CORRESPONDENCE
Ann Thorac Surg 1992;54:1244-9
1245
angiography is not necessary as a routine procedure for evaluation of the GEA in coronary revascularization.
Giuseppe Tavilla, M D Department of Cardiopulmona y Surgety Catharina Hospital, PO Box 1350 5602 ZA, Eindhouen The Netherlands References 1. Saito T, Suma H, Terada Y, Wanibuchi Y, Fukuda S, Furuta S. Availability of the in situ right gastroepiploic artery for coronary artery bypass. Ann Thorac Surg 1992;53:266-8. 2. Tavilla G, van Son JAM, Verhagen AF, Smedts F. Retrogastric versus antegastric routing and histology of the right gastroepiploic artery. Ann Thorac Surg 1992;53:105741. Fig 1. Obtained length of the right gastroepiploic artey pedicle from the abdomen (left) to over the ascending aorta (right). Our autopsy data confirm the clinical and angiographical findings of Saito and co-workers that with an in situ GEA all coronary arteries could be reached, although we believe that retrogastric routing may be more appropriate for the main right and circumflex arteries and their branches. In our clinical routine we use the retrogastric routing to revascularize the posterior and inferior surface of the heart, although this may be technically more demanding. An advantage of the retrogastric versus antegastric routing is a decreased risk of injury during later laparotomy. A disadvantage of retrogastric routing may be the more difficult control of bleeding, but ligation of the GEA branches instead of stapling can decrease this complication. Finally, we agree that from an anatomical standpoint, preoperative celiac
Reply
To the Editor:
My colleagues and I are grateful for Dr Tavilla’s favorable comments on our article [l]. In fact, in situ right gastroepiploic artery (GEA) pedicle is long enough to reach to any part of the coronary artery in the majority of patients (Fig 1). The choice of the intraabdominal route, anterior or posterior to the liver and the stomach, may depend on the surgeon’s preference. One practical point that I would like to mention is there is no big difference in the length of the pedicle required at the time of the anastomosis between the anterior and the posterior route. To get a clear view of the anastomotic site at the time of graft-coronary artery anastomosis, the heart is retracted upward and the distal part of the circumflex or the right coronary artery comes out more anteriorly. In this situation, the pedicle located in the posterior route needs additional length to reach the target site because the hole in the diaphragm was made at a very deep (posterior) site. On the other hand, the pedicle through the anterior route does not require such additional length because the hole is located more anteriorly in the diaphragm (Fig 2). Thus, the length of the pedicle required to the anastomosis is not significantly different between the anterior and the posterior route unless the anastomosis is performed at the deep site of the pericardial space, placing the heart at a nearly natural position in the posterior route technique. Again, I thank Dr Tavilla for reconfirming our findings positively.
Hisayoshi Suma, M D Department of Cardiovascular Surgery Mitsui Memorial Hospital 1-lzumicho, Kanda, Chiyodaku Tokyo 101, Japan Reference 1. Saito T, Suma H, Terada Y, Wanibuchi Y, Fukuda S, Furuta S. Availability of the in situ right gastroepiploic artery for coronary artery bypass. Ann Thorac Surg 1992;53:26&8.
Electrical Instability During Reperfusion To the Editor: Fig 2. Required length of the in situ right gastroepiploic a r t e y pedicle for the anterior and posterior route at the time of anastomosis. The target coronary artery comes u p anteriorly by retraction of the heart upward; the pedicle through the posterior route needs additional length whereas the anterior route does not.
In their recent article, Kinoshita and associates [l] presented a multivariate analysis of factors associated with ventricular fibrillation during reperfusion after cardioplegia. The phenomenon of reperfusion-induced arrhythmias is complex, and this group of investigators is to be commended for their efforts to improve our
1246
CORRESPONDENCE
understanding of it. I have one observation and one criticism that I would like to share with Dr Kinoshita and associates. The electrophysiologic recovery of the heart after cardioplegic arrest is currently not well understood. It is influenced by a large number of factors, a few of which were pointed out in Dr Kinoshita’s study [l].Others probably include the intensity of the ischemia (a term that includes other features in addition to the duration of ischemia); the presence or absence of ventricular scarring or hypertrophy; the completeness of revascularization in ischemic heart disease; and the precise conditions of reperfusion with regard to pressure, flow, and chemical composition of the reperfusate. None of these factors were included in the multivariate analysis. This observation then leads to my one criticism of the study, which is a criticism of data interpretation rather than data acquisition or analysis. Dr Kinoshita and associates conclude that the severity of cardioplegia-related ischemia-reperfusion injury is not related to the occurrence of ventricular fibrillation. I agree that their study did not find a statistically significant association between ischemia-reperfusion injury and ventricular fibrillation after cardioplegia. However, considering the many factors that probably influence reperfusion arrhythmias and this study’s relatively small and heterogenous study population, a negative finding is not totally unexpected. When interpreting their data, such absence of proof cannot be construed as proof of absence. Additional research is required to increase our understanding of electrophysiologic recovery after cardioplegia. Moreover, the notion that reperfusion arrhythmias in some way reflect the metabolic and functional recovery of the heart from ischemiareperfusion injury should not be abandoned based on this one study with negative findings.
