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Combined Valve Procedures
CORRESPONDENCE
Combined Valve Procedures To the Editor:
misconstrued our conclusions, which I would like to list here: (1)surgical correction of tetralogy of Fallot into a single lung results in a higher mortality and morbidity; (2)the increased pulmonary vascular resistance of this condition produces right heart failure, which appears to be the reason for poor results in these patients; (3) at the time of correction every effort should be made to revascularize both lungs; and (4) even if it is impossible to establish blood flow into both lungs, a number of patients with correction into a single pulmonary artery will survive the operation, and many of the survivors will have excellent late results. I continue to believe these conclusions and suggest that, whenever possible, it is advantageous to correct tetralogy of Fallot into both lungs by means of methods that reestablish pulmonary artery flow in patients with acquired atresia of one of the pulmonary arteries. However, if this is not possible, we agree with the authors’ conclusion that repairs should be made into a single pulmonary artery and that the use of a valved conduit may improve the early and late results in these patients.
We heartily concur with the article by George M. Callard and associates, Combined Valvular and Coronary Artery Surgery (Ann Thorac Surg 22:338, 1976), ie, coronary artery bypass should be performed routinely with valve replacement in patients who have major coronary artery lesions. We have performed 16 combined procedures in the past twelve months, 10 aortic valve replacements with coronary artery revascularization and 6 mitral valve replacements associated with coronary artery revascularization procedures. It is our policy routinely to study the coronary arteries of all patients undergoing valve operations. Of the 16 patients, 4 were totally asymptomatic but did have significant constrictive coronary artery lesions that were bypassed. The authors indicate that coronary artery bypass grafting may lower the operative risk and improve the results in high-risk patients with coronary artery and valve disease. The mortality rate among our 16 patients is 0. We strongly believe that the operative risk is actually lower for patients in whom the defects are totally Reference corrected (ie, valve repair plus bypass) than for those 1. Donahoo JS, Brawley RK, Haller JA, et al: Correcin whom even asymptomatic coronary disease is distion of tetralogy of Fallot in patients with one pulregarded. monary artery in continuity with the right venOur operative technique varies somewhat from the tricular outflow tract. Surgery 74:887, 1973 authors’ in that we use hypothermic anoxic cold cardioplegic arrest by injecting the cold cardioplegic SO- James S . Donahoo, M . D . lution into the aortic root. We have performed the Department of S u r g e q entire operation during one aortic cross-clamping and The Johns Hopkins Hospital have taken as long as one and one-half hours to do Baltimore. M D 21205 these operations.
Steven 1. Phillips, M . D . Robert H . Zeff, M . D . Chamnahn Kongtahworn, M . D . 1047 5th Ave Des Moines, IA 50314
Correction of Tetralogy of Fallot To the Editor: I enjoyed Dr. Mistrot’s article, ”Tetralogy of Fallot with a Single Pulmonary Artery: Operative Repair” (Ann Thorac Surg 23:249, 1977), and I would like to comment. I believe the technique of using a valve-containing conduit to prevent pulmonary valvular regurgitation in patients in whom tetralogy of Fallot must be corrected into a single pulmonary artery is a good one. Although the follow-up is short, results seem to substantiate the rationale for this approach. I disagree, however, with some points within the paper. In referring to a paper written by us in 1973 [l], Dr. Mistrot states that ”several authors advocated palliative operations rather than correction.” I think that Dr. Mistrot 594
Reply To the Editor: Concerning Dr. Donahoo’s letter, the entire sentence in which reference was given to his paper is as follows: ”In view of an operative mortality of 44 to 48%, several authors have held that a palliative systemicpulmonary artery shunt using cardiopulmonary bypass is preferable to repair in patients with TOF and a single pulmonary artery.” The reference to Dr. Donahoo’s paper was pertaining to a 44% operative mortality reported by his group for repair with this clinical entity. Additionally, Dr. Campbell, in the discussion of this paper, states that he recommends palliative shunting rather than operative repair. I think the conclusions of Dr. Donahoo’s paper are valid, and repair, when it can be performed into a pulmonary artery that has been isolated from the main trunk by a previous shunt, is advisable. However, in none of our patients was this possible, due to complete obliteration of the involved pulmonary artery or ”acquired atresia.” The data from Dr. Donahoo’s paper would indicate that a good chance of survival can be anticipated in the particular group of patients
Combined Valve Procedures To the Editor:
misconstrued our conclusions, which I would like to list here: (1)surgical correction of tetralogy of Fallot into a single lung results in a higher mortality and morbidity; (2)the increased pulmonary vascular resistance of this condition produces right heart failure, which appears to be the reason for poor results in these patients; (3) at the time of correction every effort should be made to revascularize both lungs; and (4) even if it is impossible to establish blood flow into both lungs, a number of patients with correction into a single pulmonary artery will survive the operation, and many of the survivors will have excellent late results. I continue to believe these conclusions and suggest that, whenever possible, it is advantageous to correct tetralogy of Fallot into both lungs by means of methods that reestablish pulmonary artery flow in patients with acquired atresia of one of the pulmonary arteries. However, if this is not possible, we agree with the authors’ conclusion that repairs should be made into a single pulmonary artery and that the use of a valved conduit may improve the early and late results in these patients.
