CORRESPONDENCE
Ann Thorac Surg 1991:52:1204-8
References 1. Carlon CA, Mondini PG, de Marchi R. Su una nuova anastomosi vasale per la terapia chirurgica di alcuni vizi cardiovascolari. Giorn It Chir 1950;6:760-74. 2. Carlon CA, Mondini PG, De Marchi R. Surgical treatment of some cardiovascular diseases (a new vascular anastomosis). J Int Coll Surg 1951;15:1-11. 3. Glenn WWL. Circulatory bypass of the right side of the heart. IV. Shunt between the superior vena cava and distal right pulmonary artery: report of clinical application. N Engl J Med 1958;259:117-20. 4. Robicsek F. An epitaph for cavopulmonary anastomosis. Ann Thorac Surg 1981;34:200-20. 5. Carlon CA, Albertini B. Su un accorgimento di tecnica nella anastomosi fra vena cava superiore e ram0 destro dell’arteria polmonare per la terapia della trasposizione dei grandi vasi. Boll SOCTriveneta Chir 1952;6:1-8. 6. de Leva1 M, Kilner P, Gewillig M, Bull C. Total cavopulmonary connection: a logical alternative to atriopulmonary connection for complex Fontan operations. Experimental studies and early clinical experience. J Thorac Cardiovasc Surg 1988; 96:682-95.
Penetrating Cardiac Injuries To the Editor: Attar and colleagues [l]present an elegant series of patients with penetrating cardiac injuries. I have only one problem with their presentation, and that is their mention that “pericardial window was performed in 10 patients.” Do the authors really mean a “window”? Too often, tube drainage of the pericardium is reported as a “window”-an operation that creates an opening between the pericardium and the left (rarely the right) pleura to drain resistant pericardial effusions [Z, 31 and is not always ultimately successful [4]. Attar and colleagues are not alone in their terminology; I do not know why tube drainage of the pericardium is so often referred to as a “window.” Surely, no other major cavity is drained by a window. Somehow, for the pericardium, the terms became confused in many physicians’ minds by slipshod extension. (Of course, if I inferred wrongly and Attar and colleagues did produce a true window, that would have been unusual under the conditions of acute trauma.) Terminology is only a quibble unless it serves to enlighten or to obscure facts and concepts [5]. In this case, the reader should be apprised of exactly what was done. We should reserve the term pericardial window for its original, precise meaning. If pericardial tube drainage (as it has often been described) has become a “window,” how should we rename the fenestration of pericardium with pleura?
David H . Spodick, M D , DSc Division of Cardiology Department of Medicine St. Vincent Hospital Worcester, M A 01604
References 1. Attar S, Suter CM, Hankins JR, Sequeira A, McLaughlin JS. Penetrating cardiac injuries. Ann Thorac Surg 1991;51:7114. 2. Edmunds LH Jr, Norwood W, Low DW. Atlas of cardiothoracic surgery. Philadelphia: Lea & Febiger, 1990:2C-l. 3. Gregory JR, McMurtrey MJ, Mountain CF. A surgical approach to the treatment of pericardial effusion in cancer patients. Am J Clin Oncol 1985;8:319-23.
1205
4. Spodick DH. Pericardial windows are suboptimal [Editorial]. Am J Cardiol 1983;51:607. 5. Spodick DH. Cardiolocution: the cardiologist’s assault on English. Am J Cardiol 1981;48:973-4.
Reply
To the Editor:
Dr Spodick questioned the meaning of the term pericardial window performed in 10 patients with penetrating cardiac injuries. We used this term to denote opening the pericardium through the subxiphoid approach to detect blood in the pericardial sac. If blood was detected, stemotomy was performed and the bleeding site controlled. If the exploration was negative, the implication was that penetration of the cardiac chambers had not occurred and further surgical intervention was not necessary; the pericardium was not drained in this situation. In more recent times we have rarely used subxiphoid windows in acute trauma. However, we still find the procedure useful in cases of multiple trauma when the patient becomes hemodynamically unstable during operation in the abdomen or on the extremities. We continue to use this procedure in cases of pericardial effusion of unknown etiology, in uremia, and in cases of malignant pericardial effusion with pericardial tamponade. In these situations, the pericardial window can be diagnostic as well as therapeutic. Finally, we occasionally perform a pericardial window through a thoracotomy incision to drain the pericardium into the pleural cavity. Our experience with this has not been as rewarding as that with the more extensive pericardiectomy.
