- Email: [email protected]
Stentless valved composite graft for Bentall operation
CORRESPONDENCE
Treatment of Pneumothorax With VATS and Bullectomy Under Local Anesthesia To the Editor: Video-assisted thoracic surgery (VATS) is, at present, the minimally invasive surgical technique of choice for the treatment of spontaneous recurrent or persistent pneumothorax. Usually, it requires general anesthesia and single-lung ventilation. We found the article by Mukaida and colleagues [1], about a small series of 4 high-risk patients, operated with secondary pneumothorax under local and epidural anesthesia very interesting. In relation to this work, we propose to perform VATS under local anesthesia and sedation [2] in elderly patients with serious pathology who cannot tolerate general anesthesia, or who have high surgical risk. We present 2 such cases here. Case 1 is a 87-year-old man who had a history of pulmonary tuberculosis (1950) with residual fibrotic lesions. He was admitted to another hospital for right tension pneumothorax, and was treated with thoracic drainage for 7 days, with persistent air leak and pulmonary reexpansion deficit. Right VATS was performed with three trocars, under local anesthesia and sedation. We observed pleural adhesions at the apex and mediastinum, and a single perforated 5 ⫻ 3 cm bulla located at the posterior segment of right upper lobe. Dissection of the bulla was carried out with two EndoGIA-35 mm (Ethicon Endo-Surgery Inc, Cincinnati, OH), completing the operation with pulverization of 5g purified talcum powder [3] and two thoracic drainages. He did not present air leak postoperatively, and the drainages were removed after 3 days, maintaining the pulmonary expansion and without complication. He was released from the hospital on the fourth day. After 18 months follow-up, recurrence of pneumothorax was not observed. Case 2 is a 67-year old male ex-smoker with previous history of arterial hypertension, stroke 5 years ago and severe coronary artery disease, treated with aortocoronary bypass grafting, later obstructed. He presented spontaneous right pneumothorax with significant persistent air leak, initially treated with thoracic drainage for 6 days. Under local anesthesia and sedation, right VATS was performed with three trocars, showing apical adhesions, that were freed, and a large apical bulla that was excised with three EndoGIA-35-mm; we then added talcum powder pleurodesis [3] and one thoracic drain. After this procedure, no air leakage was presented, and the drainage was removed after 3 days. The patient was released from the hospital on the fourth day, and remains asymptomatic after 1 year follow-up. In both cases, 200 mg of mepivacaine chlorohydrate was used for local anesthesia and 5 mg of intravenous midazolam for sedation. Patients were under continuous monitoring of blood pressure, electrocardiogram, and oxygen saturation. In patients at high-risk for general anesthesia, due to advanced age, previous pathology, or both, diagnostic thoracoscopy or VATS [4] are possible under local anesthesia and sedation, allowing the employment of the same number of trocars and the same bullectomy techniques. In our experience, pleurodesis by pleural abrasion should be replaced by chemical pleurodesis with 5g of purified and sterile talcum powder. The excellent results obtained, without complication and reduced postoperative stay, indicate that this technique should be considered to resolve well selected cases. Mercedes de la Torre Bravos, MD Thoracic Surgery Department Juan Canalejo Hospital Las Jubı´as no. 84 15006-La Corun˜a, Spain © 1999 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
Juan J. Rivas de Andre´s, MD Hospital Miguel Seruet Isabel la Catolica 1 Zaragoza 50009, Spain e-mail: [email protected].
References 1. Mukaida T, Andou A, Date H, Aoe M, Shimizu N. Thoracoscopic operation for secondary pneumothorax under local and epidural anesthesia in high-risk patients. Ann Thorac Surg 1998;65:297–306. 2. Nezu K, Kushibe K, Tojo T, Takahama T, Kitamura S. Thoracoscopic wedge resection of blebs under local anesthesia with sedation for treatment of a spontaneous pneumothorax. Chest 1997;111:230–5. 3. Tschopp JM, Brutsche M, Frey JG. Treatment of complicated spontaneous pneumothorax by simple talc pleurodesis under thoracoscopy and local anesthesia. Thorax 1997;52:329–32. 4. Rivas de Andre´s JJ, Torres J. Thoracoscopy and spontaneous pneumothorax. Ann Thorac Surg 1993;55:811.
