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Pulmonology and video surgery
CORRESPONDENCE
Ann Thorac Surg 1993:56:1214-20
, A.
I
BILATERAL ATRIAL DRAINAGE
To Femoral
1219
Fig 1. Schematic diagram of bilateral bypass with the double reservoir principle. (L.A. = left atrium; R.A. = right atrium.) (Reprinted from Cass N H , Ross DN. The evaluation of a bypass technique using the lung as an oxygenator. Guy’s Hosp Rep 1959;108:237-44.)
LINKED RESERVOIRS
results, our recommendations are somewhat different on all four points. We prefer moderate hypothermia, which is easy to achieve by placing a disposable heat-exchanger in the arterial line. This will enable the surgeon to complete the peripheral anastomoses on the electrically fibrillated rather than beating heart, with intermittent aortic cross-clamping instead of using the potentially traumatic 5-0 loops around the coronary arteries. We also believe that cannulating through the left ventricular apex is unnecessary. Left atrial cannulation is perfectly adequate. The ventricle can be decompressed, if necessary, either by advancing the atrial cannula into the left ventricular cavity across the mitral valve or by placing a small-caliber suction tube through the same route into the left ventricle [5, 61. In full agreement with Sweeney and Frazier, however, we do not recommend the use of cardioplegia with bilateral bypass because topical rewarming of the myocardium due to drainage of relatively warm blood in the cavities cannot be avoided. The combination of the method with warm blood cardioplegia may open new avenues in the future.
Endre Bodnar, M D 9 West End Ct West End Ave Dinner, Middx, HA5 1BP United Kingdom Donald N . Ross, FRCS 25 Wimpole St London W1 United Kingdom
References 1. Sweeney MS, Frazier OH. Device-supported myocardial revascularization: safe help for sick hearts. Ann Thorac Surg 1992;54:1065-70. 2. Bodnar E, Ross DN. Bilateral cardiac bypass without an oxygenator for coronary surgery. Artif Organs 1983;6:379-82. 3. Bodnar E, Drury PJ, Senador-Gomez G, Ross DN. Emergency left heart bypass. Proc ISAO 1979;2:333-6. 4. Cass NH, Ross DN. The evaluation of a bypass technique using the lung as an oxygenator. Guy’s Hosp Rep 1959;108: 237-44. 5. Bodnar E, Drury PJ, Ross DN. Atrial cannulation and ventricular venting for temporary left heart bypass. Proc ESAO 1979;6:59-63.
6. Bodnar E, Drury PJ, Senador-Gomez J, Ross DN. Decompression of the left ventricle during left heart bypass. Proc ISAO 1982;4:148-52.
Pulmonology and Video Surgery To the Editor: The recently published comments of Dr Wagner [l, 21, although somewhat poetic, deserve a prose response. As one who has been heavily involved in the pulmonary field for some years-and has enjoyed a long and positive interaction with my colleagues in cardiothoracic surgery and other disciplines-I could recount numerous prior instances in which concerns about ”turf” and “green” arose. The “green” sometimes had a monetary implication, but often a heavy envy overlay. None of these prior issues has been resolved by inflammatory statements. All have been worked out by adherence to simple principles: (1) physicians should be allowed to d o those things that they have been trained to do; (2) an adequate training experience can be defined; and (3) the quality of those carrying out these procedures should be monitored-as it certainly is these days. In my view, cardiothoracic surgeons, pulmonologists, interventional radiologists, and others all may have a role to play in the many exciting investigational and clinical applications of thoracoscopy. Medicine is already under attack from many external forces. It is imperative that we avoid internal divisiveness. Adherence to the fundamental principles outlined above should allow us to work out this-and other-issues among ourselves.
Kenneth M . Moser, M D Division of Pulmonay and Critical Care Medicine University of California, Sun Diego Medical Center 200 West Arbor Drive Sun Diego, C A 92103-8372 References 1. Wagner RB. Making some SENSE out of thoracoscopy. Ann Thorac Surg 1993;55:332. 2. Wagner RB. Pulmonology and video surgery: color it green. Ann Thorac Surg 1993;55:1284.
