Extraanatomical bypass of the aortic root: an experimental technique.

Endocarditis involving a prosthetic aortic valve is associated with persistently positive blood cultures and aortic regurgitation. With rare exception, it is a fatal disease. An experimental technique was developed that would allow for removal of the infected aortic prosthesis with debridement and permanent closure of the aortic root. An extraanatomical outflow for the left ventricle was created using a valve-containing conduit between the apex of the left ventricle and the descending thoracic aorta (apicoaortic anastomosis). The procedure was performed on 5 mongrel dogs through a left thoracotomy without use of cardiopulmonary bypass. Four survived the procedure and required no cardiotonic support. One died as a result of a technical problem. Intraoperative pressure determination revealed a 0 to 15 mm Hg gradient across the apioaortic prosthesis and a left ventricular end-diastolic pressure of 0 to 4 mm Hg. Both postoperative angiocardiogram and postmortem examination confirmed patency of the aortocoronary bypass grafts and good function of the prosthesis.     

Meetings in North Americe,April–September, 1976

The results of major pulmonary resection in 58 patients greater than 70 years of age were reviewed. The histological distribution and extent of nodal metastases in this age group are the same as in younger patients. The absolute five-year survival rate for the 55 patients undergoing curative resection was 30% (17 patients). It was 36% (11 patients) for those patients with squamous cell carcinoma and 22% (5 patients) for those with adenocarcinoma. The operative mortality was only 14% (8 patients). Of the 49 patients treated by lobectomy, 17 lived five years or more free of disease, whereas none of the 6 patients treated by pneumonectomy survived five years.The five-year survival rate of 30% in this series of elderly patients treated by major pulmonary resection makes resections in such patients with bronchogenic carcinoma worthwhile.     

Gastroesophageal reflux in esophageal scleroderma: diagnosis and implications.

Fifty-three patients with scleroderma were evaluated by history, barium swallow, and esophageal function tests. The most common esophageal symptoms were heartburn and dysphagia. Abnormal motility was seen radiologically in 43 patients, gastroesophageal reflux in only 9. Esophageal function tests demonstrated: (1) abnormal motility in 51 patients and lack of a distal esophageal high-pressure zone in 18; (2) moderate to severe gastroesophageal reflux in 38; and (3) abnormal acid-clearing ability in 50. Eleven patients, including 8 with peptic stricture, underwent the combined Collis-Belsey operation. Symptomatically, reflux was abolished in all and dysphagia in 10. Roentgenograms showed that regression of strictures was complete in 5 and partial in 3. Postoperative esophageal function tests in 9 patients demonstrated a competent distal esophageal valvular mechanism in 7. Gastroesophageal reflux, not impaired motility, is the major cause of esophageal symptoms in scleroderma. Its effecitve operative control is not contraindicated by systemic disease in these patients.     

The effect of glucagon in animals on chronic propranolol therapy

Eleven adult mongrel dogs were divided into two groups. Group 1 animals served as controls and Group 2 received propranolol (6 mg/kg/day) orally in divided doses for 15 to 21 days. Prior to cardiopulmonary bypass, cardiac output, first derivative of left ventricular pressure (dp/dt), peak systolic pressure, heart rate, and central venous pressure were recorded. The animals were then placed on cardiopulmonary bypass and subjected to 30 minutes of global ischemia at the myocardial temperature of 32 degrees C. Following cessation of cardiopulmonary bypass the baseline studies were repeated. In Group 2 animals following the repeat studies, glucagon was administered at a rate of 0.13 microgram/kg/min. The cardiac index and dp/dt were decreased by 43.3% (p less than 0.001) and 40.5% (p less than 0.001) in comparison to Group 1 animals. In Group 2 dogs, after bypass and glucagon infusion, cardiac index increased by 38% (p less than 0.02), dp/dt rose by 78% (p less than 0.05), and peak systolic pressure increased by 24.8% (p less than 0.05). These studies show the benefit of glucagon in the treatment of low cardiac output in the presence of beta-adrenergic blockade.     

Scalene Node Biopsy in Pulmonary Carcinoma: When Is It Indicated?

