AMERICAN ASSOCIATION FOR

THORACIC SURGERY

75TH ANNUAL MEETING

HYNES CONVENTION CENTER and

SHERATON BOSTON HOTEL and TOWERS

APRIL 23-26, 1995

MONDAY MORNING, APRIL 24, 1995

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

8:45 a.m. PLENARY SESSION

Auditorium, Hynes Convention Center

Moderators: Robert B. Wallace, M.D.

James L. Cox, M.D.

1. LONG-TERM SURVIVAL BENEFIT OF CABG AND PTCA IN PATIENTS WITH CORONARY ARTERY DISEASE

Robert H. Jones, M.D., Karen Kesler, M.S.*, Harry R. Phillips, III, M.D.*, Daniel B. Mark, M.D.*, Peter K. Smith, M.D.*, Charlotte L. Nelson, M.S.*, Mark F. Newman, M.D.*, Joseph G. Reves, M.D.*, Robert W. Anderson, M.D and Robert M. Califf, M.D.*

Durham, North Carolina

The purpose of this study was to evaluate long-term survival benefit of CABG and PTCA in 9263 patients with symptomatic coronary artery disease confirmed to involve one, two, or three vessels by cardiac catheterization at a single academic medical center between 1984 and 1990. Clinical data was pro-spectively entered into an established cardiovascular database, and annual follow-up was 97% complete for a minimum and mean interval of 2.5 and 5.4 years. Outcomes were analyzed by intention to treat by medicine (n = 3038), PTCA (n = 2799) or CABG (n = 3426). Differences among treatment groups in nine baseline characteristics known to influence outcome (ejection fraction, age, gender, acute myocardial infarction, comorbid disease, congestive heart failure, chest pain, peripheral vascular disease, mitral regurgitation) were adjusted by statistical models previously shown to be valfd. A severity of coronary artery stenosis variable, defined by the number of 75% stenoses, presence of any 95% stenoses, and LAD and proximal LAD location of stenosis, best defined survival benefit from CABG and PTCA compared to medical treatment. Adjusted hazard ratios for the three treatment pairs are illustrated for nine discrete anatomic groups comprising this anatomic severity index.

Trends apparent in our previous report of intermediate-term outcomes in this patient group are more definitive and statistically valid in these long-term outcome data. These data justify the following generalizations regarding selection of treatment in patients with symptomatic coronary artery disease: 1) either PTCA or CABG confers long-term survival benefit over medical treatment in all patients; 2) all patients with single-vessel disease, except those with >95% proximal LAD stenosis, benefit from PTCA in comparison to CABG; 3) all three-vessel patients and two-vessel patients with severe LAD stenosis benefit from CABG in comparison to PTCA; 4) other two-vessel patients and one-vessel patients with >95% proximal LAD stenosis can be treated with either PTCA or CABG; 5) these relative benefit ratios must be interpreted in light of the absolute rate of death in each anatomic subgroup which is least in patients with single-vessel disease and greatest in patients with severe three-vessel disease.

*By invitation

2. COMPARISON OF EARLY FUNCTIONAL RESULTS AFTER VOLUME REDUCTION OR LUNG TRANSPLANTATION FOR COPD

Henning Gaissert, M.D.*, Elbert P. Trulock, M.D.*, Sudhir Sundaresan, M.D.*, Joel D. Cooper, M.D. and G. Alexander Patterson, M.D.

St. Louis, Missouri

Bilateral lung volume reduction is designed to improve pulmonary function by restoration of diaphragmatic and chest wall mechanics. For selected patients with end stage emphysema this procedure may offer a treatment alternative to lung transplantation. Functional performance and survival in the first six months after volume reduction (VR) were compared to single (SLT) and bilateral lung transplantation (BLT) in a group of patients with emphysema due to chronic obstructive pulmonary disease. Following evaluation, patients were enrolled in a supervised intensive pre- and postoperative program of pulmonary rehabilitation. Supplemental oxygen was administered as needed to keep Sa02 greater than 90%. Functional assessment including PFT, room air ABG, and six minute walk test was obtained before operation (Pre) and at three and six months postop. Twenty-three patients underwent VR (mean age 55 years), 40 patients SLT (55 years), and 27 patients BLT (49 years). Early mortality was 0, 0 and 2/27 in the VR, SLT and BLT groupsm respectively. Six month mortality was 0, 3/40 and 2/27 in the VR, SLT and BLT groups, respectively.

