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The Practice ofCoronary Surgery in the United Kingdom and Ireland: A Survey /I. Sh aJei Brompton Hospital. London. England

The author has sent a questionnaire to 172 memb ers of the Society of Cardiothoracic Surgeo ns but has received only 49 answe rs. However. abo ut one third of the members do not pra ctice coronary surgery. 50 an estimated 40 % of active

memo

bers submitted answe rs. The quest ionnaire was mainly distri· butcd to Co nsultants in the National Health Service. The questions refer to cardiopulmonary bypass, myocardial protection. grafts. closure of the chest. and pos toperative medi cation . Key word s Survey - Coronaryartery surgery

A survey to evaluate the variations . among cardiac surgeons in Britain and Ireland. wit h regard to the ir current practice of coronary surgery was carried out. A question-

na ire was distributed through the mailing of th e Society of Cardiothoracic Surgeo ns of Great Britain and Ireland to all memb ers. Forty-nine (an est imated 40 %ofactive mem bers) ret urned completed a nswers. The following results were obtained : Ca r dinpulmona ry lIypass (CPII) Thirty -one surgeons (63 .3 %) use non-pu lsatile CI'II. and 18 su rgeons (36 .7 crcl) use pulsatile CPB. For venous cannu lation. 22 su rgeo ns (44 .9 "10) use two-stage single cannula. 10 120.4 "10) use bas ket right atrial ca nnula . wh ile 171 34.7 "10) use two sepa rate caval cannu lae . Mannitol is added routinely to the priming fluid of th e pump in 25 151 'Yo) a nswers. and not add ed routinely in 24 149"10) answers. 21 surgeons (42 .9 %) do not usuall y use a vent . 18 surgeons 136 .3%) us e aorti c root venting . 8 surgeons 116.3 "10) use pulmonary a rte ry venting. only one surgeon (2 .0 "10) uses left atrial venting . and one uses left ventricular venting. M~' o c ard i a l

protection

42 surgeons 185 .7 %) usually use cold ca rdioplegia for myocardial prot ectio n. 33 of th em 178.6 %) use SI. Thomas' crystalloid ca rdioplegia . and 9 121.4%) use blood ca rdioplegia. Eight surgeons among those who use cardioplegia (19 .0 %) do not repeat ca rdioplegic infus ions unless the re is electrica l act ivity of the heart. an d 34 su rgeons repeat infusio ns at time intervals of aortic cross -clamping: 2 surgeo ns (4.8 %) every 15 minutes , 10 surgeons (23 .8 %) every 20

Thom e. cnrdlovasc. Sllrg-('oIl38 ( 19901 362- 364 © (;l'or){ Th ieme Verlag Stuttgart - New York

Obe rblic k fibe r die Praxis der Knron ur r-hlrurgle im Unite d Kingdom und in Irlan d Ocr Autor berichtet tiber ci ne Frag en bogen akt ton. bei der 172 Mitglieder der Socie ty of Cardiothoracic Surgeons a ngesc hrie ben wurde n. Von dies en antworte ten jedoch nur 4 9 . Etwa 1/ 3 der angeschriebenen Kollegen istje doc h nlcht mit dc r Koron a rchirurgie befaBt. Deshalb bctragt der Prozentsatz dcr a uswc rtbaren Antworten rund 40 %. Ocr Fragebogen wur de hauptsfich Iich an die Kollegen des National Health Service vorsa ndt. Die Frage n beziehen sich auf den kard iopulmonalen Bypass. die Myokardprotektiun. die Grafts. den Thora xvcrschluB und auf die postoperativ e Medika tion .

minu tes . 4 surgeons (9 .5 %) eve ry 25 minutes . 15 su rgeons minutes . 1 surgeon (2.4 % ) if morc than 30 minutes , an d 2 surgeo ns (4.8) at variable intervals. 16 surgeo ns of those who use ca rdioplegia (38 .1 %J administer cardioplegia into th e inserted gra fts during ao rt ic clamping. Among the surgeo ns who use cardioplegia. 2 14.8 'Yo)employ sys temic hypoth ermia of 20 - 25' C. 37 188.1'Yo}of 25-30'C . a nd 317 .1%) of30-35 'C. 38 su rgeo ns of th ose who use cold ca rdioplegia (90.5 "101 employ also topical ca rd iac cooling: 24 (63 .2 %) use cold salin e. 9 123.7%) use slushed ice. an d 5 1J:l.2 "1ol use special cooling devices. Four surgeons 19.5"10) using cold blood cardio plegia give also wa rm blood ca rdioplegia before aortic unclam ping. 7 surgeons (14.3 %) usually use interm ittent aortic clamp ing with vent ricular fibrillation. The intervening periods du ring whi ch the heart is beating ar e used for per forming the proximal graft anastomoses . All surg eons wh o use intermittent aortic clamping employ systemic hypothermia betwe en 30-35' C. ( :~ 5 . 7 IX)) eve ry 30

