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Back to Annual Meeting Program
1:45 p.m. SIMULTANEOUS SCIENTIFIC SESSION A - ADULT CARDIAC SURGERY Room 6A/B, San Diego Convention Center
Moderators: Delos M. Cosgrove, M.D. John A. Waldhausen, M.D.
20. THE 25-YEAR HISTORY OF INTRA-AORTIC BALLOON PUMPING: A RETROSPECTIVE REVIEW. David F. Torchiana, M.D.*, Gregory Hirsch, M.D.*, Mortimer J. Buckley, M.D., Chiwon Hahn, M.D.*, John Allyn, M.D.*, John F. Drake*, John B. Newell* and W. Gerald Austen, M.D. Boston, Massachusetts and Halifax, Nova Scotia, Canada Discussant: D. Glenn Pennington, M.D.
The intra-aortic balloon pump (IABP) has been in use clinically for 25 years evolving from surgical implantation in the MICU or OR to 96% percutaneous implants in the cath lab (83%) in the present era. The table displays the number of IABP insertions at our institution by 5 year intervals and shows trends in selected variables.
In spite of the advancing age of the population (38% over age 70 from 1990-95) mortality has declined. Vascular complications (VC) are more frequent in women (9.8 vs 6.6%, p<0.0001) and female sex is an independent predictor (p<0.0001) of VC in a stepwise logistic regression model (odds ratio 1.66, 95% CI 1.31 to 2.11). Independent predictors of death are age, intra- or postoperative IABP placement, CHF, cardiogenic shock and transthoracic insertion. Insertion for ischemia, an associated CABG or PTCA and percutaneous insertion are predictive of a more favorable outcome.
In a subgroup of 193 intraoperative insertions from 1990-95, independent predictors of mortality were determined based on pre-, intra- and immediate postoperative variables. We have developed indications for use of other forms of circulatory assistance based on these variables.
*By invitation 21. RATIONALE OF THE COX MAZE PROCEDURE FOR ATRIAL FIBRILLATION DURING REDO MITRAL VALVE SURGERY. Junjiro Kobayashi, M.D.*, Yoshio Kosakai, M.D.*, Fumitaka Isobe, M.D.*, Yoshikado Sasako, M.D.*, Kiyoharu Nakano, M.D.*, Kiyoyuki Eishi, M.D.* and Yasunaru Kawashima, M.D. Osaka, Japan Discussant: Fred A. Crawford, Jr., M.D.
There has been a steady increase in the rate of reoperation for mitral valve diseases with chronic atrial fibrillation (AF). This study examined the rationale of the Cox maze operation for AF during redo mitral valve surgery. Between June 1992 and July 1995, we performed the maze procedure in 42 patients (pts) as a concommitant operation of redo mitral valve surgery (maze group). Associated procedures were tricuspid valve surgery in 27 pts and aortic valve surgery in 15 pts. The mean age at operation was 57.3 ± 9.7 years, and the mean interval from the previous operation was 14.3 ± 10.5 years. AF was already present at the time of the previous operation in 29 pts (69%). There was neither hospital death nor late death. Sinus rhythm was regained in 28 pts (67%), and atrial A-wave was detected in 20 pts (48%) by pulsed Doppler study. Pts who recovered sinus rhythm had shorter history of AF (9.0 ±6.0 years versus 15.9 ± 4.6 years: p<0.01), larger f-wave of VI on EKG (0.18 ± 0.10 mV versus 0.10 ± 0.08 mV: p<0.05), and smaller cardiothoracic ratio (63 ± 8% versus 67 ± 5%: p<0.05) compared to patients with persistent AF. At the same period of time, 54 pts underwent mitral valve reoperation without the maze procedure (control group). Aortic cross clamp time and cardiopulmonary bypass time was slightly longer (p<0.05 and p<0.05) in the maze group (133 ± 28 and 221 ± 43 min.) than in the control group (126 ± 65 and 197 ± 78 min.). There was no significant difference in the amount of chest tube drainage or transfusion between both groups (890 ±510 and 2120 ± 1600 ml in the maze group; 840 ± 480 and 2140 ± 1760 ml in the control group). The incidence of reopening the chest for bleeding was not significantly different between both groups (14% in the maze group, 7% in the control group). The operation without transfusion was possible in the same frequency (17% in the maze group; 20% in the control group). These results suggest that the maze procedure should be considered in selected patients with a high possibility of regaining sinus rhythm in redo mitral valve surgery.
*By invitation 22. SURGERY FOR ASYMPTOMATIC AND MILDLY SYMPTOMATIC MITRAL REGURGITATION. Miguel Sousa Uva, M.D.*, Gilles Dreyfus, M.D.*, Giuseppe Rescigno, M.D.*, Naji Al Aile, M.D.*, Evelyne Palsky, M.D.*, Frederic Pouillard, M.D.* and Arrigo Lessana, M.D.* Paris, France Supported by: Claude Planche, Paris, France Discussant: Lawrence H. Cohn, M.D.
The ideal timing for surgical intervention in patients with mitral regurgitation is controversial. Surgery is currently indicated for patients who are at least in NYHA class II with severe mitral regurgitation and left ventricular enlargement. In view of the good preoperative echocardiographic predictability of valve repair, earlier valvuloplasty could prevent progressive deterioration of LV function and development of rhythm disturbances.
The purpose of this study was to review the risk benefit ratio of mitral valve repair in patients with pure mitral regurgitation and no or mild symptoms. Between 1/89 and 12/94, 102 asymptomatic or mildly symptomatic patients with grade 3 or 4/4 isolated mitral regurgitation were referred for mitral valve repair. Mean age (±SD) was 52.5 ± 13.4 years. Thirty-two patients were in NYHA class I and 70 were in NYHA class II. Degenerative mitral valve disease was the cause of mitral regurgitation in 79% of the patients. Mean pulmonary artery pressure was 24.3 ± 11.4 mmHg and 73% of the patients were in sinus rhythm. Preoperative end systolic and end diastolic left ventricular diameters were 40.7 ± 6.3 mm and 65.8 ± 7.1 mm respectively.
One hundred patients had mitral valve repair and 2 patients required mitral valve replacement. Posterior leaflet resection was used in 78 patients, chordal transposition in 30 and chordal shortening in 22 patients. One patient died in the hospital for an operative mortality of 1%. One patient required early reoperation for residual mitral incompetence and required valve replacement. Follow-up was 98% complete and ranged from 6 to 77 months (median 25.5 months). There were no late deaths and no late reoperations. Freedom from thromboembolic events was 95.7% at 4 years. There were no anticoagulant related complications and no endocarditis. At follow-up, 82% of the patients were in NYHA class I and 18% remained in class II. Among the 20 patients in chronic atrial fibrillation preoperatively, 10 were in sinus rhythm at follow-up. Mean residual mitral regurgitation and mean transmitral gradient at last follow-up were 0.44 ± 0.65 and 3.4 ± 2.0 mmHg respectively. End systolic and end diastolic left ventricular diameters were 35.9 ± 7.1 mm and 53.9 ± 6.7 mm respectively (p<0.001 vs preoperative values).