Stentless Valved Composite Graft for Bentall Operation To the Editor: I read with interest the paper by Urbanski [1]. Despite the lack of the systolic property of the aortic root using a stentless valve inserted in a rigid Dacron tube, I nevertheless agree with the opportunity to use a stentless valve in selected cases requiring a Bentall-like operation. I also performed some button-Bentall operations using a Toronto SPV bioprosthesis (St. Jude Medical, St. Paul, MN), assembled during aortic clamping period with a collagen-coated woven Dacron vascular tube (Intervascular, La Ciotat, France) for combined replacement of aortic valve, root, and ascending aorta. The advantage of choosing the stentless bioprosthesis are: (1) to have a larger orifice valve in comparison to a stented bioprosthesis for the same aortic annulus; (2) to reduce the likelihood of thromboembolism and probably prosthetic endocarditis due to the laminar blood flow through the Toronto SPV valve; and (3) possibly to prolong the durability of the bioprosthesis, reducing the commissural stress in comparison with a stented bioprosthesis. I use a slightly different technique of implantation of the Toronto SPV bioprosthesis inside the Dacron tube, in comparison with that presented in the above article [1]. The vascular tube is everted at one end leaving a rim of 5 to 7 mm. Then I first secure the Toronto SPV inside the tube, putting three single stitches to the edge at three equidistant points of the inferior suture line (the annular suture), corresponding at the three equidistant transversal color stitches of the Toronto SPV, to avoid any distortion. After sewing the bioprosthetic valve and the tube together to the native aortic annulus, as Urbanski does, the rim of the Dacron tube is inverted and sewn to a corresponding short rim of aortic root, left during dissection of the aortic root and coronary buttons. This continuous suture is useful in improving hemostasis of a weak suture line, and for better securing the Dacron tube when redo operation become necessary because of valve failure. This only takes a few more minutes, and then the posts are fixed inside the vascular tube, taking care to avoid any distortion of the Toronto SPV valve, and the sinus of Valsalva suture is complete. There is one topic on which I do not agree with Dr Urbanski. I think there is no reason to choose a Dacron tube with a smaller Ann Thorac Surg 1999;68:2383–91 • 0003-4975/99/$20.00 PII S0003-4975(99)01060-7
2384
CORRESPONDENCE
diameter than that of the bioprosthesis. The external shape of the Toronto SPV bioprosthesis is cylindrical and so the valve can be inserted into a cylinder. By reducing the annular diameter of the bioprosthesis, and by insertion in a smaller size tube, we can cause some degree of distortion to the cusps. Furthermore, increasing the surface of coaptation of the cusps causes major stress on these surfaces, and probably cause predisposition to earlier calcification. I always use a 1-mm larger Dacron tube in respect to the Toronto SPV, and at postoperative color Doppler echocardiography, both transthoracic and transesophageal, bioprosthesis incompetence was not revealed. Since usually some degree of distal ascending aorta dilation is common when Bentall operation is scheduled, employing a larger size Dacron tube yields a reduction in the chance of mismatch between the aorta and vascular prosthesis, extending the indications of this surgical technique. In conclusion, this technique is an attractive alternative in selected cases, with optimal results, but should be performed by experienced surgeons. Uberto Da Col, MD Divisione di Cardiochirurgia Ospedale Silvestrini 06100 Perugia, Italy
Reference 1. Urbanski PP. Replacement of the ascending aorta and aortic valve with a valved stentless composite graft. Ann Thorac Surg 1999;67:1501–2.
