The accomplishments of open heart surgery

The Accomplishments of Open Heart Surgery The Status of 35 Patients 18 to 36 Months Following the Operation* CH VRI Fs P . BAILEY, u .n ., F . A .C .C ., BE NJA%IIN G . MUSSER, M .D ., and DRYDEN P . MIoRSE, AI .D .

Philadelphia . Pennsylvania

extraeorporeal circulation is now assured a permanent role in the treatment of certain cardiac lesions . Due to the relaticely recent advent of this type surgery, there have been fete reports except of the immediate results . Accordingly, a review of our first 35 surviving patients, operated on with the aid of total cardiopulmonary bypass 18 to 36 months ago, was undertaken . The first successfi l, complete bypass of the heart and lungs ,vas accomplished in 1953 b} Gibbon who was able to repair an atrial septal defect in a bung woman, using an open technique and a filming type oxygenator . Lillehei, in 1954, following experimental work in animals, utilized the method of cross airculation In repair a ventricular septal defect, using an open technique and cross transfusion with a human donor . This work was followed be the development of a bubble type oxygcrater by DeWall' and others .'-' Preliminary to these complete bypass operations, pumps' had been developed and successfully used for bypass of each side of the heart alone by Dodrill ; Bailey.' and other, .

T

'the technique employed in all these cases involved the use of the Friedland-Genteinhardt oxygenator, a modification of the DeWall apparatus (Fig . 1) . Two Sigmamotor pumps were used to replace, respectively, the right and left ventricles . The bodily venous return was withdrawn from the venae cavae through separate catheters, and the oxygenated blood was returned to the arterial circuit by way of a suhclavian catheter . An additional Sigrnamotor pump was used in some of the patients for retrograde perfusion of the coronary sinus with oxygenated blood .' Throughout the entire series, the rate of cxtracorporeal flow was mainrained at nearly the patient's normal cardiac output (adult average over 3,000 cc per minute) . The last patient in the series, operated on August 21, 1957, was perfused by a new principle involving the use of the patient's own lungs as an oxtgenator . 7 The technique of eannulization in this case was as shown in Figure 2 . All of these patients were in a supine position when explored using a transverse incision through the bed of the third or fourth rib, and transecting the sternum at that level . Elective cardiac arrest was not used in this series . Since then arrest was used for a period of one year and now has been abandoned .

HE csE of

T'

SELEC1ltN

or PA'rnEN'rs

Of these 35 patients, 23 were suffering from aortic stenosis and 2 from aortic insufficiency . Of the ten patients with congenital defects . three had congenital aortic stenosis . There were four patients with the tetralogy- of Fallot and three with ventricular septal defects .

ACQUIRED AoRTne STExosts In this group there were 21 men and 2 worneu . The 2 women were aged 42 and 53 years, respectively . The ages of the men ranged from

* From the Department of Thoracic Surgery, Hahnernann Medical College and Hospital and the Bailey Thoracic Clinic, Philadelphia, Pennsylvania . This work was snpprated the Mary Bailey Foundation tur Heart and Great Vessel Research, Philadelphia, Pcnosylvania . } At the time these patients were operated nn our mortality with open heart surgery had keen 42 per cent u, this relatively small beginning series . Thr current mortality with open heart surgery at this clinic is 18 .2 per rent . The total series now, is in excess of 400 . by

wcaus,', 1939,

147



144

Accomplishments

of

Open Heart Surgery

TABLE I

TABLE I I

The Age Distribution of 23 Patients with Acquired Aortic (Calcific) Stenosis Operated on by an Open Technique

Complete Pre- and Postoperative Physiologic Data' in a 45-Year-Old Man (l .S .) with Severe Calcifie Aortic Stenosis

Age (yr)