Sajuh Attar, M D loseph S . Mchughlin, M D Division of Thoracic and Cardiovascular Surgery University of Maryland School of Medicine and Hospital 22 South Green St Baltimore, M D 21201
Mammary Artery to Saphenous Vein Bypass Graft: An Alternative Method of Redo Operation To the Editor: A patient underwent redo coronary artery revascularization that included grafting of the left internal mammary artery to the stump of a saphenous vein graft to the left anterior descending artery, which was occluded. The procedure was done without cardiopulmonary bypass. Because of the simplicity of the procedure we describe its details. A 49-year-old man underwent double aortocoronary bypass grafting and radical pericardiectomy in 1983. He did well initially, but returned in 1990 (aged 56 years) with incapacitating angina. Thallium scanning showed reversible changes in the distribution of the anterior wall. Angiography revealed a grade 111 ventricle with anterolateral and inferobasal hypokinesis. The vein graft to the obtuse marginal artery of the circumflex was patent. The native left anterior descending artery was occluded and filled the stump of a vein graft through collateral circulation. The artery was small and diseased. At operation, dense adhesions were found. The left internal mammary artery was dissected and an end-to-side anastomosis was performed to the remnant of the saphenous vein without
Ann Thorac Surg 1991:52:1204-8
References 1. Carlon CA, Mondini PG, de Marchi R. Su una nuova anastomosi vasale per la terapia chirurgica di alcuni vizi cardiovascolari. Giorn It Chir 1950;6:760-74. 2. Carlon CA, Mondini PG, De Marchi R. Surgical treatment of some cardiovascular diseases (a new vascular anastomosis). J Int Coll Surg 1951;15:1-11. 3. Glenn WWL. Circulatory bypass of the right side of the heart. IV. Shunt between the superior vena cava and distal right pulmonary artery: report of clinical application. N Engl J Med 1958;259:117-20. 4. Robicsek F. An epitaph for cavopulmonary anastomosis. Ann Thorac Surg 1981;34:200-20. 5. Carlon CA, Albertini B. Su un accorgimento di tecnica nella anastomosi fra vena cava superiore e ram0 destro dell’arteria polmonare per la terapia della trasposizione dei grandi vasi. Boll SOCTriveneta Chir 1952;6:1-8. 6. de Leva1 M, Kilner P, Gewillig M, Bull C. Total cavopulmonary connection: a logical alternative to atriopulmonary connection for complex Fontan operations. Experimental studies and early clinical experience. J Thorac Cardiovasc Surg 1988; 96:682-95.
Penetrating Cardiac Injuries To the Editor: Attar and colleagues [l]present an elegant series of patients with penetrating cardiac injuries. I have only one problem with their presentation, and that is their mention that “pericardial window was performed in 10 patients.” Do the authors really mean a “window”? Too often, tube drainage of the pericardium is reported as a “window”-an operation that creates an opening between the pericardium and the left (rarely the right) pleura to drain resistant pericardial effusions [Z, 31 and is not always ultimately successful [4]. Attar and colleagues are not alone in their terminology; I do not know why tube drainage of the pericardium is so often referred to as a “window.” Surely, no other major cavity is drained by a window. Somehow, for the pericardium, the terms became confused in many physicians’ minds by slipshod extension. (Of course, if I inferred wrongly and Attar and colleagues did produce a true window, that would have been unusual under the conditions of acute trauma.) Terminology is only a quibble unless it serves to enlighten or to obscure facts and concepts [5]. In this case, the reader should be apprised of exactly what was done. We should reserve the term pericardial window for its original, precise meaning. If pericardial tube drainage (as it has often been described) has become a “window,” how should we rename the fenestration of pericardium with pleura?
David H . Spodick, M D , DSc Division of Cardiology Department of Medicine St. Vincent Hospital Worcester, M A 01604
References 1. Attar S, Suter CM, Hankins JR, Sequeira A, McLaughlin JS. Penetrating cardiac injuries. Ann Thorac Surg 1991;51:7114. 2. Edmunds LH Jr, Norwood W, Low DW. Atlas of cardiothoracic surgery. Philadelphia: Lea & Febiger, 1990:2C-l. 3. Gregory JR, McMurtrey MJ, Mountain CF. A surgical approach to the treatment of pericardial effusion in cancer patients. Am J Clin Oncol 1985;8:319-23.
1205
4. Spodick DH. Pericardial windows are suboptimal [Editorial]. Am J Cardiol 1983;51:607. 5. Spodick DH. Cardiolocution: the cardiologist’s assault on English. Am J Cardiol 1981;48:973-4.
Reply
To the Editor:
Dr Spodick questioned the meaning of the term pericardial window performed in 10 patients with penetrating cardiac injuries. We used this term to denote opening the pericardium through the subxiphoid approach to detect blood in the pericardial sac. If blood was detected, stemotomy was performed and the bleeding site controlled. If the exploration was negative, the implication was that penetration of the cardiac chambers had not occurred and further surgical intervention was not necessary; the pericardium was not drained in this situation. In more recent times we have rarely used subxiphoid windows in acute trauma. However, we still find the procedure useful in cases of multiple trauma when the patient becomes hemodynamically unstable during operation in the abdomen or on the extremities. We continue to use this procedure in cases of pericardial effusion of unknown etiology, in uremia, and in cases of malignant pericardial effusion with pericardial tamponade. In these situations, the pericardial window can be diagnostic as well as therapeutic. Finally, we occasionally perform a pericardial window through a thoracotomy incision to drain the pericardium into the pleural cavity. Our experience with this has not been as rewarding as that with the more extensive pericardiectomy.
Sajuh Attar, M D loseph S . Mchughlin, M D Division of Thoracic and Cardiovascular Surgery University of Maryland School of Medicine and Hospital 22 South Green St Baltimore, M D 21201
Mammary Artery to Saphenous Vein Bypass Graft: An Alternative Method of Redo Operation To the Editor: A patient underwent redo coronary artery revascularization that included grafting of the left internal mammary artery to the stump of a saphenous vein graft to the left anterior descending artery, which was occluded. The procedure was done without cardiopulmonary bypass. Because of the simplicity of the procedure we describe its details. A 49-year-old man underwent double aortocoronary bypass grafting and radical pericardiectomy in 1983. He did well initially, but returned in 1990 (aged 56 years) with incapacitating angina. Thallium scanning showed reversible changes in the distribution of the anterior wall. Angiography revealed a grade 111 ventricle with anterolateral and inferobasal hypokinesis. The vein graft to the obtuse marginal artery of the circumflex was patent. The native left anterior descending artery was occluded and filled the stump of a vein graft through collateral circulation. The artery was small and diseased. At operation, dense adhesions were found. The left internal mammary artery was dissected and an end-to-side anastomosis was performed to the remnant of the saphenous vein without
