American Association for

Thoracic Surgery

73RD ANNUAL MEETING

Hyatt Regency Hotel, Chicago, IL

APRIL 25-28, 1993

MONDAY MORNING, April 26, 1993

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

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

Moderators: John L. Ochsner, M.D.

Martin F. McKneally, M.D.

1. Retransplantation in Heart-Lung Recipients With Obliterative Bronchiolitis

DAVID H. ADAMS, M.D. *, ANDREW D. COCHRANE,

FRACS*, ASGHAR KHAGHANI, FRCS* and

MAGDI H. YACOUB, FRCS

Harefield, United Kingdom

Obliterative bronchiolitis remains the leading cause of morbidity and mortality in long term surviving heart-lung recipients. Despite enhanced im-munosuppressive therapy, a significant number of patients progress to end stage respiratory failure leaving retransplantation as the only therapeutic option. Between October 1986 and September 1992, 33 heart-lung recipients with Obliterative bronchiolitis (80% ventilator dependent) have undergone retransplantation (range: 9-83 months; mean: 27 months after the first operation). Twenty-four patients underwent repeat heart-lung transplantation. Post-operative complications included bleeding, multi-system organ failure, and infection. Twelve patients (50%) died in <30 days, and 7 patients (29%) survived >1 year. Four patients are currently alive and well (survival range 33-67 months).

Recently, we have investigated the role of single lung retransplantation in 9 heart-lung recipients with Obliterative bronchiolitis. One patient died in <30 days, and thus far 4/7 patients (57%) have survived > 1 year. Five patients are currently alive (survival range 2-23 months) and 3 patients have returned to full-time employment.

Retransplantation in heart-lung recipients with Obliterative bronchiolitis is a high risk procedure, but it can result in rehabilitation of otherwise incapacitated patients. Single lung retransplantation appears to be the preferred option in carefully selected patients.

*By Invitation

2. Current Results and Indications of Single, Bilateral and Heart and Lung Transplantation for Pulmonary Hypertension

KO BANDO, M.D. *, ROBERT J. KEEN AN, M.D. *,

IRVIN L. PARADIS, M.D.*, JOHNM. ARMITAGE M.D.*,

KEITH L. STEIN, M.D.*, ROBERTL. HARDESTY, M.D.,

HENRY T. BAHNSON, M.D. and

BARTLEY P. GRIFFITH, M.D.

Pittsburgh, Pennsylvania

The indications for single (SLT), bilateral (BLT) and heart and lung transplantation (HLT) in pulmonary hypertension (PH) remain controversial. We retrospectively analyzed the results from 10 SLT, 21 BLT and 21 HLT performed between January 1989 and August 1992 on 52 consecutive patients with PH due to primary pulmonary hypertension (n = 24), Eisenmenger's syndrome (ES) (n = 25), and CREST syndrome (n = 3). There were no differences among the 3 allograft groups (SLT, BLT and HLT) in age, gender, pre-operative (pre-op) pulmonary arterial pressure (PAP) or pre-op NYHA functional class. HLT was performed for PH with left ventricular (LV) dysfunction defined as an LV ejection fraction (EF) <35% determined by MUGA scan and for ES with complex congenital heart disease (CHD), ES with atrial septal defect (ASD) or patent ductus (PDA) was treated by isolated lung transplantation with cardiac repair (PDA closure: SLT(l), BLT(7); ASD closure: SLT(l), BLT(2). Early after transplantation (mean:post-op 4 weeks), all groups demonstrated significant hemodynamic improvement compared to before transplantation as follows (mean ± SD, *p<.05 vs pre-op by paired t test).

Post-op ventilation/perfusion (V/Q) scans (mean: 18 weeks, values expressed as % ± SD) demonstrated significant V/Q mismatch in SLT allografts (V: 35.0±12.0/Q: 85.2 ±5.0 to allograft) whereas no V/Q mismatch was present in the BLT and HLT recipients (p<.05 SLT vs BLT & HLT be analysis of variance). Operative mortality was similar among the allograft groups (SLT:20%; BLT & HLT: 14%; p = NS). SLT pts experienced the lowest one year survival (SLT:40%; BLT:67%; HLT:70%; p<.05 by life table analysis) and symptomatic recovery (mean post-op NYHA class: SLT:2.2*; BLT:1.1; HLT:1.0; *p<.05 by Kruskal-Wallis statistic).