William L. Holman, M D Department of Surge y University of Alabama at Birmingham Birmingham, A L 35294
Reference 1. Kinoshita K, Mitani A, Tsuruhara Y, Kanegae Y, Tokunaga K. Analysis of determinants of ventricular fibrillation induced by reperfusion: dissociation between electrical instability and myocardial damage. Ann Thorac Surg 1992;53:999-1005.
Pulmonary Pseudotumor To the Editor: In the May 1992 issue of The Annals of Thoracic Surge y there was an article titled ”Rounded atelectasis: a pulmonary pseudotumor” [l]. In it, initial description of pulmonary pseudotumor was credited to A. Blesovsky in 1966. I would like to remind the reader that in 1965 I reported a case of “twisted lingula” simulating a solitary pulmonary nodule [2].
Hussam A. Fadhli, M D Thoracic and Cardiovascular Clinic 3749 Lewis Dr Port Arthur, T X 77642
References 1. Szydlowski GW, Cohn HE, Steiner RM, Edie RN. Rounded atelectasis: a pulmonary pseudotumor. Ann Thorac Surg 1992;53:817-21. 2. Fadhli H, Derrick JR. Twisted lingula: a cause of a solitary pulmonary nodule. Ann Thorac Surg 1965;1:7534.
Ann Thorac Surg 1992;54:124&9
Hemolysis After Open Heart Operations To the Editor: We read with great interest the article by Okita and colleagues [l], who administered propranolol to treat postoperative hemolysis due to different causes. We wish to report our experience with pentoxifylline (Trental; Hoechst-Roussel, Somerville, NJ) in the treatment of postoperative hemolysis. This drug may be useful in patients in whom propranolol can not be employed for clinical conditions (eg, congestive heart failure, bradycardia, bronchostenosis). In these patients we used pentoxifylline as a first step and, if the patients’ clinical conditions allowed it, propranolol as a secondary step (Figs 1, 2). Pentoxifylline is a hemorrheologic drug that reduces blood viscosity by acting directly on red blood cells. It also reduces platelet aggregation and improves fibrinolytic activity. More malleable red blood cells result; therefore, mechanical resistance is increased while resistance to shearing stress is improved. A 20-year-old man with minor Pthalassemic anemia was reoperated on for failing mitral and aortic bioprostheses. Two St. Jude mechanical valves were used. One week postoperatively he started showing hemolysis-related symptoms with lactate dehydrogenase (LDH) levels up to 4,821 IU and a plasma free hemoglobin level of 90 mg/dL. Dark urine and a creatinine level of 221 pmol/L (2.5 mg/dL) were also present. The echocardiogram showed reduced ventricular contractility. We started using 400 mg of pentoxifylline three times daily. After 1 week there was a complete regression of symptoms. Lactate dehydrogenase, creatinine, and free hemoglobin levels were back to normal values. Six years after operation the patient is asymptomatic. A 50-year-old man underwent redo mitral and aortic valve replacement for failing bioprostheses. Two Medtronic-Hall prostheses were employed. Nine days postoperatively, an apical systolic murmur and clinical evidence of hemolysis (LDH, 3,980 IU; plasma free hemoglobin, 72 mg/dL) prompted a transesophageal echocardiogram. Two small mitral and aortic paravalvular leaks were detected and the ventricular contractility was normal. We started with 400 mg of pentoxifylline three times daily, which successfully reduced the hemolysis. The addition of 20 mg of propranolol twice daily completely resolved the hemolysis. Eighteen months postoperatively, the patient is in good clinical condition with no signs of hemolysis. A 50-year-old man underwent redo aortic and mitral valve
LDU
-i
7000
m-
um-
Moo1000-
OJ
7. l
PROP
. I. 2. 3.
o
.
4
. 6.
5
. 8. 9. i b i l 1 2 1 3 1 4
7
PDSxRRIllM DAVS
”
21 ’
Fig 1 . Clinical course of lactate dehydrogenase (LDH) level.
