12:00 noon ADJOURN FOR LUNCH - VISIT EXHIBITS

1:30 p.m. SCIENTIFIC SESSION - Grand Ballroom

Moderators: Bruce A. Reitz, M.D.

William A. Gay, Jr., M.D.

6. Surgical Management of Neonatal Coarctation: A Study of 221 Patients

FRANCOIS LACOUR-GAYET, M.D. *, STEFANO CONTE, M.D. *,

ALAIN SERRAF, M.D. *, JACQUELINE BRUNIAUX, M.D.*,

MIGUEL SOUSA-UVA, M.D.* ,

and CLAUDE PLANCHE, M.D. *

Plessis Robinson, France

Sponsored by: Aldo Castaneda, M.D., Boston, Massachusetts

Optimal surgical management of neonatal coarctation remains controversial. We report our entire experience using a single surgical technique: the extended end to end anastomosis (EEEA). From Aug 83 to Aug 92, 221 consecutive neonates underwent coactation repair with EEEA. Mean age and weight at operation were respectively 13 days ± 8 and 3.1 kg ± 0.5. Pre-operative conditions required Prostaglandin E, infusion in 66% and ven-tilatory support in 50%. The coarctation was isolated in 68 patients, associated with isolated VSD in 72 and associated with complex intracardiac anomalies in 81. The EEEA was performed through a left thoracotomy in 196 patients and through a sternotomy associated with intracardiac repair in 25.

- In the group of isolated coarctation: all patients were operated through left thoracotomy; arch hypoplasia rate was 60%. Early mortality and 5 years actuarial survival rates were respectively 2.9% and 96%.

- In the group of coarctation with VSD, 96% were operated through left thoracotomy. Arch hypoplasia rate was 71%. A pulmonary artery banding was associated in 41% (30/72). A spontaneous closure of the VSD occurred in 38%. Early mortality and 5 years actuarial survival rates were respectively 1.4% and 93%.

- In the group of complex coarctation: 74% were operated through left thoracotomy and 26% through sternotomy in a single stage associated with either a biventricular repair or a palliative procedure. Arch hypoplasia rate was 96%. Early mortality was 20%; eighteen secondary deaths occurred, all in relation with the associated lesions. The 5 years actuarial survival rate was 58% (p<0.001).

Mean follow up was 35 months ± 27, ranging from 0.2 to 10 years. Overall residual or recurrent coarctation rate was 11% (25/221), leading to 18 reoperations and 2 angioplasties. Overall actuarial survival rate at 5 years was 80% ±3%.

	Arch	Left	One stage	Recurrent	Early	5 years
Pts Groups	Hypoplasia	Thoraco.	Sternolomy	Coa	Mortality	Survival
Isolated CoA	41	68	0	9	2	96%
68 pts	60%	700%	0%	13%	2.9%
CoA + VSD	51	69	3	9	1	93%
72 pts	71%	96%	4%	12.5%	1.4%
Complex CoA	78	59	21	7	16	58%
81 pts	96%	73%	27%	8.6%	20%
Total	170	196	25	25	19	80%
221 pts	77%	89%	11%	11%	8.6%

Conclusion: Neonatal coarctation is safely managed by EEEA; long term prognosis is mainly related to associated cardiac lesions.

*By Invitation

7. Staged Operation for Pulmonary Atresia and Ventricular Septal Defect With Major Aortopulmonary Collateral Arteries: Complete Unifocalization Based on New Concept of Peribronchial Surgery