Reply To the Editor: I thank Dr Da Col for his comment on our reported technique. If I understand Dr Da Col correctly, he sutures both the tube graft and the prosthetic valve to the aortic annulus. I have abandoned this technique after a few cases. I now move the stentless valve away from the end of the Dacron tube, and only suture the tube graft to the annulus, thus we are able to later remove the prosthetic valve in cases of degeneration, without touching the proximal suture line. The added security in hemostasis Dr Da Col expects from an additional suture between the Dacron tube and the remnants of the aortic wall, does not seem necessary. Since I started using interrupted plegetted mattress sutures for the proximal anastomosis, we have not observed any bleeding problems in 25 consecutive cases. I agree with Dr Da Col, that the insertion of the valve prosthesis in a smaller tube is not an optimal solution. Unfortunately, tube grafts in odd sizes, corresponding to the valve sizes, are not commercially available. I feel that the potential hazard of late regurgitation, due to dilation of the Dacron tube as reported by Franke and colleagues [1], is increased when a prosthetic valve smaller than the tube graft is used, as Dr Da Col proposes. The discussion about oversizing or undersizing could become obsolete, if the composite graft could be prefabricated using a specially designed tube graft of exact matching size, and preferably without crimping at the site of the attachment of the prosthetic valve. Paul P. Urbanski, MD Herz- und Gefa¨ß-Klinik Salzburger Leite 1 97616 Bad Neustadt, Germany e-mail: [email protected]. © 1999 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
Ann Thorac Surg 1999;68:2383–91
Reference 1. Franke U, Jurmann MJ, Uthoff K, et al. In vivo morphology of woven, collagen-sealed Dacron prostheses in the thoracic aorta. Ann Thorac Surg 1997;64:1096– 8.
Transaortic Access for Excision of a Left Ventricular Myxoma To the Editor: Talwalkar and associates [1] recently published an alternative operative approach for excision of rare left ventricular myxoma. A left atrial approach was used with mobilization of the anterior mitral valve leaflet to enhance exposure of the subvalvar region and facilitate excision of a left ventricular myxoma, which was entangled within the chordal apparatus and lay between the anterolateral papillary muscle and the left ventricular wall. After tumor excision, the detached mitral leaflet was reattached to the annulus. A separate transventricular or transaortic approach was thus avoided. We congratulate Talwalkar and associates on their positive result. This method seems to be especially valuable if the myxoma is attached to the anterolateral papillary muscle tissue. In this special case, where a left-sided transatrial exposure alone may be difficult to achieve without risking damage to the subvalvar apparatus of the mitral valve, the method offers an elegant approach. Tear stress to the thin chordae, and possibly disrupture of the tumor, might otherwise occur while opening the mitral valve apperture with a clamp. According to the authors, other aspects of using a transleaflet access, include avoiding a ventriculotomy with possible damage to small coronary artery branches, or a transaortic approach with an increased risk for systemic embolization. On the other hand, we would like to draw attention to some hazards inherent in this method, and we therefore only consider it useful in those patients where other means are not likely to be successful. We list some items of concern below as we found a detailed discussion also missing from the article. (1) Scar healing of mitral valve tissue will eventually damage the valve apparatus; and (2) A transaortic approach may be feasible in these cases as well. Clamping the ascending aorta for bypass and applying thorough suction throughout removal of the myxoma will usually prevent systemic embolization. Recently, we operated on a patient for mitral valve myxoma using a transaortic resection. The tumor emerged from the ventricular side of the anterior valve leaflet. Intraoperatively, after dissection of the left atrium and transverse aortotomy, the large broad-based myxoma, 4 cm in diameter, became visible as it nearly reached the supraventricular area of the ascending aorta. Transaortic inspection revealed that the relatively soft tumor arose with a broad basis from parts of the anterior papillary muscle and from the backside of the anterior mitral valve leaflet. Tumor resection was followed by inspection of both atria. In our opinion, in most cases of ventricular myxoma, a transaortic approach may still be the method of choice. However, if the myxoma involves the ventricular side of the mitral valve, or is attached to chordae or the papillary muscle without direct view or direct access, or when gentle separation cannot otherwise be achieved, this alternative method should be used. Postoperatively, a scar is left on the anterior mitral valve leaflet, which might represent a weak point for future problems such as endocarditis, shrinkage, or deformation of the leaflet. Only 0003-4975/99/$20.00
