American Association for

Thoracic Surgery

72ND ANNUAL MEETING

Century Plaza Hotel, Los Angeles, CA

APRIL 26-29, 1992

MONDAY MORNING, April 27, 1992

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

8:45 a.m. SCIENTIFIC SESSION - Los Angeles Ballroom

1. Video Assisted Thoracic Surgical Resection of Malignant Lung Tumors

RALPH J. LEWIS, M.D., ROBERT J. CACCAVALE, M.D.*

and GLENN E. SISLER, M.D.*

New Brunswick, New Jersey

In a series of over 125 patients, who underwent Video Assisted Thoracic Surgery for a multitude of problems, 40 patients underwent resection of malignant parenchymal tumors. Lesions consisted of T1No primary tumors, metastatic tumors or parenchymal lymphoma. All resections of primary tumors were considered curative, and pathological specimens revealed squamous cell carcinoma, adenocarcinoma and broncho-alveolar carcinoma. Mediastinal, hilar and fissure nodes were biopsied, and frozen sections were obtained before resection. Utilizing various staplers, liga clips, and conventional thoracic instruments, these lesions are removed by lobectomy, partial lung (segmental) or wedge resection. A double lumen tube allows deflation of the operative lung. Three to four incisions, about 2 to 5 centimeters in length, are made in the intercostal spaces taking care not to bruise, spread or fracture any ribs. A thoracoscope with an attached microcamera projects the intra-thoracic contents on a screen allowing complex surgery to be performed. All patients had markedly reduced post operative pain and made an uneventful recovery. Most patients were discharged between 3-6 days and did not require post operative intensive care services. Video Assisted Thoracic Surgery seems to be another option for removing certain types of malignant parenchymal tumors.

*By Invitation

2. Subglottic Tracheal Resection and Synchronous Laryngeal Reconstruction

MICHAEL A. MADDAUS, M.D.*, JULIUS L.R. TOTH, M.D.*,

PATRICK J. GULLANE, M.D.* and

F. GRIFFITH PEARSON, M.D.

Toronto, Ontario

Post intubation injury of the upper airway commonly results in stenotic lesions of larynx, subglottis and adjacent trachea. The traditional approach to surgical correction is laryngofissure for the laryngeal component, and staged plastic reconstruction of the subglottic stenosis. Reported results are variable and unpredictable, and a significant number of patients do not achieve permanent extubation. We report experience with 17 patients with combined laryngeal, subglottic and tracheal stenosis, who were successfully managed by a one stage operation: circumferential resection of subglottis and trachea with primary thyrotracheal anastomosis, combined with laryngofissure and laryngeal reconstruction. These procedures required the collaboration of Otolaryngology and Thoracic Surgery.

Between 1972 and 1991, our Thoracic Surgical Division did 60 circumferential subglottic tracheal resections with primary thyrotracheal anastomosis. There was no operative mortality and all 60 patients were successfully extubated. In 17 of these patients, a concomitant laryngofissure for laryngeal reconstruction was required: excision of interarytenoid scar -10, in-terarytenoid mucosal graft - 4, mobilization of cricoarytenoid joint - 3. A temporary laryngotracheal stent (usually a Montgomery T-tube) was maintained post-operatively in all cases (duration 3 months to greater than 1 year). All patients are now permanently extubated and none have developed functionally significant re-stenosis. Vocal function is satisfactory to good in all patients.

The approach described for these combined laryngotracheal lesions provides superior results to those reported using traditional staged and plastic techniques of reconstruction. The collaboration of Otolaryngology and Thoracic Surgery was essential to achieve these results.

*By Invitation

3. A New Video Thoracoscopy Surgical Technique for Interruption of Patent Ductus Arteriosus in Infants and Children

FRANCOIS LABORDE, M.D.*, PHILIPPE NOIRHOMME, M.D.*,

JOSEPH KARAM, M.D.*, ALAIN BATISSE, M.D.*

PATRICK BOUREL, M.D.* and

OLIVIER SAINT MAURICE, M.D.*

Paris, France

Sponsored by: Francis M. Fontan, M.D., Bordeaux, France

Surgical endoscopy techniques are of growing interest in many fields. Endovascular closure of Patent Ductus Arteriosus (PDA) did not prove to be completely satisfactory. Classical surgical interruption of PDA can be advantageously replaced by Video Thoracoscopy Surgical Interruption (VTSI).

Under general anesthesia and intubation, two 5 mm holes were made through the left thoracic wall. A video camera and different adequate surgical tools were introduced (scissors, dissectors, electrocauthery, retractors, etc.). PDA was dissected and exposed. Two titanium clips were applied, completely interrupting the PDA.

Ten patients with isolated PDA were treated from April to October 1991. Mean age was 18 months (range: 3 months to 6 years). All had successful complete PDA interruption with only VTSI. Hospital stay was short: 2-3 days. The first 4 patients had a 24 hour thoracic drainage while the last 6 did not, thus decreasing post-operative pain. There was neither minor nor major complication and no death.

We conclude that VTSI is sure and safe: all ten PDAs were successfully and completely interrupted as was proved by echo doppler. VTSI is advantageous: decrease of post-operative discomfort and pain, no scar, no rib retraction, no painful thoracic drainage, very short hospital stay. We now use VTSI routinely in infants and children. Availability of smaller-sized surgical tools should allow VTSI use in prematures and newborns.

9:45 a.m. INTERMISSION - VISIT EXHIBITS

*By Invitation

10:30 a.m. SCIENTIFIC SESSION

4. Are Two Internal Thoracic Arteries Better Than One?

DELOS M. COSGROVE, M.D., ARTHUR HILL, M.D.*,

BRUCE W. LYTLE, M.D., PAUL C. TAYLOR, M.D.*,

ROBERT W. STEWART, M.D.*, ROBERTO NOVOA, M.D.*,

PATRICK M. MCCARTHY, M.D.*,

LEONARD R. GOLDING, M.D.*,

MARLENE GOORMASTIC, MPH* and

FLOYD D. LOOP, M.D.

