The Current Status of Cardiac Surgery

The Current Status of Cardiac Surgery

Edited by D. B. Longmore, FRCS, LRCP, MB, BS

Consultant Clinical Physiologist National Heart Hospital, London

MTP Medical and Technical Publishing Co. Ltd.

Published by MTP Medical and Technical Publishing Co. Ltd., St. Leonard's House, St. Leonardgate, Lancaster, England Copyright 1975 D. B. Longmore Softcover reprint of the hardcover 1st edition 1975

This book, or parts thereof, may not be reproduced in any form without permission, except for short extracts for review purposes

ISBN-13:978-94-011-6614-0 e-ISBN-13:978-94-011-6612-6 DOl: 10.1007/978-94-011-6612-6

First published 1975

Contents

Preface D. B. Longmore

Part I Cardiac Transplantation

1. Introduction D. B. Longmore 3 2. Transplantation of other organs R. Y. Caine 6 3. Logistics of organ acquisition J. J. Van Rood 12 4. The significance of tissue typing and matching in cardiac trans-

plantation J. R. Batchelor 17 5. Vascular lesions in experimental transplantation J. F. Mowbray 20 6. Cardiac transplantation today P. K. Caves 28 7. The place of transplantation Ch. Dubost 40

Part 2 FaUot's Tetralogy

8. The surgical anatomy of Fallot's tetralogy R. H. Anderson and A. E. Becker 49

9. Angiographic aspects of Fallot's tetralogy in infants J. F. N. Taylor and G. R. Graham 62

10. The present indications of palliation in Fallot's tetralogy D. Waterston 69 11. Total correction after previous Blalock-Taussig shunt M. F. Sturridge 71 12. Total correction after the Brock procedure S. C. Lennox 73 13. Radical corrective surgery after Waterston shunts Jane Somerville

and Rosa Barbosa 78 14. Current concepts in the management of Fallot's tetralogy A. Starr 84 15. Primary total correction of Fallot's tetralogy under the age of two

years. M. H. Yacoub 16. Correction of tetralogy of Fallot W. Klinner 17. Revaluation after total correction of Fallot's tetralogy F. Fontan and

A. Choussat 18. The need for homograft reconstruction of the right ventricular outflow

tract in Fallot's tetralogy D. N. Ross

95 103

104

117

Part 3 Prosthetic Valves 19. The design characteristics of heart valves K. Reid 123 20. Echocardiographic studies following mitral valve replacement D. G.

Gibson 127 21. Myocardial preservation during aortic valve replacement R. N.

Sapsford 133 22. The cage ball prosthesis A. Starr 144 23. Five years experience with the Bjork-Shiley disc valve in aortic,

mitral and tricuspid valvular disease V. Bjork 160 24. The Australian experience with prosthetic valves H. D. Sutherland 179 25. The use of Starr-Edwards composite seat valves (models 2320 and

6320) in the aortic and mitral positions W. P. Cleland 192 26. Mitral valve replacement S. C. Lennox 196 27. The use of Starr-Edwards valves (model 1260) M. F. Sturridge 198 28. The use of Braunwald Cutter valves: Part 1 J. E. C. Wright 200 29. Experience with the Bjork-Shiley prosthesis: Part I J. G. Bennett 202 30. Experience with the Bjork-Shiley prosthesis: Part II G. H. Smith 204 31. The use of the Braunwald Cutter valve: Part II J. K. Ross 206

Part 4 Tissue Valve Replacement and Repair 32. Viability of homografts and problems of long-term storage N.

33. 34 35.

36. 37. 38. 39. 40.

Al-Janabi Problems of sterilisation in homograft preparation Eunice Lockey Tissue valve preparation. A. Carpentier, J. Reiland and Ch. Dubost Mechanical characteristics of vena cava and a technique for its use, unsupported, for mitral valve replacement B. T. Williams Homograft and autograft replacement of the aortic valve D. N. Ross Experience with heterografts C. G. Duran Homograft replacement of the mitral valve M. H. Yacoub Experience with tissue heart valves Marian I. Ionescu Late results of cardiac valve replacement with autologous fascia lata

209 215 219

226 234 246 253 260

41. D. J. Parker Reconstructive Dubost

272 valve surgery A. Carpentier, J. Reiland and Ch.