Patients (not

10-19 20-29 30 39 40-49 50-59

Gradient into IN t I by planimrtrv-

9

TOTAL

Preoperative Postoperative

blow st , -

:18 32

ti stolic C alculated election functional time/beat valve area stri Inn°1

9 .28 -1 .20

0 .34 0 .8

23 NOTE : This patient uas operand on in our early series before the present technique of subtotal excision of calcium from the cusp [callers was developed . He really represents the effect only of accurate commissurotomy upon the circulatory dvnainie;- %VI- believe that the results of cotnntisatn'otnmv plus valve sadpturing in tcrms:of final cater area will he nmch better (see Figure 3} Tls d~7td in, this and tlu subsequent tables were obth Shalom Cardiopulmonary I .aboratotaingdm the ;
29 to 58 years, and they were grouped by dccade9, as •s hes4nt. it-T'aItAClllz ,rttlht}relpaticnts reported of, sm-.vt--'Qnd'prbgGesth'e~abntic stenosi3 .,_The prCd'oninunt'Glinical'svtbptodis svelte those of Of IWeaath -pain,1L taws irhrthe chest,

s1{Ol, tneis

M

attic'tylicftpc : i2I1".th'

with actlutrad hak'rt-diaxase'were«Ia etIr $ •> taurtdwdiologists

dr'tpt6isi/Permsylanatx

4rne ruse flleabt :Assoc ht'I'tan'fu4ictionaI Class /it or ' III, !heir' alru Ir ecp aliy,div d d hetweelt=-those, twa All the fsatitnts3n histseaiez,hadpreoperative entu'tlic :

city

et

iht'aortic Istah-e

surgery .

Inlmost cases this

was ac-

Azatiotir-via,the,posterior It ansthoraeie punc-

tureroute y,llbuturDl'oor .Oases

tneasruvrnentiof-ihehprzss4krggadil ntt(systo}rch)

ieisossc

for

chmilpiished ;hy .the,technique of left heart cath-

pressures as measured --b I

ttm,confirau hht .ndtS-

n

Ov

the

brachial arterial

puncturee and the

n

H}0on n n s e e"J'dt}l'

I

WA PU

P

PUMP I

A

'a A ) .iK-`

~~

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CAVAE

I

-

;A

~ .ll )

-

Fro . 1 . The "standard" cardiopulmonary bypass . Unoxygenated blood front tit I mtAc'"es a -trhsstvn' , $N 6laek)i :putuprzd- throlsghea(ibubbkshigig,cnator Xhdiuiktri'itt+dtwWiiltlotr*tdolitfmW4ta'di ; a S 4 rrasttuy,(mhetd1iclaviinchaa : :nos+ been supplanted by the femoral for this purpose) . THE, AMERICAN JOURNAL (IF' CARDIOLOGY



149

Bailey, Musser, and Morse

TABLE III Catheterization Results in Congenital and Acquired Calcific Aortic Stenosis in Those Patients Studied Pre- and Postoperatively

Case No .

1,BC . 2 . C .M . 3, J . C . 4. F. S. 5 .J .11 . 7, J .I . 8 . C .W. I0, E .S .

The "autogenous hmg' cardiac bypass . In this method the patients' own lungs arc used to oxygenate the blood_ This particular technique, developed by Dr . Gumersindo Blanco of the Bailey Thoracic Clinic, avoids the trauma to the blood elements caused by mechanical oxygenators, and allows successful complete cardiac bypass for periods as long as two hours . Venous blood (in black) is collected by gravity drainage from a single large or double catheter in the right atrium, and passed into the pulmonary artery. Oxygenated blood (shaded lines) is similarly drawn from the left atrium and passed into the femoral artery . An oxygenator (connected to ends of clamped tubes) is included in the circuit for emergency use if indicated . FIG . 2 .

ventricular pressure was obtained by direct anterior suhxiphoid puncture of the left ventricle because it had been elected to perform simultaneous- ventriculographic evaluation of possible mitral regurgitation . The measurement of the gradient across the aortic valve is understood to be only one part of the physiologically threefold determination of the degree of obstruction at the valve . The measurement of flow and of the period the valve was open during each cardiac cycle was not always performed but such complete evaluation is illustrated in Table II, This shows the complete pre- and postoperative physiologic data as determined by combined right and left heart catheterization of a 45-year-old man who had severe calcitic aortic stenosis . With the reservation that the measured gradient only approximately indicates the. degree of physiologic obstruction, the results of pre- and postoperative physiologic studies in these patients are presented in Table III . AUGUST,

