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Coronary artery bypass grafting without splenectomy
CORRESPONDENCE
Repair of Thoracic Dissections To the Editor: In February 1989, we reported treating the ascending aorta with 25% glutaraldehyde solution before graft insertion in patients with type A thoracic aortic dissections [l]. Since the report, we have operated on 5 additional patients without technical difficulty in the same manner described in our report. However, we have recently encountered a serious complication that may have been related to glutaraldehyde usage. We wish to bring this problem to the readership’s attention. On January 28,1990, a 65-year-old patient underwent resection of the ascending aorta from 5 mm above the coronary ostia to the mid transverse arch for an acute type A thoracic dissection. After the resection was completed, the proximal and distal ends of the remaining aorta were treated for 7 minutes with 25% glutaraldehyde-soaked cotton balls. The graft was sewn in place and the patient came off cardiopulmonary bypass without difficulty. However, the patient could not be weaned from positivepressure ventilation and required tracheostomy on the 14th postoperative day. Three months later, we are still unable to wean the patient from the ventilator. We performed a phrenic nerve conduction study and found that when the phrenic nerves were stimulated percutaneously in the neck, neither diaphragm moved. In the laboratory, we found that when the phrenic nerve came in contact with 25% glutaraldehyde solution for 4.5 minutes, the nerve lost its ability to conduct. Conduction did not return 1 hour later when the experiment was terminated. In the patient in question, we believe that the glutaraldehyde may have come in contact with the phrenic nerves as they pass around the aortic arch and caution that it is essential to protect the phrenic nerves with Silastic sheeting or some other form of impermeable barrier while applying the glutaraldehyde to the distal ascending aorta or aortic arch.
Graeme L. Hammond, M D Department of Surgey Yule University School of Medicine 333 Cedar St, PO Box 3333 New Haven, CT 06510-8062
Reference 1. Vasseur B, Hammond GL. New technique for repair of ascending thoracic aortic dissections. Ann Thorac Surg 1989;47: 318-9.
Postoperative Drainage and Pericardial Effusion To the Editor: We read with interest the paper by Smulders and associates [l] showing that the incidence of postoperative pericardial effusion was not reduced by prolonging chest tube drainage time. We wish to draw attention to a similar recent study from our previous institution (21, where the criteria for drainage tube removal were standard but the placement of drainage tubes was not. Patients had either a single anterior mediastinal drainage tube or a posterior pericardial and an anterior mediastinal drainage tube. We found that posterior pericardial effusion was significantly more common in those with a single anterior chest tube, and in addition these patients had a significantly higher incidence of late postoperative tamponade. We therefore suggest that although duration of chest drainage may not alter the incidence of postoperative effusion, the positioning of drainage 0 1990 by The Society of Thoracic Surgeons
tubes may alter the incidence of both postoperative effusion and late cardiac tamponade.
Alan 1. 8y a n , FRCS Papworth Hospital Cambridge, UK Gianni D. Angelini, M D , MCh, FRCS Northern General Hospital Sheffield, UK
References 1. Smulders YM, Wiepking ME, Moulijn AC, et al. How soon should drainage tubes be removed after cardiac operations? Ann Thorac Surg 1989;48:540-3. 2. Angelini GD, Penny WJ, El-Ghamary F, et al. The incidence and significance of early pericardial effusion after open heart surgery. Eur J Cardiothoracic Surg 1987;1:165-8.
Reply
To the Editor:
In their paper, Angelini and co-workers convincingly demonstrated the risks of using only a single drainage tube placed in the anterior mediastinum. We agree that it is much safer to use both a posterior pericardial and an anterior mediastinal drainage tube. This conviction partly originates in our observation that, during the postoperative course, the pericardial and mediastinal drains often show completely different output patterns. This suggests that clots and/or newly formed fibrinous adhesions may soon separate the posterior pericardial and the anterior mediastinal space. This may happen even more readily if the pericardium is (partly) closed, which is recommendable because it facilitates possible reoperation and because the closed pericardium can act as a barrier against infection during the postoperative period. However, we feel that even if the pericardium is left open, a posterior pericardial chest tube is necessary to ensure the drainage of fluid accumulating behind the heart when the patient is in supine position during the early postoperative course, and thus to reduce the incidence of postoperative pericardial effusion and the risk of cardiac tamponade.