While there is universal agreement that palpable scalene lymph nodes should be biopsied in the preoperative evaluation of patients with carcinoma of the lung, the role of biopsy of nonpalpable scalene nodes remains unclear. This report evaluates the results of biopsy of nonpalpable scalene lymph nodes in 101 consecutive patients with bronchogenic carcinoma otherwise deemed candidates for pulmonary resection. The overall incidence of biopsy positive for metastatic disease was 8.9%. No patient with a peripheral primary lesion, regardless of size or cell type, had metastasis to scalene nodes. Six of 15 patients with centrally located adenocarcinomas showed scalene node metastasis, while only 1 of 40 patients with central squamous cell carcinomas had a positive scalene biopsy. Bilateral biopsy was no more likely to yield positive information than ipsilateral biopsy alone. We now recommend preoperative biopsy of nonpalpable scalene nodes only in patients with central lesions in whom the cell type is adenocarcinoma or unknown.     

Carcinoma of the Lung in Women

The 5-year survival of 293 men and of 78 women undergoing pulmonary resection and mediastinal lymph node dissection is compared. These patients were broken into two age groups: Group 1, 40 through 49 years of age, and Group 2,50 years of age and older. They were subdivided further according to clinical stage, cell type, and sex.Of the 25 men in Group 1, 15 (60%) survived 5 years, while 98 (37%) of the 268 men in Group 2 survived 5 years. Among the 31 women in Group 1, 5 (16%) survived for 5 years, while 15 (32%) of the 47 women in Group 2 survived for that length of time. The survival among women in the younger age group was significantly lower than for both groups of women in the older age group (p = 0.0335) and men in the younger age group (p = 0.0033). This is believed to be due to the higher incidence of both Stage III disease and adenocarcinoma in the younger women. Twenty-two of the younger women (71%) were classified Stage III compared with 14 (30%) of the older women. Fourteen younger men (56%) had reached Stage III, and 101 older men (38%) were classified as Stage III.These data suggest that sex is an important factor in determining survival because there appears to be a relationship between it and the stage of the disease, and cell type. Overall, women had a poorer 5-year survival than men. Younger women have a strikingly lower survival than any other group, which is explained by their higher incidence of both Stage III classification and adenocarcinoma.     

Combined Collis-Nissen reconstruction of the esophagogastric junction.

Recent reports have indicated that combined Collis-Belsey reconstruction of the esophagogastric junction fails to control reflux in 30 to 46% of patients undergoing the procedure. The major factor thought to be responsible for this result is the limited Belsey fundoplication possible after construction of the gastroplasty tube. This report describes our technique of combining the Collis gastroplasty with a 360-degree Nissen type fundoplication. The radiographic and manometric characteristics of the distal esophageal high-pressure zone produced by the Collis-Nissen operation are discussed.     

Mediastinal Metastases in Bronchogenic Carcinoma: Influence of Postoperative Irradiation,Cell Type,and Location

A 17-year experience with 136 patients with bronchogenic carcinoma and mediastinal metastases is reported. Six died postoperatively. Postoperative mediastinal irradiation was given to 110 patients surviving curative resection who had evidence of tumor spreading to the mediastinal lymph nodes. The remaining 20 patients did not receive radiation therapy.Of the 136 patients, 29 (21.3%) lived 5 years free from disease and 9 survived 10 or more years. Of the 110 patients who survived operation and underwent irradiation, 29 (26.4%) survived 5 years. None of the 20 patients not receiving radiation therapy lived 5 years. Of the patients who underwent irradiation, 18 of the 50 patients with squamous cell carcinoma survived 5 years, while only 7 of 55 with adenocarcinoma survived 5 years.We do not believe that the discovery of mediastinal lymph node involvement in bronchogenic carcinoma is a contraindication to pulmonary resection. As in our previous reports, histological cell type has proved to be an important indicator of absolute survival. Patients with squamous cell carcinoma had an absolute 5-year survival of 33.9%, while the patients with adenocarcinoma had an absolute survival of 12.3%.The level of lymph node metastasis has an influence on prognosis as well. Patients with subcarinal lymph node metastases had a lower survival than patients with superior mediastinal involvement.     