279

Part S Open-Heart Surgery under One Year of Age 42. Open-heart surgery in the first year of life J. Stark 293 43. Experience with infant perfusions A. Starr 298 44. Management of ventricular septal defects in infants A. J. Furst 302 45. Total surgical correction of total anomalous pulmonary venous

drainage in infancy F. Midgley 307

46. Operative treatment of patients with transposition of the great arteries in infancy J. Stark 312

47. Treatment of valvar stenosis A. Rees 319

Part 6 Post-Operative Care following Cardio-thoracic Surgery

48. Osmolar balance after open-intracardiac operations in children P. B. Deverall 325

49. Peripheral temperature measurement as an aid to postoperative care H. R. Matthews 330

50. Atrial pressure measurement after open-heart surgery R. D. Bradley 337 51. Assessment of left ventricular function and simultaneous measure-

ments of pressure and dimension D. G. Gibson 339 52. Measurement of cardiac output in infants and young children using

thermodilution A. Rees 344 53. Cardiac output and its derivatives using an implantable electro­

magnetic flow probe and intra-cardiac manometers B. T. Williams, A. F. Rickards and J. H. Chamberlain 347

54. The place of the computer and automation in postoperative care T. D. Preston 357

Part 7 Ischaemic Heart Disease 55. Selection of patients for coronary artery surgery J. L. Waddy 367 56. Pre and postoperative investigation R. Balcon 372 57. Problems of technique in aorto-coronary bypass operations. J. E. C.

Wright 374 58. The coronary bypass operation A. Starr 381 59. Coronary endarterectomy C. Hahn, N. Radovanovic and B. Faidutti 386 60. Postoperative blood flow in auto-coronary saphenous vein bypass

grafts B. T. Williams, A. F. Rickards, J. F. C. Wright and C. A. Barefoot 396

61. Pathological aspects of ischaemic heart disease E. G. J. Olsen 401 62. The intra-aortic balloon pump R. J. Donnelly 406 63. Infarctectomy C. Hahn, E. Hazif and B. Faidutti 413 64. Surgical treatment of left ventricular aneurysm H. H. Bentall 415 65. Management of postinfarction mitral regurgitation M. H. Yacoub 420 66. The treatment of postinfarction VSD B. N. Pickering 426

Part 8 Results of Surgery in Rare Congenital Heart Disease

67. Results of surgery in rare congenital heart disease Ch. Dubost 435

Part 9 Discussion Index 489

List of Contributors

N. AI-Janabi, PhD Senior Biologist, Surgical Department, National Heart Hospital; Honorary Lecturer, Cardio-Thoracic Institute, London

R. H. Anderson, FRCS, MD Department of Paediatrics, Cardio-thoracic Institute, Brompton Hospital, London

R. Balcon, MRCS, LRCP, MB, BS Consultant Cardiologist, London Chest Hospital; Consultant Cardiologist, South­end General Hospital, England

Rosa Barbosa, MD 181, Voluntaris Da, Patria Apto 201, Rio de Janeoro, Brazil

C. A. Barefoot,MD Carolina Electronics, King, North Carolina 27021, USA

J. R. Batchelor, MRCS, LRCP, BChir, MB, MD Professor, McIndoe Research Unit, Queen Victoria Hospital, East Grinstead, Sussex, England

A. E. Becker, PRCS, MD Department of Cardiology and Ex­perimental Physiology, Amsterdam

J. G. Bennett, FRCS Senior Registrar, Brompton Hospital, London

H. H. Bental). FRCS, LRCP, MB, BS Professor of Cardiac Surgery, Royal Post­graduate Medical School; Consultant Thoracic Surgeon, Hammersmith Hospital, London

V. O. Bjork, MD Professor of Cardiac Surgery, Royal Post­graduate Medical School, Consultant Thoracic Surgeon, Hammersmith Hospital, London

R. D. Bradley, MB, BS Consultant Physiologist, St Thomas's Hospital, London

R. Y. Caine, FRCS, LRCP, MD, BS, MS Professor of Surgery, University of Cambridge, England

A. Carpentier, MD Professor of Cardiac Surgery, Hopital Broussais, Paris, France

P. K. Caves, FRCS, MD Senior Lecturer in Cardiac Surgery, Royal Infirmary, Edinburgh, Scotland

J. H. Chamberlain, MB, BS, MRCP Consultant Clinical Physiologist, Guy's Hospital, London

A. Chousset Hopital Du Tondu, Bordeaux, France

W. P. Cleland, FRCP, FRCS Director of Department of Surgery, In­stitute of Diseases of the Chest, London; Consultant Surgeon, Brompton Hospital, London; Senior Lecturer in Thoracic Surgery, Royal Postgraduate Medical School, London