”
28
Ann Thorac Surg 1992;54:1244-9
1245
angiography is not necessary as a routine procedure for evaluation of the GEA in coronary revascularization.
Giuseppe Tavilla, M D Department of Cardiopulmona y Surgety Catharina Hospital, PO Box 1350 5602 ZA, Eindhouen The Netherlands References 1. Saito T, Suma H, Terada Y, Wanibuchi Y, Fukuda S, Furuta S. Availability of the in situ right gastroepiploic artery for coronary artery bypass. Ann Thorac Surg 1992;53:266-8. 2. Tavilla G, van Son JAM, Verhagen AF, Smedts F. Retrogastric versus antegastric routing and histology of the right gastroepiploic artery. Ann Thorac Surg 1992;53:105741. Fig 1. Obtained length of the right gastroepiploic artey pedicle from the abdomen (left) to over the ascending aorta (right). Our autopsy data confirm the clinical and angiographical findings of Saito and co-workers that with an in situ GEA all coronary arteries could be reached, although we believe that retrogastric routing may be more appropriate for the main right and circumflex arteries and their branches. In our clinical routine we use the retrogastric routing to revascularize the posterior and inferior surface of the heart, although this may be technically more demanding. An advantage of the retrogastric versus antegastric routing is a decreased risk of injury during later laparotomy. A disadvantage of retrogastric routing may be the more difficult control of bleeding, but ligation of the GEA branches instead of stapling can decrease this complication. Finally, we agree that from an anatomical standpoint, preoperative celiac
Reply
To the Editor:
My colleagues and I are grateful for Dr Tavilla’s favorable comments on our article [l]. In fact, in situ right gastroepiploic artery (GEA) pedicle is long enough to reach to any part of the coronary artery in the majority of patients (Fig 1). The choice of the intraabdominal route, anterior or posterior to the liver and the stomach, may depend on the surgeon’s preference. One practical point that I would like to mention is there is no big difference in the length of the pedicle required at the time of the anastomosis between the anterior and the posterior route. To get a clear view of the anastomotic site at the time of graft-coronary artery anastomosis, the heart is retracted upward and the distal part of the circumflex or the right coronary artery comes out more anteriorly. In this situation, the pedicle located in the posterior route needs additional length to reach the target site because the hole in the diaphragm was made at a very deep (posterior) site. On the other hand, the pedicle through the anterior route does not require such additional length because the hole is located more anteriorly in the diaphragm (Fig 2). Thus, the length of the pedicle required to the anastomosis is not significantly different between the anterior and the posterior route unless the anastomosis is performed at the deep site of the pericardial space, placing the heart at a nearly natural position in the posterior route technique. Again, I thank Dr Tavilla for reconfirming our findings positively.
Hisayoshi Suma, M D Department of Cardiovascular Surgery Mitsui Memorial Hospital 1-lzumicho, Kanda, Chiyodaku Tokyo 101, Japan Reference 1. Saito T, Suma H, Terada Y, Wanibuchi Y, Fukuda S, Furuta S. Availability of the in situ right gastroepiploic artery for coronary artery bypass. Ann Thorac Surg 1992;53:26&8.
Electrical Instability During Reperfusion To the Editor: Fig 2. Required length of the in situ right gastroepiploic a r t e y pedicle for the anterior and posterior route at the time of anastomosis. The target coronary artery comes u p anteriorly by retraction of the heart upward; the pedicle through the posterior route needs additional length whereas the anterior route does not.
In their recent article, Kinoshita and associates [l] presented a multivariate analysis of factors associated with ventricular fibrillation during reperfusion after cardioplegia. The phenomenon of reperfusion-induced arrhythmias is complex, and this group of investigators is to be commended for their efforts to improve our
1246
CORRESPONDENCE
understanding of it. I have one observation and one criticism that I would like to share with Dr Kinoshita and associates. The electrophysiologic recovery of the heart after cardioplegic arrest is currently not well understood. It is influenced by a large number of factors, a few of which were pointed out in Dr Kinoshita’s study [l].Others probably include the intensity of the ischemia (a term that includes other features in addition to the duration of ischemia); the presence or absence of ventricular scarring or hypertrophy; the completeness of revascularization in ischemic heart disease; and the precise conditions of reperfusion with regard to pressure, flow, and chemical composition of the reperfusate. None of these factors were included in the multivariate analysis. This observation then leads to my one criticism of the study, which is a criticism of data interpretation rather than data acquisition or analysis. Dr Kinoshita and associates conclude that the severity of cardioplegia-related ischemia-reperfusion injury is not related to the occurrence of ventricular fibrillation. I agree that their study did not find a statistically significant association between ischemia-reperfusion injury and ventricular fibrillation after cardioplegia. However, considering the many factors that probably influence reperfusion arrhythmias and this study’s relatively small and heterogenous study population, a negative finding is not totally unexpected. When interpreting their data, such absence of proof cannot be construed as proof of absence. Additional research is required to increase our understanding of electrophysiologic recovery after cardioplegia. Moreover, the notion that reperfusion arrhythmias in some way reflect the metabolic and functional recovery of the heart from ischemiareperfusion injury should not be abandoned based on this one study with negative findings.