KAZUO SAWATARI, M.D.*, YASUHARU IMAI, M.D.,

TAKAMASA TAKEUCHI, M.D.*, YUKIHISA 1SOMATU, M.D.*,

KOJIRO KODERA, M.D.*, MAKOTO NAKAZA WA, M.D.* and

KAZUO MOMMA, M.D.*

Tokyo, Japan

Since 1982, we have followed the protocol of staged operation for pulmonary atresia and ventricular septal defect (VSD) with major aorto-pulmonary collateral arteries (MAPCAs). In first-stage repair (unifocaliza-tion), intrapulmonary arteries were unified and associated peripheral pulmonary stenosis was released. In case of absent or severely hypoplastic central pulmonary arteries (PA Index<50), new central pulmonary arteries were created. Finally, the unifocalization was completed by modified Blalock-Taussig shunt with the ligation of MAPCAs. In second-stage repair, right ventricular-pulmonary arterial (RV-PA) continuity was established with the closure of VSD. From 1982 to October 1992, 70 patients, whose ages ranged from 1 month to 24 years (mean 5.5 years), underwent unifocalization. There were one early and two late deaths (mortality rate 4%). Isolated area from 1 segment to 2 lobes, being solely supplied from MAPCAs due to arborization abnormalities, was present in 48 patients (69%). In the primary series of 18 patients, intrapulmonary arteries were unified at the hilum with equine pericardial conduits (intrapulmonary bridges). In the recent series, however, unification of intrapulmonary arteries was successfully achieved by direct anastomoses avoiding the use of prosthetic conduits in the vicinity of intrapulmonary bronchi locating in the middle of hilum where isolated intrapulmonary arteries contiuing from MAPCAs became in close proximity to hilar intrapulmonary arteries connecting to central pulmonary arteries. New central pulmonary arteries were created with equine pericardial conduits in 11 out of 16 patients with severely hypoplastic central pulmonary arteries and in 11 patients with absent central pulmonary arteries. Second-stage repair has been completed in 45 patients. The VSD was closed with a perforated patch in 9 patients with severe pulmonary hypertension or severely hypoplastic hilar intrapulmonary arteries. There were 3 early and 2 late deaths (mortality rate 11%). Postoperative right ventricular/left ventricular systolic pressure ratios (RVP/LVP) ranged from 0.36 to 1.00 (mean 0.61). There was no relationship between the size of central pulmonary arteries (PA Index) and postoperative RVP/LVP. We conclude that unifocalization can be best achieved by direct anastomoses between hilar intrapulmonary arteries around intrapulmonary bronchi in the middle of hilum where essential deformities of arborization abnormalities exist. The majority of patients with MAPCAs can have successful repair by our unifocalization technique when hilar intrapulmonary arteries are of adequate size without severe pulmonary hypertensive change.

*By Invitation

8. Early and Late Results of Mitral Valve Repair in Children

ALON S. AHARON, M.D.*, HILLEL LAKS, M.D.,

DAVIS C. DRINKWATER, M.D., REEMA CHUGH, M.D.*,

RICHARD N. GATES, M.D.*, LESTER C. PERMUT, M.D.* and

ABBAS ARDEHALI, M.D.*

Los Angeles, California

Mitral valve repair in children has the advantage of avoiding MV replacement with its attendant need for anticoagulation and reoperation. Forty-seven children with congenital mitral regurgitation underwent mitral valve repair between May, 1982 and February, 1992. The group ranged in age from 6 months to 17 years (mean 5.2 years + / - 4.2) and excluded patients undergoing primary repair of newly diagnosed complete atrioventricular canal (AVC). Two patients with prior repair of AVC, and 1 patient with congenital mitral insufficiency and bacterial endocarditis were included in the study. Five patients had grade III and 18 patients had grade IV MR by preoperative echocardiography. Associated cardiac anomalies were present in 37 of 47 patients and 81% of the patients required concomitant intracar-diac procedures. Associated lesions included: Single ventricle (30%), ASD (27%), VSD (15%), pulmonary atresia/stenosis (15%), TV atresia (11%), TAPVR (6%), dextrocardial (6%), TV insufficiency (4%), AS (4%), and transposition of the great vessels (2%). The methods of mitral valve repair included annuloplasty in 44/47 (94%), repair of the anterior leaflet in 18/47 (38%), cleft closure of the anterior leaflet in 12/47 (26%), chorda! shortening in 9/47 (19%) and repair of the posterior leaflet in 5/47 (11%). The technique of annuloplasty was modified to allow annular growth. Follow up data was available from 1 to 8 years, (mean 4.0 years + / - 2.5). All patients since 1988 had intraoperative transesophageal echocar-diograms. There were 2 (4%) early (<30 days) deaths. One after Fontan procedure and MV repair, and 1 after combined aortic valve replacement and MV repair. Three late deaths (6%) occurred in 6, 9 and 20 months postoperatively. All 3 patients had persistent moderate to severe MR. The actuarial survival rate was 94% at 8 years. Mitral valve repair failed in 5/47 (11%) patients who then required MVR. Two of these patients had required annuloplasty only. One patient underwent emergent MVR for flail anterior leaflet on postoperative day 0, 1 patient underwent MVR on postoperative day 7 for severe MR and CHF, and 3 patients underwent MVR 6, 14 and 48 months postoperatively for progressive, severe MR. Actuarial freedom from reoperation was 91 % after 2 years and 89% after 4, 6, and 8 years. One thromboembolic event (2%) occurred resulting in transient right sided paralysis in a 17 year old patient after combined mitral valve repair and AYR 18 months postoperatively, despite adequate an-ticoagulation. Ninety-seven percent of long term survivors were asymptomatic. All patients received postoperative echocardiograms, and 94% had minimal to no mitral regurgitation. We conclude that mitral reconstruction can be performed with low early and late mortality. The need for reoperation is relatively low and valve growth has occurred with the use of a modified annuloplasty.

