- Email: [email protected]
Endomyocardial biopsy of cardiac neoplastic involvement
Ann Thorac Surg 2003;75:1358 – 64
CORRESPONDENCE
1363
Table 1. Effect of Off-Pump Versus On-Pump Surgery: Original and New (Inclusive of Use of Cell Saver or Tranexamic Acid) Adjusted Effect Sizes Original Adjusted Effect Size Odds Ratio/ Mean Difference
95% CI
p
Odds Ratio/ Mean Difference
95% CI
p
0.82
0.59 –1.12
0.22
0.94
0.62–1.24
0.75
0.36 0.43 0.45
0.27– 0.49 0.25– 0.74 0.26 – 0.79
⬍0.001 0.002 0.005
0.42 0.56 0.60
0.29 – 0.50 0.28 – 0.81 0.30 – 0.86
⬍0.001 0.05 0.07
Blood loss ⬎ 1,000 mL Transfusion RBC (units) (0 vs ⬎0) PLT (units) (0 vs ⬎0) FFP (units) (0 vs ⬎0) FFP ⫽ fresh-frozen plasma;
PLT ⫽ platelets;
RBC ⫽ red blood cells.
the off-pump group of our high-risk series [1] was 39% (19% over the same period in the whole off-pump population). Following Dr Millner’s comments, we have performed a new adjusted logistic regression analysis for blood loss and transfusion requirement, including in the statistical model the use of TA and CS as well as all other previous variables (Table 1). This analysis confirmed that the effect of off-pump surgery on blood loss ⬎1,000 mL was not significant. However, the use of offpump surgery still had a significant effect on any red blood cell (RBC) and PLT transfusions. Interestingly, despite the higher requirement of RBC transfusion in the on-pump group, on discharge, a hemoglobin level ⬍ 10 g/dL was recorded in 47% of patients in this group as compared with 29% in the off-pump group. The effect of off-pump surgery on the use of any FFP transfusion was moderately significant in the original adjusted analysis, but only reached a borderline significance in the new model. The new adjusted analysis, therefore, confirms our original findings. These seems to be supported by most of the reports in the literature, which show either similar or lower blood loss with off-pump coronary surgery, and a unanimous reduction in transfusion requirement when compared with conventional technique [4]. Raimondo Ascione, MD Barnaby C. Reeves, PhD Gianni D. Angelini, FRCS Department of Cardiac Surgery Bristol Heart Institute Bristol Royal Infirmary Upper Maudlin Street Bristol BS2 8HW, United Kingdom
References 1. Chamberlain MH, Ascione R, Reeves BC, Angelini GD. Evaluation of the effectiveness of off-pump coronary artery bypass grafting in high-risk patients: an observational study. Ann Thorac Surg 2002;73:1866 –73. 2. Angelini GD, Taylor FC, Reeves BC, Ascione R. Early and mid-term outcome after off-pump and on-pump surgery in Beating Heart Against Cardioplegic Arrest Studies (BHACAS 1 and 2): a pooled analysis of two randomised controlled trials. Lancet 2002;359:1194 –9. 3. Ascione R, Williams S, Lloyd CT, et al. Reduced postoperative blood loss and transfusion requirement after beating-heart coronary operations: a prospective randomised study. J Thorac Cardiovasc Surg 2001;121:689 –96. 4. Ascione R, Caputo M, Angelini GD. Off-pump coronary artery bypass grafting: not a flash in the pan. Ann Thorac Surg 2003;75:306 –13. © 2003 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
Endomyocardial Biopsy of Cardiac Neoplastic Involvement To the Editor: Hardikar and colleagues [1] have recently described a patient with cardiac involvement by relapsed acute lymphoblastic leukemia. The right atrial mass was surgically excised owing to right heart dysfunction. The authors emphasize the importance of early diagnosis for potential aggressive therapy. For earlier diagnosis it is worth emphasizing that intracardiac masses may also be diagnosed preoperatively using endomyocardial biopsy [2–5]. This procedure is well suited for biopsy of right-sided neoplasms, and with transseptal puncture, left atrial tumors may be diagnosed [2, 3]. Such “closed” biopsy allows early diagnosis without sternotomy. In the case of aggressive neoplasms, or cardiac involvement by metastatic tumor, it may be appropriate only to treat medically or be conservative. The critically ill patient may thus be spared anesthesia and a sternotomy. In the case of lymphoid and hematological neoplasms the diagnosis can be made and tissue for flow cytometry and cell markers can be obtained [4, 5]. With inoperable lymphoid tumors that may be treated with monoclonal antibody therapy such as Rituxan (antibody to CD20 —a marker of B cells) such determination of cell markers and accurate diagnosis may be very valuable for treatment decisions. As the paper mentions, immunocompromised patients may also have fungal infections, which may be assessed. It is important to remember that infective endocarditis may be atypical in such patients. In addition to valvular masses, mural or endocardial masses are also described in immunocompromised patients. Finally, in addition to tumor diagnosis myocardial cardiotoxicity due to prior chemotherapy, including anthracycline drugs, may be assessed and graded by heart biopsy [2]. If the patient requires additional chemotherapy, this information is also useful for treatment planning.