Conclusion: In spite of encouraging early hemodynamic improvement, SLT for PH is associated with significantly decreased late survival and poor functional outcome when compared to BLT and HLT. We conclude that BLT is a more satisfactory option for PH in pts with preserved LV function. Pts with PH and severe LV dysfunction or ES combined with complex CHD still require HLT.

*By Invitation

3. Pediatric Lung Transplantation: Indications, Techniques and Early Results

THOMAS L. SPRAY, M.D., GEORGE B. MALLORY,

M.D. *, CHARLES B. CANTER, M.D. * and

CHARLES B. HUDDLESTON, M.D. *

St. Louis, Missouri

Improvement in the results of adult lung transplantation (LTX) for end-stage pulmonary disease has led to application of these techniques to the pediatric population. From 7/90 to 9/92 30 LTX (21 bilateral sequential, 6 single) in 27 patients have been performed in our pediatric transplant program (1.5 - 23 years, mean age 10.6 years). Six children had been on continuous ventilator support for 18 days to 4.5 years prior to LTX and 2 were on extracorporeal membrane oxygenation. Indications for LTX in this pediatric population include: cystic fibrosis (N = 10), pulmonary hypertension and associated congenital heart disease (N = 7), pulmonary atresia, ventricular septal defect (VSD), and nonconfluent pulmonary arteries (N = 3), pulmonary fibrosis (N = 6), and acute respiratory distress syndrome (ARDS) (N = 1). Three children underwent retransplantation for acute graft failure (N = 2) or chronic rejection (N = 1). Pulmonary fibrosis was related to treatment of acute of myelogenous leukemia with bone marrow transplantation in two children and to bronchiolitis obliterans, bronchopulmonary dysplasia, interstitial pneumonitis, and Histiocytosis-X. Ten children underwent LTX and concomitant cardiac repair. Bilateral LTX, VSD closure and pulmonary homograft reconstruction of the right ventricular (RV) outflow tract to the transplanted lungs was performed in 3 children utilizing a new technique which avoids the need for combined heart/lung transplantation. Two patients had VSD closure and LTX for Eisenmenger's syndrome and 2 had liga-tion of a patent ductus arteriosus and LTX. Three additional children underwent atrial septal defect closure and LTX. There have been 7 early deaths (26%) and 3 late deaths (sepsis - 2, hemorrhage - 1, ARDS - 2, lym-phoproliferative disease - 2, bronciolitis obliterans (OB) - 2, and pseu-doaneurysm of the RV - 1). Bronchial complications were seen in 7 of 53 anastomoses at risk (13%) (disruption - 1, stenosis - 6), and were treated with pneumonectomy (1) or stent implantation (6).

LTX in children has been associated with acceptable early results, although modification of the adult implantation technique has been necessary. LTX and repair of complex congenital heart defects is possible; heart/lung transplantation may only be required for patients with severe left heart dysfunction and associated pulmonary vascular disease. OB remains a major concern for longterm graft function in the pediatric LTX patient.

9:45 a.m. INTERMISSION - VISIT EXHIBITS

*By Invitation

10:30 a.m. SCIENTIFIC SESSION - Grand Ballroom

Moderators: Aldo R. Castaneda, M.D.

Martin F. McKneally, M.D.

