CORRESPONDENCE
Ann Thorac Surg
167
1990;49:166-70
Table 1. Tetracycline Pleurodesis in 4 Patients Patient No.
1
Variable Age (yr) Sex Predisposing disease Roentgenogram Severity of air leak Duration of air leak (days) Pain Result of pleurodesis
2
35 M Asthma Normal
3
4
Severe Decrease in air leak to grade 3 in four hours, no leak at 24 hours
None Unsuccessful; death in 24 hours
None Unsuccessful; death in 48 hours
4
1 17
5
15
45 M AIDS, PCP, TB Bilateral interstitial infiltrates + cysts 4 13
26 F AIDS, PCP, TB Bilateral interstitial infiltrates
71 F Old TB RUL fibrosis
Moderate Resolution of residual pneumothorax in 24 hours
4
~~
AIDS = acquired Immunodeficiency syndrome,
PCP = Pneumocystis carinii pneumonia;
syndrome (AIDS), TP was not associated with pain, and it was unsuccessful in closing the air leak and associated with early mortality. We are aware of only three other reports dealing with TP for active air leak [2-4]. Patients with Pneumocystis carinii pneumonia complicating AIDS frequently sustain spontaneous pneumothorax with persistent air leak [5]. Tetracycline pleurodesis has not previously been described for persistent air leaks in patients with AIDS, but our lack of success in these 2 patients may contraindicate its use in such patients. I feel that TP was unsuccessful in these 2 patients with AIDS because of lack of pleural inflammation, as both of these patients experienced no pain with TP.
Vijay Chechani, M D Division of Pulmonary Medicine, Department of Medicine University of Missouri-Columbia School of Medicine One Hospital Drive Columbia, M O 65212
References 1. Almassi GH, Haasler GB. Chemical pleurodesis in the presence of persistent air leak. Ann Thorac Surg 1989;47786-7. 2. Macoviak JA, Stephenson LW, Ochs R, Edmunds LH. Tetracycline pleurodesis during active pulmonary-pleural air leak for prevention of recurrent pneumothorax. Chest 1982;81: 78-81. 3. Olivier AF. Tetracycline pleurodesis for refractory pneumothorax among inoperable elderly surgical candidates. Chest 1982;82:512. 4. Goldszer RC, Bennett J, Van Campen J, Rudnitzky J. Intrapleural tetracycline for spontaneous pneumothorax. JAMA 1979;241:724-5. 5. Fleisher AG, McElvaney G, Lawson L, Gerein AN, Grant D, Tyers FO. Surgical management of spontaneous pneumothorax in patients with acquired immunodeficiency syndrome. Ann Thorac Surg 1988;45:21-3.
Reply
To the Editor:
We disagree with Dr Chechani that AIDS is a contraindication to chemical pleurodesis. His failure in 2 patients with AIDS and
RUL = right upper lobe,
TB = pulmonary tuberculosis
Pneumocystis carinii pneumonia is probably due to inadequate time allowed for the tetracycline to remain in the pleural space (five minutes) and the fact that both patients were probably preterminal, as evidenced by their demise within 48 hours after pleurodesis. In addition, there appear to have been no maneuvers carried out to distribute the tetracycline uniformly throughout the pleural space by altering the patient’s position. Our experience with 2 AIDS patients subsequent to our published report indicates that effective pleurodesis can be accomplished, although one may have to instill tetracycline in the pleural space on multiple occasions. In fact, in 1 of our patients with bilateral spontaneous pneumothorax and P carinii infection, the right pneumothorax required three trials of tetracycline pleurodesis before final resolution of pneumothorax and cessation of air leak was achieved. Furthermore, there is no evidence in our patients that instillation of sclerosants into the pleural space caused any kind of rapid demise, despite their altered immunological defense mechanisms. Our only real failure with the technique described [ l ] has been in a patient receiving steroids. Whether a trial of vitamin A before sclerotherapy in these patients will help bring about effective chemical pleurodesis is speculative. G. Hossein Almassi, M D George B . Haasler, M D Milwaukee Regional Medical Center 8700 W Wisconsin Ave Milwaukee. W l 53226
Reference 1. Almassi GH, Haasler GB. Chemical pleurodesis in the presence of persistent air leak. Ann Thorac Surg 1989;47:786-7.