Yvo M . Smulders, M D Adrian C. Moulijn, M D , PhD Iacques 1. Koolen, M D , PhD Academic Medical Center Meibergdreef 9 1105 AZ Amsterdam, The Netherlands
Coronary Artery Bypass Grafting Without Splenectomy To the Editor: It was with considerable interest that 1 read the presentations of Thompson and associates [ l ] and Koike and colleagues [2] in consecutive issues of The Annuls. Thompson and colleagues demonstrated the safety of performing cardiac operations in patients with idiopathic thrombocytopenic purpura (ITP) without prophylactic or concomitant splenectomy. On the other hand Koike and colleagues espoused simultaneous cardiac surgery and splenectomy “as an ideal surgical procedure” for ITP patients based on success with their patient. As attested to by the cited references of these two papers the world’s literature is not flooded with advice on how to handle the Ann Thorac Surg 1990;50:330-7
0003-4975/90/$3.50
Ann Thorac Surg 1990;50:33&7
ITP patient in need of cardiac surgery. Having borne personal witness to the patient presented in Dr Thompson’s paper, I drew from this experience in the following case. A 53-year-old woman underwent cardiac catheterization for atypical chest pain and a borderline stress test. She had chronic ITP diagnosed 6 months previously. At the time of her cardiac catheterization she had been off steroids for 2 months and her platelet count was 65 x 109/L.During the procedure the left main coronary artery was dissected, extending down both the left anterior descending and circumflex coronary arteries with subsequent severe chest pain, S-T segment elevation, and cardiogenic shock. She underwent emergency coronary artery bypass grafting with reverse saphenous vein grafts to the left anterior descending coronary artery and an obtuse marginal branch of the circumflex. One gram of methylprednisolone was given intravenously before the induction of anesthesia. After cardiopulmonary bypass and the administration of protamine, 12 units of platelets and 0.3 &kg of arginine vasopressin were administered intravenously. An attempt to give yglobulin as described by Schmidt [3] was aborted with less than half the calculated dose given because of induced hypotension. The first platelet count postoperatively was 130 x 109/L. There was no excessive bleeding. The platelet count remained greater than 100 x 109/L with continued steroid dosage, which was slowly tapered after 2 weeks. This patient now represents the third reported ITP patient undergoing coronary artery bypass grafting without splenectomy. In view of this and the fact that not everyone with ITP requires splenectomy it is difficult to categorize concomitant CABG and splenectomy as “ideal.” These patients certainly pose the risk of hemorrhagic complications, but I believe their treatment has to be individualized. Preoperative in vivo assessment of platelet dynamics as performed by Thompson and associates is certainly worthwhile as is assessment of steroid response. Splenectomy should be reserved for those who demonstrate a bleeding problem after platelet transfusion and steroids, and thrombocytopenia is the culprit.
Greg A. Bowman, M D Thoracic Surgery Service Brooke A r m y Medical Center Fort Sam Houston, TX 78234
References 1. Thompson LD, Cohen AJ, Edwards FH, Barry MJ. Coronary artery bypass in idiopathic thrombocytopenia without splenectomy. Ann Thorac Surg 1989;48:721-2. 2. Koike R, Suma H, Obu T, et al. Combined coronary revascularization and splenectomy. Ann Thorac Surg 1989;48:85?-4. 3. Schmidt RE. High dose intravenous gammaglobulin for idiopathic thrombocytopenia purpura. Lancet 1981;2:475-6.
Reply
To the Editor:
Doctor Thompson and associates [l] indicate that use of cardiopulmonary bypass in patients with ITP does not invariably mandate splenectomy. It is a fact that corticosteroid or massive yglobulin administration offer clinical remissions, and not everyone with ITP requires splenectomy. Splenectomy should be indicated in some patients with chronic ITP in whom such a medical therapy is not effective. In our patient [2], aggravation of angina pectoris was induced by preoperative yglobulin administration, but the increase in platelets was not enough. He also experienced ventricular ar-
CORRESPONDENCE
331
rhythmia during coronary angiography due to contrast media injection. His coronary artery was considered to be very sensitive to increased blood viscosity caused by massive yglobulin, contrast media, or the increase in platelets. The patient’s status was chronic and did not respond to medical therapy. Splenectomy as well as coronary revascularization was considered to be necessary for him. We thought that a one-stage operation was convenient for the patient because he could resume his normal life and return to work after a few months, instead of returning to the hospital for a second operation, splenectomy. Considering his younger age, we performed the one-stage operation of coronary revascularization using arterial grafting and splenectomy, although there was no previous report. We have preferentially been performing a gastroepiploic artery-right coronary artery anastomosis instead of using the right internal mammary artery. The dissection and division of the gastroepiploic artery, however, does not compromise the organs in the abdomen from our clinical experience. Splenectomy itself is not a serious invasion as coronary revascularization using the splenic artery has been reported [3]. Of great importance is the choice of conduit in such a patient: vein graft or arterial graft? Victorzon and co-workers [4] reported that not only native coronary artery but also saphenous vein revealed hyperconstriction in response to endogenous serotonin released from circulating platelets. Homcy and associates [5] reported that long-term administration of steroids made saphenous vein fragile. In the patients on steroids with platelet disorders, saphenous vein may be highly occluded. So, arterial graft should be the graft of choice. We emphasize that GEA grafting is very convenient for revascularization in the patients requiring laparotomy as described above.