P. B. DeveraJI. PRCS, LRCP, MB, BS Consultant Cardio-Thoracic Surgeon, Leeds General Hospital; Lecturer in Thoracic Surgery, University of Leeds, England

R. J. Donnelly, FRCS. MB. BS Consultant Cardio-thoracic Surgeon, Broadgreen Hospital, Liverpool

Ch. Dubost, MD Professor de Clinique Chirurgicale Cardio- Vasculaire, Chirurgien de L'Hopital Broussais, Paris, France

C. M. G. Durran, MD Jefe Servicio Cardiovascular Centro Medico Nacional "Marques de Valdecil/a", Universidad de Santander, Spain_

Current Status of Cardiac Surgery

D. Faidutti, MD Clinique Universitaire de Chirurgie Cardio­Vasculaire, 1121 Geneva 4, Switzerland

A. F. Fontan, MD Professor of Cardiac Surgery, Hopital du Tondu, Bordeaux, France

A. J. Furst, MD Senior Surgical Registrar, The Hospital for Sick Children, London

D. G. Gibson, DChir, MD Consultant Cardiologist, Brompton Hos­pital, London

G. R. Graham, MD Consultant in Clinical Physiology, The Hospital for Sick Children, London

C. Hahg. MD Professor, Surgical Department, Hopital Camonal, Clinique Universitaire de Chirur­gie Cardio-Vasculaire, 1121 Geneva 4, Switzerland

E. Hauf, MD Clinique Universitaire de Chirurgie Cardio­Vasculaire, 1121 Geneva 4, Switzerland

Marlan I. lonescn, FRCS Consultant Thoracic Surgeon, Leeds General Infirmary, England

W. Klinner, MD ProJessor of Surgery, Herzchirugische Klinik der University Miinchen

S. C. Lennox, FRCS, LRCP, MD, MS Consultant Surgeon, The Brompton Hos­pital, London

Eunice Lockey, Dsc, MD, FRCPath Consultant Pathologist, The National Heart Hospital, London

~. Longmore, FRCS, LRCP, MD, MS Consultant Physiologist, The National Heart Hospital, London

H. R. Matthews, FRCS, LRCP, MD, DS Senior Surgical Registrar. Broadgreen Hospital, Liverpool, England

F. Midgley, FRCS Senior Surgical Registrar, The Hospital for Sick Children, London

J. F. Mowbray, DChir, MD Reader in Immunopathy, St. Mary's Hospital, London

E. G. J. Olsen, MRCS, LRCP, MD, DS, MD Consultant Pathologist, The National Heart Hospital, London

D. J. Parker, FRCS, MRCP, MB, CHB Senior Lecturer, Honorary Consultant Surgeon, Cardio-Thoracic Institute; Consultant Thoracic Surgeon. The National Heart Hospital, London

B. N. Pickering, FRCS, LRCP, MB, BS ConsultamCardio-thoracic Surgeon, Colindale Hospital, London

T. D. Preston, FRCS, DChir, MD Computer Director, Westminster Hospital, London

N. Radovanovlc, MD Clinique Universitaire de Chirurgie Cardio­Vasculaire, 1121 Geneva 4, Switzerland

A. Rees, FRCS Senior Surgical Registrar, The Brompton Hospital, London

K. Reid, FRCS Senior Surgical Registrar, National Heart Hospital, London

A. F. Rickards, MD, MRCP Consultant Cardiologist, National Heart Hospital, London

D. N. Ross, FRCS, MB, CHD Director, Department of Surgery, Institute of Cardiology; Consultant Surgeon, The National Heart Hospital & Guy's Hospital, London

J. K. Ross MS, FRCS Thoracic Surgeon4 Southaml!ton Chest Hospital R. N. Sapiford. FRCS, MB, CHB Senior Surgical Registrar, The Hospital for SiCK Children, London

Current Status of Cardiac Surgery

G. H. Smith, FRCS, LRCP, MD, DS Consultant Cardio-vascular Surgeon. Northern General & United ShejJield Hos­pitals. ShejJield .. England

l. Somervme, MD, MRCP Consultant Cardiologist. The National Heart Hospital. London