These data show that: 1) with appropriate expertise, the feasibility of mitral valve repair can be predicted preoperatively; 2) the safety and the stability of mitral valve repair, together with the improvement in late LV dimensions, suggest that early intervention could be proposed for asymptomatic or mildly symptomatic patients before LV dilatation occurs.
2:45 p.m. INTERMISSION - VISIT EXHIBITS
*By invitation 3:15 p.m. SIMULTANEOUS SCIENTIFIC SESSION A - ADULT CARDIAC SURGERY Room 6A/B, San Diego Convention Center
Moderators: Delos M. Cosgrove, M.D. John A. Waldhausen, M.D.
23. GEOMETRIC MISMATCH OF THE AORTIC AND PULMONARY ROOTS IS THE CAUSE OF AORTIC INSUFFICIENCY AFTER THE ROSS PROCEDURE. Tirone E. David, M.D., Gary D. Webb, M.D.*, Ahmed Omran, M.D.*, Susan Armstrong, McS.* and Zhao Sun, Ph.D.* Toronto, Ontario, Canada Discussant: Ronald C. Elkins, M.D.
Aortic insufficiency (AI) is common after aortic valve replacement (AYR) with pulmonary autograft (PA). This problem can be prevented by adjusting the diameters of the aortic annulus and of the sinotubular junction of the aorta to those diameters of the PA.
Seventy-five patients underwent AYR with PA during the past five years. Their mean age was 33 years, range 10 to 53; 46 pts were men. Aortic stenosis was the predominant lesion in 38 pts, AI in 29, and mixed lesions in 8. The aortic valve was bicuspid in 49 pts, other congenital in 21, and prosthetic disease in 5. Eleven pts had had previous aortic valve surgery. The diameters of the aortic annulus and of the sinotubular junction of the aortic root were measured after excising the diseased aortic valve. The diameter of the sinotubular junction of the PA was also measured and the diameter of its annulus was assumed to be 10% larger than the diameter of its sinotubular junction. The following values were obtained.
The diameter of the aortic annulus was within 2 mm of that of the PA in 36 pts and larger in 39 pts. Reduction of the diameter of the aortic annulus in these 39 pts was accomplished by plicating the fibrous tissue underneath the commissures of the non-coronary aortic sinus. The diameter of the sinotubular junction was within 2 mm of that of the PA in 38 pts and larger in 37 pts. These 37 pts required plication of the proximal ascending aorta to adjust its diameter to that of the PA. The PA was implanted as a free standing root in 54 pts, as a root inside of the aortic root in 19, and as free-hand valve graft in 2.
There was one operative death due to myocardial infarction and no late deaths during the mean follow-up of 15 months, range 3 to 58. One pt developed stenosis of the pulmonary homograft and one developed a false aneurysm between the mitral valve and the PA. Both were successfully reoperated on with preservation of the PA. There has been no other valve related complications. All pts are asymptomatic.
Annual Doppler echocardiographic studies revealed no AI in 55 pts and only mild AI in 19. The mean systolic gradient across the PA was less than 3 mmHg in all pts.
These findings suggest that correction of the diameters of the aortic annulus and of the ascending aorta is important to prevent AI after AYR with PA.
*By invitation 24. EARLY AND LONG-TERM RESULTS OF HETERO-TOPIC AND DOMINO HEART TRANSPLANTATION FOR PATIENTS WITH END-STAGE HEART FAILURE AND PULMONARY HYPERTENSION. Cornelius Dyke, M.D.*, Asghar Khaghani, FRCS*, Francesco Santini, M.D.*, Farah Bhatti, FRCS*, Rosemary Radley-Smith, FRCP* and Magdi Yacoub, FRCS Harefield, Middlesex, United Kingdom Discussant: Robert L Hardesty, M.D.
Patients with end-stage cardiac failure and pulmonary hypertension (PH) present a difficult management problem and represent a high risk group of patients undergoing cardiac transplantation. Using a "prepared" heart from a heart-lung recipient with PH (the domino operation) or transplanting the heart in the heterotopic position (HHT) are two strategies that have been used in these patients. Optimal treatment however remains unclear. To clarify these issues, we have reviewed the results of HHT and domino transplantation in patients with moderate to severe PH. Records of all HHT (n=101) and domino transplants (n=136) were reviewed. Significant PH was identified in 30 patients receiving HHT and 39 patients receiving a domino heart. Age and sex distribution were similar in both groups, respectively (mean 41 ± 9y, 26M:4F vs 45.9 ± 14y, 30M:9F). Patients were equally distributed in NYHA III and IV between groups. Eleven of 39 patients in the domino group were transplanted urgently, compared with 4 of 30 patients who received HHT. In all but five patients undergoing HHT, the donor PA was anastomosed to the recipient RA so that the donor provided left heart assistance only. Hemodynamic data before and after transplantation are shown below.
HHT and domino transplantation significantly reduced the degree of PH in survivors, both in the near and the long-term. Actuarial survival in the HHT group was superior however immediately after transplantation and remained so up to ten years follow-up.
The improved survival after HHT may be due to superior left heart assistance in a donor heart unburdened by a high right ventricular workload. We conclude that HHT gives superior early and long-term results in patients with PH associated with end-stage congestive heart failure.
1995-96 Graham Fellow *By invitation 25. CLINICAL EXPERIENCE WITH 100 CONSECUTIVE PATIENTS UNDERGOING ORTHOTOPIC HEART TRANSPLANTATION WITH BICAVAL AND PULMONARY VENOUS ANASTOMOSES. Alfredo Trento, M.D.*, Johanna J.M. Takkenberg, M.D.*, Lawrence S.C. Czer, M.D.*, Carlos Blanche, M.D.*, Sharon Nessim, Dr.P.H.*, Mabelle H. Cohen* and Jack M. Matloff, M.D. Los Angeles, California Discussant: Bartley P. Griffith, M.D.
Total orthotopic heart transplantation (TOHT) with bicaval and pulmonary venous anastomoses produces normal anatomic size and synchronous contraction of the atria, but may require longer ischemic time than the standard technique (SOHT) originally described by Shumway and Lower.
