Ann Thorac Surg 1990;49:166-70
A
CORRESPONDENCE
B
169
C
Fig 1. ( A ) The gastroepiploic a r t e y (arrows) anastomosed to the circumflex a r t e y appears stringlike. ( B ) A closer view. (C) The gastroepiploic artery enlarged after nitroglycerin injection. the spasm only in the free GEA graft, I would like to show that it can occur in the in situ graft. The patient was a 56-year-old man in whom the right GEA was anastomosed to the circumflex artery. The diagonal and the anterior descending coronary arteries were bypassed with the sequential left internal mammary artery graft, and the right ventricular branch and the posterior descending coronary artery were bypassed with a sequential saphenous vein graft. After uneventful recovery, angiography was performed 1 month postoperatively. Although the other two grafts were widely patent, the GEA seemed to be a string (Figs lA, 1B). After nitroglycerin injection from a catheter located at the orifice of the gastroduodenal artery, the GEA enlarged (Fig 1C). Although catheter or guidewire stimulation was thought to be a cause of spasm, I have not experienced such a vigorous spasm in angiograms of the internal mammary artery. Therefore, I agree with the opinion of Mills and Everson that the GEA is prone to vasospasm. As a matter of fact, I have frequently observed surprisingly high free flow in the GEA after intraluminal papaverine injection at the time of operation even though its free flow was disappointingly low before papaverine injection. Mills and Bringaze [2] have described the efficacy of intraoperative intraluminal papaverine injection for the internal mammary artery graft; this method is extremely useful for the GEA graft also. 1 routinely have used it.
Hisayoshi Suma, M D Mitsui Memorial Hospital 1 Kanda Izumicho Chiyodaku Tokyo 101, lapan References 1. Mills NL, Everson CT. Right gastroepiploic artery: a third arterial conduit for coronary artery bypass. Ann Thorac Surg 1989;47:70fj-11. 2. Mills NL, Bringaze WL 111. Preparation of the internal mammary artery graft. Which is the best method? J Thorac Cardiovasc Surg 1989;98:7%9.
Repair of Ductus Diverticulum Aneurysm To the Editor: I congratulate Baisden and co-workers [ l ] on the repair of a ductus diverticulum aneurysm using hypothermic circulatory
arrest. They note in their report that their particular patient represented the 27th reported case of such an aneurysm repaired in an adult, and I would like to add the 28th. In 1987 a 52-year-old man was noted to have an abnormality on his chest roentgenogram. Work-up revealed the ductus diverticulum aneurysm. Repair of the aneurysm was done using a median sternotomy and hypothermic circulatory arrest and a patch repair of the aneurysm using Dacron. We were fortunate that the phrenic and recurrent laryngeal nerves were not injured and the patient made a good recovery. Repair of this type of aneurysm is easily accomplished with hypothermic circulatory arrest. Our experience would reinforce that of Baisden and co-workers using this beneficial technique in select cases.
Michael K . Wood, M D Peninsula Hospital Burlingame, C A 94010 Reference 1. Baisden C, Sand M, Keith S, Jackson J, Mullen P, Brown W. Ductus diverticulum aneurysm and coronary stenosis: repair using circulatory arrest. Ann Thorac Surg 1989;48:432-3.
Importance of Precordial Electrocardiogram Monitoring During Coronary Artery Bypass Grafting To the Editor: Routine precordial electrocardiogram (ECG) monitoring during coronary artery bypass grafting simultaneously with use of standard leads helps early detection of anterior myocardial injury. Until recently we used to monitor only standard ECG leads during coronary artery bypass grafting. This gives information only about the inferior wall of the myocardium. For early detection and treatment of anterior injury we now monitor one precordial ECG lead during the bypass procedure. The patient is placed on the table with routine monitoring lines. After anesthesia, preparation, and draping, one precordial sterile ECG pad with electrode is placed over left anterior chest wall and connected to the ECG monitor together with standard leads. This precordial ECG lead stays under the V-drape or towel. Precordial ECG monitoring during coronary artery bypass grafting gives valuable information about the anterior part of the myocardium.
170
CORRESPONDENCE
It is easy to apply and keep in place, and the only requirements are a sterile ECG pad and the lead. Simultaneous monitoring of standard leads and precordial lead covers the anterior and posterior walls of the myocardium. It helps early detection of compromised anterior myocardium and treatment while the patient is still on the operating table, and prevents late diagnosis of anterior wall injury in the cardiovascular intensive care unit.
Zlhan Bahadir, M D Edward B. Diethrich, M D Arizona Heart Znstitute PO Box 10,000 Phoenix, AZ 85064
Resection of Atriocaval Adrenal Carcinoma To the Editor: 1 read the case report by Shahian and associates [l] with interest because my colleagues and I have had some experience with technique of resection of atriocaval adrenal carcinoma using hypothermic circulatory arrest 121. Shahian and associates correctly emphasize the safety and excellent surgical exposure when one employs the technique of profound hypothermia and circulatory arrest. In addition, we have been impressed with the smooth postoperative convalescence and tumor-free survival that is exhibited by patients undergoing this procedure. Shahian and associates may be interested to note that we previously reported resection of an adrenocortical carcinoma in a lV2-year-old child using the same surgical principles (31. This patient had no tumor recurrence on early follow-up. In my opinion, cardiothoracic surgeons owe a debt of gratitude to Drs Reitz and Marshall for their pioneering articles that so clearly elucidated the indications and technique for employing profound hypothermia and circulatory arrest 14, 51.