Must the Mitral Valve Always Be Removed During Prosthetic Replacement? To the Editor: Mitral prosthetic replacement may be a hazardous procedure, particularly if the patient is seen as an emergency with poorly controlled cardiac failure. At operation the stent of the prosthesis is frequently found to be incorporated within the left ventricular wall, and its removal may cause irreparable damage to the heart.
168
CORRESPONDENCE
We describe such a patient whom we treated by a new technique, leaving the stent of the failing mitral prosthesis in situ and inserting within it a Starr-Edwards valve. A 58-year-old woman had undergone mitral valve replacement with a 35-mm Carpentier-Edwards bioprosthesis for severe rheumatic valve disease in July 1979. She made an uneventful recovery and remained well until 1988, when worsening exertional dyspnea developed. Over the following 9 months, her condition deteriorated. She appeared cachectic and breathless at rest. She was in atrial fibrillation, and there was a loud pansystolic and mid-diastolic murmur at the apex and signs of biventricular failure. The chest radiograph showed cardiomegaly, pulmonary congestion, and a right pleural effusion. Cardiac catheterization showed moderate left ventricular function and only moderate mitral regurgitation. Cardiac chamber pressures (in mm Hg) were as follows: right atrium V wave, 20 (mean, 10); right ventricle, 70/15; pulmonary artery, 70/37; pulmonary capillary wedge, 35; left ventricle, 100110; and aorta, 105/60. The mean mitral diastolic gradient was 21 with a cardiac output of 3 L and a valve area of 0.56 cm’. These findings were consistent with severe mitral prosthetic stenosis, pulmonary hypertension, and tricuspid regurgitation. Mitral prosthetic replacement was recommended. At operation, the prosthetic leaflets were rigid and partially calcified. The heart tissues in general were extremely friable, and the valve struts were buried within the left ventricular wall. The valve leaflets were removed with knife and rongeur until the inner aspect of the stent was free from debris. We judged that removal of the stent carried an exceptional risk of severe damage. A 6M Starr-Edwards sizer fit perfectly inside the CarpentierEdwards stent. This valve was chosen and anchored with 12 pledgetted sutures attached to the inner aspect of the CarpentierEdwards sewing ring. The Starr-Edwards valve was then seated and tied into place within the existing Carpentier-Edwards stent (Figs 1, 2). The heart was rewarmed and vented, and resumed beating after cardioversion from ventricular to atrial fibrillation. Good ejection was shortly evident and the patient came off bypass easily on a small dose of adrenaline and dopamine. The
Ann Thorac Surg 1990;49:16670
Fig 2 . Postoperative lateral chest radiograph showing Starr-Edwards valve within the Carpentier-Edwards stent. left atrial pressure was measured by direct puncture at 15 mm Hg and there was no evidence of mitral regurgitation. The patient made an uneventful recovery; she was ventilated for 12 hours and spent three days in the intensive care unit, during which time her small dose of inotropic agents was weaned. The patient was discharged to convalescence as routine on the tenth postoperative day without evidence of cardiac failure and with a satisfactorily functioning Starr-Edwards prosthesis. Echocardiography carried out 4 weeks postoperatively showed normal motion of the Starr-Edwards prosthesis and normal left ventricular function. Doppler studies showed a mean gradient of 5 mm Hg across the mitral prosthesis, a value similar to that obtained across a normally functioning prosthesis [l]. This technique, successful in this case, may be advantageous in those rare cases in which removal of a large prosthesis would risk serious ventricular damage.
C . Campanella, M D C. F . Hider, FFARCS A. 1. Duncan, FRCS(E) P . Bloomfield, MRCPfUK) Royal lnfirmary Lauriston Place Edinburgh, Scotland
Reference 1 . Panidis IP, Ross J, Mintz GS. Normal and abnormal prosthetic valve function as assessed by Doppler echocardiography. J Am Coll Cardiol 1986;8:317.
Spasm of the Gastroepiploic Artery Graft To the Editor: I enjoyed the recent article by Mills and Everson [l]. In this
Fig 1 . Preoperative lateral chest radiograph showing Carpentier-Edwards bioprosthesis in mitral position.
article, they documented the spasm of the gastroepiploic artery (GEA) graft by postoperative angiogram. Although they reported
Ann Thorac Surg
167
1990;49:166-70
Table 1. Tetracycline Pleurodesis in 4 Patients Patient No.