	VR		SLT		BLT
Time	FEV1,L(%)	room air pO2	FEVi.L(%)	room air pO2	FEV1,L(%)	room air pO2
Pre	076 ± 033	65 8 ± 8 0	047 ± 0 13	52.5 ± 9.4	0.51 ± 0 18	552 ± 85
	(25 ± 8)		(18 ± 4)		(17 ± 9)
3 mo	1.21 ± 060	71 6 ± 12	1 51 ± 0.50	80 6 ± 9 8	2 66 ± 0.82	88. 7 ± 15
	(39 ± 16)		(56 ± 13)		(83 ± 14)
6 mo	1.36 ± 0.70	75 8 ± 10	1 57 ± 0.45	80 9 ± 9 1	2.9 ± 0 74	90 2 ± 8 5
	(43 ± 17)		(58 ± 12)		(90 ± 12)
Data are presented as mean ± standard deviation, Values in parentheses are percent of predicted normal

At six months FEV, was improved by 79% (VR), 234% (SLT) and 469% (BLT) over preoperative values. Exercise endurance as measured by six minute walk test increased by 22% (VR), 47% (SLT) and 84% (BLT) and room air pC>2 increased by 15, 54, and 63% from baseline, respectively. At six months all SLT and BLT patients and 21 of 23 VR patients were free of supplemental oxygen. Although single and bilateral lung transplantation result in superior pulmonary function, volume reduction achieves satisfactory improvement of disabling symptoms early after operation while avoiding immunosuppression and transplant-specific complications.

*By invitation

3. VIDEO THORACOSCOPIC SURGICAL INTERRUPTION: THE TECHNIQUE OF CHOICE FOR PATENT DUCTUS ARTERIOSUS. ROUTINE EXPERIENCE IN 201 PEDIATRIC CASES

Francois Laborde, M.D.*, Thierry A. Folliguet, M.D.*, Alain Batisse, M.D.*, Alain Dibie, M.D.*, Edouardo Da-Cruz, M.D.* and Daniel Carbognani, M.D.*

Paris, France

Sponsored by: J. N. Cunningham, M.D., Brooklyn, New York

Video Thoracoscopic Surgical Interruption (VTSI) for patent ductus arteriosus (PDA) is a well-standardized procedure, already described. We present our entire series of VTSI from the first case performed on 9/5/91 to 10/31/94.

201 patients underwent VTSI in a variety of age groups: < 6 months (53 pts, 26.4%), 6-48 months (116 pts, 57.7%), > 48 months (32 pts, 16%). The mean weight was 12.6 Kg (1.3 Kg - 65 Kg). 35 patients exhibited asymptomatic pulmonary hypertension, while the remainder were asymptomatic. Associated intracardiac anomalies included ASD (3), VSD (5) and APVR (1).

All patients underwent VTSI of their PDA using two titanium clips. Assessment of closure was evaluated by post-operative echocardiogram prior to extubation. 2.5% (5 pts) had a patent ductus following VTSI, all occurring in our early experience and related to insufficient dissection resulting in inadequate clip placement. Four pts had immediate clip repositioning (3 by VTSI, 1 by thoracotomy). Subsequent echocardiogram revealed persistent closure in these patients. A persistent PDA with minimal flow was discovered in one asymptomatic patient following discharge. Recurrent laryngeal nerve dysfunction was noted in 5 pts (4 transient, 1 persistent). There was no mortality, hemorrhage, transfusion requirement or chylothorax in this series. Mean operative time was 20 mn ± 10 mn, and hospital stay averaged 48 hr > 6 mos, 72 hr < 6 mos.

In conclusion, this is a safe, rapid, cost effective technique resulting in excellent results and a shortened hospital stay. VTSI represents the technique of choice for PDA closure.

9:45 am INTERMISSION - VISIT EXHIBITS

*By invitation

10:30 am PLENARY SESSION

Auditorium, Hynes Convention Center

Moderators: Mortimer J. Buckley, M.D.

James L. Cox, M.D.

4. TUMOURS OF THE ESOPHAGOGASTRIC JUNCTION (EGJ): LONG-TERM SURVIVAL IN FUNCTION OF LYMPH NODE METASTASIS PATTERNS. REFLECTION ON TNM CLASSIFICATION

Toni E. Lerut, M.D., Willem H. Steup, M.D.*, Paul De Leyn, M.D.*, Dirk van Raemdonck, M.D.* and Willy Coosemans, M.D.*

Leuven, Belgium

Introduction: EGJ tumours still give reason for debate as they may be considered as a separate entity with a specific behavior, not compatible to pure esophageal or gastric tumours and because of their poor survival after surgical resection.

Material and methods: From 1983 to 1993, 259 patients with EG-junction tumours, i.e. tumours with their centre located at the Z-line, were operated. A retrospective study was made in the group of patients from 1983 to 1989 (n=95), in order to have a minimum of follow-up of 5 years and a maximum follow-up of 10 years. Results were analysed in function of lymph node metastasis pattern.