John P. Veinot, MD, FRCPC Department of Laboratory Medicine, Room 103 Ottawa Hospital, Civic Campus 1053 Carling Ave Ottawa, Ontario, Canada K1Y 4E9 e-mail: [email protected] 0003-4975/03/$30.00
MISCELLANEOUS
Outcome
New Adjusted Effect Size
1364
CORRESPONDENCE
References 1. Hardikar A, Shekar P, Stubberfield J, Craddock DR, Bignold LP. Cardiac involvement in a case of acute lymphoblastic leukemia. Ann Thorac Surg 2002;73:1310 –2. 2. Veinot JP. Diagnostic endomyocardial biopsy pathology: secondary myocardial diseases and other clinical indications—a review. Can J Cardiol 2002;18:287–96. 3. Chan KL, Veinot J, Leach A, Bedard P, Smith S, Marquis JF.
Ann Thorac Surg 2003;75:1358 – 64
Diagnosis of left atrial sarcoma by transvenous endocardial biopsy. Can J Cardiol 2001;17:206 –8. 4. Alter P, Grimm W, Tontsch D, Maisch B. Diagnosis of primary cardiac lymphoma by endomyocardial biopsy. Am J Med 2001;110:593–4. 5. Burling F, Devlin G, Heald S. Primary cardiac lymphoma diagnosed with transesophageal echocardiographyguided endomyocardial biopsy. Circulation 2000;101:E179 – 81.
MISCELLANEOUS
CORRESPONDENCE
1363
Table 1. Effect of Off-Pump Versus On-Pump Surgery: Original and New (Inclusive of Use of Cell Saver or Tranexamic Acid) Adjusted Effect Sizes Original Adjusted Effect Size Odds Ratio/ Mean Difference
95% CI
p
Odds Ratio/ Mean Difference
95% CI
p
0.82
0.59 –1.12
0.22
0.94
0.62–1.24
0.75
0.36 0.43 0.45
0.27– 0.49 0.25– 0.74 0.26 – 0.79
⬍0.001 0.002 0.005
0.42 0.56 0.60
0.29 – 0.50 0.28 – 0.81 0.30 – 0.86
⬍0.001 0.05 0.07
Blood loss ⬎ 1,000 mL Transfusion RBC (units) (0 vs ⬎0) PLT (units) (0 vs ⬎0) FFP (units) (0 vs ⬎0) FFP ⫽ fresh-frozen plasma;
PLT ⫽ platelets;
RBC ⫽ red blood cells.
