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Is a Bronchopleural Fistula a Contraindication to Pleurodesis?
Is a Bronchopleural Fistula a Contraindication to Pleurodesis? To the Editor: We read with interest the description of life-threatening complications related to minocycline pleurodesis by Li and associates [1] in the September 2011 issue of The Annals of Thoracic Surgery. We are interested in their experience, have several questions based on their description, and also wish to add to the discussion. First, Li and colleagues discussed the cause of bronchopleural (BP) fistulas in general terms, but they did not describe the cause in their case. Could they elaborate on the cause of this BP fistula? In addition, the stapled bronchial stump had been torn in the bronchoscopic examination; why did this happen? Were there problems with the stapling during the operation? We would like to know more about the surgical procedure for the bronchial stump. Second, we agree that a bronchoscopic examination is not a routine postoperative examination. Considering that 16 days had passed since the surgery, should computed tomography have been used, at least once? Given that there was leakage of only forced expiratory air, Li and associates stated that it would have been difficult to differentiate a BP from an alveolar pleural (AP) fistula in this case. However, when a leak persists for more than 7 days, we believe that one should not rely on the amount of air leakage, even in the case of a small leak. A BP fistula should have been suspected earlier. Last, but not least, we disagree with the comment by Li and associates that the presence of a BP fistula with an expanded lung is not a contraindication to chemical pleurodesis. Their claim that chemical pleurodesis does not damage the underlying lung or cause significant problems is based on a report by Light and associates [2]. However, that article dealt with an AP fistula causing a pneumothorax. We believe that a BP fistula is a contraindication to pleurodesis, which may do nothing other than cause aspiration pneumonia. Mitsuhiro Kamiyoshihara, MD, PhD Toshiteru Nagashima, MD Hitoshi Igai, MD, PhD Department of General Thoracic Surgery Maebashi Red Cross Hospital 3-21-36 Asahi-Cho, Maebashi Gunma 371-0014, Japan e-mail: [email protected]
References 1. Li CY, Kuo SW, Lee JM. Life-threatening complications related to minocycline pleurodesis. Ann Thorac Surg 2011;92: 1122– 4. 2. Light RW, O’Hara VS, Moritz TE, et al. Intrapleural tetracycline for the prevention of recurrent spontaneous pneumothorax. Results of a Department of Veterans Affairs cooperative study. JAMA 1990;264:2224 –30.
The Need for Alternative Methods of Cardiopulmonary Resuscitation When Sternal Compression Is Contraindicated To the Editor: We read with great interest the case report recently published by Scherner and colleagues [1] regarding their experience with © 2012 by The Society of Thoracic Surgeons Published by Elsevier Inc
destruction of a percutaneous aortic valve implant during postoperative cardiopulmonary resuscitation (CPR) necessitated by a refractory ventricular arrhythmia unresponsive to defibrillation and drug therapy. After a total of 75 minutes of CPR, they determined that life-support action was no longer effective and the patient subsequently died. Autopsy findings revealed compression and deformation of the aortic valve prosthesis as the only abnormality caused by CPR, which most likely led to failed resuscitation. To prevent this fatal complication in future cases, they developed an alternative method of chest compression in which one rescuer compresses the left hemithorax over the apex of the heart to avoid compressing the valve while a second rescuer uses two hands to provide a stabilizing force over the right hemithorax. They reported successful use of this method in another patient who required resuscitation after transcatheter aortic valve implantation. This case report illustrates that this new technology creates a new relative contraindication with the utilization of sternal compressions (standard CPR) after cardiac arrest. The reason for damage to the percutaneous valve could be explained by a study conducted by Hwang and colleagues [2]. During transesophageal echocardiography, they found that a significant narrowing of the left ventricular outflow tract or the aorta occurred in all patients, with the degree of compression at the area of maximal compression ranging from 19% to 83% (mean ⫹/⫺ SD ⫽ 49 ⫹/⫺ 19%). We faced a similar clinical scenario during a left ventricular assist device exchange. In our case report [3], standard CPR was a known contraindication in patients with mechanical assist devices who suffer a cardiac arrest because the inflow cannula of a left ventricular assist device directly underlies the compression point of the sternum. Therefore, we immediately performed abdominal only CPR (AO-CPR) rather than not provide any external cardiac compression and/or internal cardiac massage while the surgeon rapidly deployed extra corporeal membrane oxygenation, which took 15 minutes. In our patient, AO-CPR could have served as an effective bridge between cardiac arrest and the initiation of extra corporeal membrane oxygenation because it provided a mean calculated coronary perfusion pressure of 15 mm Hg. The European Society of Cardiothoracic Surgery recently published a specific guideline by Dunning and colleagues [4] addressing the unique circumstances associated with resuscitation after cardiac surgery, including the timing of emergency resternotomy, the number of attempts at defibrillation before reopening, the administration of epinephrine, and emergency resternotomy sets. However, not addressed by the above guideline or the current American Heart Association guidelines [5] are circumstances when sternal compressions are contraindicated, such as found in these two clinical scenarios. As evidenced, there are two possible ways of addressing this problem: either provide an alternative method of external chest compression, such as provided by Scherner and colleagues [1], or use an alternative method of resuscitation, such as in our case with AO-CPR. Future research is needed to understand the mechanism of producing effective coronary perfusion pressure and the return of spontaneous circulation in both preclinical animal and human studies using these two new methods. Eric M. Rottenberg, AAS 301B Fenway Rd Columbus, OH 43214 Ann Thorac Surg 2012;93:2117–23 • 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2011.10.051
MISCELLANEOUS
CORRESPONDENCE
References 1. Li CY, Kuo SW, Lee JM. Life-threatening complications related to minocycline pleurodesis. Ann Thorac Surg 2011;92: 1122– 4. 2. Light RW, O’Hara VS, Moritz TE, et al. Intrapleural tetracycline for the prevention of recurrent spontaneous pneumothorax. Results of a Department of Veterans Affairs cooperative study. JAMA 1990;264:2224 –30.
