- Email: [email protected]
A Simpler Alternative to the Bentall Operation Using a Stentless Valve
Ann Thorac Surg 2011;91:640 – 6
CORRESPONDENCE
643
Edson Marchiori, MD, PhD
References
Department of Radiology Fluminense Federal University Rua Marquês do Paraná, 303 24033-900 Niterói, Rio de Janeiro, Brazil e-mail: [email protected]
1. Nobre LF, Marchiori E, Carrão ÂD, Zanetti G, Mano CM. Pulmonary instillation of activated charcoal: early findings on computed tomography (letter). Ann Thorac Surg 2011;91: 642–3. 2. Huang CC, Wu HS, Lee YC. Extensive tracheobronchitis and lung perforation after alkaline caustic aspiration. Ann Thorac Surg 2010;89:1670 –3. 3. Culpepper JA, Veremakis C, Guntupalli KK, Sladen A. Malpositioned nasogastric tube causing pneumothorax and bronchopleural fistula. Chest 1982;81:389. 4. Sheffner SE, Gross BH, Birnberg FA, Birk P. Iatrogenic bronchopleural fistula caused by feeding tube insertion. J Can Assoc Radiol 1985;36:52–5. 5. Seder DB, Christman RA, Quinn MO, Knauft ME. A 45-yearold man with a lung mass and history of charcoal aspiration. Respir Care 2006;51:1251– 4. 6. Graff GR, Stark J, Berkenbosch JW, Holcomb GW 3rd, Garola RE. Chronic lung disease after activated charcoal aspiration. Pediatrics 2002;109:959 – 61.
Ângelo Duarte Carrão, MD Clinica DMI—Diagnóstico Médico por Imagens São José, Santa Catarina, Brazil Gláucia Zanetti, MD, PhD Claudia Mauro Mano, MD Department of Radiology Fluminense Federal University Niterói, Rio de Janeiro, Brazil
References
Reply To the Editor: We appreciate Nobre and colleagues’ [1] experience regarding our article [2]. Various types of damage of the respiratory system may occur during corrosive ingestion, as well as therapeutic gastric lavage. Nasogastric tubes can inadvertently pass through the tracheobronchial tree perforating into the pleural space [3, 4]. Dense charcoal in pleural effusion and lung consolidation are probably secondary to the instillation of a large volume of charcoal solution into the distal airways. Besides, pneumothorax and pleural effusions indicate the presence of bronchopleural fistula. The fistula would be closed by early and aggressive thoracoscopic interventions. Activated charcoal is considered a benign therapeutic substance for the gastrointestinal tract, but it is toxic for the respiratory tract. Some adverse pathologic consequences of charcoal aspiration include acute changes in pulmonary microvascular permeability, lung edema, and the development of obliterative bronchiolitis have been reported [5, 6]. We totally agree with the point that the presence of highdensity material in the lung parenchyma, or in the pleural space, is suggestive of accidental activated charcoal instillation. In addition, we look forward to further discussion of the management of activated charcoal aspiration. Chung Chieh Huang, MD Division of Thoracic Surgery Show Chwan Memorial Hospital No. 542, Chung-Shan Rd, Section 1 Chang-Hwa City, 500, Taiwan e-mail: [email protected] © 2011 by The Society of Thoracic Surgeons Published by Elsevier Inc
A Simpler Alternative to the Bentall Operation Using a Stentless Valve To the Editor: I was rather surprised to read the article by Stewart and colleagues [1], which appeared in the March issue. This elaborate surgical procedure is perhaps justifiable in the 5 patients with type A dissection involving the arch of the aorta, but the other 15 patients only required a replacement of the aortic valve and the ascending aorta. In my opinion, the following steps are unnecessary in those patients and increase the length of the operation and the risk involved: 1. Axillary artery cannulation using a Hemashield graft (Boston Scientific, Natick, MA). Alternative: Cannulate the aortic arch. 2. Core cooling to 28°C or less. Alternative: Keep normothermia. 3. Coronary button anastomoses. Alternative: Implant the valve subcoronarily. 4. Circulatory arrest with unilateral antegrade cerebral perfusion. Alternative: Apply the aortic clamp just below innominate artery and anastomose just below the clamp. These steps contributed to the long cross-clamp, perfusion, and operating times. Although not mentioned in the article, I am sure the blood loss and blood requirement also was high. Our group has published a simpler, safer, and faster method of replacing the valve and the ascending aorta in a much older (mean age, 73 ⫾ 4 years) group of patients [2, 3]. We have done this operation in 84 patients with good short-term and long-term results. If you want, I can send copies of our publication to you. Alexander John, MD Department of Cardiac Surgery Schuechtermann Clinic Ulmenallee 11 49214 Bad Rothenfelde Germany e-mail: [email protected]
References 1. Stewart AS, Takayama H, Smith CR. Modified Bentall operation with a novel biologic valved conduit. Ann Thor Surg 2010;89:938 – 42. 0003-4975/$36.00
MISCELLANEOUS
1. Huang CC, Wu HS, Lee YC. Extensive tracheobronchitis and lung perforation after alkaline caustic aspiration. Ann Thorac Surg 2010;89:1670 –3. 2. Menzies DG, Busuttil A, Prescott LF. Fatal pulmonary aspiration of oral activated charcoal. BMJ 1988;297:459 – 60. 3. Graff GR, Stark J, Berkenbosch JW, Holcomb GW 3rd, Garola RE. Chronic lung disease after activated charcoal aspiration. Pediatrics 2002;109:959 – 61. 4. Seder DB, Christman RA, Quinn MO, Knauft ME. A 45-yearold man with a lung mass and history of charcoal aspiration. Respir Care 2006;51:1251– 4.