The grafts 45 surgeons (91.4 "10) prefer taking th e saphenous vein initially from th e leg and four surgeons 18.2 %) from the thigh . 29 su rgeons (59 .2 "10) avoid inserting sequenti al grafts. while 20 su rgeons (40 .8 'Yo) prefer inserting them . 26 surgeons 153 .1%) use beparinized blood to distend the harvested vein. and 23 146.9 %) use hepari nized saline. 39 surgeons (79 .6 %) use one suture for the distal coronary anastomosis. and 10 (20.4 %) use two sutures . 7 surg eons (14 .3 'Yo) measure routinely gra ft blood 1I0w. All surgeons use the intern al ma mmary artery liMA)as

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Summar)'

Thom e. car diovasc. .)'llrgeo1l 38 ( 19 90 /

The Practice o/Coronary Surgery in the Unite d Kingdom and Ireland Table 1 CardiopulmonaryBypass(CPS) (Total answers = 49)

Table 2

Non-pulsatile CPB Pulsatile CPB

31 18

(63.3 %) (36.7 %)

Cold cardioplegia Intermittent aortic clamping

Venous cannulation: Single two-stage venous cannula Single basket atrial cannula Two separatevenous cannula

22 10 17

(44.9%) (20.4%) (34.7%)

Mannitol: Added routinely to theprime Not added routinely

25 24

(51.0 %1 (49.0 %1

Venting: No vent Aortic root vent Pulmonary arteryvent Left atrial vent Left ventricular vent

21 (42.9%) 18 (36.3%) 8 (16.3%) 1 (2.0%) 1 (2.0%)

Closure of the chest 35 surgeons 171.4%) do not leave temporary pacin g wir es unless ther e is an indicati on, and 15 (30.6 %) leave the m routin ely. 4:, surge ons (87 .8%) do not atte mpt to close the peri cardium and 6 (12.2 %) att empt to close it. When intraaortic balloon pumping is required. 26 surgeons (53 .1 (X) initially try to insert the balloon by a per cutaneous technique, and 23 (46 .9 %) do not try the percutaneous technique. 28 surgeons (57.1%) remove the balloon by exposing and repairin g the fem oral ar tery , and 21 14 2.9 %) remove it by a closed method and app lying pr essure to the groin. Posto perative med ica tion

22 surgeons (44.9 %) give intravenou s glyceryl trinitrate to all patients in the early postoperative period , 24 149.0 %) give it only to cont rol arter ial hyper tension, an d 3 16.1 %) never use it. 31 surgeons (63 .3%) never use nitrate dermal patches in the early postop er ative period, 12124.5%) use them occasionally, and 6 (12.2%) routinely. If patient s were receiving beta-b locker s pr eoper atively, 16 surgeons 132 .7 %) prescrib e them routinely afte r operat ion, and 33 167.3 %) give them only if ther e is an indication . 10 surgeons 120.4%) give postoperative diuretics to their pati ents, and 39 179 .6 %) give them only ifther e is an indicati on. Calcium heparin , as prophylaxis for deep venou s thrombosis, is prescribed routinely by 19 surgeons (38.8 "101. occasion ally by 5 surgeons (10.2 %1. and never given by 25 surgeons (51.0% ). To impro ve graft patency, 48 surgeo ns (98.0 %) give aspirin postoper atively: 33 (68.8%) give it ind efinitely, 14 129.2"10) for one yea r, and one (2.0 "10 ) for less tha n one yea r. The dose of as pirin was 75 mg daily in 27 answe rs 156.3%), 300 mg daily in 14 answers (29.2 %1. 300 mg on altern ate days in 5 answers (10.4 %), and other dosage in 2 answers (4.-2 %).30 surgeons 161 .2 %)give dipyrid amo le IPersanti n®) postoperatively to improve graft paten cy: 3 (10 %) for less than one yea r, 21 170.0 %) for on e yea r, and 6 120%) ind efinitely. 10 surgeons 120.4%) give oral anticoagula nts to

Myocardialprotection (Total answers ",49)

Cold cardioplegia (n

=

42 7

(85.7%1 (14.3%)

33 9

(78 6%) (21.4%)

42):

Crystalloid (St. Thomas') Cold blood Repeating infusion: None unlessthe re is cardiacactivity Every 15minutes Every20 minutes Every25 minutes Every30 minutes If more than30 minutes At variable inte rvals

8 (19.0%) 2 (48 %) 10 (23.8%) 4 (9.5%) 15 (35.7%) 1 (2.3 %) 2 (48 %)

Cardioplegia into insertedgrafts: Yes No

16 26

(38.1%) (61.9%)