Treatment of Pneumothorax With VATS and Bullectomy Under Local Anesthesia To the Editor: Video-assisted thoracic surgery (VATS) is, at present, the minimally invasive surgical technique of choice for the treatment of spontaneous recurrent or persistent pneumothorax. Usually, it requires general anesthesia and single-lung ventilation. We found the article by Mukaida and colleagues [1], about a small series of 4 high-risk patients, operated with secondary pneumothorax under local and epidural anesthesia very interesting. In relation to this work, we propose to perform VATS under local anesthesia and sedation [2] in elderly patients with serious pathology who cannot tolerate general anesthesia, or who have high surgical risk. We present 2 such cases here. Case 1 is a 87-year-old man who had a history of pulmonary tuberculosis (1950) with residual fibrotic lesions. He was admitted to another hospital for right tension pneumothorax, and was treated with thoracic drainage for 7 days, with persistent air leak and pulmonary reexpansion deficit. Right VATS was performed with three trocars, under local anesthesia and sedation. We observed pleural adhesions at the apex and mediastinum, and a single perforated 5 ⫻ 3 cm bulla located at the posterior segment of right upper lobe. Dissection of the bulla was carried out with two EndoGIA-35 mm (Ethicon Endo-Surgery Inc, Cincinnati, OH), completing the operation with pulverization of 5g purified talcum powder [3] and two thoracic drainages. He did not present air leak postoperatively, and the drainages were removed after 3 days, maintaining the pulmonary expansion and without complication. He was released from the hospital on the fourth day. After 18 months follow-up, recurrence of pneumothorax was not observed. Case 2 is a 67-year old male ex-smoker with previous history of arterial hypertension, stroke 5 years ago and severe coronary artery disease, treated with aortocoronary bypass grafting, later obstructed. He presented spontaneous right pneumothorax with significant persistent air leak, initially treated with thoracic drainage for 6 days. Under local anesthesia and sedation, right VATS was performed with three trocars, showing apical adhesions, that were freed, and a large apical bulla that was excised with three EndoGIA-35-mm; we then added talcum powder pleurodesis [3] and one thoracic drain. After this procedure, no air leakage was presented, and the drainage was removed after 3 days. The patient was released from the hospital on the fourth day, and remains asymptomatic after 1 year follow-up. In both cases, 200 mg of mepivacaine chlorohydrate was used for local anesthesia and 5 mg of intravenous midazolam for sedation. Patients were under continuous monitoring of blood pressure, electrocardiogram, and oxygen saturation. In patients at high-risk for general anesthesia, due to advanced age, previous pathology, or both, diagnostic thoracoscopy or VATS [4] are possible under local anesthesia and sedation, allowing the employment of the same number of trocars and the same bullectomy techniques. In our experience, pleurodesis by pleural abrasion should be replaced by chemical pleurodesis with 5g of purified and sterile talcum powder. The excellent results obtained, without complication and reduced postoperative stay, indicate that this technique should be considered to resolve well selected cases. Mercedes de la Torre Bravos, MD Thoracic Surgery Department Juan Canalejo Hospital Las Jubı´as no. 84 15006-La Corun˜a, Spain © 1999 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
Juan J. Rivas de Andre´s, MD Hospital Miguel Seruet Isabel la Catolica 1 Zaragoza 50009, Spain e-mail: [email protected].
References 1. Mukaida T, Andou A, Date H, Aoe M, Shimizu N. Thoracoscopic operation for secondary pneumothorax under local and epidural anesthesia in high-risk patients. Ann Thorac Surg 1998;65:297–306. 2. Nezu K, Kushibe K, Tojo T, Takahama T, Kitamura S. Thoracoscopic wedge resection of blebs under local anesthesia with sedation for treatment of a spontaneous pneumothorax. Chest 1997;111:230–5. 3. Tschopp JM, Brutsche M, Frey JG. Treatment of complicated spontaneous pneumothorax by simple talc pleurodesis under thoracoscopy and local anesthesia. Thorax 1997;52:329–32. 4. Rivas de Andre´s JJ, Torres J. Thoracoscopy and spontaneous pneumothorax. Ann Thorac Surg 1993;55:811.