4. Aortic Dissection: Is Elective Reoperation Advisable?

JEAN E. BACHET, M.D., JEAN LUC TERMIGNON,

M.D.*, BERTRAND GOUDOT, M.D.*,

GILLES DREYFUS, M.D. *, ALAIN PIQUOIS M.D. *

and DANIEL GUILMET, M.D. *

Suresnes, France

From January 1977 to June 1992, 140 patients (pts) underwent emergency surgery for Type A acute Aortic dissection. Because of the location of the in-timal tear, the replacement of the ascending aorta was extended to the transverse arch in 41 pts (30%). One hundred and nine pts (88%) survived surgery. During the same period, 30 pts had to be reoperated on, once (23), twice (3) or three times (4) for a total of 41 reoperations. Seventeen pts had had the initial repair in our Institution, 13 pts had been operated on elsewhere. Reoperation was indicated for: Aortic valve disease (7), recurring dissection (10), threatening aneurysmal evolution of a persisting dissection (22) or infective false aneurysm (2). The re-do procedure involved: the aortic root and/or ascending aorta in 13 cases including 8 Bentall (Group 1); the transverse arch alone in 6 cases (Group II); the transverse arch and Descending aorta in 8 cases (Group III) and the descending or Thoraco-abdominal aorta in 14 cases (Group IV). The risk-factors for reoperation have been analyzed in the 109 survivors initially operated on in our Institution. Six out of 18 Marfan pts (33%) versus 11 out of 91 non-Marfan pts (12%) were reoperated upon (p = 0.023). None of 30 pts surviving arch replacement at initial repair, required a reoperation, versus 17 out of 79 (21.5%) pts surviving a replacement limited to the ascending aorta (p = 0.013). The overall mortality rate of reoperation was 16% (5/30 pts) with a risk of 12% (5/41) at each procedure. (Group I: 0%; Group II: 0%; Group III: 12.5%; Group IV: 29%). Hospital mortality was influenced by emergency (4/5) (p = 0.005) and Thoraco-abdominal replacement (5/22) (p = 0.035). The late survival rate after reoperation is 53.3 ± 9.9% and 45.6 ± 11% at 5 and 7 years respectively. The late survival rate, after the initial repair, of the reoperated pts is 79.3 ± 7.4% and 63.6 ± 10.2% at 5 and 10 years, respectively.

In conclusion, aortic dissection is an evolving process that may require one or several reoperations after the initial repair. At initial emergency operation, the resection of the entry site, when located on or extending to the transverse arch, has reduced the risk of reoperation, in our experience. Elective reoperation must be considered before the occurence of complications, especially in Marfan pts. It entails a relatively low risk, except in case of Thoraco-abdominal replacement and allows a satisfactory long-term survival rate.

*By Invitation

5. The Influence of Arterial Coronary Bypass Grafts on the Mortality of Coronary Reoperations

BRUCE W. LYTLE, MD, DERRICK McELROY, M.D.*,

PATRICK McCARTHY, M.D.*, FLOYD D. LOOP, M.D.,

ROBERT W. STEWART, M.D.* and

DELOS M. COSGROVE, M.D.

Cleveland, Ohio

During the years 1988 through 1991, 1663 patients underwent a first reoperation for isolated coronary bypass grafting with 58 (3.5%) in-hospital deaths. At the primary operation 575 patients had received at least one internal mammary artery (IMA) graft and 489 patients had at least one patent IMA graft present at the time of reoperation. At reoperation 1014 patients received at least one IMA graft, 10 received an inferior epigastric graft and 37 a gastroepiploic graft. Subgroups according to numbers of IMA grafts at primary operation, reoperation and in-hospital mortality rates are shown below.

Of 489 patients with patent IMA grafts at reoperation the IMA was damaged in 17 (3.5%) and of 428 with a patent IMA graft to the left anterior descending coronary artery (LAD) 14 (3.3%) were damaged necessitating regrafting. All patients with damaged IMA's survived.

Multivariate testing of variables for their association with in-hospital mortality identified no IMA graft at either primary surgery or reoperation (p<0.0001), advancing age (p = 0.0046) and female gender (p = 0.036) as factors linked to increased risk. Left ventricular function, left main stenosis, extent of native coronary atherosclerosis and the interval between operations did not influence mortality. Furthermore, the presence of a atherosclerotic vein graft to the LAD, a factor shown to increase in-hospital risk in previous studies, did not increase risk during these years. The observation that patent IMA and atherosclerotic vein grafts do not appear to be factors specifically increasing the risk of reoperation we attribute to the use of retrograde car-dioplegia and increased surgical experience.

The use of IMA grafts at a primary operation does not increase the risk of a reoperation and the use of IMA grafts at reoperation does not increase in-hospital mortality.

11:15 a.m. PRESIDENTIAL ADDRESS

"Giants: How and Why They Grew"

John L. Ochsner, M.D., New Orleans, Louisiana

*By Invitation