respectively. Late mortality was 17% (2.5% per patient-year) in Group I and 13% (1.8% per patient-year) in Group II, while the incidence of reoperation per patient-year was 3.8% in Group I and 1.8% in Group II. At 16 years, actuarial rates for freedom from reoperation were 43.0 ±13% (Group I) and 74.0 ± 11% (Group II); freedom from endocarditis, 92.0 ±4% (Group I) and 74.0 ±11% (Group II); and late survival, 55.0 ± 14% (Group I) and 77.2 ± 10% (Group II). Valve degeneration occurred in 15 homografts (2.8% per patient-year), whereas there was no instance of primary tissue failure among the pulmonary autografts.

This experience would indicate that either the homograft or autograft valve can be used in children with acceptable results. However, the pulmonary autograft gives better long-term performance, and, if growth potential is realized, may represent the ideal valve substitute in children.

INTERMISSION - VISIT EXHIBITS

*By Invitation

10:35 a.m. SCIENTIFIC SESSION - Sheraton Ballroom

5. Primary Soft-Tissue Sarcoma of Chest Wall: Results of Surgical Resection

MARK S. GORDON*, STEVEN I HAJDU*,

MANJIT S. BAINS and MICHAEL BURT*

New York, New York

Primary soft tissue sarcomas of chest wall are uncommon and data concerning treatment and results are sparse. Most studies have categorized these tumors as truncal sarcomas and inferred a poor prognosis. In order to assess the results of surgical treatment we reviewed our forty year experience. Methods: Records of 189 patients admitted to our institution from 1948 to 1988 were reviewed. Pathologic material was available for review in 149 (79%) and comprise this report. Survival was calculated by Kaplan-Meier method; comparisons by log rank analysis; significance defined as p<0.05. Results: Age: 3 wk to 86 yr (median 38); M:F 2:1. Presenting complaint was mass or pain in 97%. 90 (60%) were high grade and 59 (40%) low. Histologic types: desmoid (n = 32), liposarcoma (n = 23), rhabdomyosarcoma (n = 18), fibrosarcoma (n = 17), embryonal rhabdomyosarcoma (n = 14), malignant peripheral nerve sheath tumor (n = 13), malignant fibrous histiocytoma (n = 11), spindle cell sarcoma (n=4), synovial sarcoma (n = 3), heman-giopericytoma (n = 3), alveolar soft part sarcoma (n = 3), and others (n = 8). Resection was the primary treatment in 140 (94%). Local recurrence occurred in 26%. Metastases occurred in 52 (35%) (metachronous in 42, synchronous in 10), and were more common in high grade (46/90, 51%) than low (6/59, 10%). Overall 5 year survival was 62%. Five year survival in high grade sarcomas (55%) was significantly less than low (90%) (p<0.0001). Tumor size, age or sex were not prognostic. Conclusions: Survival of patients with primary soft tissue sarcomas of chest wall after resection is similar to that of patients with extremity sarcomas. Resection alone is adequate for low grade (5 year survival: 90%) but adjuvant treatments should be considered for high grade sarcomas of chest wall.

*By Invitation

6. Long Term Follow-Up After Prosthetic Replacement of the Superior Vena Cava Combined With Resection of Mediastinal Pulmonary Malignant Tumors

PHILIPPE G. DARTEVELLE*, ALAIN R. CHAPELIER*,

BERNARD LENOT*, PIERRE CORBI* and

JACQUES CERRINA*

LePlessis Robinson, France

Sponsored by: Arthur D. Boyd, Mamaroneck, New York

Major invasion of the Superior Vena Cava (SVS) by tumors is a classical contra-indication to surgery. The use of vascular prostheses suitable for venous replacement enables the radical resection of such tumors.

Between 1979 and 1989, 19 patients underwent complete resection of lung cancer (n = 6) or malignant mediastinal tumors (n = 13) involving the SVC with concomitant venous reconstruction with Polytetrafluoroethylene (PTFE) grafts. Bronchogenic carcinoma (4 T4 Nl and 2 T4 N2) required pneumonectomy extended to the SVC with reconstruction using a PTFE graft (size 18) interposed between the origin of the SVC and the right atrium.

The removal of malignant mediastinal tumors (4 undifferentiated cancers, 2 carcinoid tumors, 2 thymomas, 2 lymphoblastomas, 1 adenocarcinoma, 2 germinal tumors) needed the resection of the SVC and innominate veins (n = 13) pericardium (n = 12) lung (upper lobectomy n = 4, Wedge resection n = 5) and right phrenic nerve (n = 12). Venous reconstruction was performed by interposition of a PTFE graft (size 13) between innominate vein and the right atrium.

One patient died in the postoperative course (5.2%).

Additional chemotherapy was given to 6 patients, radiotherapy to 5 and combined treatment to 7 other patients.

The cumulative survival rate is 44%at 5 years.

Nine patients are alive, at 91 and 97 months (undifferentiated mediastinal cancers), 6 and 45 months (bronchogenic carcinoma), 23 and 39 months (carcinoid tumors), 29 months (thymoma), 12 and 20 months (germinal tumors). One died at 68 months (thymoma) from myasthenis gravis without recurrence of the tumor.

Late graft patency was proved by angiogram or CT Scan in all patients but one at 32 ± 9 months (mean ± standard error).

Conclusions:

- Radical surgery of malignant tumors involving the SVC provides an acceptable survival rate.

- PTFE grafts used to replace SVC maintain long term patency.

11:15 a.m. PRESIDENTIAL ADDRESS

F. Griffith Pearson, Toronto, Ontario, Canada

12:00 p.m. ADJOURN FOR LUNCH - VISIT EXHIBITS

*By Invitation