Ryu Koike, M D Department of Thoracic Surgery Osaka Medical College 2-7 Daigakucho, Takatsukishi Osaka 569, japan
References 1. Thompson LD, Cohen AJ, Edwards FH, Barry MJ. Coronary artery bypass in idiopathic thrombocytopenia without splenectomy. Ann Thorac Surg 1989;48:721-2. 2. Koike R, Suma H, Oku T, Satoh H, Sawada Y, Takeuchi A. Combined coronary revascularization and splenectomy. Ann Thorac Surg 1989;48:8534. 3. Edwards WS, Blakely WR, Lewis CE. Technique of coronary bypass with autogenous arteries. J Thorac Cardiovasc Surg 1973;65:272-5. 4. Victorzon M, Tapparelli C, Muller-Schwinitzer E. Comparison of the actions of serotoninergic agents on human saphenous veins and platelets. Eur J Pharmacol 1986;124:107-11. 5. Homcy CJ, Liberthson RR, Fallon JT, Gross S, Miller LM. Ischemic heart disease in systemic lupus erythematosus in the young patients: report of six cases. Am J Cardiol 1982;49: 47844.
Closed Chest Cardiac Massage To the Editor: I read with interest Classics in Thoracic Surgery, ”The Introduction of Closed Chest Cardiac Massage,” by Steven F. Bolling [l]. When I read it my memory flew back to around 1958 when Dr Hugh A. Stout stopped me in the hallway of Mercy Hospital in
Repair of Thoracic Dissections To the Editor: In February 1989, we reported treating the ascending aorta with 25% glutaraldehyde solution before graft insertion in patients with type A thoracic aortic dissections [l]. Since the report, we have operated on 5 additional patients without technical difficulty in the same manner described in our report. However, we have recently encountered a serious complication that may have been related to glutaraldehyde usage. We wish to bring this problem to the readership’s attention. On January 28,1990, a 65-year-old patient underwent resection of the ascending aorta from 5 mm above the coronary ostia to the mid transverse arch for an acute type A thoracic dissection. After the resection was completed, the proximal and distal ends of the remaining aorta were treated for 7 minutes with 25% glutaraldehyde-soaked cotton balls. The graft was sewn in place and the patient came off cardiopulmonary bypass without difficulty. However, the patient could not be weaned from positivepressure ventilation and required tracheostomy on the 14th postoperative day. Three months later, we are still unable to wean the patient from the ventilator. We performed a phrenic nerve conduction study and found that when the phrenic nerves were stimulated percutaneously in the neck, neither diaphragm moved. In the laboratory, we found that when the phrenic nerve came in contact with 25% glutaraldehyde solution for 4.5 minutes, the nerve lost its ability to conduct. Conduction did not return 1 hour later when the experiment was terminated. In the patient in question, we believe that the glutaraldehyde may have come in contact with the phrenic nerves as they pass around the aortic arch and caution that it is essential to protect the phrenic nerves with Silastic sheeting or some other form of impermeable barrier while applying the glutaraldehyde to the distal ascending aorta or aortic arch.
Graeme L. Hammond, M D Department of Surgey Yule University School of Medicine 333 Cedar St, PO Box 3333 New Haven, CT 06510-8062
Reference 1. Vasseur B, Hammond GL. New technique for repair of ascending thoracic aortic dissections. Ann Thorac Surg 1989;47: 318-9.
