Letters to the Editor
FIGURE 1. The needlescope shows 3-point fixation of the bar with No. 5 Ethibond suture by using an endo-needle holder.
Jin Yong Jeong, MDa Jongho Lee, MDb a Department of Thoracic and Cardiovascular Surgery Incheon St. Mary’s Hospital b Daejeon St. Mary’s Hospital College of Medicine The Catholic University of Korea Seoul, South Korea References 1. Bond SJ, Nagaraj HS. Correction of pectus excavatum through a minimally invasive approach with subxyphoid incision and 3-point fixation. J Thorac Cardiovasc Surg. 2013;146:1294-6. 2. Park HJ, Jeong JY, Jo WM, Shin JS, Lee IS, Kim KT, et al. Minimally invasive repair of pectus excavatum: a novel morphology-tailored, patientspecific approach. J Thorac Cardiovasc Surg. 2010;139:379-86. 3. Schier F, Bahr M, Klobe E. The vacuum chest wall lifter: an innovative, nonsurgical addition to the management of pectus excavatum. J Pediatr Surg. 2005;40:496-500. 4. Hebra A, Gauderer MW, Tagge EP, Adamson WT, Othersen HB Jr. A simple technique for preventing bar displacement with the Nuss repair of pectus excavatum. J Pediatr Surg. 2001;36:1266-8. 5. Del Frari B, Schwabegger AH. How to avoid pectus bar displacement in the MIRPE or MOVARPE technique: results of 12 years’ experience. Ann Plast Surg. 2014;72:75-9.
http://dx.doi.org/10.1016/ j.jtcvs.2013.12.070 1722
CORONARY-CORONARY RADIAL ARTERY CONDUIT TO SOLVE THE PROBLEM OF CORONARY ARTERY ANEURYSMS To the Editor: We have read with great interest the recently published article by Ucak and colleagues1 discussing surgical treatment of coronary artery aneurysms (CAAs). We do agree that a surgical approach to solve the problem of CAAs is the most reasonable modality of treatment, because of the possibility of rupture, thrombosis, and consequent distal coronary embolization. Although the choice of surgical technique is still controversial (resection and plication of the aneurysm with eventual venous patch plasty,2,3 proximal and distal ligation with distal coronary bypass,2,3 graft interposition,4 and so on), every new technique is desirable and welcomed. Although it was only a single case report by the same group of authors,3 they concluded that resection of a CAA in the left anterior descending (LAD) coronary artery and an
The Journal of Thoracic and Cardiovascular Surgery c May 2014
end-to-end coronary artery anastomosis technique could be applied with confidence and that it was the most feasible procedure among all the techniques.1 We speculate that there is a weak point in the suggested technique, which we would like to be considered. Although epicardial tissue on both sides of the LAD was approximated, mobilization and strain at both ends of the resected LAD can surely produce unwanted tension and traction on, or even tearing or disruption of an end-to-end LAD anastomosis, particularly with a lower heart rate (distension during diastole). We would also hesitate to use the internal thoracic artery as an interposed conduit because of the possible mismatch in diameter (diameter of the resected LAD was 4 mm at the proximal and the distal level).3 To the best of our knowledge, only Firstenberg and colleagues4 have reported interposition of a reverse saphenous vein graft to reconstruct the right coronary artery bed after resection of a giant CAA. Although the authors1,3 have hesitated to use a reverse saphenous vein graft, because of possible decreased patency, we would like to suggest the radial artery as the conduit of choice in such circumstances. A radial artery graft has excellent long-term patency, is adapted to higher arterial pressures, has a thick muscular wall, and the caliber is large enough (especially in its proximal part) to match most of the diameters of the coronary arteries (even a diameter of 4 mm).5 We have used a radial artery segment as a coronary-coronary graft for a single distal lesion of the large LAD coronary artery (both anastomoses were performed in an end-to-side fashion) running well over the cardiac apex, with an excellent postoperative result.5 We do believe that coronary-coronary bypass with a radial artery (with end-to-end anastomoses) might be the procedure
Letters to the Editor
of choice for reconstruction of the coronary artery bed after resection of a CAA. Dusko Nezic, MD, PhD, FETCS Slobodan Micovic, MD Department of Cardiac Surgery ‘‘Dedinje’’ Cardiovascular Institute Belgrade, Serbia References 1. Ucak A, Inangil G, Selcuk A, Temizkan V. Different surgical approaches in the coronary artery aneurysms. J Thorac Cardiovasc Surg. 2014;147:1434-50. 2. Li D, Wu Q, Sun L, Song Y, Wang W, Pan S, et al. Surgical treatment of giant coronary artery aneurysm. J Thorac Cardiovasc Surg. 2005;130: 817-21. 3. Inan K, Ucak A, Onan B, Hastaoglu O, Temizkan V, Yilmaz A. Combined surgical approach to multiple giant coronary artery aneurysms. Heart Surg Forum. 2009;12:E294-6. 4. Firstenberg M, Azoury F, Lytle B, Thomas J. Interposition vein graft for giant coronary aneurysm repair. Ann Thorac Surg. 2000;70:1397-8. 5. Nezic D, Cirkovic M, Knezevic A, Mangovski LA. Coronary-coronary radial artery graft for single, distal LAD lesion. Ann Thorac Surg. 2004;78: 1078-80.
