Hemorrhage during Redo Sternotomy

97 Correspondence

the clip. This maneuver prolongs the operation by only one or two more minutes, and provides a safe and complete closure.

G. Merin, M . D . Department of Curdiothoracic Surgery Lady Davis Carmel Hospital 7 , Michal St 34362 Haifa, Israel

Hemorrhage during Redo Sternotomy To the Editor: I read with interest the article on catastrophic hemorrhage during redo stemotomy by Dobell and Jain in The Annuls (Ann Thorac Surg 37273,1984). I have encountered this problem and am satisfied with the following maneuver for dealing with it. During performance of a repeat median sternotomy with a cast-cutting oscillating saw, a 6-cm laceration of the right ventricle occurred. The massive hemorrhage was controlled fairly well by plugging, and the external iliac artery was quickly exposed and cannulated. A 38F balloon tracheal tube was inserted into the right atrium through the ventricular tear and the tricuspid valve, As soon as the balloon was inflated and with the tube maintained under gentle traction, hemostasis was fully obtained and cardiopulmonary bypass initiated. Conventional cannulation of the venae cavae through the right atrium was eventually performed, and the right ventricular tear was easily repaired. Subsequent replacement of a degenerated mitral bioprosthesis was achieved without any problem. The patient’s postoperative course was uneventful. I think this technique might be useful to others in such disagreeable circumstances.

E. Negre, M . D . Service de Chirurgie Thoracique et Cardio-Vasculaire Hopital Saint-Elon Centre Hospitalier et Universituire de Montpelier 34059 Montpelier, France

Reply To the Editor: I think we may learn many useful tricks in the correspondence relating to our article, “Catastrophic Hemorrhage during Redo Sternotomy.” Dr. Negre describes such a maneuver, and I hope The Annals will have space for other techniques to be applied in similarly desperate situations. Basic to these recovery techniques is the preparation or actual prophylactic cannulation of groin vessels. Anthony R. C. Dobell, M . D . Division of Cardiovascular and Thoracic Surgery The Montreal Children’s Hospital 2300 Tupper Montreal, PQ, Canada H3H 1P3

Hydroxyethyl Starch in CABG To the Editor: I was quite pleased to read the recent reports in The Annals by Kirklin and colleagues [ l ] and by Belcher and Lennox [2] con-

cerning the use of hydroxyethyl starch (HES) in myocardial revascularization. In 1982, Drs. Cosgrove, Lester, and I reported the results of a prospective randomized trial of HES and albumin for volume expansion in patients after coronary bypass [3]. Sixty patients participated in the trial, 33 of whom received a mean of 1,210 ml of HES during the first 24 postoperative hours. We found a slight elevation of prothrombin and partial thromboplastin times at 24 hours and a depression of fibrinogen levels on postoperative day 7 in the HES group when compared with the albumin group. In addition, mediastinal drainage was slightly elevated in the HES group. However, none of these differences achieved statistical significance. These effects of HES on coagulation profile were also noted by Kirklin and colleagues, and the differences between the HES and albumin groups were reported as significant. The patients in their study received a mean of 1,847 ml of HES, approximately 600 ml more than our patients received. Belcher and Lennox did not report any differences in coagulation variables between the HES and control groups, but their patients received a mean of 866 ml of HES. This suggests a dose-dependent effect of HES on coagulation as opposed to a hemodilution effect. Clinically, despite these mild derangements in coagulation profile, HES appears to be a viable alternative to blood and blood by-products for postoperative volume expansion in cardiac patients. In view of the large volume of coronary artery procedures being performed in North America, the expanded use of HES will undoubtedly result in substantial financial savings and conservation of banked blood.

James T. Diehl, M . D . Department of Cardiovascular Surgery University of Toronto Toronto General Hospital Toronto, Ont, Canada M5G 1L7

References 1. Kirklin JK, Lell WA, Kouchoukos NT Hydroxyethyl starch versus albumin for colloid infusion following cardiopulmonary bypass in patients undergoing myocardial revascularization. Ann Thorac Surg 3740, 1984 2. Belcher P, Lennox SC: Avoidance of blood transfusion in coronary artery surgery: a trial of hydroxyethyl starch. Ann Thorac Surg 37365, 1984 3. Diehl JT, Lester JL 111, Cosgrove DM: Clinical comparison of hetastarch and albumin in postoperative cardiac patients. Ann Thorac Surg 34:674, 1982

Reply To the Editor: My associates and I certainly agree with Dr. Diehl that HES is a viable alternative to other colloid osmotic agents for volume expansion following coronary artery surgery. The small differences among coagulation studies of HES remain unexplained. As he indicates, use of HES does not correlate with increased clinical bleeding. Although there may be a dose-dependent effect of HES on coagulation, I know of no direct evidence to support this notion. In fact, as reported in our study, there was no relationship between the total dose of HES and the amount of clinically apparent bleeding following cardiac surgical procedures. Although the effects on the coagulation system appear to be mild, I believe that they should be considered when ad-