1939

Age (yr)

t4 57 14 45 38 44 53 37 42 45

type of lesion

Date of operation

C A C

4/12/56 5/29/56 6/21/56 7/13/56 7/18/56 7/25/56 31/2/56 6/12/57 8/9/57 8/21/57

A A A A

A

Aortic valve systolic gradient --(mm Hg)--- . Preop- Postoperative erative 57 54 145 200 152 146 80" 85 78 0 118

22 17 43 70 70 8 39" 40 -2° 42

congenital. A = aca;uired . " By planimetry (all other gradients measured "peak to peak") and ventricle to brachial artery' Increase in flow 231 cc to 292 cc per systolic ejection period second, in less time (034 second to 0 .2(1 second per systole) . This patient has had a remarkably good result clinically . He is asymptomatic and working full time . VOTE : C =

COMPLICATIONS OF SURUERS

One patient had continued bloody pleural drainage postoperatively which required reexploration 24 hours after surgery, at which time the hemorrhage was observed to come from the aortic suture line . This was repaired, the thorax was rccloscd and no further difficulty was encountered . In one patient with congenital aortic stenosis, a significant amount of aortic insufficiency was produced so there was a progressive postoperative drop in the diastolic blood pressure to a level of 10 unit II ,I following surgery . Local wound complications occurred in five patients . In two of these, small draining sinuses developed which healed after a short time . Two more had hematonras of the wound which became infected and resulted in nonunion of the sternum . In an additional patient, nonunion of the sternum occurred without infection . Two of these patients with nonunion are still complaining of discomfort . A number of the patients had pulmonary complications . Tracheotomy was necessary in two patients of the aortic series . In many of them, excessive tracheobronchial secretions necessitated bronchoscopy in addition to multiple tracheal aspirations .



150

Accomplishments of Open Heart Surgery

A B A, a typical aortic valve with sever(- calcification completely imunobilizing the cusps, and obliterating the commissurc to the right . B and C, the same valve similarly oriented after removal of the calchre non thr concave side of each cusp, and incision of the fused commissure . Two leaflets are now freely mobile . Fir. . 3 .

In several of the patients, manifestations of cerebral disturbances developed postoperatively . One patient (T . H .) had evidence of air embolism to the middle cerebral artery as determined by neurologieexamination . Recovery was complete . Another became franklyy° psychotic and agitated, but he improved before discharge . A third was confused for three days following surgery and had a minor facial weakness . It was thought that this latter episode might have been related to Embolism occurring at the time of surgery . In one case, there was difficulty with the circulation in the left arm, presumably due to acute arterial insufficiency from the left suhclavian cannulation . This subsided with physiotherapy . Hemolytic jaundice developed in one patient

during his hospital stay . Hepatitis occurred in another patient four months after surgery, requiring rehospitalization . Both patients recovered . POSTOPERATIVE

PIIVSIOLOCIC

sTCnIEs

Although subjectively the patients with aortic stenosis were completely' relieved, or at least greatly improved symptomatically, the catheterization data in the patient , who have returned for study show that in these earl'- open procedures for aortic stenosis Ice failed to bring about a return to normal pressure and flow relationships (Fables 11 and 1Ili . Because of the severe degree of valvular calcification, fibrosis and rigidity of the valve leaflets, a coruplete obliteration of the pressure gradient was

A B Fie . 4 . A, the typical appearance of the pulmonary valve in purr pulmonary' stenosis in a patient with tetralogy of Fallot . Although the valve at first appears to he a simple cone, in fact, each rudimentary commissure can he recognized by a tissue bridge raphc extending to the arterial wall . B, the same valve similarly oriented after division of the coinnissures . A good opening may he obtained quickly and easily without production of insufficiency . Infundibular stenusis is, of course, mole common than such valvular obstruction in the tetralogy of Fallot . TIIE AMERICAN IOtRNAI OF CARDIOLOGY