J. Stark, FRCS Consultant Thoracic Surgeon. The Hos­pital for Sick Children. London

A. Starr, MD professor of Surgery. Chief of Cardio-Pul­monary Surgery. University of Oregon Medical School. USA

M. F. Sturridge, FRCS. MD, DS, MS Consultant Thoracic Surgeon. London Chest Hospital and Middlesex Hospital. London

H. D. Sutherland, MS, FRCS, FRAcs Consultant Surgeon. Royal Adelaide Hospital. South Australia

J. F. N. Taylor, MRCS, MRCP, MD Senior Research Fellow. Paediatric Cardiology. The Hospital for Sick Children. London

J. J. Van Rood, MD Professor, Surgical Department. Oegtgeest. Nr Leiden. The Netherlands

J. L. Waddy, FARCS Cardiologist. Royal Adelaide Hospilol. South Australia

D. J. Waterston, FRCS, MD, DCH Consultant Surgeon. The Hospitalfor Sick Children. London

D. T. Wmlams. FRCS Consultant Cardio-thoracic Surgeon. St Thomas's Hospital. London

J. E. C. Wright, MRCS, LRCP, MD, DS Consultant Cardio-Thoracic Surgeon. London Chest Hospital and Southend General Hospital; Honorary Consultant. The Italian Hospital. London

M. H. Yacoub, FRCS, LRCP Consultant Thoracic Surgeon. Harefield Hospital and The National Heart Hospital. London

Acknowledgements

The tremendous success of the 1974 cardiac surgical course was due to two main factors. Firstly, Dr Albert Starr who was Moderator and whose attendance at every session was of immeasurable value. He was able to make these great contributions because the organisers and the secretariat had produced an impeccable and well-planned course.

Many of the contributors were extremely helpful and co-operated on the production of the edited version of the course and I wish to thank those who helped with the editorial work and who gave so much time and effort.

This book could not have been produced without generous help from ICI and encouragement from Mr. Beale of ICI. It would also have been im­possible to produce in its present form without the generosity of MTP. An enormous amount of hard work has been undertaken by Miss M. Smith at the National Heart Hospital and the editorial staff of Medical and Technical Publishing Company. Finally, I would like to take the opportunity to thank all those who have helped during the transcription and preparation and who have overcome problems due to postal strikes throughout Europe.

Preface

This book consists of an edited report of the proceedings of the Fifth Cardiac Surgical Course run by the Royal Post-Graduate Medical School, The Institute of Cardiology, The Institute of Diseases of the Chest, The Institute of Child Health, The National Heart Hospital, The Brompton Hospital, The Hammersmith Hospital and Great Ormond Street Children's Hospital. These organisations encompass most of the major London hospitals associated with cardiac surgery.

The course has been run annually, its aim being to help young men and women who are training in the specialised field of cardiac surgery. Thus this book consists of the proceedings of a teaching course rather than of a symposium, the 60 authors having been charged with the task of teaching rather than displaying their results or discussing their latest ideas and the proceedings reflect an interesting appraisal of the current status of cardiac surgery. The speakers were chosen from all over the world, because they were leaders in their field or because they have access to up to date and reliable information, and I am grateful to all the lecturers for their cooperation in the production of this volume.

Ten thousand surgical cases are reported. These figures are drawn from experience in the United Kingdom, France, Germany, Switzerland, the United States of America, Australia and New Zealand. The reader may be surprised to find that only a handful of experiments are described. This does not necessarily mean that cardiac surgery has passed the stage when its exponents spend a proportion of their time in the experimental laboratory, but regrettably, it does mean that a lot of the experimentation has now to be done in the operating theatre, using the human subject as the final arbiter for the safety and efficiency of any procedure. This is the current situation with regard to the ideal method of replacing the aortic valve.

Although routine major cardiac surgery is only just over a decade old the exponential growth of the discipline has now ceased, the principles are established and the era of extravagant claims for its advances and results has passed. It was the fact that cardiac surgery has now attained this stable state that led to the decision that this particular year of the

Current Status of Cardiac Surgery

Cardiac Surgical course should be published. The book is not intended to be comprehensive and there are areas in which it is impossible to use it as a reference work, but where subjects are dealt with they are compre­hensively covered and up to date.