Methods:We retrospectively compared 100 consecutive patients transplanted with TOHT between 7/91 and 9/95 with 64 patients transplanted with the standard technique (SOHT) between 12/89 and 3/92. Recipient age was older (57 ± 11 vs 53 ± 12 yr, p = 0.03), and donor weight was lower (p = 0.03) with TOHT; donor-recipient weight ratio was lower with TOHT vs SOHT (0.92 vs 1.03, p = 0.003, geometric mean), and 28.0 vs 9.4% of pts had a donor-recipient weight mismatch <0.8 (p = 0.005). All pts receiving SOHT were given 14 days of OKT3 induction, while most TOHT pts had 10 or 7 days of OKT3 (p<0.001); other donor and recipient characteristics did not differ, including the technique of preservation.
Results:Ischemic and pump time were longer with TOHT (160 vs 135 min and 127 vs 112 min, p<0.001, geometric mean). Length of hospital stay was shorter with TOHT (14.4 vs 18.9 days, p<0.001, geometric mean). Surgical (30 d) survival was 100% with TOHT and 94 ± 3% with SOHT, 1 yr survival 98 ± 2% vs 83 ± 5%, and 2 yr survival 96 ± 2% vs 80 ± 5% (mean±SEM; p = 0.008). Recipient age, duration of OKT3 therapy and donor-recipient weight mismatch did not affect survival. In the first month post-transplant 2 pts with SOHT died of infection: 1 of right ventricular failure and 1 of rejection; in the TOHT group, no early deaths were observed. One month cardiac output was higher with TOHT (6.4 ± 0.6 vs 5.3 ± 1.2 L/min, p = 0.0002) as was cardiac index (3.5 ± 0.6 vs 2.8 ± 0.7 L/min/m2, p = 0.0006); at 6 months cardiac output and index did not differ. Tricuspid regurgitation was reduced with TOHT at 1 yr (mean 1.2 vs 2.0, p = 0.01); mitral regurgitation did not differ between the groups. Pacemaker placement was not required with TOHT, but 15 pts with SOHT needed permanent pacemaker postop (p<0.0001).
Conclusions: TOHT offers an improved alternative to SOHT with 30 day mortality of 0% in more than 100 consecutive patients, improved long-term survival, reduced length of hospital stay, better cardiac function, and elimination of the need for pacemaker insertion. Normal anatomy and synchronous function of the atria, and a shorter course of OKT3 may have contributed to these results.
*By invitation 26. LONG-TERM EFFECTIVENESS OF OPERATIONS FOR ASCENDING AORTIC DISSECTION. Joseph F. Sabik, M.D.*, Bruce W. Lytle, M.D., Patrick M. McCarthy, M.D., Robert W. Stewart, M.D.*, Floyd D. Loop, M.D. and Delos M. Cosgrove, M.D. Cleveland, Ohio Discussant: D. Craig Miller, M.D.
From 1978 to 1994, 211 patients underwent operation for dissection of the ascending aorta (AA). Surgical strategies were composite aortic valve (AV) and AA graft replacement (CG) for patients with an abnormal AV and abnormal sinuses (49), AV replacement and supracoronary AA graft for patients with abnormal AV and normal sinuses (26), and valve resuspension with supracoronary aortic root repair and AA graft for patients with normal sinuses and a normal AV (136). The aortic resection was extended into the aortic arch (AAr) only if the intimal tear extended into the AAr. For patients (132) with a false lumen extending beyond the level of the aortic resection the dissection was repaired with Teflon felt and the distal graft suture line. The in-hospital mortality was 14% (30/211). Preoperative shock and coronary bypass grafting were associated with increased risk and the use of circulatory arrest was a factor decreasing mortality (all p<0.01).
Follow-up of in-hospital survivors documented late survival of 79% at 5 and 58% at 10 postoperative years (mean postoperative interval 53 months). Advanced age, early year of surgery, AAr replacement, and CG operations were all associated with decreased late survival (all p<0.02). The presence of a residual distal false lumen did not decrease late survival. Thirteen patients underwent reoperation, 6 for proximal complications (4 for endocarditis, 2 for sinus-valve complications) and 7 for distal complications (4 with aneurysmal changes in residual false lumen, 3 for new aortic complications).
We conclude: 1) for patients with ascending aortic dissections, supracoronary repair of the dissected aortic root and valve resuspension is an effective long-term treatment for patients with normal aortic sinuses, and 2) the presence of a residual distal false lumen does not decrease late survival and produces a low risk of aneurysmal change and reoperation over the first 10 postoperative years. These data should be considered when contemplating more aggressive surgical approaches for patients with ascending aortic dissections.
4:35 p.m. EXECUTIVE SESSION (Limited to Members)
6:30 p.m. MEMBER RECEPTION San Diego Aerospace Museum
*By invitation 1:45 p.m. SIMULTANEOUS SCIENTIFIC SESSION B - GENERAL THORACIC SURGERY Room 6C/F, San Diego Convention Center
Moderators: E. Carmack Holmes, M.D. Valerie W. Rusch, M.D.
27. FUNCTIONAL AND OXIMETRIC ASSESSMENT OF PATIENTS FOLLOWING BILATERAL LUNG REDUCTION SURGERY. Michael Bousamra, II, M.D.*, George B. Haasler, M.D.*, Randolph Lipchik, M.D.*, Daniel Henry, M.D.*, Joseph H. Chammas, M.D.*, Gordon N. Olinger, M.D., Kathryn Menard-Rothe, R.R.T.* and Dennis C. Sobush, P.T., M.S. Milwaukee, Wisconsin Discussant: Keith S. Naunheim, M.D.
The mechanism whereby bilateral lung reduction surgery (BLRS) reduces oxygen requirement in emphysema patients remains hypothetical. To clarify this issue, a detailed assessment of the effect of BLRS on postoperative respiratory function and oxygen (62) requirement was undertaken. Thirty patients underwent BLRS via median sternotomy and were followed for at least three months. Patients routinely completed a 6-week program of cardiopulmonary rehabilitation which continued into the postoperative period. Integral to this program were pre- and post-operative spirometry, six-minute walk distances, and exercise oximetry. Change in dyspnea perception was measured by the transitional dyspnea index (TDI). Twelve patients also underwent measurement of mean inspiratory pressure (MIP) and mean expiratory pressure (MEP). Data were analyzed by paired Student's /-test. Spirometric values, six-minute walk distances, mean MIP and MEP were all significantly improved following BLRS.
Twenty-five of 30 patients used supplemental O2, (20 continuous, 5 as needed) before BLRS. Exertional desaturation (arterial saturation < 88%) was noted in all patients tested on room air and in 48% (12/25) of those tested on supplemental O2. Following BLRS, only 11 of 30 patients remain on supplemental O2(4 continuous, 7 as needed). Exertional desaturation, however, continues in 15 of 19 patients tested on room air and in 7 of 11 patients tested on supplemental O2. Notably, ten patients who desaturate on room air, and of these, six who also desaturate on supplemental O2, discontinued O2 use due to marked reduction in dyspnea.