Ann Thorac Surg 1993:56:1214-20
, A.
I
BILATERAL ATRIAL DRAINAGE
To Femoral
1219
Fig 1. Schematic diagram of bilateral bypass with the double reservoir principle. (L.A. = left atrium; R.A. = right atrium.) (Reprinted from Cass N H , Ross DN. The evaluation of a bypass technique using the lung as an oxygenator. Guy’s Hosp Rep 1959;108:237-44.)
LINKED RESERVOIRS
results, our recommendations are somewhat different on all four points. We prefer moderate hypothermia, which is easy to achieve by placing a disposable heat-exchanger in the arterial line. This will enable the surgeon to complete the peripheral anastomoses on the electrically fibrillated rather than beating heart, with intermittent aortic cross-clamping instead of using the potentially traumatic 5-0 loops around the coronary arteries. We also believe that cannulating through the left ventricular apex is unnecessary. Left atrial cannulation is perfectly adequate. The ventricle can be decompressed, if necessary, either by advancing the atrial cannula into the left ventricular cavity across the mitral valve or by placing a small-caliber suction tube through the same route into the left ventricle [5, 61. In full agreement with Sweeney and Frazier, however, we do not recommend the use of cardioplegia with bilateral bypass because topical rewarming of the myocardium due to drainage of relatively warm blood in the cavities cannot be avoided. The combination of the method with warm blood cardioplegia may open new avenues in the future.
Endre Bodnar, M D 9 West End Ct West End Ave Dinner, Middx, HA5 1BP United Kingdom Donald N . Ross, FRCS 25 Wimpole St London W1 United Kingdom
References 1. Sweeney MS, Frazier OH. Device-supported myocardial revascularization: safe help for sick hearts. Ann Thorac Surg 1992;54:1065-70. 2. Bodnar E, Ross DN. Bilateral cardiac bypass without an oxygenator for coronary surgery. Artif Organs 1983;6:379-82. 3. Bodnar E, Drury PJ, Senador-Gomez G, Ross DN. Emergency left heart bypass. Proc ISAO 1979;2:333-6. 4. Cass NH, Ross DN. The evaluation of a bypass technique using the lung as an oxygenator. Guy’s Hosp Rep 1959;108: 237-44. 5. Bodnar E, Drury PJ, Ross DN. Atrial cannulation and ventricular venting for temporary left heart bypass. Proc ESAO 1979;6:59-63.
6. Bodnar E, Drury PJ, Senador-Gomez J, Ross DN. Decompression of the left ventricle during left heart bypass. Proc ISAO 1982;4:148-52.
Pulmonology and Video Surgery To the Editor: The recently published comments of Dr Wagner [l, 21, although somewhat poetic, deserve a prose response. As one who has been heavily involved in the pulmonary field for some years-and has enjoyed a long and positive interaction with my colleagues in cardiothoracic surgery and other disciplines-I could recount numerous prior instances in which concerns about ”turf” and “green” arose. The “green” sometimes had a monetary implication, but often a heavy envy overlay. None of these prior issues has been resolved by inflammatory statements. All have been worked out by adherence to simple principles: (1) physicians should be allowed to d o those things that they have been trained to do; (2) an adequate training experience can be defined; and (3) the quality of those carrying out these procedures should be monitored-as it certainly is these days. In my view, cardiothoracic surgeons, pulmonologists, interventional radiologists, and others all may have a role to play in the many exciting investigational and clinical applications of thoracoscopy. Medicine is already under attack from many external forces. It is imperative that we avoid internal divisiveness. Adherence to the fundamental principles outlined above should allow us to work out this-and other-issues among ourselves.
Kenneth M . Moser, M D Division of Pulmonay and Critical Care Medicine University of California, Sun Diego Medical Center 200 West Arbor Drive Sun Diego, C A 92103-8372 References 1. Wagner RB. Making some SENSE out of thoracoscopy. Ann Thorac Surg 1993;55:332. 2. Wagner RB. Pulmonology and video surgery: color it green. Ann Thorac Surg 1993;55:1284.