151

Bailey, Musser, and Morse TABLE IV Catheterization Data :n a Patient with Tetralogy of Fallot (J .J . 1, Age 3 pears, Operated on March 28, 1957 Immediately pr cope I'erative Pressure -s ( rein Fig) Main pulmonary artery Right ventricle Brachial artery Right atrium Pulmonary venous capillary Oxygen contents (VOL (~) Superior vcna eava Inferior yea a eava Right atrium (high) Right atrium (middle 1 Right atrium (low) Right ventricle, tricuspid Right ventricle, apex Main pulmonary artery Right pulmonary artery Brachial artery capacity Brachial artery saturation (%)

6 . ..cribs

postoperative

100/0 106/70 (0) (2 ) 11

s

9 .2 11 6 12 . 1 I 1 6 8 .2 II I 8 .8

VESratcut.Att SEPIAL

19 .4

DELEL]

73 .3

not obtained . (,In our more recent experience with such valves, to be reported later, a new technique has been developed for removing the calcium and much of the scar tissue from the concave side of each cusp . The "sculpturing" restores mobility and function to the valve to a near-normal extent (Fig . 3) .) '1Elk .],00Y of

branous portion of the interventricular septum and averaged approximately 15 cm in diameter . In each case, the ventricular septum was repaired with simple or mattress sutures . In one case this saas supplemented by Iv al on . In pledgets to reinforce the mattress 'sutures no case was a conduction bundle disturbance initiated by the repair . The protruding portion of the supraventricular wall was resecred in the three cases in which obstruction was of the infundibular tope . In the patient with purely valvular stenosis, the pulmonary artery was opened and the commissures were incised along the line of congenital fusion (Fig . 4) . All four patients had been catheterized preoperatively and in each case the right ventricular systolic pressure was found to be over 75 Inn 11g . In the two patients in whom postoperative catheterization studies have been carried out, complete cure has been demon'Oated I1v the physiologic data (Tables IV and A'1 .

FALIJH'

The ages of the four patients with tetralogy of Fallot were 2, 3, t5, and 22 years, respectively . Three of the four had infundibular stenosis ; one hail a valvular stenosis ; none had comirined stenosis . All the defects were in the mem-

Our first attempt at closure of a ventricular septal defect was made in 1952 . 1 '1 this patient was treated without the use of an open technique, a pedicled pericardial plug- being pulled through the ventricular defect to block it . Beenuse of significant obstruction to the right ventricular outflow tract, it later was necessary- to remote the tampon in the defect . Our first successful modern closure of a ventricular defect took place in July 1956, in an 18-Ncarold boy . Two additional patients are included in our 18- to 36-month follow-up . In each of these cases, the defect as shown in Table \t has been approximateiv I to I5 cm in diameter and was closed with simple sutures . The demonstration by catheterization of complete cor-

TABLE V Surgical Findings and Results in Four Patients with the Tetralogy of Fallot (Postoperative Patient, age (yr) . and Sex

Date

Defect ((m)

S .F .,

2.

M

15 . F

FIN ., 22, 1'

Cllosale

Infundibular Simple suture mcmbra- Infundibular Mattress suture nous septum .5 ; high membranous Valvular Simple .5 ; high Inhmdibular Mattress over Ivalon pledgets

1 .5

.I .E .,°

Type of pulmonary obstruction

5/31 /57

1 .5 X 1 11 ;

8/6/57

1

8/16/57

1

Present condition

Excellent (see Table IV Excellent (catheterization 5 months postop . shows cure) h .ccellent Excellent (asymptomatic working)

' Complete relief of both the pulmonary stenosis and the ventricular septa] defect has been proved by rathetrrizacion Table IV) . tcGUS1,

1959



Accomplishments of Open Heart Surgery

1 52

TABLE VI Operative Findings and Results in Three Patients with Ventricular Septal Defect Now 18 to 36 Months Postoperative Patient and Age

Operation date

T .H ., 18 yr S.S . .