Systemic hypothermia: 20-25°C 25- 30°C 30- 35°C

2 37 3

(4.8%) (88.1%) (7.1 %)

Topical cardiac cooling: Yes Cold saline Slushed ice Cooling device No Warm cardioplegia: Ves No Intermittentaortic clamping(n Hypothermia 30- 35°C

38 (90.5%1 24 (63.2%) 9 (23.7%) 5 (13.2%) 4 (95 %) 4 38 =

(9.5%) (90.5%)

7): 7 (100.0%)

improve graft patency: 9 (9W}{) for few weeks. and one for six months . 18 surgeo ns (36 .7'%)) give oral anticoagulants if the patient had concomitant ventricular an eurysmectomy, and 19 sur geons 138.8%) give them if the patient had concomitant endartectomy. Allsurgeons give proph ylactic antibiotics: 6(1 2.2%) for 24 hours, 36 173.5%) for 48 hour s, and 7 (14.3 %) for mor e than 48 hours and less tha n one week. The a ntibiotics used in the ord er of popularity a re : Cepha losporines (32.9%), flucloxacillin (28.9 %), genta mycin 114.5%1. netilmicin (3.9 %), penicillin (2.6 %). erythromycin (1.3 %), ka nam ycin (1.3 'ro). Hz-receptor antagonists are given routinely in 3 answe rs 16.1 %), and given only if there is an indicati on in 46 answer s (93.9 %). The first line of tr eatin g supra ventricular arrhythmias postoperatively was in the order of frequency: Digitalis (69.4 %), verapamil 124.5%), beta-blocker s 14.1 %), amiodarone (2.0 %). (10 %)

Change in pra ctice 11 surgeons 122.5 %)wa nt to expand the ir use of the IMA for grafting. Four surgeons (8.2 %)wan t to sta rt using blood and warm cardioplegia, and two surgeons want to use pulmonary artery venting. Comment The questionnair e was answe red by fort y-nine surgeons who currently practice coronary surgery in Great Britain

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a gra ft: 46 (93 .9 %) use it whenever possible, an d :, 16.1%) use it only occas iona lly. 26 surgeons (53.1 %) heparinize the patient and divide the IMA after dissection and 23 146.9 %) keep it in continuity until the time of the anastomos is . 22 surgeons (44.9 %) said that they use bilaterallMAs, and 24 149.0 %)said that they use the IM A for sequential grafting.

:'163

J1lOrac. cardiol'asc. Surgeofl .18 (19 90) Table 3

II. ."haft-i

Drugs to improve graft patency(Total answers = 49)

Aspirin: Given by Not givenby

48 (98.0%) I (2%)

Period of administration: Indefinitely One year l essthan I year

33 (68.8%) 14 (29.2%) I (2.0%)

Dosage:

75 mg daily 300 mg daily 300 mgonalternate days Other dosage

27 14 5 2

(56.3%) (29.2%) (1 0.4%) (4.2 %)

Given by Not given by

30 19

(612 %) (38 8%)

Period of administration: One year l ess than I year Indefinitely

21 (70.0%) 3 (10.0%) 6 (20.0%)

Dipyrida mole (Persantin®);

Oral anticoagulants: Given by Notgiven by Period of administration: Few weeks Six months Given for ventricular aneurysmectomy Givenfor endartectomy

10 (20.4%) 39 (79.6%) 9

I

(90.0%) (10.0%)

18 19

(36.7 %) (38.8%)

a nd Ireland. As with any survey, it has its limitations . Nevertheless. it gives an idea of the difference in views among surgeo ns about various practical points of coronary surgery . The variations in the techniqu e of surgery a nd in the genera l management of the pat ient are to be expected, sin ce these depend largely on the experience of the individual surgeon. and the accumulated information available to eac h center. However, it will appear that there a re ma ny unsolved questions in many aspects of this common surg ery, and furth er resea rch should be directed to answer points relevan t to the everyday handling of the coronary surgical patient. The area of postoperative medication in particular appears vague and requires better understanding. It a ppea rs that certa in a reas in the field of corona ry s urgery are gaining more interest. Extending the use of intern al mam ma ry a rtery for gra fting, replacing blood for crystalloid ca rdioplegia, and the use of wa rm ca rdioplegia to reduce reperfusion injury are examples. Only further experimenta l and clinical research will cha nge the current practice. Acknov..led ge mc nt

I wish to thank Professor G. H. Smith. the Honorary Secretary and Treasurer of the Society of Thoracic and Cardiovascular Surgeo ns of Grea t Britain and Ireland, for allowing this survey to take place. I also wish to acknowledge the ass istance of Miss Sarah Frost-wcllings, the Secretary in the Society, for distributing the question naire. I wish also to thank those surgeons who gave their time to complete the questionnaire,

II. Shalei.

u s. H ies

Brompton Hospital Fulham Head LondonSW3 611 P England

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