Results: Hospital mortality rate was 6.2% (6/95) overall. Actuarial survival analysis showed a 5- and 10-year survival rate of 33% and 31%, respectively. Five- (and ten-) year survival of TNM stages I (n=13), II (n=13), III (n=28), and IV (n=40) was 90% (90%), 70% (70%), 28% (28%) and 11% (8%), respectively. For node negative patients (n=26), five- (and ten-) year survival was 72% (72%), compared to 18% (16%) for node positive patients (n=68; p<0005). If lymph node metastases were both abdominal and thoracic (n=28), five- (and ten-) year survival was 13% compared to 26% (26%) if metastases were only confined to the abdomen (n=37; p=>005). When tumours were staged as an esophageal carcinoma, individual patient staging changed, as did the five- and ten-year survival rates. Figures were as follows: Stages I (n=13), II (n=13), III (n=27) and IV (n=41) with 90% (90%), 70% (70%), 37% (37%) and 10% (10%) respectively for five- and ten-years survival. When stage IV organ metastases were excluded, 5- (and 10-) year survival were 16% (11%) and 15% (9%) for patients staged as gastric (n=28) and esophageal (n=28) carcinoma, respectively.

Conclusions: Tumours of the EGJ tend to have a pattern of lymph node metastasis to both abdominal and thoracic cavity. A reasonable 5- and 10-year survival can be obtained even in patients with lymph node metastasis after wide excision and two field lymph node dissections for stage III and IV. When staging the tumours respectively as gastric or oesophageal carcinoma no difference is seen in survival curves. We suggest to include a N2 labeling for thoracic lymphnode metastasis instead of the actual M+Ly in the actual TNM staging which better reflects the potential for curative surgery in this group. Finally, there was almost no further difference in 10-year survival as compared to 5-year survival.

*By invitation

5. THE ROSS PROCEDURE (PULMONARY AUTOGRAFT) INTERNATIONAL REGISTRY: THE FIRST 18 MONTHS RESULTS. CHANGING DEMOGRAPHICS AND OUTCOMES

James H. Oury, M.D., A. Craig Eddy, M.D.,

S. Kathryn Mackey, R.N.*, Joseph C. Cleveland, M.D.,

William W. Angell, M.D., Ronald C. Elkins, M.D. and

Donald N. Ross

Missoula, Montana

In April 1993 the Ross Procedure Registry was established. Last year we reported the preliminary results of this registry which encompassed the initial results of the procedure on the 657 entered patients. This included both Mr. Ross' series of 417 patients as well as 240 cases done by other surgeons since 1986. Since that time post-operative follow-up data on these patients has been gathered and the number of patients entered in the registry has doubled. A total of 1022 patients have been cataloged in this registry by 95 surgeons from 75 centers around the world. The purpose of this report is to compare the demographics and outcomes of the 773 more recent pulmonary autografts which have been done since 1986 with Mr. Ross' original series of 249 cases and to examine the fate of the autograft and the right ventricular outflow tract (RVOT) in these two groups.

Demographics:			Implant Technique
	Mean Age	Sex (M/F)	Subcoronary/Inclusion/Root
Ross' Data	29 (9-60 yr)	80% / 20%	100% / 0% / 0%
Post 86 Data	21 (1 day=73 yr)	72% / 28%	10% / 15% / 75%

Mortality Data:
	Early (30) Day	Late	Primary Etiology Early	Primary Etiology Late
Ross' Data	6.6%	7.4%	Hemorrhage/Arrhythmia	Cardiac Failure
Post 86 Data	1.6%	0.5%	Cardiac Insufficiency	Cardiac Arrest

Reoperative Incidence (Cause):			RVOT Status:
				Acceptable	Revised
Ross' Data	20%	(RVOT 25% / AI 75%)	Ross' Data	95%	5%
Post 86 Data	2.3%	(RVOT 6% / AI 94%)	Post 86 Data	99.6%	0.4%

Explant Data:
	Early (30 Day)	Late	Etiology Early	Etiology Late
Ross' Data	0	14%	N/A	AI
Post 86 Data	0	2.3%	N/A	AI

Postoperative NYHA Classification Data:
	Class I	Class II	Class III	Class IV
Ross' Data	No Data	No Data	No Data	No Data
Post 86 Data	94%	4%	1.5%	0.5%

Postoperative Echo Data:
	# of pts c echo data	EF>50%	Mean EF	AI (0 Trace/Mod)	Mean Ao Gradient
Ross' Data	No Data	No Data	No Data	No Data	No Data
Post 86 Data	188/605	95%	66%	88% / 12%	4.5 Torr

Conclusions:

1. Implantation of the pulmonary autograft as a root has clearly evolved to be the technique of choice and has resulted in a marked decrease in explantation of the autograft due to technical failure.

2. With advancing technology RVOT homograft problems have nearly disappeared and no longer play a major role in the failure of the Ross procedure.

3. Both early and late mortality have markedly decreased due to improved myocardial preservation techniques and an improved technical understanding of the procedure.

4. This recent data reconfirms the efficacy of the Ross procedure as it has now evolved as a revolutionary solution to aortic valvular disease.

11:15 am PRESIDENTIAL ADDRESS

Reflections-Projections!

Robert B. Wallace, M.D., Washington, D.C.

12:00 pm ADJOURN FOR LUNCH - IN EXHIBIT HALL

*By invitation