1
Variable Age (yr) Sex Predisposing disease Roentgenogram Severity of air leak Duration of air leak (days) Pain Result of pleurodesis
2
35 M Asthma Normal
3
4
Severe Decrease in air leak to grade 3 in four hours, no leak at 24 hours
None Unsuccessful; death in 24 hours
None Unsuccessful; death in 48 hours
4
1 17
5
15
45 M AIDS, PCP, TB Bilateral interstitial infiltrates + cysts 4 13
26 F AIDS, PCP, TB Bilateral interstitial infiltrates
71 F Old TB RUL fibrosis
Moderate Resolution of residual pneumothorax in 24 hours
4
~~
AIDS = acquired Immunodeficiency syndrome,
PCP = Pneumocystis carinii pneumonia;
syndrome (AIDS), TP was not associated with pain, and it was unsuccessful in closing the air leak and associated with early mortality. We are aware of only three other reports dealing with TP for active air leak [2-4]. Patients with Pneumocystis carinii pneumonia complicating AIDS frequently sustain spontaneous pneumothorax with persistent air leak [5]. Tetracycline pleurodesis has not previously been described for persistent air leaks in patients with AIDS, but our lack of success in these 2 patients may contraindicate its use in such patients. I feel that TP was unsuccessful in these 2 patients with AIDS because of lack of pleural inflammation, as both of these patients experienced no pain with TP.
Vijay Chechani, M D Division of Pulmonary Medicine, Department of Medicine University of Missouri-Columbia School of Medicine One Hospital Drive Columbia, M O 65212
References 1. Almassi GH, Haasler GB. Chemical pleurodesis in the presence of persistent air leak. Ann Thorac Surg 1989;47786-7. 2. Macoviak JA, Stephenson LW, Ochs R, Edmunds LH. Tetracycline pleurodesis during active pulmonary-pleural air leak for prevention of recurrent pneumothorax. Chest 1982;81: 78-81. 3. Olivier AF. Tetracycline pleurodesis for refractory pneumothorax among inoperable elderly surgical candidates. Chest 1982;82:512. 4. Goldszer RC, Bennett J, Van Campen J, Rudnitzky J. Intrapleural tetracycline for spontaneous pneumothorax. JAMA 1979;241:724-5. 5. Fleisher AG, McElvaney G, Lawson L, Gerein AN, Grant D, Tyers FO. Surgical management of spontaneous pneumothorax in patients with acquired immunodeficiency syndrome. Ann Thorac Surg 1988;45:21-3.
Reply
To the Editor:
We disagree with Dr Chechani that AIDS is a contraindication to chemical pleurodesis. His failure in 2 patients with AIDS and
RUL = right upper lobe,
TB = pulmonary tuberculosis
Pneumocystis carinii pneumonia is probably due to inadequate time allowed for the tetracycline to remain in the pleural space (five minutes) and the fact that both patients were probably preterminal, as evidenced by their demise within 48 hours after pleurodesis. In addition, there appear to have been no maneuvers carried out to distribute the tetracycline uniformly throughout the pleural space by altering the patient’s position. Our experience with 2 AIDS patients subsequent to our published report indicates that effective pleurodesis can be accomplished, although one may have to instill tetracycline in the pleural space on multiple occasions. In fact, in 1 of our patients with bilateral spontaneous pneumothorax and P carinii infection, the right pneumothorax required three trials of tetracycline pleurodesis before final resolution of pneumothorax and cessation of air leak was achieved. Furthermore, there is no evidence in our patients that instillation of sclerosants into the pleural space caused any kind of rapid demise, despite their altered immunological defense mechanisms. Our only real failure with the technique described [ l ] has been in a patient receiving steroids. Whether a trial of vitamin A before sclerotherapy in these patients will help bring about effective chemical pleurodesis is speculative. G. Hossein Almassi, M D George B . Haasler, M D Milwaukee Regional Medical Center 8700 W Wisconsin Ave Milwaukee. W l 53226
Reference 1. Almassi GH, Haasler GB. Chemical pleurodesis in the presence of persistent air leak. Ann Thorac Surg 1989;47:786-7.