Postoperative Drainage and Pericardial Effusion To the Editor: We read with interest the paper by Smulders and associates [l] showing that the incidence of postoperative pericardial effusion was not reduced by prolonging chest tube drainage time. We wish to draw attention to a similar recent study from our previous institution (21, where the criteria for drainage tube removal were standard but the placement of drainage tubes was not. Patients had either a single anterior mediastinal drainage tube or a posterior pericardial and an anterior mediastinal drainage tube. We found that posterior pericardial effusion was significantly more common in those with a single anterior chest tube, and in addition these patients had a significantly higher incidence of late postoperative tamponade. We therefore suggest that although duration of chest drainage may not alter the incidence of postoperative effusion, the positioning of drainage 0 1990 by The Society of Thoracic Surgeons
tubes may alter the incidence of both postoperative effusion and late cardiac tamponade.
Alan 1. 8y a n , FRCS Papworth Hospital Cambridge, UK Gianni D. Angelini, M D , MCh, FRCS Northern General Hospital Sheffield, UK
References 1. Smulders YM, Wiepking ME, Moulijn AC, et al. How soon should drainage tubes be removed after cardiac operations? Ann Thorac Surg 1989;48:540-3. 2. Angelini GD, Penny WJ, El-Ghamary F, et al. The incidence and significance of early pericardial effusion after open heart surgery. Eur J Cardiothoracic Surg 1987;1:165-8.
Reply
To the Editor:
In their paper, Angelini and co-workers convincingly demonstrated the risks of using only a single drainage tube placed in the anterior mediastinum. We agree that it is much safer to use both a posterior pericardial and an anterior mediastinal drainage tube. This conviction partly originates in our observation that, during the postoperative course, the pericardial and mediastinal drains often show completely different output patterns. This suggests that clots and/or newly formed fibrinous adhesions may soon separate the posterior pericardial and the anterior mediastinal space. This may happen even more readily if the pericardium is (partly) closed, which is recommendable because it facilitates possible reoperation and because the closed pericardium can act as a barrier against infection during the postoperative period. However, we feel that even if the pericardium is left open, a posterior pericardial chest tube is necessary to ensure the drainage of fluid accumulating behind the heart when the patient is in supine position during the early postoperative course, and thus to reduce the incidence of postoperative pericardial effusion and the risk of cardiac tamponade.
Yvo M . Smulders, M D Adrian C. Moulijn, M D , PhD Iacques 1. Koolen, M D , PhD Academic Medical Center Meibergdreef 9 1105 AZ Amsterdam, The Netherlands
Coronary Artery Bypass Grafting Without Splenectomy To the Editor: It was with considerable interest that 1 read the presentations of Thompson and associates [ l ] and Koike and colleagues [2] in consecutive issues of The Annuls. Thompson and colleagues demonstrated the safety of performing cardiac operations in patients with idiopathic thrombocytopenic purpura (ITP) without prophylactic or concomitant splenectomy. On the other hand Koike and colleagues espoused simultaneous cardiac surgery and splenectomy “as an ideal surgical procedure” for ITP patients based on success with their patient. As attested to by the cited references of these two papers the world’s literature is not flooded with advice on how to handle the Ann Thorac Surg 1990;50:330-7
0003-4975/90/$3.50
Ann Thorac Surg 1990;50:33&7
ITP patient in need of cardiac surgery. Having borne personal witness to the patient presented in Dr Thompson’s paper, I drew from this experience in the following case. A 53-year-old woman underwent cardiac catheterization for atypical chest pain and a borderline stress test. She had chronic ITP diagnosed 6 months previously. At the time of her cardiac catheterization she had been off steroids for 2 months and her platelet count was 65 x 109/L.During the procedure the left main coronary artery was dissected, extending down both the left anterior descending and circumflex coronary arteries with subsequent severe chest pain, S-T segment elevation, and cardiogenic shock. She underwent emergency coronary artery bypass grafting with reverse saphenous vein grafts to the left anterior descending coronary artery and an obtuse marginal branch of the circumflex. One gram of methylprednisolone was given intravenously before the induction of anesthesia. After cardiopulmonary bypass and the administration of protamine, 12 units of platelets and 0.3 &kg of arginine vasopressin were administered intravenously. An attempt to give yglobulin as described by Schmidt [3] was aborted with less than half the calculated dose given because of induced hypotension. The first platelet count postoperatively was 130 x 109/L. There was no excessive bleeding. The platelet count remained greater than 100 x 109/L with continued steroid dosage, which was slowly tapered after 2 weeks. This patient now represents the third reported ITP patient undergoing coronary artery bypass grafting without splenectomy. In view of this and the fact that not everyone with ITP requires splenectomy it is difficult to categorize concomitant CABG and splenectomy as “ideal.” These patients certainly pose the risk of hemorrhagic complications, but I believe their treatment has to be individualized. Preoperative in vivo assessment of platelet dynamics as performed by Thompson and associates is certainly worthwhile as is assessment of steroid response. Splenectomy should be reserved for those who demonstrate a bleeding problem after platelet transfusion and steroids, and thrombocytopenia is the culprit.
