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Isolated bilateral coronary ostial stenosis with complete obstruction of the left main artery
Ann Thorac Surg 1995;59:784-94
CORRESPONDENCE
785
tomosis is being done there is no myocardial ischemia because retrograde warm blood is being infused continuously. By the time we finish the proximal anastomoses, the heart usually regains a good r h y t h m on its own, a n d once the aortic clamp is released, in most instances we are ready to come off bypass. With this method, the use of inotropes is rare a n d defibrillation is hardly ever necessary. As stated, the advantage of our technique rests in the fact that as soon as the distal anastomoses are done the myocardium is no longer ischemic and is perhaps more uniformly perfused by warm blood through the retrograde cannula. Therefore, there is a discrepancy in all our cases between ischemic time and clamp time. Once again, it was very nice to read Aranki and associates' article, which seems to support the basic philosophy of a single-clamp technique.
Department of Cardiac Surgery Brigham and Women's Hospital 75 Francis St Boston, MA 02115
Shantikumar K. Gandhi, MD
References
Cardiovascular and Thoracic Surgery Kansas Heart Institute, PA 833 Garfield Topeka, KS 66606
1. Aranki SF, Rizzo RJ, Adams DH, et al. Single-clamp technique: an important adjunct to myocardial and cerebral protection in coronary operation. A n n Thorac Surg 1994;58: 296 -303. 2. Becker H, Vinten-Johansen J, Buckberg GD, Follette DM, Robertson JM. Critical importance of ensuring cardioplegic delivery with coronary stenoses. J Thorac Cardiovasc Surg 1981;82:507-15. 3. Weisel RD, Hoy FB, Baird RJ, et al. Improved myocardial protection during a prolonged cross-clamp period. A n n Thorac Surg 1983;36:664-74. 4. Guyton RA. Myocardial protection as an integral part of overall operative strategy. Preoperative preparation a n d planning for optimal results. In: Chitwood WR, ed. Myocardial preservation: clinical applications. Philadelphia: Hanley and Belfus, 1988:279-89.
Reference 1. Aranki SF, Rizzo RJ, Adams DH, et al. Single-clamp technique: an important adjunct to myocardial and cerebral protection in coronary operation. A n n Thorac Surg 1994;58: 296-303.
Reply To the Editor: We appreciate Dr G a n d h i ' s kind comments regarding our recent report on the single-clamp technique [1]. It is interesting to know that more surgeons are using this technique than generally perceived. Doctor G a n d h i makes two very important points. He is focusing his comments mainly on the myocardial protection aspect of this technique, which we believe to be extremely important a n d is underestimated. Considering the higher frequency of cardiac complications after coronary artery bypass grafting as compared with cerebral complications it is obvious that the greatest impact of this technique would be in its contribution to myocardial protection. In the presence of critical coronary artery stenosis, there is an inevitable n o n h o m o g e n e o u s cooling and distribution of cardioplegia to ischemic myocardial zones that require it most. By sequentially constructing the distal and proximal anastomoses, and by adding retrograde delivery of cardioplegia, an even distribution and better protection is achieved. However, the most critical phase is after removal of the clamp. Using the single-clamp technique the heart is revascularized totally and is able to meet the maximal oxygen d e m a n d imposed by the reactive hyperemia that follows global ischemia. In the conventional technique of constructing the proximal anastomoses, after removal of the clamp this period constitutes, in our opinion, an "unprotected ischemia t i m e " because the heart is still critically ischemic, hyperemic, a n d no longer hypothermic. Experimental [2] and clinical studies [3] cited in our article support these observations. In a review of myocardial protection, Guyton [4] advocates the use of the single-clamp technique for the following scenarios: in the presence of severe proximal coronary stenoses, for acute myocardial ischemia, in the presence of poor left ventricular function, a n d for all coronary reoperations. These scenarios describe the type of patients that we are seeing in the current era of coronary surgery. © 1995 by The Society of Thoracic Surgeons
The second important point that Dr Gandhi makes relates to the route of cardioplegia delivery. W h e n antegrade cardioplegia alone is used it is important to perform the distal and proximal anastomoses sequentially to improve cardioplegia delivery. On the other hand, w h e n antegrade/retrograde delivery is used, the order of anastomosis construction becomes less important. Retrograde sinus perfusion with oxygenated blood during construction of the proximal anastomoses is a logical m e t h o d to reduce the duration of ischemia.