William L. Holman, M D Department of Surge y University of Alabama at Birmingham Birmingham, A L 35294
Reference 1. Kinoshita K, Mitani A, Tsuruhara Y, Kanegae Y, Tokunaga K. Analysis of determinants of ventricular fibrillation induced by reperfusion: dissociation between electrical instability and myocardial damage. Ann Thorac Surg 1992;53:999-1005.
Pulmonary Pseudotumor To the Editor: In the May 1992 issue of The Annals of Thoracic Surge y there was an article titled ”Rounded atelectasis: a pulmonary pseudotumor” [l]. In it, initial description of pulmonary pseudotumor was credited to A. Blesovsky in 1966. I would like to remind the reader that in 1965 I reported a case of “twisted lingula” simulating a solitary pulmonary nodule [2].
Hussam A. Fadhli, M D Thoracic and Cardiovascular Clinic 3749 Lewis Dr Port Arthur, T X 77642
References 1. Szydlowski GW, Cohn HE, Steiner RM, Edie RN. Rounded atelectasis: a pulmonary pseudotumor. Ann Thorac Surg 1992;53:817-21. 2. Fadhli H, Derrick JR. Twisted lingula: a cause of a solitary pulmonary nodule. Ann Thorac Surg 1965;1:7534.
Ann Thorac Surg 1992;54:124&9
Hemolysis After Open Heart Operations To the Editor: We read with great interest the article by Okita and colleagues [l], who administered propranolol to treat postoperative hemolysis due to different causes. We wish to report our experience with pentoxifylline (Trental; Hoechst-Roussel, Somerville, NJ) in the treatment of postoperative hemolysis. This drug may be useful in patients in whom propranolol can not be employed for clinical conditions (eg, congestive heart failure, bradycardia, bronchostenosis). In these patients we used pentoxifylline as a first step and, if the patients’ clinical conditions allowed it, propranolol as a secondary step (Figs 1, 2). Pentoxifylline is a hemorrheologic drug that reduces blood viscosity by acting directly on red blood cells. It also reduces platelet aggregation and improves fibrinolytic activity. More malleable red blood cells result; therefore, mechanical resistance is increased while resistance to shearing stress is improved. A 20-year-old man with minor Pthalassemic anemia was reoperated on for failing mitral and aortic bioprostheses. Two St. Jude mechanical valves were used. One week postoperatively he started showing hemolysis-related symptoms with lactate dehydrogenase (LDH) levels up to 4,821 IU and a plasma free hemoglobin level of 90 mg/dL. Dark urine and a creatinine level of 221 pmol/L (2.5 mg/dL) were also present. The echocardiogram showed reduced ventricular contractility. We started using 400 mg of pentoxifylline three times daily. After 1 week there was a complete regression of symptoms. Lactate dehydrogenase, creatinine, and free hemoglobin levels were back to normal values. Six years after operation the patient is asymptomatic. A 50-year-old man underwent redo mitral and aortic valve replacement for failing bioprostheses. Two Medtronic-Hall prostheses were employed. Nine days postoperatively, an apical systolic murmur and clinical evidence of hemolysis (LDH, 3,980 IU; plasma free hemoglobin, 72 mg/dL) prompted a transesophageal echocardiogram. Two small mitral and aortic paravalvular leaks were detected and the ventricular contractility was normal. We started with 400 mg of pentoxifylline three times daily, which successfully reduced the hemolysis. The addition of 20 mg of propranolol twice daily completely resolved the hemolysis. Eighteen months postoperatively, the patient is in good clinical condition with no signs of hemolysis. A 50-year-old man underwent redo aortic and mitral valve
LDU
-i
7000
m-
um-
Moo1000-
OJ
7. l
PROP
. I. 2. 3.
o
.
4
. 6.
5
. 8. 9. i b i l 1 2 1 3 1 4
7
PDSxRRIllM DAVS
”
21 ’
Fig 1 . Clinical course of lactate dehydrogenase (LDH) level.
”
28