These findings indicate significant improvements in spirometric volumes, exercise capacity, inspiratory and expiratory pressures, and perception of dyspnea after BLRS. BLRS does not prevent exercise-induced hypoxia in these patients despite improvement of dyspnea. The mechanism by which BLRS improves dyspnea and reduces O2 use in emphysema patients may not be related to improvement of underlying hypoxia. Discontinuance of supplemental oxygen due to reduction in dyspnea and improved physical performance may not be warranted.
*By invitation 28. THORACOSCOPIC LUNG REDUCTION SURGERY FOR GENERALIZED EMPHYSEMA. Robert J. McKenna, Jr., M.D.*, Richard J. Fischel, M.D.*, Matthew Brenner, M.D.* and Arthur F. Gelb, M.D.* Los Angeles, Irvine and Lakewood, California Sponsored by: Quentin R. Stiles, M.D., Los Angeles, California Discussant: Claude Deschamps, M.D.
Lung reduction surgery can dramatically improve the quality of life for selected patients with generalized emphysema. Optimal patient selection criteria and surgical procedure need to be determined. Reviewed are 163 patients who underwent thoracoscopic lung reduction. The average age was 67 ± 7 years, the mean FEV1 was 0.65 ± 0.26L. These patients underwent bilateral (78) or unilateral (85) stapled lung reduction surgery. The average hospital length of stay was 11 days; there were two operative mortalities in the bilateral group due to respiratory failure and acute abdomen, and three in the unilateral group died due to myocardial infarct (2) and tension pneumothorax (1). The primary morbidity of the procedure was air leak, which occurred in 38% of patients.
Postoperative dyspnea improved to Grade 0-2 in 53% of patients after unilateral procedure vs 85% of patients after bilateral procedure. Oxygen dependency was eliminated in 18 of 50 unilateral patients (36%) compared to 30 of 40 in bilateral patients (68%). Prednisone dependence was eliminated in 38 of 51 (54%) unilateral patients compared to 30 of 35 (85%) bilateral patients. Improvement in FEV1 was related to preoperative TLC, RV, grams resected at operation, bilateral vs unilateral procedure in upper vs lower lobe disease prominence. The most important factor was location of the emphysema. Bilateral procedures produced an average improvement in the FEV( of 83% for upper lobe disease vs 35% for lower lobe disease. Average improvement in the FEV1 for unilateral procedures was 34% for upper lobe disease vs 17% for lower lobe disease.
There were no further mortalities at one-year postop for the bilateral patients; however, 17% of the unilateral patients died by one-year postop. This appeared especially in patients whose room air pO2 preoperatively was ≤50.
In conclusion, the stapled lung reduction surgery can dramatically improve the quality of life of patients with emphysema who have upper lobe predominant disease and undergo bilateral stapled lung reduction surgery.
*By invitation 29. DOBUTAMINE STRESS ECHOCARDIOGRAPHY IN EVALUATION OF THE LUNG VOLUME REDUCTION CANDIDATE. Joseph I. Miller, Jr., M.D. Atlanta, GeorgiaDiscussant: Alex G. Little, M.D.
Evaluation of cardiac function must be performed in selection of candidates for lung volume reduction (LVR). Dobutamine stress echocardiography (DSE) is a non-invasive means of evaluating left and right ventricular function (LVF/RVF). DSE was performed in 210 patients (pts) evaluated for LVR. Pts age range was 53-75 yrs (mean 68). Of 210 pts, 61 underwent LVRS. Right heart catheterization (RHC) was performed in all 61 pts operated. Of 149 pts evaluated but not operated upon, DSE showed 18 pts had ischemia or evidence of pulmonary hypertension (PH). These 18 pts underwent LHC + RHC. Ten pts had moderate to severe coronary disease and 4 had PH which prevented them from undergoing LVRS. An additional 10 pts on RHC showed moderate to severe PH despite a normal DSE. Of 61 pts undergoing LVRS, 20 pts had abnormal DSE suggesting ischemia and 9 had evidence of RV dysfunction and/or suggesting PH. All had LHC + RHC. Of 20 pts with ischemia, 15 were found to have CAD with blockages >50%. Five pts had PTCA before LVRS. One pt with an (L) main disease had a combined procedure. Of 9 pts with suggestion of RVD/PH on DSE, only 1 was found to have PH which precluded LVRS. Of remaining 41 pts who had RHC with normal DSE, RHC showed increased pulmonary pressures in 10 of 40 pts but did not preclude surgery. DSE provides a good screening indicator of LV function but does not give valid information concerning PH. We would recommend DSE and RHC in all pts ultimately selected for LVRS.
2:45 p.m. INTERMISSION - VISIT EXHIBITS
*By invitation 3:15 p.m. SIMULTANEOUS SCIENTIFIC SESSION B - GENERAL THORACIC SURGERY Room 6C/F, San Diego Convention Center
Moderators: E. Carmack Holmes, M.D. Valerie W. Rusch, M.D.
30. LONG-TERM RESULTS AFTER REOPERATION FOR FAILED ANTIREFLUX PROCEDURES. Claude Deschamps, M.D.*, Julie O. Johnson, R.N., P.E.*, Victor F. Trastek, M.D., Mark S. Allen, M.D.*, W. Spencer Payne, M.D. and Peter C. Pairolero, M.D. Rochester, Minnesota Discussant: Andre C.H. Duranceau, M.D.
From January 1960 to June 1995, 185 patients underwent reoperation without esophageal resection for recurrent gastroesophageal reflux disease (GERD) or obstructive symptoms. There were 102 males and 83 females. Median age was 58 yrs (range 20 - 84 yrs). A single previous antireflux operation was performed in 147 patients, two in 33 and three in 5. Median time interval between the most recent antireflux operation and reoperation was 36 months (range 1 - 291). Indications for surgery were symptoms in 184 patients and a large paraesophageal hernia in one. Surgical approach was via a thoracotomy in 133 patients (71.9%), celiotomy in 27 (14.6%) and a thoraco-abdominal incision in 25 (13.5%). A Nissen fundoplication was performed in 107 patients (57.8%), a Belsey Mark IV in 47 (25.4%), a truncal vagotomy and antrectomy with Roux-en-Y reconstruction in 17 (9.2%), an anatomical hernia repair in 12 (6.5%), and a Hill gastropexy in 2 (1.1%). A Collis gastroplasty was added to the fundoplication in 116 patients (62.7%) and a pyloroplasty was also performed in 17 (9.2%). There was one hospital mortality (0.5%) and 47 patients (25.4%) had at least one complication. Median postoperative hospital stay was 9 days (range 5-58). Follow-up was complete in 156 patients (84.3%) for a median of 44 months (range 3 - 283). One-hundred and thirty-seven patients (87.8%) were improved. Functional results were classified as excellent in 65 patients (41.6%), good in 29 (18.6%), fair in 43 (27.6%) and poor in 19 (12.2%). No single operative approach or procedure proved to be functionally superior, though transthoracic approach is favored from a technical viewpoint. Reoperation with esophageal preservation after a failed antireflux procedure will result in significant functional benefit with low mortality and acceptable morbidity. The type of repair should be tailored to the individual patient.