Stentless Valved Composite Graft for Bentall Operation To the Editor: I read with interest the paper by Urbanski [1]. Despite the lack of the systolic property of the aortic root using a stentless valve inserted in a rigid Dacron tube, I nevertheless agree with the opportunity to use a stentless valve in selected cases requiring a Bentall-like operation. I also performed some button-Bentall operations using a Toronto SPV bioprosthesis (St. Jude Medical, St. Paul, MN), assembled during aortic clamping period with a collagen-coated woven Dacron vascular tube (Intervascular, La Ciotat, France) for combined replacement of aortic valve, root, and ascending aorta. The advantage of choosing the stentless bioprosthesis are: (1) to have a larger orifice valve in comparison to a stented bioprosthesis for the same aortic annulus; (2) to reduce the likelihood of thromboembolism and probably prosthetic endocarditis due to the laminar blood flow through the Toronto SPV valve; and (3) possibly to prolong the durability of the bioprosthesis, reducing the commissural stress in comparison with a stented bioprosthesis. I use a slightly different technique of implantation of the Toronto SPV bioprosthesis inside the Dacron tube, in comparison with that presented in the above article [1]. The vascular tube is everted at one end leaving a rim of 5 to 7 mm. Then I first secure the Toronto SPV inside the tube, putting three single stitches to the edge at three equidistant points of the inferior suture line (the annular suture), corresponding at the three equidistant transversal color stitches of the Toronto SPV, to avoid any distortion. After sewing the bioprosthetic valve and the tube together to the native aortic annulus, as Urbanski does, the rim of the Dacron tube is inverted and sewn to a corresponding short rim of aortic root, left during dissection of the aortic root and coronary buttons. This continuous suture is useful in improving hemostasis of a weak suture line, and for better securing the Dacron tube when redo operation become necessary because of valve failure. This only takes a few more minutes, and then the posts are fixed inside the vascular tube, taking care to avoid any distortion of the Toronto SPV valve, and the sinus of Valsalva suture is complete. There is one topic on which I do not agree with Dr Urbanski. I think there is no reason to choose a Dacron tube with a smaller Ann Thorac Surg 1999;68:2383–91 • 0003-4975/99/$20.00 PII S0003-4975(99)01060-7
2384
CORRESPONDENCE
diameter than that of the bioprosthesis. The external shape of the Toronto SPV bioprosthesis is cylindrical and so the valve can be inserted into a cylinder. By reducing the annular diameter of the bioprosthesis, and by insertion in a smaller size tube, we can cause some degree of distortion to the cusps. Furthermore, increasing the surface of coaptation of the cusps causes major stress on these surfaces, and probably cause predisposition to earlier calcification. I always use a 1-mm larger Dacron tube in respect to the Toronto SPV, and at postoperative color Doppler echocardiography, both transthoracic and transesophageal, bioprosthesis incompetence was not revealed. Since usually some degree of distal ascending aorta dilation is common when Bentall operation is scheduled, employing a larger size Dacron tube yields a reduction in the chance of mismatch between the aorta and vascular prosthesis, extending the indications of this surgical technique. In conclusion, this technique is an attractive alternative in selected cases, with optimal results, but should be performed by experienced surgeons. Uberto Da Col, MD Divisione di Cardiochirurgia Ospedale Silvestrini 06100 Perugia, Italy
Reference 1. Urbanski PP. Replacement of the ascending aorta and aortic valve with a valved stentless composite graft. Ann Thorac Surg 1999;67:1501–2.