2:30 p.m. BASIC SCIENCE LECTURE

"Molecular Biology: New Common Ground for Cardiothoracic Surgery"

Andrew S. Wechsler, M.D., Richmond, Virginia

3:15 p.m. INTERMISSION - VISIT EXHIBITS

*By invitation

4:00 p.m. SCIENTIFIC SESSION - Grand Ballroom

Moderators: Tom R. DeMeester, M.D.

William A. Gay, Jr., M.D.

9. Survival Related to Nodal Status After Sleeve Resection for Primary Lung Cancer

REZA MEHRAN, M.D.*, JEAN DESLAURIERS, M.D.,

LIU GUOJIN, M.D.*, MICHEL PIRAUX, M.D.* and

MAURICE BEAULIEU, M.D.*

Ste-Foy, Quebec, Canada

Sleeve lobectomy is a lung saving procedure indicated for central tumors for which the alternative is a pneumonectomy. At present time, the relationship between survival and nodal status is unclear because in most series, the presence of N, disease significantly worsens the prognosis with few or no long term survivors.

During the period 1972-1992, 142 patients underwent sleeve resection for lung cancer at our institution. Mean age was 60.7 ± 9.1 years (11-78). Indications for surgery were a central tumor in 112 patients (79%), a peripheral tumor in 18 patients (13%) and compromised pulmonary function in 12 patients. One hundred and twenty patients had pre-operative mediastinoscopy which was negative in all but 6 patients. The general characteristics of the study population and the survival are shown in the table.

Pathological nodal	No	N1	PN0-N1	N2	Total
Status
Number of patients	73 (51.4%)	55 (38.7%)	-	14	142
Histology
* Squamous	55 (75.3%)	43 (78.2%)	NS	5	103 (72.5%)
* Non squamous	14 (19.2%)	12(21.8%)		9	35 (24.6%)
* Carcinoid	4	-		-	4
"T" status
* T1	6	5		1	12
* T2	55 (75.3%)	43 (78.2%)	NS	9	107 (75.3%)
* T3-4	12	7		4	23
Extent of Surgery
* Complete	67 (91.8%)	51 (92.7%)	NS	6	124 (87%)
* Incomplete	6	4		8	18
Survival
* Median	2931 days	1433 days	NS (0.12)	560 days	11 52 days
* 3 years	67%	58%		7%	57%
* 5 years	57%	46%	NS	0%	46%
* 10 years	44%	27%		0%	33%

The operative mortality was 2.1% (3/142). Follow-up was complete for the 139 remaining patients and there was no significant difference in survival between patients with N₀ or N, status. The incidence of local recurrence was also not significantly different between these two groups (N₀: 16.4%, N,: 21.8%). Among the 14 patients with N₂ disease, none survived 5 years.