Terrill E . Theman, M D
Ann Thorac Surg 1990;49: 16670
References 1. Shahian DM, Nieh PT, Libertino JA. Resection of atnocaval adrenal carcinoma using hypothermic circulatory arrest. Ann Thorac Surg 1989;48:421-2. 2. Theman TE, Stauffer RA, Lennert JB, Saunders CD. Profound hypothermia and circulatory arrest in excision of renal cell carcinoma invading the vena cava. Can J Surg 1988;31:15%5. 3. Theman TE, Williams WG, Simpson JS, et al. Tumor invasion of the upper inferior vena cava: the use of profound hypothermia on circulation arrest as a surgical adjunct. J Pediatr Surg 1978;13:3314. 4. Marshall FF, Reitz BA, Diamond DA. A new technique for management of renal cell carcinoma involving the right atrium: hypothermia and cardiac arrest. J Urol 1984;131:103-7. 5. Marshall FF, Reitz BA. Supradiaphragmatic renal cell carcinoma tumor thrombus: indications for vena caval reconstruction with pericardium. J Urol 1985;133:26&8.
Valvular Xenograft to Bioprosthesis To the Editor: I enjoyed the September supplement to The Annals, as well as participation in the program that produced the papers contained therein. I give congratulations to the editors and organizers of a very special meeting. In the interest of historical accuracy 1 must correct an item in Alain Carpentier’s paper 111. I was no longer at Edwards Laboratories when he visited in 1968, having already started Hancock Laboratories. Animal implants were underway by that time and I did not have the opportunity of meeting Alain until some 2 years later at a lecture that he presented at Mt. Sinai Hospital in New York City, hosted by Bob Litwak. Our first formalin-fixed valve was implanted clinically in October 1968. Following experimental work our first glutaraldehyde-fixed valves were clinically implanted in April 1970. Warren D. Hancock Hancock jaffe Laboratories 2 Jenner St, Suite 100 Itvine, C A 92718
Section of Cardiothoracic Surgery
Reference
St. Luke’s Hospital
1. Carpentier A. From valvular xenograft to valvular bioprosthesis: 19651970. Ann Thorac Surg 1989;48:S724.
Bethlehem, PA 18015
A
CORRESPONDENCE
B
169
C
Fig 1. ( A ) The gastroepiploic a r t e y (arrows) anastomosed to the circumflex a r t e y appears stringlike. ( B ) A closer view. (C) The gastroepiploic artery enlarged after nitroglycerin injection. the spasm only in the free GEA graft, I would like to show that it can occur in the in situ graft. The patient was a 56-year-old man in whom the right GEA was anastomosed to the circumflex artery. The diagonal and the anterior descending coronary arteries were bypassed with the sequential left internal mammary artery graft, and the right ventricular branch and the posterior descending coronary artery were bypassed with a sequential saphenous vein graft. After uneventful recovery, angiography was performed 1 month postoperatively. Although the other two grafts were widely patent, the GEA seemed to be a string (Figs lA, 1B). After nitroglycerin injection from a catheter located at the orifice of the gastroduodenal artery, the GEA enlarged (Fig 1C). Although catheter or guidewire stimulation was thought to be a cause of spasm, I have not experienced such a vigorous spasm in angiograms of the internal mammary artery. Therefore, I agree with the opinion of Mills and Everson that the GEA is prone to vasospasm. As a matter of fact, I have frequently observed surprisingly high free flow in the GEA after intraluminal papaverine injection at the time of operation even though its free flow was disappointingly low before papaverine injection. Mills and Bringaze [2] have described the efficacy of intraoperative intraluminal papaverine injection for the internal mammary artery graft; this method is extremely useful for the GEA graft also. 1 routinely have used it.
Hisayoshi Suma, M D Mitsui Memorial Hospital 1 Kanda Izumicho Chiyodaku Tokyo 101, lapan References 1. Mills NL, Everson CT. Right gastroepiploic artery: a third arterial conduit for coronary artery bypass. Ann Thorac Surg 1989;47:70fj-11. 2. Mills NL, Bringaze WL 111. Preparation of the internal mammary artery graft. Which is the best method? J Thorac Cardiovasc Surg 1989;98:7%9.
Repair of Ductus Diverticulum Aneurysm To the Editor: I congratulate Baisden and co-workers [ l ] on the repair of a ductus diverticulum aneurysm using hypothermic circulatory
arrest. They note in their report that their particular patient represented the 27th reported case of such an aneurysm repaired in an adult, and I would like to add the 28th. In 1987 a 52-year-old man was noted to have an abnormality on his chest roentgenogram. Work-up revealed the ductus diverticulum aneurysm. Repair of the aneurysm was done using a median sternotomy and hypothermic circulatory arrest and a patch repair of the aneurysm using Dacron. We were fortunate that the phrenic and recurrent laryngeal nerves were not injured and the patient made a good recovery. Repair of this type of aneurysm is easily accomplished with hypothermic circulatory arrest. Our experience would reinforce that of Baisden and co-workers using this beneficial technique in select cases.