644
CORRESPONDENCE
2. John A, Al-Hariri B, Ackemann J, Warnecke H. Replacing the diseased aortic valve and the proximal aorta in the elderly patient. Eur J Cardiothorac Surg 2007;31:939 – 40. 3. John A, Al-Hariri B, Ackemann J, El-Mehsen M, Roethemeyer S, Warnecke H. Subcoronary implantation of a stentless valve in patients with aortic aneurysms. Asian Cardiovasc Thorac Ann 2008;16:355– 60.
Alternative Technique for Internal Mammary Artery To the Editor: We read with interest the article by Thingnam and colleagues [1] of a simple and inexpensive technique for internal mammary artery harvest. This technique is not new. We have published similar technique for harvesting the mammary artery using the Moussalli bar [2]. The Moussalli bar was a modified drip stand. If the bar was not available, we used the Roberts clamp. The advantage of the Moussalli bar is the presence of grooves that hold the wires more securely than the Roberts clamp. We do not use simple loops of wires but figure-of-eight loops, which are more effective in securing the bar and distributing the forces on the sternal half. We disagree with the authors in relation to using conventional retractors such as the Delacroix-Chevalier, which is commonly used for mammary artery harvest through sternotomy [1]. We use this retractor, and it is not necessary to keep readjusting the blades. Once the retractor has been inserted at the beginning of the mammary dissection, it remains in situ until the procedure is completed. We agree with the authors that the two techniques allow an uninterrupted view of the entire course of the mammary artery, without the presence of blades, as is the case with conventional retractors [1, 2].
Ann Thorac Surg 2011;91:640 – 6
technique device by our senior consultant (SKT) [3] for more than 15 years, which uses a Roberts clamp and single stainless steel wire loops. The need for a special instrument, such as the Moussali bar, is obviated because once hitched up by any self-retaining sternal retractor, the Roberts clamp woven through wire loops is well stabilized. The Roberts clamp has an added advantage that the handles of the clamp get stuck between the retractor and the sternum, which prevents its rotation and stabilizes the assembly. Instead of using a figure of 8, we propose the use of a single loop, as it consumes only one stainless steel wire, and the chances of cutting it through the sternum are minimized, unless passed though the lower intercostal space. This method gives a panoramic view of the underside of the sternum without the hindrance of the blades of the conventional spreader. Nevertheless, our effort resurrected the technique. Prashant N. Mohite, MS Shyam K. Thingnam, MCh Department of Cardiovascular and Thoracic Surgery Postgraduation Institute of Medical Research and Education Sector- 12 Chandigarh, 160015 India e-mail: [email protected]
References 1. Hasan RI, Yonan NA, Moussalli H. Technique of dissecting the internal mammary after using the Moussalli bar. Eur J Cardiothorac Surg 1990;4:571–2. 2. Sarvananthan S, Hasan R. Alternative technique for internal mammary artery (letter). Ann Thorac Surg 2011;91:644. 3. Thingnam SK, Kuthe SA, Mohite PN, Singh H, Mishra AK, Srinivasan B. Simple and inexpensive technique for internal mammary artery harvest. Ann Thorac Surg 2010;89:651–2.