Cleveland, Ohio

It has been well-documented that survival, reoperation-free survival and freedom from cardiac events are positively influenced by the use of one internal thoracic artery (ITA) graft during myocardial revascularization. To test the hyposthesis that two ITA grafts incrementally improve surgical results, three groups of 327 patients receiving none, one or two ITA grafts were computer matched. Patients were matched according to the year of operation, age, gender, extent of disease, left ventricular function, completeness of revascularization, and history of congestive heart failure. No patients were lost to follow-up; the mean follow-up was 93 ± 37 months with 7,587 patient-years of follow-up available for analysis. There was a statistically significant trend towards improved survival, reoperation-free survival and freedom from cardiac events at eight years as the number of ITA grafts increased.

	Survival	Reop-free Survival	Cardiac Event-free Survival
Veins	73	67	39
1 ITA	84	79	49
2 ITAs	86	86	63
p value	.003	.0001	.0001

To evaluate the influence of ITA grafting for different age groups, patients were separated into groups <60 and those >60 years of age. In patients <60, there was a statistically significant trend for improving survival, reoperation-free survival and event-free survival at eight years as the number of ITA grafts increased.

	Survival	Reop-free Survival	Cardiac Event-free Survival
Veins	77	69	41
1 ITA	88	82	51
2 ITAs	93	92	71
p value	.0001	.0001	.0001

The difference between one and two ITA grafts was statistically significant (p <0.05) for cardiac event-free survival for the entire group and patients <60. In patients >60 years of age, less beneficial influence can be seen as the number of ITA grafts increased from one to two.

	Survival	Reop-free Survival	Cardiac Event-free Survival
Veins	68	64	36
1 ITA	77	76	46
2 ITAs	75	74	51
p value	NS	NS	.04

We conclude 1) two ITA grafts provide an incremental improvement in survival, reoperation-free survival and freedom from cardiac events and 2) this incremental benefit is more pronounced in younger patients.

*By Invitation

5. Superiority of Surgical Reperfusion vs. PTCS in Acute Coronary Occlusion

BRADLEY S. ALLEN, M.D.*, GERALD D. BUCKBERG, M.D.,

FRANCIS M. FONTAN, M.D.,

MARVINM, KIRSH, M.D., GEORGE POPOFF, M.D.*,

FRIEDHELM BEYERSDORF, M.D.*,

JEAN-NOEL FABIANI, M.D.* and

CHRISTOPHER ACAR, M.D.*

Los Angeles, California

Although PTCA is successful in > 90%of pts after acute coronary occlusion, overall mortality remains approximately 10% with higher subgroup mortality (i.e. LAD occlusion, multivessel disease, age > 70 yrs, cardiogenic shock) and early recovery of regional wall motion is marginal. This multi-center survey shows that controlled surgical reperfusion in acute coronary occlusion reduces overall and subgroup mortality and restores substantial early contractility.

In a survey from 6 institutions, 156 consecutive pts with acute coronary occlusion documented by angiography underwent surgical revascularization with controlled reperfusion using amino acid enriched blood cardioplegia on total vented bypass. Ventricular wall motion was studied by ECHO or MUG A at post-operative day 5-7, and scored by an independent radiologist (0 = normal, 1 = mild hypokinesia, 2 = severe hypokinesia, 3 = akinesia, 4 = dyskinesia). Results are compared to 1,203 patients with acute coronary occlusion treated by PTCA in 5 reported medical series.

Surgical patients were revascularized at longer ischemic intervals 6.3 vs 3.6 hrs*, had a greater incidence of LAD occlusion 61% vs 43%*, multivessel disease 42% vs 10% and cardiogenic shock 41% vs 9%* with 12 pts undergoing CPR en route to the operating room. Surgical results were superior in all categories with overall mortality reduced from 8.8% (after PTCA) to 3.9%* after CABG. All surgical deaths occurred in patients with preoperative cardiogenic shock. Regional wall motion recovered significantly (score < 2) in 140/156 (90%) of surgical patients with an average score of 0.9 ± 0.8 (normal to mild hypokinesia) despite longer ischemic times. Subgroup mortality is shown below.

Reperfusion	PTCA (uncontrolled n = 1203)	CABG (controlled n = 156)
Ischemic Time:(hr)	3.6 ± 1.8	6.3 ± 3.6 (1.5-36 hrs)*
Mortality: Overall	105/1203 (8.8%)	6/156* (3.9%)*
LAD occlusion	39/331 (11%)	5/95 (5%)
3 vessel Dis.	27/158 (17%)	0/66 (0%)*
Age ≥ 70 yrs	49/209 (23%)	1/22 (5%)*
Preop Shock	49/114 (43%)	6/64 (9%)*

This multi-center study demonstrates that controlled surgical reperfusion lowers mortality in all groups compared to PTCA, despite a longer ischemic time and more pts in cardiogenic shock. Early and substantial return of segmental wall motion in sugical pts suggests superior muscle salvage, supports an aggressive approach to treating acute coronary occlusion, and implies that the mode of reperfusion is more important than the rapidity of reperfusion after acute ischemia.

*p < 0.05

11:15 a.m. PRESIDENTIAL ADDRESS

The Association at 75; The Challenge of the Future

(Do we need a stress test?)

John A. Waldhausen, M.D., Hershey, Pennsylvania

12:00 noon ADJOURN FOR LUNCH - VISIT EXHIBITS

*By Invitation