Transfer factor in the treatment of carcinoma of the lung

From 1976 to 1982, 63 patients with carcinoma of the lung underwent curative pulmonary resection, mediastinal lymph node dissection, and postoperative mediastinal irradiation when indicated. After operation, the patients were randomized by cell type and stage of disease into two groups. Beginning 1 month postoperatively, Group 1 patients (N = 28) received 1 ml of transfer factor that had been extracted from the blood of normal individuals. Subsequent doses were administered at 3-month intervals. Group 2 patients (N = 35) served as controls. There were no significant differences between the two groups with respect to age, sex, extent of resection, histological cell type, or stage of disease. Twenty of the 28 treated patients were alive and free from disease from 7 to 77 months after treatment, whereas 17 of the 35 control patients were free from disease. The 1-year survival for Group 1 was 84% and for Group 2, 81%. The 2-year survival was 78% for Group 1 and 46% for Group 2 (p = 0.045). The survival rates by stage of disease were as follows: Stage I, 15 out of 17 or 88% in Group 1 and 15 out of 23 or 65% in Group 2 (p = 0.097); Stages II and III, 5 out of 11 or 45% in Group 1 and 3 out of 12 or 25% in Group 2 (p = 0.304). The results of the study suggest that the administration of transfer factor to patients who have undergone pulmonary resection for carcinoma of the lung can have a significant impact on the prolongation of life.     

The Benefits of Corticosteroids in Endotoxic Shock

The experiments reported here were undertaken to study the effects of pharmacological doses of corticosteroids administered alone or in conjunction with prolonged (12-hour) assisted circulation in 22 dogs subjected to LD_50–60Escherichia coli endotoxin. The most striking findings were lengthened survival time, higher cardiac output, decreased fluid requirement, and minimal evidence of pulmonary congestion or injury in the animals treated with steroids only. Unexplained mesenteric infarction prematurely terminated the experiments in animals undergoing assisted circulation.The benefits of corticosteroids in experimentally induced endotoxic shock are clearly demonstrated in these experiments. Further studies are needed to clarify the supportive role of assisted circulation in endotoxic shock and to determine any possible advantage of hypothermia over normothermia during its course.     

Bronchogenic Carcinoma and Postoperative Empyema: Is Survival Really Enhanced?

From 1959 to 1974, 542 patients underwent curative resection for bronchogenic carcinoma. Postoperative empyema occurred in 17 of these patients. The overall 5-year survival of these 17 patients was only 18%, compared with 27% in the 525 patients without empyema. We were unable to demonstrate by our study or by a review of the literature that postoperative empyema favorably influences survival in patients who have had pulmonary resection for bronchogenic carcinoma.     

Complications of Pulmonary Resection

The following complications of pulmonary resection are discussed with reference to their frequency of occurrence, etiology, diagnosis, and treatment: pulmonary insufficiency, arrhythmias, residual intrapleural air spaces, prolonged air leaks, postpneumonectomy empyema, bronchopleural fistula, cardiac herniation, lobar gangrene, esophagopleural fistula, pulmonary embolism, and tumor embolism.     

An Operation for the Hypoplastic Left Heart Syndrome: Preliminary Report

A successful first-stage operation for physiological correction of hypoplastic left heart syndrome is reported. This consists of creating a proximal communication between the pulmonary artery and the aorta while perfusing the lungs through a 3 mm orifice in a flap of pulmonary artery wall. The flap is turned in to partition the main pulmonary artery. We believe this operation has more potential for subsequent correction using the Fontan approach than previously reported first-stage procedures. Thus, further trial is indicated in selected patients.     

The effect of levarterenol and phentolamine on the hypertensive pulmonary vasculature

The pulmonary vascular response to the infusion of levarterenol and phentolamine separately and in various combinations was studied in 6 calves with experimentally produced pulmonary hypertension. Infusion of levarterenol alone increased the pulmonary artery pressure from a mean of 57 to 70 mm. Hg, the left atrial pressure from a mean of 9 to 17 mm. Hg, and the systemic arterial pressure from a mean of 30 to 51 mm. Hg. There was no change in pulmonary vascular resistance or cardiac output. Infusion of phentolamine alone decreased systemic artery pressure from a mean of 101 to 89 mm. Hg. There was no change in pulmonary artery pressure, pulmonary vascular resistance, or cardiac output. When infusion of levarterenol and phentolamine was properly titrated to maintain systemic arterial pressure at the level obtained subsequent to creation of pulmonary hypertension, pulmonary vascular resistance decreased from a mean of 16 to 10 units and cardiac output increased from a mean of 3.2 to 5.0 liters per minute. When levarterenol and phentolamine were improperly titrated, the hemodynamic response corresponded to the effect of the predominant drug. This study demonstrates that levarterenol and phentolamine, properly administered, increase cardiac output and lower pulmonary vascular resistance in calves with experimentally produced pulmonary hypertension.     