Size and location of defect

Method of closure

"/12/56

1 . 5 cm ; posterior . high 6/27/57 1-it Cut ; superior

6 yr

C, J- 0 I3 in(,

4/2/57

Simple mattress sutures Simple sutures

1 . 5 cm ; beneath sep- Simple sutures tal leaflet of tricuspid valve

Complications

Result

Cerebral air embolism- - Excellent no permanent damage (working) None Good (normal weight gain) None Excellent

Complete closure of the defect has been proved by catheterization (see Table VII) . rection of One such defect is shown in Table Vll .

(6)° 59/4 40/19 (11) 124/70

(5) 36/7 26/10 (6) 136/68

12 .3 13 .1 12 .6 13 .0 12 .4 14-1 15 .8 15 .8 15 .8 15 . 9 17 .6 18 .8 93-6 3-3 0 6 .1

12 .6

symptoms, for seven years in one case and two years in the other . 'These consisted of shortness of breath, precordial (anginoid) pain, swelling of the feet and palpitation . Both had been on digitalis for more than one year and had received mercurial diuretics, and both were on a salt-free diet prior to surgery . The man's blood pressure was 165 1/40/0 mm H,q, and the woman's 150/20/0 . At surgery, in both cases, the ascending aorta was opened and under direct vision, mattress sutures were placed to obliterate the region of the noncoronary bearing cusp and one-third of the circumference of the aorta . This produced a competent hiscuspid valve in each case (Fig . 5) . Both of these patients remain improved at the present time . Clinically and hemodynamieally the evidences of aortic regurgitation are much reduced . 'lhe signs of congestive heart failure, angina pectoris, and the palpitation previously present in each case have disappeared . Aortographic evidence of complete correction in such cases is now available (Fig . 6) .

14 .6

COMMENTS

13 .7 14 . 1 14 .1 13 .6 14 .7 14 .3 19-3 19-3 94-8 5.6 0

'The late results of corrective surgery in these earl- cases clearly demonstrate that certain defects which cannot be treated adequately by the techniques of closed heart surgery, now may he relieved or even "cured" with an open technique made possible by the use of the pump oxygenator . The clinical improvement in these patients has been documented by the postoperative studies which, at least in most cases, show complete cure . It is anticipated that the results of more recent work with the open heart procedure will

PURE AORTIC INSUFFICIENCY

We now have two patients who survived more than 18 months following plication and resection of the noncoronary hearing cusp of the aortic valve . One of these patients was 37 years old, and the other 36 . Both had had severe clinical TABLE VII Pte- and Postoperative Catheterization Data in a 13-Year Old Boy (C .l.) with a Ventricular Septal Defect Operated on April 2, 1957 Prroperative Pressures (mm Hg) Right atrium Right ventricle Pulmonary artery Pulmonary venous capillary Brachial artery Oxygen contents (vol Superior vena cava Inferior vena cava Right atrium (high) Right atrium (middle) Right atrium (low) Right ventricle (apex) Right ventricle (outflow) Main pulmonary artery Right pulmonary artery Left pulmonary artery Brachial artery Brachial artery capacity Brachial artery saturation (gc) Blood flow (L/min) Shunt (right-to-left) Shunt (left-tn-right)

5

Months Postoperative

Figures in parentheses mean average pressure .

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Bailey_ Musser, and Morse

h''n; . . A, the aurtit nrb:e in a patient it ert ao rtic insufIicie,ev . 'I 'hi lend er edges are rolled :mrl shortened so that the (reps (it) not meet and tend to prulal'se into the ventricle during, diastole . B, the same valve illustratine excision of the noncoronary hearing cusp (arrow and dotted outfinr indicate the excised cusp) . C, the valve after suture of the remaining cusps together to form a competent bicuspid valve D, a linger is introduced thrnuch the valve limo helm to shnw the c " of the apertur' s i prod nerd_