Michael K . Wood, M D Peninsula Hospital Burlingame, C A 94010 Reference 1. Baisden C, Sand M, Keith S, Jackson J, Mullen P, Brown W. Ductus diverticulum aneurysm and coronary stenosis: repair using circulatory arrest. Ann Thorac Surg 1989;48:432-3.
Importance of Precordial Electrocardiogram Monitoring During Coronary Artery Bypass Grafting To the Editor: Routine precordial electrocardiogram (ECG) monitoring during coronary artery bypass grafting simultaneously with use of standard leads helps early detection of anterior myocardial injury. Until recently we used to monitor only standard ECG leads during coronary artery bypass grafting. This gives information only about the inferior wall of the myocardium. For early detection and treatment of anterior injury we now monitor one precordial ECG lead during the bypass procedure. The patient is placed on the table with routine monitoring lines. After anesthesia, preparation, and draping, one precordial sterile ECG pad with electrode is placed over left anterior chest wall and connected to the ECG monitor together with standard leads. This precordial ECG lead stays under the V-drape or towel. Precordial ECG monitoring during coronary artery bypass grafting gives valuable information about the anterior part of the myocardium.
170
CORRESPONDENCE
It is easy to apply and keep in place, and the only requirements are a sterile ECG pad and the lead. Simultaneous monitoring of standard leads and precordial lead covers the anterior and posterior walls of the myocardium. It helps early detection of compromised anterior myocardium and treatment while the patient is still on the operating table, and prevents late diagnosis of anterior wall injury in the cardiovascular intensive care unit.
Zlhan Bahadir, M D Edward B. Diethrich, M D Arizona Heart Znstitute PO Box 10,000 Phoenix, AZ 85064
Resection of Atriocaval Adrenal Carcinoma To the Editor: 1 read the case report by Shahian and associates [l] with interest because my colleagues and I have had some experience with technique of resection of atriocaval adrenal carcinoma using hypothermic circulatory arrest 121. Shahian and associates correctly emphasize the safety and excellent surgical exposure when one employs the technique of profound hypothermia and circulatory arrest. In addition, we have been impressed with the smooth postoperative convalescence and tumor-free survival that is exhibited by patients undergoing this procedure. Shahian and associates may be interested to note that we previously reported resection of an adrenocortical carcinoma in a lV2-year-old child using the same surgical principles (31. This patient had no tumor recurrence on early follow-up. In my opinion, cardiothoracic surgeons owe a debt of gratitude to Drs Reitz and Marshall for their pioneering articles that so clearly elucidated the indications and technique for employing profound hypothermia and circulatory arrest 14, 51.
Terrill E . Theman, M D
Ann Thorac Surg 1990;49: 16670
References 1. Shahian DM, Nieh PT, Libertino JA. Resection of atnocaval adrenal carcinoma using hypothermic circulatory arrest. Ann Thorac Surg 1989;48:421-2. 2. Theman TE, Stauffer RA, Lennert JB, Saunders CD. Profound hypothermia and circulatory arrest in excision of renal cell carcinoma invading the vena cava. Can J Surg 1988;31:15%5. 3. Theman TE, Williams WG, Simpson JS, et al. Tumor invasion of the upper inferior vena cava: the use of profound hypothermia on circulation arrest as a surgical adjunct. J Pediatr Surg 1978;13:3314. 4. Marshall FF, Reitz BA, Diamond DA. A new technique for management of renal cell carcinoma involving the right atrium: hypothermia and cardiac arrest. J Urol 1984;131:103-7. 5. Marshall FF, Reitz BA. Supradiaphragmatic renal cell carcinoma tumor thrombus: indications for vena caval reconstruction with pericardium. J Urol 1985;133:26&8.
Valvular Xenograft to Bioprosthesis To the Editor: I enjoyed the September supplement to The Annals, as well as participation in the program that produced the papers contained therein. I give congratulations to the editors and organizers of a very special meeting. In the interest of historical accuracy 1 must correct an item in Alain Carpentier’s paper 111. I was no longer at Edwards Laboratories when he visited in 1968, having already started Hancock Laboratories. Animal implants were underway by that time and I did not have the opportunity of meeting Alain until some 2 years later at a lecture that he presented at Mt. Sinai Hospital in New York City, hosted by Bob Litwak. Our first formalin-fixed valve was implanted clinically in October 1968. Following experimental work our first glutaraldehyde-fixed valves were clinically implanted in April 1970. Warren D. Hancock Hancock jaffe Laboratories 2 Jenner St, Suite 100 Itvine, C A 92718
Section of Cardiothoracic Surgery
Reference
St. Luke’s Hospital
1. Carpentier A. From valvular xenograft to valvular bioprosthesis: 19651970. Ann Thorac Surg 1989;48:S724.
Bethlehem, PA 18015