http://dx.doi.org/10.1016/ j.jtcvs.2014.01.024
Reply to the Editor: We thank Drs Nezic and Cirkovic for their comments and contributions to our article about surgical treatment options for coronary artery aneurysm. We think that they are correct in pointing out most of the issues that they stated. As mentioned in our previous article,1 resection of the aneurysmal segment of the coronary artery and end-to-end anastomosis may cause tension on the anastomosis side. This undesirable tension can lead to fatal complications. As we stated in the previous report,1 to avoid this situation the coronary artery was mobilized at both ends, and we then approximated the epicardial tissue on both sides of the left anterior descending coronary artery to avoid any unexpected tension on the anastomoses. We believe that it is reliable approach for aneurysm cases because of both the advantage of end-to-end
anastomosis with native tissue and reducing graft mismatch with the dilated coronary artery. On the other hand this method, is not very useful for sequential coronary artery aneurysms cases or if there is not enough intact coronary artery tissue after resection to get closer. Autografts (left internal thoracic artery, radial artery, saphenous vein) should be carefully chosen to avoid diameter mismatch in coronary artery aneurysm surgery. Vascular structures adjacent to the aneurysmal segment could lack of normal vascular quality and may have become enlarged and tortuous. As in our case, the use of internal thoracic artery or radial artery in interpositional revascularization techniques for dilated coronary artery may lead to diameter mismatch. If the proximal part of the radial artery were to be used as a graft, the diameter mismatch problem would be partially eliminated. Otherwise, patency time would be short because of the graft mismatch. In addition, it should be remembered that radial artery spasm can easily be provoked during manipulation. Finally, use of the radial artery as the interposed graft for aneurysmal coronary artery revascularization has not been sufficiently demonstrated in the literature. In a case presented by Nezic and colleagues,2 a radial artery graft was used as intercoronary end-to-side bypass for stenotic the distal left anterior descending lesions. They used intercoronary anastomosis techniques for occlusion of the left anterior descending coronary artery. Their case is not coronary aneurysm, and their native coronary arteries were more appropriately matched to the radial artery in diameter. We therefore think that a radial artery graft should not be the first choice for interposition in a dilated native coronary segment after resection of coronary artery aneurysm. As a result, in selected cases of short-segment, single coronary artery aneurysm in the setting of a postresectional dilated coronary
artery, we believe that native coronary end-to-end anastomosis technique would be useful. Alper Ucak, MDa Gokhan Inangil, MDb Arif Selcuk, MDa Veysel Temizkan, MDa a Department of Cardiovascular Surgery b Departments of Anesthesiology and Reanimation GATA Haydarpasa Training Hospital Istanbul, Turkey References 1. Ucak A, Onan B, Hastaoglu O, Temizkan V, Yilmaz AT. Combined surgical approach to multiplegiant coronary artery aneurysms. Heart Surg Forum. 2009;12:E294-6. 2. Nezic DG, Cirkovic MV, Knezevic AM, Mangovski LA. Coronary-coronary radial artery graft for single, distal LAD lesion. Ann Thorac Surg. 2004;78:1078-80.
http://dx.doi.org/10.1016/ j.jtcvs.2014.02.018
Reply to the Editor: We appreciate the comment from Abud and colleagues1 regarding our study investigating the influence of left ventricular function on the development of systolic anterior motion (SAM) after mitral valve repair. Their first comment refers to the effect of annuloplasty on the development of SAM. It is believed that excess annular reduction predisposes the mitral valve to the development of SAM. Although yet to be demonstrated, any reduction in annular circumference may reduce the mitralaortic angle and consequently reduce the distance between mitral valve coaptation and the left ventricular outflow tract. Dagum and colleagues2 demonstrated in their animal study that ring annuloplasty, especially using an artificial ring with some rigidity, displaced the anterior and posterior leaflet toward the left ventricular outflow tract. Kahn and colleagues3 presented a case report suggesting that undersizing of a mitral valve annulus could be the cause of
The Journal of Thoracic and Cardiovascular Surgery c Volume 147, Number 5
1723
FIGURE 1. The needlescope shows 3-point fixation of the bar with No. 5 Ethibond suture by using an endo-needle holder.