Greg A. Bowman, M D Thoracic Surgery Service Brooke A r m y Medical Center Fort Sam Houston, TX 78234
References 1. Thompson LD, Cohen AJ, Edwards FH, Barry MJ. Coronary artery bypass in idiopathic thrombocytopenia without splenectomy. Ann Thorac Surg 1989;48:721-2. 2. Koike R, Suma H, Obu T, et al. Combined coronary revascularization and splenectomy. Ann Thorac Surg 1989;48:85?-4. 3. Schmidt RE. High dose intravenous gammaglobulin for idiopathic thrombocytopenia purpura. Lancet 1981;2:475-6.
Reply
To the Editor:
Doctor Thompson and associates [l] indicate that use of cardiopulmonary bypass in patients with ITP does not invariably mandate splenectomy. It is a fact that corticosteroid or massive yglobulin administration offer clinical remissions, and not everyone with ITP requires splenectomy. Splenectomy should be indicated in some patients with chronic ITP in whom such a medical therapy is not effective. In our patient [2], aggravation of angina pectoris was induced by preoperative yglobulin administration, but the increase in platelets was not enough. He also experienced ventricular ar-
CORRESPONDENCE
331
rhythmia during coronary angiography due to contrast media injection. His coronary artery was considered to be very sensitive to increased blood viscosity caused by massive yglobulin, contrast media, or the increase in platelets. The patient’s status was chronic and did not respond to medical therapy. Splenectomy as well as coronary revascularization was considered to be necessary for him. We thought that a one-stage operation was convenient for the patient because he could resume his normal life and return to work after a few months, instead of returning to the hospital for a second operation, splenectomy. Considering his younger age, we performed the one-stage operation of coronary revascularization using arterial grafting and splenectomy, although there was no previous report. We have preferentially been performing a gastroepiploic artery-right coronary artery anastomosis instead of using the right internal mammary artery. The dissection and division of the gastroepiploic artery, however, does not compromise the organs in the abdomen from our clinical experience. Splenectomy itself is not a serious invasion as coronary revascularization using the splenic artery has been reported [3]. Of great importance is the choice of conduit in such a patient: vein graft or arterial graft? Victorzon and co-workers [4] reported that not only native coronary artery but also saphenous vein revealed hyperconstriction in response to endogenous serotonin released from circulating platelets. Homcy and associates [5] reported that long-term administration of steroids made saphenous vein fragile. In the patients on steroids with platelet disorders, saphenous vein may be highly occluded. So, arterial graft should be the graft of choice. We emphasize that GEA grafting is very convenient for revascularization in the patients requiring laparotomy as described above.
Ryu Koike, M D Department of Thoracic Surgery Osaka Medical College 2-7 Daigakucho, Takatsukishi Osaka 569, japan
References 1. Thompson LD, Cohen AJ, Edwards FH, Barry MJ. Coronary artery bypass in idiopathic thrombocytopenia without splenectomy. Ann Thorac Surg 1989;48:721-2. 2. Koike R, Suma H, Oku T, Satoh H, Sawada Y, Takeuchi A. Combined coronary revascularization and splenectomy. Ann Thorac Surg 1989;48:8534. 3. Edwards WS, Blakely WR, Lewis CE. Technique of coronary bypass with autogenous arteries. J Thorac Cardiovasc Surg 1973;65:272-5. 4. Victorzon M, Tapparelli C, Muller-Schwinitzer E. Comparison of the actions of serotoninergic agents on human saphenous veins and platelets. Eur J Pharmacol 1986;124:107-11. 5. Homcy CJ, Liberthson RR, Fallon JT, Gross S, Miller LM. Ischemic heart disease in systemic lupus erythematosus in the young patients: report of six cases. Am J Cardiol 1982;49: 47844.
Closed Chest Cardiac Massage To the Editor: I read with interest Classics in Thoracic Surgery, ”The Introduction of Closed Chest Cardiac Massage,” by Steven F. Bolling [l]. When I read it my memory flew back to around 1958 when Dr Hugh A. Stout stopped me in the hallway of Mercy Hospital in