the off-pump group of our high-risk series [1] was 39% (19% over the same period in the whole off-pump population). Following Dr Millner’s comments, we have performed a new adjusted logistic regression analysis for blood loss and transfusion requirement, including in the statistical model the use of TA and CS as well as all other previous variables (Table 1). This analysis confirmed that the effect of off-pump surgery on blood loss ⬎1,000 mL was not significant. However, the use of offpump surgery still had a significant effect on any red blood cell (RBC) and PLT transfusions. Interestingly, despite the higher requirement of RBC transfusion in the on-pump group, on discharge, a hemoglobin level ⬍ 10 g/dL was recorded in 47% of patients in this group as compared with 29% in the off-pump group. The effect of off-pump surgery on the use of any FFP transfusion was moderately significant in the original adjusted analysis, but only reached a borderline significance in the new model. The new adjusted analysis, therefore, confirms our original findings. These seems to be supported by most of the reports in the literature, which show either similar or lower blood loss with off-pump coronary surgery, and a unanimous reduction in transfusion requirement when compared with conventional technique [4]. Raimondo Ascione, MD Barnaby C. Reeves, PhD Gianni D. Angelini, FRCS Department of Cardiac Surgery Bristol Heart Institute Bristol Royal Infirmary Upper Maudlin Street Bristol BS2 8HW, United Kingdom
References 1. Chamberlain MH, Ascione R, Reeves BC, Angelini GD. Evaluation of the effectiveness of off-pump coronary artery bypass grafting in high-risk patients: an observational study. Ann Thorac Surg 2002;73:1866 –73. 2. Angelini GD, Taylor FC, Reeves BC, Ascione R. Early and mid-term outcome after off-pump and on-pump surgery in Beating Heart Against Cardioplegic Arrest Studies (BHACAS 1 and 2): a pooled analysis of two randomised controlled trials. Lancet 2002;359:1194 –9. 3. Ascione R, Williams S, Lloyd CT, et al. Reduced postoperative blood loss and transfusion requirement after beating-heart coronary operations: a prospective randomised study. J Thorac Cardiovasc Surg 2001;121:689 –96. 4. Ascione R, Caputo M, Angelini GD. Off-pump coronary artery bypass grafting: not a flash in the pan. Ann Thorac Surg 2003;75:306 –13. © 2003 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
Endomyocardial Biopsy of Cardiac Neoplastic Involvement To the Editor: Hardikar and colleagues [1] have recently described a patient with cardiac involvement by relapsed acute lymphoblastic leukemia. The right atrial mass was surgically excised owing to right heart dysfunction. The authors emphasize the importance of early diagnosis for potential aggressive therapy. For earlier diagnosis it is worth emphasizing that intracardiac masses may also be diagnosed preoperatively using endomyocardial biopsy [2–5]. This procedure is well suited for biopsy of right-sided neoplasms, and with transseptal puncture, left atrial tumors may be diagnosed [2, 3]. Such “closed” biopsy allows early diagnosis without sternotomy. In the case of aggressive neoplasms, or cardiac involvement by metastatic tumor, it may be appropriate only to treat medically or be conservative. The critically ill patient may thus be spared anesthesia and a sternotomy. In the case of lymphoid and hematological neoplasms the diagnosis can be made and tissue for flow cytometry and cell markers can be obtained [4, 5]. With inoperable lymphoid tumors that may be treated with monoclonal antibody therapy such as Rituxan (antibody to CD20 —a marker of B cells) such determination of cell markers and accurate diagnosis may be very valuable for treatment decisions. As the paper mentions, immunocompromised patients may also have fungal infections, which may be assessed. It is important to remember that infective endocarditis may be atypical in such patients. In addition to valvular masses, mural or endocardial masses are also described in immunocompromised patients. Finally, in addition to tumor diagnosis myocardial cardiotoxicity due to prior chemotherapy, including anthracycline drugs, may be assessed and graded by heart biopsy [2]. If the patient requires additional chemotherapy, this information is also useful for treatment planning.
John P. Veinot, MD, FRCPC Department of Laboratory Medicine, Room 103 Ottawa Hospital, Civic Campus 1053 Carling Ave Ottawa, Ontario, Canada K1Y 4E9 e-mail: [email protected] 0003-4975/03/$30.00
MISCELLANEOUS
Outcome
New Adjusted Effect Size
1364
CORRESPONDENCE
References 1. Hardikar A, Shekar P, Stubberfield J, Craddock DR, Bignold LP. Cardiac involvement in a case of acute lymphoblastic leukemia. Ann Thorac Surg 2002;73:1310 –2. 2. Veinot JP. Diagnostic endomyocardial biopsy pathology: secondary myocardial diseases and other clinical indications—a review. Can J Cardiol 2002;18:287–96. 3. Chan KL, Veinot J, Leach A, Bedard P, Smith S, Marquis JF.
Ann Thorac Surg 2003;75:1358 – 64
Diagnosis of left atrial sarcoma by transvenous endocardial biopsy. Can J Cardiol 2001;17:206 –8. 4. Alter P, Grimm W, Tontsch D, Maisch B. Diagnosis of primary cardiac lymphoma by endomyocardial biopsy. Am J Med 2001;110:593–4. 5. Burling F, Devlin G, Heald S. Primary cardiac lymphoma diagnosed with transesophageal echocardiographyguided endomyocardial biopsy. Circulation 2000;101:E179 – 81.
MISCELLANEOUS