Sajiram Sarvananthan Ragheb Hasan, FRCS (CTh) Cardiothoracic Department Manchester Heart Centre Manchester Royal Infirmary Oxford Rd Manchester M13 9WL, United Kingdom e-mail: [email protected]
References
MISCELLANEOUS
1. Thingnam SK, Kuthe SA, Mohite PN, Singh H, Mishra AK, Srinivasan B. Simple and inexpensive technique for internal mammary artery harvest. Ann Thorac Surg 2010;89:651–2. 2. Hasan RI, Yonan NA, Moussalli H. Technique of dissecting the internal mammary after using the Moussalli bar. Eur J Cardiothorac Surg 1990;4:571–2.
Reply To the Editor: We appreciate that Hasan and colleagues [1] reported the technique of internal mammary artery harvest using the Moussali bar approximately 2 decades ago. However, with the availability of the conventional retractors, such as the DelacroixChevalier, the technique was scarcely used and has recently has gone into oblivion. The use of the Roberts clamp instead of the Moussali bar, which the authors mention in the Letter to the Editor [2], was not noted in their original article. We have been following the © 2011 by The Society of Thoracic Surgeons Published by Elsevier Inc
Is the Use of Effective Orifice Area Index Calculator Appropriate in Definition of Prosthesis-Patient Mismatch? To the Editor: We read with great interest the article by Kobayashi and colleagues [1]. In this article, the effective orifice area index (EOAI) was calculated by dividing “the published in vivo effective orifice area” by the body surface area (BSA), which might mean that the authors used the values in the EOAI calculator of the ATS-Advanced Performance (AP)-valve (ATS Medical Inc, Minneapolis, MN) provided by the manufacturer [2] when they calculated the EOAI of prosthetic valves. Actually, this assumption was supported by the fact that mean EOAI value of the ATS-AP 16-mm valves in Table 3 was exactly the same as the EOA value in the EOAI calculator of ATS-AP 16-mm valve divided by the mean BSA value of the group of patients in Table 2. This “EOAI” should be appropriately named the “projected EOAI” as described by Pibarot and colleagues [3], which is very useful in choosing the appropriate size of the prosthetic valve during operation for the purpose of prevention of prosthesispatient mismatch. Because the EOAI calculator for the ATS-AP 16-mm valve is based on the mean EOA data from a small echocardiographic cohort (N ⫽ 8) [4], it is mandatory to measure the real EOAs of the implanted prosthetic valves of patients by postoperative Doppler echocardiography with the continuous formula, which can meet the definition of prosthesis-patient mismatch in the EOAI [3]. We and perhaps other readers would 0003-4975/$36.00
CORRESPONDENCE
643
Edson Marchiori, MD, PhD
References
Department of Radiology Fluminense Federal University Rua Marquês do Paraná, 303 24033-900 Niterói, Rio de Janeiro, Brazil e-mail: [email protected]
1. Nobre LF, Marchiori E, Carrão ÂD, Zanetti G, Mano CM. Pulmonary instillation of activated charcoal: early findings on computed tomography (letter). Ann Thorac Surg 2011;91: 642–3. 2. Huang CC, Wu HS, Lee YC. Extensive tracheobronchitis and lung perforation after alkaline caustic aspiration. Ann Thorac Surg 2010;89:1670 –3. 3. Culpepper JA, Veremakis C, Guntupalli KK, Sladen A. Malpositioned nasogastric tube causing pneumothorax and bronchopleural fistula. Chest 1982;81:389. 4. Sheffner SE, Gross BH, Birnberg FA, Birk P. Iatrogenic bronchopleural fistula caused by feeding tube insertion. J Can Assoc Radiol 1985;36:52–5. 5. Seder DB, Christman RA, Quinn MO, Knauft ME. A 45-yearold man with a lung mass and history of charcoal aspiration. Respir Care 2006;51:1251– 4. 6. Graff GR, Stark J, Berkenbosch JW, Holcomb GW 3rd, Garola RE. Chronic lung disease after activated charcoal aspiration. Pediatrics 2002;109:959 – 61.