Jin Yong Jeong, MDa Jongho Lee, MDb a Department of Thoracic and Cardiovascular Surgery Incheon St. Mary’s Hospital b Daejeon St. Mary’s Hospital College of Medicine The Catholic University of Korea Seoul, South Korea References 1. Bond SJ, Nagaraj HS. Correction of pectus excavatum through a minimally invasive approach with subxyphoid incision and 3-point fixation. J Thorac Cardiovasc Surg. 2013;146:1294-6. 2. Park HJ, Jeong JY, Jo WM, Shin JS, Lee IS, Kim KT, et al. Minimally invasive repair of pectus excavatum: a novel morphology-tailored, patientspecific approach. J Thorac Cardiovasc Surg. 2010;139:379-86. 3. Schier F, Bahr M, Klobe E. The vacuum chest wall lifter: an innovative, nonsurgical addition to the management of pectus excavatum. J Pediatr Surg. 2005;40:496-500. 4. Hebra A, Gauderer MW, Tagge EP, Adamson WT, Othersen HB Jr. A simple technique for preventing bar displacement with the Nuss repair of pectus excavatum. J Pediatr Surg. 2001;36:1266-8. 5. Del Frari B, Schwabegger AH. How to avoid pectus bar displacement in the MIRPE or MOVARPE technique: results of 12 years’ experience. Ann Plast Surg. 2014;72:75-9.
http://dx.doi.org/10.1016/ j.jtcvs.2013.12.070 1722
CORONARY-CORONARY RADIAL ARTERY CONDUIT TO SOLVE THE PROBLEM OF CORONARY ARTERY ANEURYSMS To the Editor: We have read with great interest the recently published article by Ucak and colleagues1 discussing surgical treatment of coronary artery aneurysms (CAAs). We do agree that a surgical approach to solve the problem of CAAs is the most reasonable modality of treatment, because of the possibility of rupture, thrombosis, and consequent distal coronary embolization. Although the choice of surgical technique is still controversial (resection and plication of the aneurysm with eventual venous patch plasty,2,3 proximal and distal ligation with distal coronary bypass,2,3 graft interposition,4 and so on), every new technique is desirable and welcomed. Although it was only a single case report by the same group of authors,3 they concluded that resection of a CAA in the left anterior descending (LAD) coronary artery and an
The Journal of Thoracic and Cardiovascular Surgery c May 2014
end-to-end coronary artery anastomosis technique could be applied with confidence and that it was the most feasible procedure among all the techniques.1 We speculate that there is a weak point in the suggested technique, which we would like to be considered. Although epicardial tissue on both sides of the LAD was approximated, mobilization and strain at both ends of the resected LAD can surely produce unwanted tension and traction on, or even tearing or disruption of an end-to-end LAD anastomosis, particularly with a lower heart rate (distension during diastole). We would also hesitate to use the internal thoracic artery as an interposed conduit because of the possible mismatch in diameter (diameter of the resected LAD was 4 mm at the proximal and the distal level).3 To the best of our knowledge, only Firstenberg and colleagues4 have reported interposition of a reverse saphenous vein graft to reconstruct the right coronary artery bed after resection of a giant CAA. Although the authors1,3 have hesitated to use a reverse saphenous vein graft, because of possible decreased patency, we would like to suggest the radial artery as the conduit of choice in such circumstances. A radial artery graft has excellent long-term patency, is adapted to higher arterial pressures, has a thick muscular wall, and the caliber is large enough (especially in its proximal part) to match most of the diameters of the coronary arteries (even a diameter of 4 mm).5 We have used a radial artery segment as a coronary-coronary graft for a single distal lesion of the large LAD coronary artery (both anastomoses were performed in an end-to-side fashion) running well over the cardiac apex, with an excellent postoperative result.5 We do believe that coronary-coronary bypass with a radial artery (with end-to-end anastomoses) might be the procedure
Letters to the Editor
of choice for reconstruction of the coronary artery bed after resection of a CAA. Dusko Nezic, MD, PhD, FETCS Slobodan Micovic, MD Department of Cardiac Surgery ‘‘Dedinje’’ Cardiovascular Institute Belgrade, Serbia References 1. Ucak A, Inangil G, Selcuk A, Temizkan V. Different surgical approaches in the coronary artery aneurysms. J Thorac Cardiovasc Surg. 2014;147:1434-50. 2. Li D, Wu Q, Sun L, Song Y, Wang W, Pan S, et al. Surgical treatment of giant coronary artery aneurysm. J Thorac Cardiovasc Surg. 2005;130: 817-21. 3. Inan K, Ucak A, Onan B, Hastaoglu O, Temizkan V, Yilmaz A. Combined surgical approach to multiple giant coronary artery aneurysms. Heart Surg Forum. 2009;12:E294-6. 4. Firstenberg M, Azoury F, Lytle B, Thomas J. Interposition vein graft for giant coronary aneurysm repair. Ann Thorac Surg. 2000;70:1397-8. 5. Nezic D, Cirkovic M, Knezevic A, Mangovski LA. Coronary-coronary radial artery graft for single, distal LAD lesion. Ann Thorac Surg. 2004;78: 1078-80.