*By invitation 31. DIAPHRAGMATIC HERNIA AND ASSOCIATED ANEMIA: RESPONSE TO SURGICAL TREATMENT. Victor F. Trastek, M.D., Ann M. Thompson, R.N., P.E.*, Mark S. Allen, M.D.*, Claude Deschamps, M.D.* and Peter C. Pairolero, M.D. Rochester, Minnesota Discussant: Nassar Altorki, M.D.
From 1985 to 1993, 49 patients (35 female, 14 male) with diaphragmatic hernia (DH) and associated anemia underwent surgical repair. Median age was 64.5 years (range 24 - 84 years). Hematologic and gastroenterologic evaluations revealed no other potential cause of bleeding. All patients had a DH (confirmed on upper gastrointestinal series in 42 patients and endoscopy in 7). Median time between diagnosis of anemia and surgical repair was 36 months (range 1 - 334 months). Forty-five patients (92%) were receiving replacement therapy including iron in 43 patients and blood transfusions in 32 (median, 6 units; range, 2-70 units). Symptoms were present in 46 patients (94%) and included heartburn in 28 (57%), early satiety with bloating in 19 (39%), regurgitation in 11 (23%), dysphagia in 7 (14%), and aspiration in 4 (8%). Preoperative endoscopic evaluation demonstrated gastric erosions at the level of the hiatus in 22 patients, esophagitis in 7, and stenosis and Barrett's disease in 1. A transthoracic uncut Collis-Nissen fundoplication was performed in 44 patients; Belsey Mark IV repair in 2; and cut Collis-Nissen fundoplication, abdominal Nissen fundoplication, and Hill repair in 1 each. Operative mortality occurred in 1 patient (2%). Significant complications occurred in 11 patients (23%). Follow-up was complete for a median of 63 months (range 4 -103 months). Forty-five patients (90%) had resolution of their anemia. Four patients experienced recurrence of their preoperative symptoms. We conclude that in patients with DH and associated anemia, surgical intervention will result in successful resolution of the anemia in most patients.
*By invitation 32. THORACOSCOPIC TOTAL ESOPHAGECTOMY WITH EN BLOC MEDIASTINAL LYMPHADENECTOMY. Takashi Akaishi, M.D.*, Iwao Kaneda, M.D.*, Norio Higuchi, M.D.*, Yoshiki Kuriya, M.D.*, Jun-Ichi Kuramoto, M.D.*, Tsuneo Toyoda, M.D.* and Akio Wakabayashi, M.D. Sendai, Ishinomaki, Sakata, Ishinoseki and Furukawa, Japan, and Irvine, California Discussant: David B. Skinner, M.D.
Total esophagectomy with en bloc mediastinal lymphadenectomy in the treatment of esophageal cancer carries a substantial morbidity and mortality rate. The most common complication is pulmonary. In order to investigate a feasibility of thoracoscopic technique, we carried out an extensive laboratory study. Encouraged by excellent results, this clinical trial was conducted.
Material and methods: From September, 1994 to September, 1995, 39 thoracic esophageal cancer patients with the lesion not invading surrounding organs underwent total esophagectomy with mediastinal lymphadenectomy by means of thoracoscopy. The ages ranged from 53 to 74. Thirty-two were males and seven were females. All patients had squamous cell carcinomas. The patient was placed on the operating table in a left decubitus position, and six trocars were placed. The posterior mediastinal pleura was widely opened, and its edges were retracted by two sutures to secure good exposure and to keep the right lung out of the field. Utilizing a standard thoracoscopic instrument and video monitori, dissection of the entire thoracic esophagus and en bloc mediastinal lymph node dissection were carried out. Upon completion of thoracoscopy, the patient was returned to a supine position, and the dissection of the stomach and anastomosis of the stomach and cervical esophagus were performed. All harvested lymph nodes were counted for each station. Spirometry and vital capacity using plethysmography were measured before and one month after surgery in all patients.
Results: All procedures were accomplished as scheduled and none was converted to open thoracotomy. The operating time was 207±45 minutes (meanistandard deviation). Estimated blood loss was 282±184 ml. The number of harvested lymph nodes was 17.6±10.3 per patient. Sixteen patients (41%) had positive lymph nodes. There was no 30-day hospital mortality. One patient died of renal failure secondary to adjuvant chemotherapy three months after surgery. Only two patients required postoperative ventilatory support. Vital capacity and forced expiratory volume for one second decreased to 85±11% and 82±16% of the preoperative values, respectively.
Conclusion: The thoracoscopic mediastinal lymphadenectomy is technically feasible, and its completeness is comparable to that of open technique. The decline of pulmonary function is significantly less than our previous experience with open technique.
*By invitation 33. ACUTE AND CHRONIC MORBIDITY DIFFERENCES BETWEEN MUSCLE SPARING AND STANDARD LATERAL THORACOTOMY. Rodney J. Landreneau, M.D., Peter F. Person, M.D.*, Robert J. Keenan, M.D.*, Lynda S. Fetterman, R.N.*, Frank A. Pigula, M.D.*, James D. Luketich, M.D.* and Robert J. Weyant, D.D.S.* Pittsburgh, Pennsylvania Discussant: Douglas J. Mathisen, M.D.
INTRODUCTION: Opinions differ regarding differences in operative time, postoperative pain and morbidity, and the occurrence of chronic post-thoracotomy pain syndromes and subjective shoulder dysfunction between totally muscle sparing thoracotomv (MST) and standard lateral thoracotomy (LT) approaches to pulmonary resection.
METHODS: 335 consecutive patients undergoing MST (n=148) or LT (n=187) to accomplish lobectomy over a 40-month period were evaluated. Local rib resection was not employed and two chest tubes were routinely used in both thoracotomy groups following surgery. Epidural analgesia was similarly utilized after surgery (MST-38%, LT-38%). The post-operative hospital course and patient functional status at one year were examined.