Ângelo Duarte Carrão, MD Clinica DMI—Diagnóstico Médico por Imagens São José, Santa Catarina, Brazil Gláucia Zanetti, MD, PhD Claudia Mauro Mano, MD Department of Radiology Fluminense Federal University Niterói, Rio de Janeiro, Brazil
References
Reply To the Editor: We appreciate Nobre and colleagues’ [1] experience regarding our article [2]. Various types of damage of the respiratory system may occur during corrosive ingestion, as well as therapeutic gastric lavage. Nasogastric tubes can inadvertently pass through the tracheobronchial tree perforating into the pleural space [3, 4]. Dense charcoal in pleural effusion and lung consolidation are probably secondary to the instillation of a large volume of charcoal solution into the distal airways. Besides, pneumothorax and pleural effusions indicate the presence of bronchopleural fistula. The fistula would be closed by early and aggressive thoracoscopic interventions. Activated charcoal is considered a benign therapeutic substance for the gastrointestinal tract, but it is toxic for the respiratory tract. Some adverse pathologic consequences of charcoal aspiration include acute changes in pulmonary microvascular permeability, lung edema, and the development of obliterative bronchiolitis have been reported [5, 6]. We totally agree with the point that the presence of highdensity material in the lung parenchyma, or in the pleural space, is suggestive of accidental activated charcoal instillation. In addition, we look forward to further discussion of the management of activated charcoal aspiration. Chung Chieh Huang, MD Division of Thoracic Surgery Show Chwan Memorial Hospital No. 542, Chung-Shan Rd, Section 1 Chang-Hwa City, 500, Taiwan e-mail: [email protected] © 2011 by The Society of Thoracic Surgeons Published by Elsevier Inc
A Simpler Alternative to the Bentall Operation Using a Stentless Valve To the Editor: I was rather surprised to read the article by Stewart and colleagues [1], which appeared in the March issue. This elaborate surgical procedure is perhaps justifiable in the 5 patients with type A dissection involving the arch of the aorta, but the other 15 patients only required a replacement of the aortic valve and the ascending aorta. In my opinion, the following steps are unnecessary in those patients and increase the length of the operation and the risk involved: 1. Axillary artery cannulation using a Hemashield graft (Boston Scientific, Natick, MA). Alternative: Cannulate the aortic arch. 2. Core cooling to 28°C or less. Alternative: Keep normothermia. 3. Coronary button anastomoses. Alternative: Implant the valve subcoronarily. 4. Circulatory arrest with unilateral antegrade cerebral perfusion. Alternative: Apply the aortic clamp just below innominate artery and anastomose just below the clamp. These steps contributed to the long cross-clamp, perfusion, and operating times. Although not mentioned in the article, I am sure the blood loss and blood requirement also was high. Our group has published a simpler, safer, and faster method of replacing the valve and the ascending aorta in a much older (mean age, 73 ⫾ 4 years) group of patients [2, 3]. We have done this operation in 84 patients with good short-term and long-term results. If you want, I can send copies of our publication to you. Alexander John, MD Department of Cardiac Surgery Schuechtermann Clinic Ulmenallee 11 49214 Bad Rothenfelde Germany e-mail: [email protected]
References 1. Stewart AS, Takayama H, Smith CR. Modified Bentall operation with a novel biologic valved conduit. Ann Thor Surg 2010;89:938 – 42. 0003-4975/$36.00
MISCELLANEOUS
1. Huang CC, Wu HS, Lee YC. Extensive tracheobronchitis and lung perforation after alkaline caustic aspiration. Ann Thorac Surg 2010;89:1670 –3. 2. Menzies DG, Busuttil A, Prescott LF. Fatal pulmonary aspiration of oral activated charcoal. BMJ 1988;297:459 – 60. 3. Graff GR, Stark J, Berkenbosch JW, Holcomb GW 3rd, Garola RE. Chronic lung disease after activated charcoal aspiration. Pediatrics 2002;109:959 – 61. 4. Seder DB, Christman RA, Quinn MO, Knauft ME. A 45-yearold man with a lung mass and history of charcoal aspiration. Respir Care 2006;51:1251– 4.
644
CORRESPONDENCE
2. John A, Al-Hariri B, Ackemann J, Warnecke H. Replacing the diseased aortic valve and the proximal aorta in the elderly patient. Eur J Cardiothorac Surg 2007;31:939 – 40. 3. John A, Al-Hariri B, Ackemann J, El-Mehsen M, Roethemeyer S, Warnecke H. Subcoronary implantation of a stentless valve in patients with aortic aneurysms. Asian Cardiovasc Thorac Ann 2008;16:355– 60.
Alternative Technique for Internal Mammary Artery To the Editor: We read with interest the article by Thingnam and colleagues [1] of a simple and inexpensive technique for internal mammary artery harvest. This technique is not new. We have published similar technique for harvesting the mammary artery using the Moussalli bar [2]. The Moussalli bar was a modified drip stand. If the bar was not available, we used the Roberts clamp. The advantage of the Moussalli bar is the presence of grooves that hold the wires more securely than the Roberts clamp. We do not use simple loops of wires but figure-of-eight loops, which are more effective in securing the bar and distributing the forces on the sternal half. We disagree with the authors in relation to using conventional retractors such as the Delacroix-Chevalier, which is commonly used for mammary artery harvest through sternotomy [1]. We use this retractor, and it is not necessary to keep readjusting the blades. Once the retractor has been inserted at the beginning of the mammary dissection, it remains in situ until the procedure is completed. We agree with the authors that the two techniques allow an uninterrupted view of the entire course of the mammary artery, without the presence of blades, as is the case with conventional retractors [1, 2].
