1854
CORRESPONDENCE
pneumonectomies; especially, why only on the right side? The maneuver of bronchial coverage with the posterior pericardial flap could be performed in the course of intrapleural pneumonectomies as well and on the left side, even more easily than on the right [2] (Fig 1). Francis Robicsek, MD, PhD Department of Thoracic and Cardiovascular Surgery Carolinas Medical Center 1001 Blythe Blvd, Ste 300 Charlotte, NC 28203 e-mail: [email protected]
References 1. de Perrot M. Use of the posterior pericardium to cover the bronchial stump after right extrapleural pneumonectomy. Ann Thorac Surg 2013;96:706–8. 2. Robicsek F, Sanger P, Daugherty HK. A modification of the technique of left pneumonectomy. J Thorac Cardiovas Surg 1969;4:543–4.
Reply To the Editor: Thank you for your comments and interest [1] regarding my article [2]. This technique can be used for right and left pneumonectomy as well as extrapleural pneumonectomy. However, the use of the posterior pericardium to cover the right bronchial stump has not been described in detail previously. More options are usually available to cover the bronchial stump after right pneumonectomy than after extrapleural pneumonectomy. Hence, the use of the posterior pericardium is particularly helpful for extrapleural pneumonectomy.
Ann Thorac Surg 2014;97:1852–7
that the higher total pulmonary vascular resistance in the Fallot group was due to a larger amount of stroke volume (secondary to pulmonary regurgitation). Pulmonary arterial compliance was also found to be in correlation with right ventricular end-diastolic volume in the Fallot group, but our opinion is that pulmonary arterial compliance could not be correlated with right ventricular end-diastolic volume. Because right ventricular volume was determined by regurgitation in the Fallot group (according to the results in the article, left ventricular volume should have increased in all of the cases with supracoronary aortic replacement because of lower compliance). The homogenous distribution and standardization of the Fallot group was disturbed by the diversity of interventions and medications (transannular patch, percutaneous valvuloplasty, shunts). What we get as a consequence from this valuable study is that right ventricular preload increases caused by pulmonary regurgitation, and the right ventricle dilates (in Table 2 of the article, right ventricle dilated 1.64 times its initial dimensions) resulting in increased pulmonary arterial stiffness secondary to increased right ventricular stroke volume. For instance, the incidence of peripheral arterial aneuryms increases in case of aortic regurgitation (aneurysm develops secondary to an increase in stroke volume). We think that the measurements of compliance, impedance, and right ventricular end-diastolic volume in cases of tetralogy of Fallot with no pulmonary regurgitation would support our argument. Habib Cakir, MD Mert Kestelli, MD Ismail Yurekli, MD Koksal Donmez, MD Department of Cardiovascular Surgery Katip Celebi University Izmir Atat€ urk Training and Research Hospital Karabaglar 35360 Izmir, Turkey e-mail: [email protected]
Marc de Perrot, MD, MS Division of Thoracic Surgery Toronto General Hospital 200 Elizabeth St Toronto, Ontario M5G 2C4 Canada e-mail: [email protected]
References 1. Robicsek F. Pericardial coverage of the bronchial stump (letter). Ann Thorac Surg 2014;97:1853–4. 2. de Perrot M. Use of the posterior pericardium to cover the bronchial stump after right extrapleural pneumonectomy. Ann Thorac Surg 2013;96:706–8.
Pulmonary Arterial Stiffness, Compliance, and Impedance To the Editor: MISCELLANEOUS
We congratulate Inuzuka and colleagues [1] on the success of their surgical procedure and excellent study recently reported online in The Annals of Thoracic Surgery. We would also like to highlight some issues. Usually, systole is shorter than diastole. Therefore, systolic pressure was measured higher in the tetralogy of Fallot group than the diastolic pressure in Table 2 of the article. This demonstrates that the kinetic energy within the pulmonary artery of the Fallot group was lower. We think Ó 2014 by The Society of Thoracic Surgeons Published by Elsevier Inc
Reference 1. Inuzuka R, Seki M, Sugimoto M, Saiki H, Masutani S, Senzaki H. Pulmonary arterial wall stiffness and its impact on right ventricular afterload in patients with repaired tetralogy of Fallot. Ann Thorac Surg 2013;96:1435–41.
Reply To the Editor: We thank Cakir and colleagues [1] for their thoughtful comments regarding our study [2]. We agree with them that pulmonary regurgitation (PR) is a major cause of right ventricular (RV) dilation in patients with tetralogy of Fallot (TOF). Because of the cross-sectional observational nature of our study, we cannot exclude the possibility that the correlation between pulmonary arterial compliance and RV end-diastolic volume is confounded by the presence of PR, as they have suggested. However, a significant correlation between RV end-diastolic volume and pulmonary arterial compliance was observed among patients without significant PR, as shown in Figure 3 in our original study [2]. Moreover, pulmonary arterial compliance continued to be significantly related to RV end-diastolic volume even after adjusting for the presence of PR (Table 3 [2]). Therefore, we speculate that the pathologic increase of systolic and diastolic dimensions is a manifestation of RV dysfunction and occurs as a direct result of increased afterload independently of PR augmentation. 0003-4975/$36.00
CORRESPONDENCE
pneumonectomies; especially, why only on the right side? The maneuver of bronchial coverage with the posterior pericardial flap could be performed in the course of intrapleural pneumonectomies as well and on the left side, even more easily than on the right [2] (Fig 1). Francis Robicsek, MD, PhD Department of Thoracic and Cardiovascular Surgery Carolinas Medical Center 1001 Blythe Blvd, Ste 300 Charlotte, NC 28203 e-mail: [email protected]
References 1. de Perrot M. Use of the posterior pericardium to cover the bronchial stump after right extrapleural pneumonectomy. Ann Thorac Surg 2013;96:706–8. 2. Robicsek F, Sanger P, Daugherty HK. A modification of the technique of left pneumonectomy. J Thorac Cardiovas Surg 1969;4:543–4.