We heartily concur with the article by George M. Callard and associates, Combined Valvular and Coronary Artery Surgery (Ann Thorac Surg 22:338, 1976), ie, coronary artery bypass should be performed routinely with valve replacement in patients who have major coronary artery lesions. We have performed 16 combined procedures in the past twelve months, 10 aortic valve replacements with coronary artery revascularization and 6 mitral valve replacements associated with coronary artery revascularization procedures. It is our policy routinely to study the coronary arteries of all patients undergoing valve operations. Of the 16 patients, 4 were totally asymptomatic but did have significant constrictive coronary artery lesions that were bypassed. The authors indicate that coronary artery bypass grafting may lower the operative risk and improve the results in high-risk patients with coronary artery and valve disease. The mortality rate among our 16 patients is 0. We strongly believe that the operative risk is actually lower for patients in whom the defects are totally Reference corrected (ie, valve repair plus bypass) than for those 1. Donahoo JS, Brawley RK, Haller JA, et al: Correcin whom even asymptomatic coronary disease is distion of tetralogy of Fallot in patients with one pulregarded. monary artery in continuity with the right venOur operative technique varies somewhat from the tricular outflow tract. Surgery 74:887, 1973 authors’ in that we use hypothermic anoxic cold cardioplegic arrest by injecting the cold cardioplegic SO- James S . Donahoo, M . D . lution into the aortic root. We have performed the Department of S u r g e q entire operation during one aortic cross-clamping and The Johns Hopkins Hospital have taken as long as one and one-half hours to do Baltimore. M D 21205 these operations.
Steven 1. Phillips, M . D . Robert H . Zeff, M . D . Chamnahn Kongtahworn, M . D . 1047 5th Ave Des Moines, IA 50314
Correction of Tetralogy of Fallot To the Editor: I enjoyed Dr. Mistrot’s article, ”Tetralogy of Fallot with a Single Pulmonary Artery: Operative Repair” (Ann Thorac Surg 23:249, 1977), and I would like to comment. I believe the technique of using a valve-containing conduit to prevent pulmonary valvular regurgitation in patients in whom tetralogy of Fallot must be corrected into a single pulmonary artery is a good one. Although the follow-up is short, results seem to substantiate the rationale for this approach. I disagree, however, with some points within the paper. In referring to a paper written by us in 1973 [l], Dr. Mistrot states that ”several authors advocated palliative operations rather than correction.” I think that Dr. Mistrot 594
Reply To the Editor: Concerning Dr. Donahoo’s letter, the entire sentence in which reference was given to his paper is as follows: ”In view of an operative mortality of 44 to 48%, several authors have held that a palliative systemicpulmonary artery shunt using cardiopulmonary bypass is preferable to repair in patients with TOF and a single pulmonary artery.” The reference to Dr. Donahoo’s paper was pertaining to a 44% operative mortality reported by his group for repair with this clinical entity. Additionally, Dr. Campbell, in the discussion of this paper, states that he recommends palliative shunting rather than operative repair. I think the conclusions of Dr. Donahoo’s paper are valid, and repair, when it can be performed into a pulmonary artery that has been isolated from the main trunk by a previous shunt, is advisable. However, in none of our patients was this possible, due to complete obliteration of the involved pulmonary artery or ”acquired atresia.” The data from Dr. Donahoo’s paper would indicate that a good chance of survival can be anticipated in the particular group of patients