RESULTS: Demographic analyses demonstrated no differences in patient age, sex, frequency of cancer diagnosis (or tumor stage), and the association of significant co-morbid medical illness between MST and LT groups. Primary postoperative variables analyzed between thoracotomy approaches are noted.
CONCLUSIONS: The relative efficacy and occurrence of acute/chronic morbidity following MST vs. LT were equivalent. Although MST may be performed more expediently, it appears that the singular advantage of MST over LT involves the preservation of chest wall musculature should rotational muscle flaps be needed later.
4:35 p.m. EXECUTIVE SESSION (Limited to Members)
6:30 p.m. MEMBER RECEPTION San Diego Aerospace Museum
*By invitation 1:45 p.m. SIMULTANEOUS SCIENTIFIC SESSION C - CONGENITAL HEART DISEASE Room 6D/E, San Diego Convention Center
Moderators: Richard A. Hopkins, M.D. Pedro del Nido, M.D.
34. LONG-TERM FOLLOW-UP (UP TO 20 YEARS) OF TRUNCUS ARTERIOSUS REPAIRED IN INFANCY. Hiranya A. Rajasinghe, M.D.*, V. Mohan Reddy, M.D.*, Doff B. McElhinney, A.B.* and Frank L. Hanley, M.D. San Francisco, California Discussant: Gordon K. Danielson, M.D.
There have been few reports of long-term follow-up after truncus arteriosus repair in infancy. A retrospective review of 165 patients who survived the initial hospital stay following complete repair of truncus arteriosus (CTR) at our institution since 1975 was performed. Follow-up was obtained by direct physician or patient contact and was completed in July 1995. The median age at CTR over the 20-year experience was 3.4 months (range: 2 days to 36 years), and 81% of patients (133/165) were less than 1 year of age. Previous pulmonary artery banding had been performed in 20 patients, and 3 patients had undergone repair of interrupted aortic arch (IAA). Significant procedures performed along with truncus repair included truncal valve replacement (TrVR; n=10) or repair (n=5) and IAA repair (n=7). Patients were followed for up to 20.1 years (median: 10.5 years). Thirty-three patients were lost at cross-sectional follow-up, but a median of 4.3 years of follow-up (167 patient-years) were available on these patients. There have been 20 late deaths: 7 of these occurred within 6 months of CTR and 10 occurred within 1 year. Nine of the late deaths occurred following reoperations for conduit replacement (n=8) or residual VSD (n=1). Actuarial survival of hospital survivors was 89.5% at 5 years, 84.5% at 10 years, and 82.9% at 15 and 20 years; survival among infants was 90.2% at 5 years, 86.8% at 10 years, and 83.0% at 15 and 20 years. Factors associated with poorer survival over time by univariate Cox regression analysis included truncus with IAA (P = 0.004) and moderate to severe truncal valve (TrV) insufficiency prior to CTR (P = 0.02). By multivariate Cox regression, only IAA (P = 0.02) was still a significant predictor of poorer survival. Since CTR, 106 patients have undergone 131 conduit replacements or revisions (CR). Median time to CR was 5.5 ± 0.3 years, and the only factor significantly associated with shorter time to CR by Cox regression analysis was smaller conduit size at CTR (continuous variable; P = 0.007). Conduit gradients at CR ranged from 15 to 156 mmHg, with a median of 61 mmHg. In addition, 25 patients have undergone 29 TrVR, and 6 patients required TrVR prior to any conduit-related reintervention, with no associated deaths or significant mortality. Actuarial freedom from TrVR among patients without pre-CTR TrV insufficiency was 92% at 10 years and 85% at 20 years. Actuarial freedom from TrVR was significantly lower (P<0.0001) among patients with TrV insufficiency prior to CTR (63% at 10 years and 41% at 20 years). Functional status at follow-up was generally excellent, with only 3 patients functioning at lower than NYHA Class I. In conclusion, 10- to 20-year survival and functional status is excellent among infants undergoing CTR. Predictably, conduit replacement or revision is almost invariably necessary. Patients with pre-CTR TrV insufficiency who do not undergo TrVR at CTR are at significantly higher risk for late TrVR and should be monitored closely for evidence of increasing TrV dysfunction.
*By invitation 35. REPAIR OF INTERRUPTED AORTIC ARCH: A 10-YEAR EXPERIENCE. Alain Serraf, M.D.*, Frarçois Lacour-Gayet, M.D.*, Monica Robotin, M.D.*, Jacqueline Bruniaux, M.D.*, Miguel Sousa Uva, M.D.*, Régine Roussin, M.D.* and Claude Planché, M.D. Le Plessis Robinson, France Discussant: Richard A. Jonas, M.D.
Seventy-eight consecutive pts presenting with interrupted aortic arch (IAA) were referred to our institution between 1985 and 1995. Three died before any attempt at operation and 75 entered a program of surgical repair. The median age at operation was 9 days (range: 1 day-6 years) and the median weight was 3.0 kg. (range: 1.8-20 kg). All but one presented in severe congestive heart failure and 31.5% had oligo anuria. The preoperative pH varied between 6.8 and 7.4 (median: 7.3). Sixty-four received PGE1 infusion and 48 were ventilated. Aggressive preoperative resuscitation was necessary in 41. Routine preoperative transfontanellar echography (TFE) since 1987 revealed intra-cerebral bleeding in 6. IAA type A was present in 35 and 40 had type B. IAA was associated with single VSD in 30 and 45 had associated complex heart defects. Significant subaortic stenosis (SAoS) was present in 29 pts, aorto-pulmonary window in 4, truncus arteriosus in 7, transposition of the great arteries or double outlet right ventricle in 7, single ventricle in 1, complete AV canal in 1 and 10 others had abnormal aortic arches. Fifty-nine underwent single stage repair and 16 had staged repair. Aortic arch repair consisted of direct anastomosis in 62 and conduit interposition in 13. Thirteen patients had associated pulmonary artery banding and 22 had concomittent repair of associated lesions: truncus repair (7), closure of AP window (4), arterial switch (3), complete AV canal (1) and 7 had direct attempt to relieve subaortic stenosis. Mean deep hypothermic circulatory arrest, cross clamp and cardiopulmonary bypass times were 39.2 ± 15.6min, 59.3 ±22.8 min and 142.8 ± 38.2 min, respectively. The postoperative mortality was 20% (70% CL: 14.8 - 25.9%) and the overall mortality was 32% (70% CL: 25.9 - 38.5%). The results have continually improved throughout time with an overall operative mortality of 13.3% since 1990 (6.6% in isolated forms and 16.6% in complex forms). Univariate statistical analysis revealed that early mortality was influenced by the preoperative renal function, detection of cerebral bleeding by TFE, the number of cardioplegic injections and the date of operation. Multivariate analysis revealed that the preoperative renal function and the number of cardioplegic injections were independent risk factors for early mortality. In the subgroup of IAA with stenosed but patent subaortic pathway, significantly better survival was obtained when the SAoS was ignored at time of surgery (p<0.05). Twenty-four pts were reoperated on for recoarctations (7), left bronchial compression (1), second stage of repair (8), three had RV-PA conduit replacement and five miscellaneous. None of the survivors were reoperated on for subaortic stenosis. Survival rate for the entire series at 8 years was 66.7% (74% for 1990-95 and 58.6% for 1985-90). The survival rate for isolated forms was 73% (87% for 1990-95 and 60% for 1985-90) and for complex forms it was 64% (73% for 1990-95 and 65.8% for 1985-90). In conclusion, IAA remains a surgical challenge with continually improving results. Early diagnosis with preoperative resuscitation and adequate myocardial protection seem to be of extreme importance for further improvements.