Pte . 6 . Left, aortogram performed prior to surgery on June 3, 1958 on a woman with severe aortic valvular insufficiency (E .A .) . The radiopaque dye injected into the aorta through a needle inserted through the suprasternal notch (and visible at the, top) reflexes massively into the large left ventricle . Right, catheter aortography on the sane patient performed postoperatively . At the same time interval after injection of the dye (film 6), there is beginning filling of the descending thoracic aorta . '['here is no reflux into the ventricle . This patient, although operated on more recently, has so far had the clinical improvement manifested by the earlier patients . AUGUST, 1959

)53



1 54

Accomplishments

of

Open Heart

Surgerv~

as the impetus for the development of advanced techniques . The scope of the field

of

treatment, the facility and capahilit

effective

of

the

surgeon, and the safety of the patient have all shown constant improvement . REFERENCE,

Photograph of i non of the polyethylene tube c. with tapered cuff into a coronary ostium . The catheters are secured with a fine silk purse-string suture, and are rcrnoved just before the last portion of the aortic wall is closed be suture . be better than in these early cases, because of greater experience in the proper technique of . In addition, such factors as the recent operation development of a more effective neutralizer of heparin, Po]vbrene ®, L° the perfection of methods of presenting air embolism," an increased familiarity with the problertis associated with the maintenance of coronary perfusion and now, new perfusion techniques (Pig . 7), will continue to improve our results . SCIAMARF A

review of our early experiences with

35

patients who had successful open heart surgery with the aid of the pump oxygenator, and who are now alive more than 18 months after surgery, is presented . Excellent grades of improvement persist in 34 . These preliminary results have been encouraging, and have served

I . LILLLHLI, C . W ., DE.WAIA ., R . .A ., READ, R . C ., WARDEN, H . F.., and VARCO, R. L . : Direct vision intracardiac surgery in man using a simple, disposable artificial oxygcnator . Ills. fittest 29 :1, 1956 . 2 . BAILEY, C . P . and GILMAN, R . A . : Clinical experience with the l'ricdlancl-Cemcinhardt oxygcnator . Presented at Spring Meeting of the Am . Soe . for Artificial Internal Organs, Atlantic City, N . I ., April 1956 . 3 . CLARK, L . C . JR ., GOTIAN, F ., and GUPTA, V . W . : The oxygenation of blood by gas dispersion . Science 3 : 85, 1950 . 4 . DODRILt, F . : Experience with the mechanical heart . .1 . .1 .M . .4 . 154 :299, 1954 . 5 . BAILEY, C . P . : Surgery of the Hem7. Lea & Febiger, Philadelphia, 1955, pp . 55-76 . 6 . BAILEY, C . P . and LIxOFF, W. : Surgical management of aortic stenosis : An evaluation of technignes and r esults . A . d-f . A . Arch . In . .Ifed. 99 : t 859, 1957 . 7 . BLANCO, G ., OCA . C., LAOLNA, S ., NUNEZ, L . L ., ScuAFFER, .L, and BATTEN, C . P. : Autogenous lung oxygenation during cardiac bypass . A 7n . J. Cardi4 . 2 : 302, 1958 . 8 . SMrrn, R . C, B .4Ir.EY, C . P ., and GOLDBERC, H . : Aortic comntissurotomy : A physiologic evaloatim, by combated heart catheterization . J. Thoracic Suig . 34 : 815, 1957 . 9 . BAILEY, C . P ., LADY, M . H ., NEPTUNE, W. B ., WE[ LLR, R ., :ARvANI'ns . C . I . .. and KAR .ASIC, J . : Experimental and clinical attempts at correction of interventricular septal defects . Ann . Sure . 136 : 919 . 1952 . 10 . WEtss, W . A ., C LMAN, J. S ., CATENACCI, A . J ., and OsTERSEac, A . E. : Heparin neutralization with polybrene administered intravenously. l .A tE.A . 166 : 603, 1958 . 11 . Nicnnis, IT . T ., MORSE, D . P ., and HIROSE, T . : Curonarv and other air embolization occurring Surgery 43 : 236, during open cardiac surgery . 1958 .

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