http://dx.doi.org/10.1016/ j.jtcvs.2014.01.024
Reply to the Editor: We thank Drs Nezic and Cirkovic for their comments and contributions to our article about surgical treatment options for coronary artery aneurysm. We think that they are correct in pointing out most of the issues that they stated. As mentioned in our previous article,1 resection of the aneurysmal segment of the coronary artery and end-to-end anastomosis may cause tension on the anastomosis side. This undesirable tension can lead to fatal complications. As we stated in the previous report,1 to avoid this situation the coronary artery was mobilized at both ends, and we then approximated the epicardial tissue on both sides of the left anterior descending coronary artery to avoid any unexpected tension on the anastomoses. We believe that it is reliable approach for aneurysm cases because of both the advantage of end-to-end
anastomosis with native tissue and reducing graft mismatch with the dilated coronary artery. On the other hand this method, is not very useful for sequential coronary artery aneurysms cases or if there is not enough intact coronary artery tissue after resection to get closer. Autografts (left internal thoracic artery, radial artery, saphenous vein) should be carefully chosen to avoid diameter mismatch in coronary artery aneurysm surgery. Vascular structures adjacent to the aneurysmal segment could lack of normal vascular quality and may have become enlarged and tortuous. As in our case, the use of internal thoracic artery or radial artery in interpositional revascularization techniques for dilated coronary artery may lead to diameter mismatch. If the proximal part of the radial artery were to be used as a graft, the diameter mismatch problem would be partially eliminated. Otherwise, patency time would be short because of the graft mismatch. In addition, it should be remembered that radial artery spasm can easily be provoked during manipulation. Finally, use of the radial artery as the interposed graft for aneurysmal coronary artery revascularization has not been sufficiently demonstrated in the literature. In a case presented by Nezic and colleagues,2 a radial artery graft was used as intercoronary end-to-side bypass for stenotic the distal left anterior descending lesions. They used intercoronary anastomosis techniques for occlusion of the left anterior descending coronary artery. Their case is not coronary aneurysm, and their native coronary arteries were more appropriately matched to the radial artery in diameter. We therefore think that a radial artery graft should not be the first choice for interposition in a dilated native coronary segment after resection of coronary artery aneurysm. As a result, in selected cases of short-segment, single coronary artery aneurysm in the setting of a postresectional dilated coronary
artery, we believe that native coronary end-to-end anastomosis technique would be useful. Alper Ucak, MDa Gokhan Inangil, MDb Arif Selcuk, MDa Veysel Temizkan, MDa a Department of Cardiovascular Surgery b Departments of Anesthesiology and Reanimation GATA Haydarpasa Training Hospital Istanbul, Turkey References 1. Ucak A, Onan B, Hastaoglu O, Temizkan V, Yilmaz AT. Combined surgical approach to multiplegiant coronary artery aneurysms. Heart Surg Forum. 2009;12:E294-6. 2. Nezic DG, Cirkovic MV, Knezevic AM, Mangovski LA. Coronary-coronary radial artery graft for single, distal LAD lesion. Ann Thorac Surg. 2004;78:1078-80.
http://dx.doi.org/10.1016/ j.jtcvs.2014.02.018
Reply to the Editor: We appreciate the comment from Abud and colleagues1 regarding our study investigating the influence of left ventricular function on the development of systolic anterior motion (SAM) after mitral valve repair. Their first comment refers to the effect of annuloplasty on the development of SAM. It is believed that excess annular reduction predisposes the mitral valve to the development of SAM. Although yet to be demonstrated, any reduction in annular circumference may reduce the mitralaortic angle and consequently reduce the distance between mitral valve coaptation and the left ventricular outflow tract. Dagum and colleagues2 demonstrated in their animal study that ring annuloplasty, especially using an artificial ring with some rigidity, displaced the anterior and posterior leaflet toward the left ventricular outflow tract. Kahn and colleagues3 presented a case report suggesting that undersizing of a mitral valve annulus could be the cause of
The Journal of Thoracic and Cardiovascular Surgery c Volume 147, Number 5
1723