This data suggests that sleeve resection is a very adequate cancer operation for patients with No-N, status who can have complete resection of their tumor. The presence of N₂ disease significantly worsens the prognosis and does not justify the use of the procedure.

*By invitation

10. Segmentectomy vs. Lobectomy in Patients With Stage I Pulmonary Carcinoma: Five Year Survival and Patterns of Intrathoracic Recurrence

WILLIAM H. WARREN, M.D. and

L. PEN FIELD FABER, M.D.

Chicago, Illinois

From 1980-87, 73 patients had a segmentectomy and 112 patients had a lobectomy for Stage 1 (T1NO, T2NO) primary pulmonary carcinoma. Patients with a previous primary malignancy, incomplete staging and/or incomplete resections were excluded. Patients were followed for 5 years for survival and for pattern of recurrent tumor. Recurrent intrathoracic carcinoma was defined as recurrence of carcinoma in the ipsilateral or contralateral hemithorax without regard to time interval, precise location within the hemithorax, or histology. No attempt was made to distinguish local recurrence from solitary metastasis or second primary tumor.

The 5 year survival in the 2 groups was not statistically different (p>0.05). However, patients undergoing a segmentectomy had a 24.7% incidence of ipsilateral recurrence vs. 4.1% contralateral recurrence. In contrast, patients undergoing a lobectomy had an 8.9% incidence of ipsilateral recurrence vs. 3.5% contralateral recurrence. This higher incidence of ipsilateral recurrence among segmentectomies (p>0.01) occurred regardless of histology, tumor size and location within the lobe.

We conclude that segmental pulmonary resections may provide long term survival similar to lobectomies in Stage I carcinoma, but with a higher incidence of ipsilateral intrathoracic recurrence. Vigilant follow-up is therefore especially important for patients undergoing segmental pulmonary resections.

11. Temporary and Permanent Restoration of Airway Patency With the Tracheal T-Tube

HERMES C. GRILLO, M.D., HENNING A. GAISSERT, M.D.*,

DOUGLAS J. MATHISEN, M.D. and

JOHN C. WAIN, M.D*

Boston, Massachusetts

The advantages of the tracheal T-tube compared to regular tracheostomy tubes are a physiologic direction of airflow, preservation of laryngeal phonation, and superior patient acceptance. Between 1968 and 1991, 69 males and 69 females (age 7 months to 95 years, mean 43.8 years) underwent placement of T-, TY- (6 patients), or a modified extended T-tube (4 patients). On admission, 84 patients had tracheostomy tubes, 4 had T-tubes, and 2 patients arrived after emergent translaryngeal intubation. Of 34 patients without airway support, 28 (82.3%) had dyspnea, 24 (70.6%) had stridor, and 6(17.8%) had persistent cough. In 13 patients tube insertion was performed in the immediate postoperative period.

Primary diagnosis was postintubation stenosis in 85 patients, burn injury in 13 patients, malignant airway tumors in 12 patients, and various disorders in 27 patients. Uses were as follows: (1) silastic tube stenting was temporary in 29 patients, of whom 14 underwent later operative reconstruction; (2) definitive permanent insertion was performed in 48 patients. A modified silastic tube was used in 4 patients with left main bronchial stenosis after right pneumonectomy and provided effective long-term palliation in 3. (3) Postoperative airway obstruction after reconstruction prompted placement in 32 patients. The T-tube was not tolerated in 28 patients (20.4%) due to obstruction of the upper limb (laryngeal edema, unreconstructible subglottic stenosis) and aspiration. Positioning of the T-tube above the vocal cords in 12 patients for subglottic stenosis was effective in 10. Five of 10 children under age 10 developed airway obstruction necessitating tube removal.

Successful long-term intubation in 109 patients exceeded 1 year in 48 patients and 5 years in 12 patients. Only 5 patients required tube removal for obstructive problems more than 2 months after placement. The tracheal T-tube restores airway patency reliably with excellent long-term results and represents the preferred management of airway obstruction not amenable to surgical reconstruction.

*By Invitation