1993-94 Graham Fellow *By invitation 36. ANATOMIC CORRECTION OF THE SYNDROME OF PROLAPSING RIGHT CORONARY AORTIC CUSP, DILATATION OF THE SINUS OF VALSALVA AND VENTRICULAR SEPTAL DEFECT. Magdi Yacoub, FRCS, Hasnat Khan, FRCS*, George Stavri, FRCS*, Elliott Shineboume* and Rosemary Radley-Smith* Uxbridge, Middlesex, United Kingdom Discussant: Yasunar Kawashima, M.D.
Aortic regurgitation due to prolapse of the right coronary cusp through a VSD is a relatively common condition. Anatomical characterization of this syndrome has shown four components which include dilatation of the right coronary sinus of Valsalva, sagging of the aortic annulus and cusp, an outlet VSD and a degree of right ventricular outflow obstruction. Based on these findings, a simple technique for correcting all the basic abnormalities was evolved and used in 46 patients. The technique consists of insertion of a series of pledgeted mattress sutures (using autogenous pericardium) through a trans-aortic approach. The stitches have the effect of closing the VSD, elevating the annulus and cusp and plicating the aortic sinus of Valsalva. Additional central plication of the cusp was necessary only in patients with longstanding aortic regurgitation. There were no early or late deaths (follow-up 3 months to 23 years). Three patients operated on early in the series with secondary changes in the valve underwent successful aortic valve replacement 5-10 years after operation. Of the remaining patients, 25 have no evidence of aortic regurgitation while 15 have trivial and 4 mild to moderate regurgitation. It is concluded that all the components of this syndrome can be corrected by a simple technique which gives good early and long-term results.
2:45 p.m. INTERMISSION - VISIT EXHIBITS
*By invitation 3:15 p.m. SIMULTANEOUS SCIENTIFIC SESSION C - CONGENITAL HEART DISEASE Room 6D/E, San Diego Convention Center
Moderators: Richard A. Hopkins, M.D. Pedro del Nido, M.D.
37. HIGHER HEMATOCRIT IMPROVES CEREBRAL OUTCOME AFTER DEEP HYPOTHERMIC CIRCULATORY ARREST. Toshiharu Shin'oka, M.D.*, Peter Laussen, M.D.*, Dominique Shum-Tim, M.D.*, Takuya Miura, M.D.*, Adre du Plessis, M.D.*, Hart G.W. Lidov, M.D., Ph.D.*, Marc Schermerhorn, M.D.* and Richard A. Jonas, M.D. Boston, Massachusetts Discussant: Steven R. Gundry, M.D.
Background: Hemodilution has been applied traditionally during deep hypothermic circulatory arrest (DHCA) to counteract the increase in viscosity and deleterious Theological effects which previous reports linked with brain injury. We have developed a unique piglet model of DHCA with magnetic spectroscopy (MRS) and near-infrared spectroscopy (MRS), then evaluation of neurological status for 4 days and finally histological assessment. The current hemodilution protocols of 3 centers undertaking neonatal DHCA have been investigated using this model.
Materials and Methods: Fifteen piglets were randomized into 3 groups (n=5/Gp). Gp I = colloid and crystalloid prime, Hct<10%; GpH = blood and crystalloid prime, Hct = 20%, GpIII = blood prime, Hct = 30%. All groups underwent 60 min DHCA at 15°C followed by 45 min rewarming. High energy phosphates and cerebral intracellular pH (pHi) were determined by MRS with assessment of cerebral redox state by NIRS. Neurological recovery was evaluated daily for 4 days by neurological deficit score (NDS; 0=normal, 500=brain death) and overall performance categories (OPC; l=normal, 5=brain death). Brain was fixed in situ on day 4 and examined by neurohistological score (0=normal, 5+=necrosis) in a blinded fashion.
Results: The results are expressed as mean ± SEM. The NDS score was best preserved in Gp III (I = 95.8, II = 112.5, III = 58.0, p<0.05 II vs. III) during the first day of recovery, although this difference diminished with time and all animals were neurologically normal after 4 days. Similar trend was observed in OPC score. Histological assessment was worst among Gp I in neocortex area (I = 1.33, II = 0.22, III = 0.40, p<0.05 I vs II, I vs III).
Summary: Severe hemodilution (Gp I) results in evidence of inadequate oxygen delivery during early cooling. Moderate dilution (Gp II) supplies adequate oxygen to the brain before and immediately after DHCA. Subsequent deterioration in redox state and neurological score may be secondary to edema resulting from inadequate colloid in the prime.
Conclusion: Whole blood priming (Gp III) with higher Hct improves cerebral recovery after DHCA relative to moderate and severe hemodilution.
*By invitation 38. SURGICAL TREATMENT OF SUBAORTIC STENOSIS FOLLOWING BIVENTRICULAR REPAIR OF DOUBLE OUTLET RIGHT VENTRICLE. Emré Belli, M.D.*, Alain Serraf, M.D.*, François Lacour-Gayet, M.D.*, Jocelyn Inamo, M.D.*, Jacqueline Bruniaux, M.D.* and Claude Planché, M.D. Le Plessis Robinson, France Discussant: Earle H. Austin, III, M.D.