Ann Thorac Surg 2011;91:640 – 6
technique device by our senior consultant (SKT) [3] for more than 15 years, which uses a Roberts clamp and single stainless steel wire loops. The need for a special instrument, such as the Moussali bar, is obviated because once hitched up by any self-retaining sternal retractor, the Roberts clamp woven through wire loops is well stabilized. The Roberts clamp has an added advantage that the handles of the clamp get stuck between the retractor and the sternum, which prevents its rotation and stabilizes the assembly. Instead of using a figure of 8, we propose the use of a single loop, as it consumes only one stainless steel wire, and the chances of cutting it through the sternum are minimized, unless passed though the lower intercostal space. This method gives a panoramic view of the underside of the sternum without the hindrance of the blades of the conventional spreader. Nevertheless, our effort resurrected the technique. Prashant N. Mohite, MS Shyam K. Thingnam, MCh Department of Cardiovascular and Thoracic Surgery Postgraduation Institute of Medical Research and Education Sector- 12 Chandigarh, 160015 India e-mail: [email protected]
References 1. Hasan RI, Yonan NA, Moussalli H. Technique of dissecting the internal mammary after using the Moussalli bar. Eur J Cardiothorac Surg 1990;4:571–2. 2. Sarvananthan S, Hasan R. Alternative technique for internal mammary artery (letter). Ann Thorac Surg 2011;91:644. 3. Thingnam SK, Kuthe SA, Mohite PN, Singh H, Mishra AK, Srinivasan B. Simple and inexpensive technique for internal mammary artery harvest. Ann Thorac Surg 2010;89:651–2.
Sajiram Sarvananthan Ragheb Hasan, FRCS (CTh) Cardiothoracic Department Manchester Heart Centre Manchester Royal Infirmary Oxford Rd Manchester M13 9WL, United Kingdom e-mail: [email protected]
References
MISCELLANEOUS
1. Thingnam SK, Kuthe SA, Mohite PN, Singh H, Mishra AK, Srinivasan B. Simple and inexpensive technique for internal mammary artery harvest. Ann Thorac Surg 2010;89:651–2. 2. Hasan RI, Yonan NA, Moussalli H. Technique of dissecting the internal mammary after using the Moussalli bar. Eur J Cardiothorac Surg 1990;4:571–2.
Reply To the Editor: We appreciate that Hasan and colleagues [1] reported the technique of internal mammary artery harvest using the Moussali bar approximately 2 decades ago. However, with the availability of the conventional retractors, such as the DelacroixChevalier, the technique was scarcely used and has recently has gone into oblivion. The use of the Roberts clamp instead of the Moussali bar, which the authors mention in the Letter to the Editor [2], was not noted in their original article. We have been following the © 2011 by The Society of Thoracic Surgeons Published by Elsevier Inc
Is the Use of Effective Orifice Area Index Calculator Appropriate in Definition of Prosthesis-Patient Mismatch? To the Editor: We read with great interest the article by Kobayashi and colleagues [1]. In this article, the effective orifice area index (EOAI) was calculated by dividing “the published in vivo effective orifice area” by the body surface area (BSA), which might mean that the authors used the values in the EOAI calculator of the ATS-Advanced Performance (AP)-valve (ATS Medical Inc, Minneapolis, MN) provided by the manufacturer [2] when they calculated the EOAI of prosthetic valves. Actually, this assumption was supported by the fact that mean EOAI value of the ATS-AP 16-mm valves in Table 3 was exactly the same as the EOA value in the EOAI calculator of ATS-AP 16-mm valve divided by the mean BSA value of the group of patients in Table 2. This “EOAI” should be appropriately named the “projected EOAI” as described by Pibarot and colleagues [3], which is very useful in choosing the appropriate size of the prosthetic valve during operation for the purpose of prevention of prosthesispatient mismatch. Because the EOAI calculator for the ATS-AP 16-mm valve is based on the mean EOA data from a small echocardiographic cohort (N ⫽ 8) [4], it is mandatory to measure the real EOAs of the implanted prosthetic valves of patients by postoperative Doppler echocardiography with the continuous formula, which can meet the definition of prosthesis-patient mismatch in the EOAI [3]. We and perhaps other readers would 0003-4975/$36.00