The Need for Alternative Methods of Cardiopulmonary Resuscitation When Sternal Compression Is Contraindicated To the Editor: We read with great interest the case report recently published by Scherner and colleagues [1] regarding their experience with © 2012 by The Society of Thoracic Surgeons Published by Elsevier Inc
destruction of a percutaneous aortic valve implant during postoperative cardiopulmonary resuscitation (CPR) necessitated by a refractory ventricular arrhythmia unresponsive to defibrillation and drug therapy. After a total of 75 minutes of CPR, they determined that life-support action was no longer effective and the patient subsequently died. Autopsy findings revealed compression and deformation of the aortic valve prosthesis as the only abnormality caused by CPR, which most likely led to failed resuscitation. To prevent this fatal complication in future cases, they developed an alternative method of chest compression in which one rescuer compresses the left hemithorax over the apex of the heart to avoid compressing the valve while a second rescuer uses two hands to provide a stabilizing force over the right hemithorax. They reported successful use of this method in another patient who required resuscitation after transcatheter aortic valve implantation. This case report illustrates that this new technology creates a new relative contraindication with the utilization of sternal compressions (standard CPR) after cardiac arrest. The reason for damage to the percutaneous valve could be explained by a study conducted by Hwang and colleagues [2]. During transesophageal echocardiography, they found that a significant narrowing of the left ventricular outflow tract or the aorta occurred in all patients, with the degree of compression at the area of maximal compression ranging from 19% to 83% (mean ⫹/⫺ SD ⫽ 49 ⫹/⫺ 19%). We faced a similar clinical scenario during a left ventricular assist device exchange. In our case report [3], standard CPR was a known contraindication in patients with mechanical assist devices who suffer a cardiac arrest because the inflow cannula of a left ventricular assist device directly underlies the compression point of the sternum. Therefore, we immediately performed abdominal only CPR (AO-CPR) rather than not provide any external cardiac compression and/or internal cardiac massage while the surgeon rapidly deployed extra corporeal membrane oxygenation, which took 15 minutes. In our patient, AO-CPR could have served as an effective bridge between cardiac arrest and the initiation of extra corporeal membrane oxygenation because it provided a mean calculated coronary perfusion pressure of 15 mm Hg. The European Society of Cardiothoracic Surgery recently published a specific guideline by Dunning and colleagues [4] addressing the unique circumstances associated with resuscitation after cardiac surgery, including the timing of emergency resternotomy, the number of attempts at defibrillation before reopening, the administration of epinephrine, and emergency resternotomy sets. However, not addressed by the above guideline or the current American Heart Association guidelines [5] are circumstances when sternal compressions are contraindicated, such as found in these two clinical scenarios. As evidenced, there are two possible ways of addressing this problem: either provide an alternative method of external chest compression, such as provided by Scherner and colleagues [1], or use an alternative method of resuscitation, such as in our case with AO-CPR. Future research is needed to understand the mechanism of producing effective coronary perfusion pressure and the return of spontaneous circulation in both preclinical animal and human studies using these two new methods. Eric M. Rottenberg, AAS 301B Fenway Rd Columbus, OH 43214 Ann Thorac Surg 2012;93:2117–23 • 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2011.10.051
MISCELLANEOUS
CORRESPONDENCE