Out of 175 patients who underwent biventricular repair for Double Outlet Right Ventricle between 1980-1995, 11 had 16 reoperations for subaortic stenosis. Four patients had palliative procedure before repair, 2 modified Blalock Taussig shunt, 2 pulmonary artery banding, one of whom was associated to coarctation repair. At first presentation, associated lesions were: pulmonary stenosis (n=4), aortic coarctation (n=l) and interrupted aortic arch (n=l). The median age at biventricular repair was 4 months (range: 0.5-216 months). Repair consisted of tunnel construction from the left ventricle to the aorta in 9 patients, 4 of whom had concommittent VSD enlargement. Two other presenting with Taussig-Bing Heart had an arterial switch operation with VSD closure. The right ventricular outflow tract was reconstructed with an infundibular patch in 3 and 2 had a "Réparation à l étage ventriculaire" (REV operation). The median postoperative left ventricle to aorta gradient was 6 mmHg (range: 0-120). Subaortic stenosis developed with time to a median value of 80 mmHg (range: 60-120) in a mean delay of 24 months. At reoperation, the subaortic stenosis was due in all cases to the protrusion of the inferior rim of the tunnel into the left ventricular outflow tract (LVOT). In addition, 5 pts had subaortic membranes and/or assymetric septal hypertrophy. Surgery consisted of membrane resection associated with myectomies in 5 or septal patch enlargement in 3. In 3 an extended septoplasty was performed. In the latter an incision was made in the septal patch and was prolonged in the muscle toward the apex until large opening of the left ventricular outflow tract. A new patch was then secured and molded around Hegar dilators passed through the aortic valve in order to align the LVOT. Three patients had a second reoperation after membrane resection and underwent an extended septoplasty, and 1 had a third reoperation after membrane resection and an incomplete septoplasty. None of the patients who underwent an extended septoplasty had to be reoperated on.
There was no early nor late death. One patient had permanent AV block which necessitated pacemaker implantation. The median postoperative LV to aorta gradient was 10 mmHg (range: 0-45). Follow-up was 100%. At 25 ± 23 months postoperatively, all patients were in NYHA class I and the median gradient between the LV and the aorta was 20 mmHg (range: 0-60).
We conclude that following repair of DORV, the subaortic region is at risk for development of stenosis. Surgical treatment adapted to the anatomic lesions can offer good early and mid-term results. It seems that an aggressive approach by an extended septoplasty avoids multiple reoperations.
1993-94 Graham Fellow *By invitation 39. SCIMITAR SYNDROME: TWENTY YEARS EXPERIENCE AND RESULTS OF REPAIR. Hani K. Najm, M.D.*, William G. Williams, M.D., John G. Coles, M.D. and Ivan M. Rebeyka, M.D.* Toronto, Ontario, Canada Discussant: Thomas L. Spray, M.D.
Twenty-three patients (pts) with Scimitar syndrome were seen in the period between 1975 and 1995. There were 8 males and 15 females whose mean age at diagnosis was 9.8 years (range 1 day-70 years). The right lung was involved in all pts with drainage to inferior vena cava (IVC)-right atrial junction in 19, right atrium in 3 and infradiaphragmatic IVC in 1. Associated anomalies were present in 21 pts including: pulmonary sequestration (8), pulmonary venous stenosis (6), dextrocardia (6), mesocardia (3), mitral valve prolapse (3), horseshoe lungs (3), azygous continuation of IVC (2), ventricular septal defect (2) and hypoplastic left ventricle (2). An atrial septal defect was present in 18.
Fifteen pts underwent repair by baffling the anomalous pulmonary venous drainage to left atrium. The mean age at surgery was 15 years (median 5.5; range: 6 months to 70 years). Preoperative catheterization revealed normal mean pulmonary artery pressure and mean shunt fraction of 2.5:1. Postoperative complications included two important neurological complications from which both recovered. Postoperatively all pts had echocardiography and 7 had cardiac catheterizations; these tests revealed evidence of pulmonary venous stenosis in 7 (47%). Two required reoperation for pulmonary obstruction. No residual left to right shunt was present after repair. The mean follow-up post repair is 7.6 years (range: 1.6-20 years) during which there were no deaths. Postoperative quantitative pulmonary perfusion scan demonstrated that the mean flow to the right lung is only 23% (range: 0-59%) with only one pt having normal flow distribution. We conclude that repair of Scimitar syndrome eliminates the left to right shunt associated with high postoperative pulmonary venous stenosis and seldom normalizes flow patterns to the right lung.
*By invitation 40. MIXED TOTAL ANOMALOUS PULMONARY VENOUS DRAINAGE - STILL A SURGICAL CHALLENGE. Ralph E. Delius, M.D.*, Marc R. de Leval, M.D., Martin J. Elliott, M.D.* and Jaroslav Stark, M.D. London, United Kingdom Discussant: Ralph S. Mosca, M.D.
AIM: Mixed total pulmonary venous drainage (TAPVD) is a rare variant of this lesion. The surgical repair of mixed TAPVD can be difficult; most groups report a high mortality with this rare morphologic subgroup. The aim of this report is to review the surgical results of a relatively large series of patients with mixed TAPVD managed at a single institution.
PATIENT POPULATION: Between 1/1/71 and 12/31/94, 232 patients with TAPVD underwent surgical correction at this institution. Twenty of these patients (8.6%) had mixed type TAPVD. The ages at the time of operation ranged from 1 day to 46 months, with a median of 2.3 months.
RESULTS: Preoperative catheterization and angiography were performed in 16 patients. A preoperative echocardiogram was obtained in 16 patients. Both diagnostic investigations were performed in 12 patients. The correct diagnosis was made preoperatively in 15 of the 16 patients (94%) who underwent catheterization. In the 16 patients who underwent preoperative echocardiography, the correct anatomy was determined in only 5 patients (31%). The sensitivity and specificity was 94% and 99%, respectively, for catheterization and 31% and 100%, respectively, for echocardiography. Two patients had postoperative complications because the diagnosis was not established by echocardiography or at operation. Severe pulmonary venous obstruction was present in 3 patients, all of whom underwent emergent operation (<8 hours after admission). All other operations were performed on an urgent or elective basis. Three patients died postoperatively (15%), all of whom had preoperative pulmonary venous obstruction. There were two late deaths, one due to pulmonary vein stenosis and the other to pulmonary hypertension. The actuarial estimate for survival at 10 years for all patients was 73%; patients who survived the initial operation had an estimated 10-year survival of 87%. All surviving patients are NYHA Class I and free of medications.
CONCLUSION: The diagnosis of mixed TAPVD can be difficult to establish by echocardiogram or at the time of operation. In stable patients, cardiac catheterization and angiography should be considered if all four pulmonary veins cannot be seen by echocardiography, since establishing the diagnosis of mixed TAPVD preoperatively may affect surgical management. Pulmonary venous obstruction is relatively infrequent in this group of patients, but if present impacts significantly on patient survival. The long-term results with this lesion are excellent.
4:35 p.m. EXECUTIVE SESSION (Limited to Members)
6:30 p.m. MEMBER RECEPTION San Diego Aerospace Museum
1973-74 Graham Fellow *By invitation |
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