Must the Mitral Valve Always Be Removed During Prosthetic Replacement? To the Editor: Mitral prosthetic replacement may be a hazardous procedure, particularly if the patient is seen as an emergency with poorly controlled cardiac failure. At operation the stent of the prosthesis is frequently found to be incorporated within the left ventricular wall, and its removal may cause irreparable damage to the heart.
168
CORRESPONDENCE
We describe such a patient whom we treated by a new technique, leaving the stent of the failing mitral prosthesis in situ and inserting within it a Starr-Edwards valve. A 58-year-old woman had undergone mitral valve replacement with a 35-mm Carpentier-Edwards bioprosthesis for severe rheumatic valve disease in July 1979. She made an uneventful recovery and remained well until 1988, when worsening exertional dyspnea developed. Over the following 9 months, her condition deteriorated. She appeared cachectic and breathless at rest. She was in atrial fibrillation, and there was a loud pansystolic and mid-diastolic murmur at the apex and signs of biventricular failure. The chest radiograph showed cardiomegaly, pulmonary congestion, and a right pleural effusion. Cardiac catheterization showed moderate left ventricular function and only moderate mitral regurgitation. Cardiac chamber pressures (in mm Hg) were as follows: right atrium V wave, 20 (mean, 10); right ventricle, 70/15; pulmonary artery, 70/37; pulmonary capillary wedge, 35; left ventricle, 100110; and aorta, 105/60. The mean mitral diastolic gradient was 21 with a cardiac output of 3 L and a valve area of 0.56 cm’. These findings were consistent with severe mitral prosthetic stenosis, pulmonary hypertension, and tricuspid regurgitation. Mitral prosthetic replacement was recommended. At operation, the prosthetic leaflets were rigid and partially calcified. The heart tissues in general were extremely friable, and the valve struts were buried within the left ventricular wall. The valve leaflets were removed with knife and rongeur until the inner aspect of the stent was free from debris. We judged that removal of the stent carried an exceptional risk of severe damage. A 6M Starr-Edwards sizer fit perfectly inside the CarpentierEdwards stent. This valve was chosen and anchored with 12 pledgetted sutures attached to the inner aspect of the CarpentierEdwards sewing ring. The Starr-Edwards valve was then seated and tied into place within the existing Carpentier-Edwards stent (Figs 1, 2). The heart was rewarmed and vented, and resumed beating after cardioversion from ventricular to atrial fibrillation. Good ejection was shortly evident and the patient came off bypass easily on a small dose of adrenaline and dopamine. The
Ann Thorac Surg 1990;49:16670
Fig 2 . Postoperative lateral chest radiograph showing Starr-Edwards valve within the Carpentier-Edwards stent. left atrial pressure was measured by direct puncture at 15 mm Hg and there was no evidence of mitral regurgitation. The patient made an uneventful recovery; she was ventilated for 12 hours and spent three days in the intensive care unit, during which time her small dose of inotropic agents was weaned. The patient was discharged to convalescence as routine on the tenth postoperative day without evidence of cardiac failure and with a satisfactorily functioning Starr-Edwards prosthesis. Echocardiography carried out 4 weeks postoperatively showed normal motion of the Starr-Edwards prosthesis and normal left ventricular function. Doppler studies showed a mean gradient of 5 mm Hg across the mitral prosthesis, a value similar to that obtained across a normally functioning prosthesis [l]. This technique, successful in this case, may be advantageous in those rare cases in which removal of a large prosthesis would risk serious ventricular damage.
C . Campanella, M D C. F . Hider, FFARCS A. 1. Duncan, FRCS(E) P . Bloomfield, MRCPfUK) Royal lnfirmary Lauriston Place Edinburgh, Scotland
Reference 1 . Panidis IP, Ross J, Mintz GS. Normal and abnormal prosthetic valve function as assessed by Doppler echocardiography. J Am Coll Cardiol 1986;8:317.
Spasm of the Gastroepiploic Artery Graft To the Editor: I enjoyed the recent article by Mills and Everson [l]. In this
Fig 1 . Preoperative lateral chest radiograph showing Carpentier-Edwards bioprosthesis in mitral position.
article, they documented the spasm of the gastroepiploic artery (GEA) graft by postoperative angiogram. Although they reported