Simultaneous treatment of aortic stenosis and coarctation by left thoracotomy with apical aortic conduit.

Acute monilial esophagitis generally responds well to oral nystatin therapy, and long-term sequelae of this condition have not been well recognized. Nor is it generally appreciated that Candida infections of the esophagus may occur in subacute or chronic form. Four men, 34, 40, 41, and 49 years old, have been treated for esophageal stenoses resulting from different types of chronic monilial esophageal involvement. All were seen with painless dysphagia and strictures of the upper half of the thoracic esophagus. In 2 patients, an associated roentgenographic pattern of “intramural esophageal pseudodiverticulosis” was present. Two patients have been treated successfully with esophageal dilation, 1 required substernal colonic bypass of the stenotic, perforated esophagus, and 1 is being evaluated for esophageal bypass. Esophageal moniliasis must be considered in the differential diagnosis of benign esophageal strictures, particularly those involving the upper half of the thoracic esophagus.     

The Blalock-Hanlon procedure. A new look at an old operation.

The Blalock-Hanlon procedure has been carried out in 48 neonates with 10 early deaths (21%). This compares favorably with the reported early mortality for balloon atrial septostomy. Most striking have been the length of palliation, freedom from complications, and low incidence of late death among these patients. In contrast, reported series of balloon septostomies have shown a high incidence of strokes, repeat hospitalization, inadequate palliation, and late deaths. Since palliation is reliable following a Blalock-Hanlon procedure, we do not favor early correction with hypothermic arrest but recommend it at 12 to 18 months of age, when conventional perfusion can be easily utilized.     

Coronary Arteriotomy with Cardioplegia

A technique for improved visualization of the coronary vessels during cardiac arrest is described. The method involves dissecting the epicardial fat from the vessel involved, marking the fat for future reference, and applying traction at the acute margin of the right ventricle. Cardioplegic solution can be infused both before and during the time of each arteriotomy.     

Cardiovascular Status after Repair by Fontan Procedure

Patients surviving a Fontan operation experience dramatic symptomatic improvement, but concern remains about the long-term results of this operation. The clinical course and postoperative hemodynamic findings in 5 long-term survivors of the Fontan procedure from our institution are presented. Attention is drawn to 3 patients who required reoperation: 1 immediately for residual mild pulmonary stenosis, 1 for late onset complete heart block, and 1 for conduit valve stenosis. Review of our patients and those described in the literature reveals that all have ascites and pleural effusions as a result of high venous pressures but that this is usually a temporary problem. Late onset of obstruction to right atrial emptying has been reported in several patients in addition to ours. This raises serious concerns about the long-term fate of cloth conduits and porcine valves in this application. Although normal sinus rhythm has been thought to be essential for adequate pulmonary perfusion in these patients, it is interesting that several patients have tolerated atrial tachyarrhythmias, junctional rhythms, and even complete heart block without serious ill effects.We conclude that the Fontan procedure is extremely effective in relieving symptoms at an operative risk that is now acceptable, but these patients require very careful long-term follow-up because they are subject to a number of long-term complications.     

The surgical therapy for pulmonary artery--right ventricular discontinuity

The results of operations performed at the University of Michigan for conditions characterized by pulmonary artery-right ventricular discontinuity are reviewed. In 5 infants with increased pulmonary blood flow, pulmonary artery banding was performed with unsatisfactory results. Two survived operation but later died of complications related to the bands. Fourteen children received shunts for conditions involving reduced pulmonary blood flow; 13 survived and have either undergone subsequent total repair or are doing well and are awaiting total repair when possible. Twelve patients have undergone total repair; valveless cloth tube conduits were utilized in 4, and 2 remain well 11 years later. More recently, fresh, antibiotic-preserved aortic allografts have been utilized for the conduit. Six of 8 patients survived the operation, and there was 1 late death. The aortic wall of one graft became calcified after 4 years and had to be replaced, although the valve leaflets remained functional. Immediate success of the totally corrective operation depends on the pulmonary vascular resistance being less than 60% of the systemic. Long-term success depends on the fate of the conduit. From previous experience we think fresh allografts should be more durable than the sterilized allografts used by most other groups; however, we have found that even fresh allografts can calcify.