Reply To the Editor: I thank Dr Da Col for his comment on our reported technique. If I understand Dr Da Col correctly, he sutures both the tube graft and the prosthetic valve to the aortic annulus. I have abandoned this technique after a few cases. I now move the stentless valve away from the end of the Dacron tube, and only suture the tube graft to the annulus, thus we are able to later remove the prosthetic valve in cases of degeneration, without touching the proximal suture line. The added security in hemostasis Dr Da Col expects from an additional suture between the Dacron tube and the remnants of the aortic wall, does not seem necessary. Since I started using interrupted plegetted mattress sutures for the proximal anastomosis, we have not observed any bleeding problems in 25 consecutive cases. I agree with Dr Da Col, that the insertion of the valve prosthesis in a smaller tube is not an optimal solution. Unfortunately, tube grafts in odd sizes, corresponding to the valve sizes, are not commercially available. I feel that the potential hazard of late regurgitation, due to dilation of the Dacron tube as reported by Franke and colleagues [1], is increased when a prosthetic valve smaller than the tube graft is used, as Dr Da Col proposes. The discussion about oversizing or undersizing could become obsolete, if the composite graft could be prefabricated using a specially designed tube graft of exact matching size, and preferably without crimping at the site of the attachment of the prosthetic valve. Paul P. Urbanski, MD Herz- und Gefa¨ß-Klinik Salzburger Leite 1 97616 Bad Neustadt, Germany e-mail: [email protected]. © 1999 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
Ann Thorac Surg 1999;68:2383–91
Reference 1. Franke U, Jurmann MJ, Uthoff K, et al. In vivo morphology of woven, collagen-sealed Dacron prostheses in the thoracic aorta. Ann Thorac Surg 1997;64:1096– 8.
Transaortic Access for Excision of a Left Ventricular Myxoma To the Editor: Talwalkar and associates [1] recently published an alternative operative approach for excision of rare left ventricular myxoma. A left atrial approach was used with mobilization of the anterior mitral valve leaflet to enhance exposure of the subvalvar region and facilitate excision of a left ventricular myxoma, which was entangled within the chordal apparatus and lay between the anterolateral papillary muscle and the left ventricular wall. After tumor excision, the detached mitral leaflet was reattached to the annulus. A separate transventricular or transaortic approach was thus avoided. We congratulate Talwalkar and associates on their positive result. This method seems to be especially valuable if the myxoma is attached to the anterolateral papillary muscle tissue. In this special case, where a left-sided transatrial exposure alone may be difficult to achieve without risking damage to the subvalvar apparatus of the mitral valve, the method offers an elegant approach. Tear stress to the thin chordae, and possibly disrupture of the tumor, might otherwise occur while opening the mitral valve apperture with a clamp. According to the authors, other aspects of using a transleaflet access, include avoiding a ventriculotomy with possible damage to small coronary artery branches, or a transaortic approach with an increased risk for systemic embolization. On the other hand, we would like to draw attention to some hazards inherent in this method, and we therefore only consider it useful in those patients where other means are not likely to be successful. We list some items of concern below as we found a detailed discussion also missing from the article. (1) Scar healing of mitral valve tissue will eventually damage the valve apparatus; and (2) A transaortic approach may be feasible in these cases as well. Clamping the ascending aorta for bypass and applying thorough suction throughout removal of the myxoma will usually prevent systemic embolization. Recently, we operated on a patient for mitral valve myxoma using a transaortic resection. The tumor emerged from the ventricular side of the anterior valve leaflet. Intraoperatively, after dissection of the left atrium and transverse aortotomy, the large broad-based myxoma, 4 cm in diameter, became visible as it nearly reached the supraventricular area of the ascending aorta. Transaortic inspection revealed that the relatively soft tumor arose with a broad basis from parts of the anterior papillary muscle and from the backside of the anterior mitral valve leaflet. Tumor resection was followed by inspection of both atria. In our opinion, in most cases of ventricular myxoma, a transaortic approach may still be the method of choice. However, if the myxoma involves the ventricular side of the mitral valve, or is attached to chordae or the papillary muscle without direct view or direct access, or when gentle separation cannot otherwise be achieved, this alternative method should be used. Postoperatively, a scar is left on the anterior mitral valve leaflet, which might represent a weak point for future problems such as endocarditis, shrinkage, or deformation of the leaflet. Only 0003-4975/99/$20.00