Reply To the Editor: Thank you for your comments and interest [1] regarding my article [2]. This technique can be used for right and left pneumonectomy as well as extrapleural pneumonectomy. However, the use of the posterior pericardium to cover the right bronchial stump has not been described in detail previously. More options are usually available to cover the bronchial stump after right pneumonectomy than after extrapleural pneumonectomy. Hence, the use of the posterior pericardium is particularly helpful for extrapleural pneumonectomy.
Ann Thorac Surg 2014;97:1852–7
that the higher total pulmonary vascular resistance in the Fallot group was due to a larger amount of stroke volume (secondary to pulmonary regurgitation). Pulmonary arterial compliance was also found to be in correlation with right ventricular end-diastolic volume in the Fallot group, but our opinion is that pulmonary arterial compliance could not be correlated with right ventricular end-diastolic volume. Because right ventricular volume was determined by regurgitation in the Fallot group (according to the results in the article, left ventricular volume should have increased in all of the cases with supracoronary aortic replacement because of lower compliance). The homogenous distribution and standardization of the Fallot group was disturbed by the diversity of interventions and medications (transannular patch, percutaneous valvuloplasty, shunts). What we get as a consequence from this valuable study is that right ventricular preload increases caused by pulmonary regurgitation, and the right ventricle dilates (in Table 2 of the article, right ventricle dilated 1.64 times its initial dimensions) resulting in increased pulmonary arterial stiffness secondary to increased right ventricular stroke volume. For instance, the incidence of peripheral arterial aneuryms increases in case of aortic regurgitation (aneurysm develops secondary to an increase in stroke volume). We think that the measurements of compliance, impedance, and right ventricular end-diastolic volume in cases of tetralogy of Fallot with no pulmonary regurgitation would support our argument. Habib Cakir, MD Mert Kestelli, MD Ismail Yurekli, MD Koksal Donmez, MD Department of Cardiovascular Surgery Katip Celebi University Izmir Atat€ urk Training and Research Hospital Karabaglar 35360 Izmir, Turkey e-mail: [email protected]
Marc de Perrot, MD, MS Division of Thoracic Surgery Toronto General Hospital 200 Elizabeth St Toronto, Ontario M5G 2C4 Canada e-mail: [email protected]
References 1. Robicsek F. Pericardial coverage of the bronchial stump (letter). Ann Thorac Surg 2014;97:1853–4. 2. de Perrot M. Use of the posterior pericardium to cover the bronchial stump after right extrapleural pneumonectomy. Ann Thorac Surg 2013;96:706–8.
Pulmonary Arterial Stiffness, Compliance, and Impedance To the Editor: MISCELLANEOUS
We congratulate Inuzuka and colleagues [1] on the success of their surgical procedure and excellent study recently reported online in The Annals of Thoracic Surgery. We would also like to highlight some issues. Usually, systole is shorter than diastole. Therefore, systolic pressure was measured higher in the tetralogy of Fallot group than the diastolic pressure in Table 2 of the article. This demonstrates that the kinetic energy within the pulmonary artery of the Fallot group was lower. We think Ó 2014 by The Society of Thoracic Surgeons Published by Elsevier Inc
Reference 1. Inuzuka R, Seki M, Sugimoto M, Saiki H, Masutani S, Senzaki H. Pulmonary arterial wall stiffness and its impact on right ventricular afterload in patients with repaired tetralogy of Fallot. Ann Thorac Surg 2013;96:1435–41.
Reply To the Editor: We thank Cakir and colleagues [1] for their thoughtful comments regarding our study [2]. We agree with them that pulmonary regurgitation (PR) is a major cause of right ventricular (RV) dilation in patients with tetralogy of Fallot (TOF). Because of the cross-sectional observational nature of our study, we cannot exclude the possibility that the correlation between pulmonary arterial compliance and RV end-diastolic volume is confounded by the presence of PR, as they have suggested. However, a significant correlation between RV end-diastolic volume and pulmonary arterial compliance was observed among patients without significant PR, as shown in Figure 3 in our original study [2]. Moreover, pulmonary arterial compliance continued to be significantly related to RV end-diastolic volume even after adjusting for the presence of PR (Table 3 [2]). Therefore, we speculate that the pathologic increase of systolic and diastolic dimensions is a manifestation of RV dysfunction and occurs as a direct result of increased afterload independently of PR augmentation. 0003-4975/$36.00