Sary F. Aranki, MD Lawrence H. Cohn, MD
Isolated Bilateral Coronary Ostial Stenosis W i t h Complete Obstruction of the Left Main A r t e r y To the Editor: We noted in the case report by Frierson a n d associates [1] that isolated bilateral ostial coronary stenosis due to atheromatous aortic disease is extremely rare, with only 6 cases reported in the literature. Isolated bilateral ostial stenosis is probably more frequently found in aortitis syndromes such as Takayasu's arteritis and syphilis, with a few case reports in orientals [2-4]. We would like to add the case of a 31-year-old Indian m a n who presented to us with class II dyspnea and angina on exertion. He was a smoker and had no other risk factor for atherosclerotic heart disease. There was no history of syphilis or tuberculosis. O n examination he h a d a pulse rate of 80 beats/ min; the pulse was felt equally at all pulse points. His blood pressure was 120/70 m m Hg. No other abnormality was detected. He h a d a normal cholesterol level (3.4 mmol/L), a n d serologic tests for syphilis were negative. Chest roentgenogram showed a normal heart shadow with no chamber enlargement, and electrocardiogram showed Q waves in leads V1-V3, T depression in leads I and avL, a n d fiat ST in leads V4-V6. A treadmill test was done using the Bruce protocol. He achieved 4 metabolic equivalents with ST depression of more than 2 m m in leads II, III, aVF, V5, a n d V6 with recovery in 4 minutes. Echocardiography showed a left ventricular ejection fraction of 0.47 and a fractional shortening of 0.24, mild aortic regurgitation, a n d trivial mitral regurgitation. Coronary angiogram showed a good-sized, well-contracfing left ventricle. Right coronary artery showed a 95% ostial stenosis (Fig 1), a n d the left coronary ostium was completely obstructed with retrograde filling from the right coronary artery (Fig 2). 0003-4975/95/$9.50
786
CORRESPONDENCE
Ann Thorac Surg 1995;59:784-94
accounting for 0.06% of patients having coronary angiograms [5]. Our patient had isolated bilateral coronary ostial stenosis with complete obstruction of the left coronary ostium and 95% ostial stenosis of the right coronary artery with no risk factors for atherosclerosis or aortitis syndromes. In spite of his severe disease he had only class II symptoms.
Adarsh Subrahmanyam Koppula, MCh Moosekunhi M. Koppalla, MCh Kurudamannil A. Abraham, MD Komarakshi Rajagopal Balakrishnan, MCh Department of Cardiovascular Surgery Southern Railway Headquarters Hospital Madras-600 023 India References
Fig 1. Right coronary sinus injection in left anterior oblique projection shows 95% right ostial stenosis with a normal right coronary artery distally.
He was operated on with a left internal mammary artery graft to the left anterior descending artery and a saphenous vein graft to the right coronary artery. He had an uneventful recovery, and follow-up at 3 months showed him to be free of angina. Complete obstruction of the left main coronary artery is rare,
Fig 2. Right coronary injection in left anterior oblique view shows normal fight coronary artery and retrograde filling of left main coronary artery up to its origin. © 1995 by The Society of Thoracic Surgeons
1. Frierson JH, Duke DJ, Berney BW, Molloy TA, Dimas AP. Isolated bilateral ostial coronary artery stenoses. Ann Thorac Surg 1993;55:993-4. 2. Tanaka K, Mizutani T, Yada I, Yuasa H, Kusagawa M. Aortocoronary bypass grafting for bilateral coronary ostial stenosis caused by Takayasu's aortitis [Letter]. J Thorac Cardiovasc Surg 1990;99:948-9. 3. Takei M, Sasaki Y, Suyama K, et al. Surgically treated case of complete obstruction of the left main coronary artery caused by Takayasu's arteritis. Am Heart J 1993;126:458-9. 4. Nakashima H, Takahara A, Yoshioka M. A case of left coronary obstruction due to syphilitic aortitis. Kokyu To Junkan 1991;39:831-5. 5. Zimmern SH, Rogers WJ, Bream PR, et al. Total occlusion of the left main coronary artery: the Coronary Artery Surgery Study (CASS) experience. Am J Cardiol 1982;49:2003-10.
Intraperitoneal Migration of an AICD Generator Placed in a Posterior Rectus Pocket To the Editor: The automatic implantable cardioverter defibrillator (AICD) has become a common therapeutic option for malignant cardiac rhythm disturbances. A small percentage of patients in whom these devices are implanted will complain of persistent discomfort or suffer a generator box migration or erosion. To minimize the risk of these complications, authors have described placing the generator in the properitoneal space [1]. Recently in this journal Habal and associates [2] advocated the use of a pocket posterior to the rectus muscle. We wish to report a patient who sut~ered a complication from an AICD generator implanted in this position. The patient was an 80-year-old man who underwent placement of a CPI Ventak 1600 (Cardiac Pacemakers, Inc, St. Paul MN) AICD device for a ventricular tachycardic arrest. The procedure was performed at an outside hospital well experienced in cardiac procedures. Nine months later he presented to his internist with migrating abdominal pain. A rectal mass was detected on physical examination, and a computed tomographic scan was obtained. The latter demonstrated the AICD generator in the patient's pelvis (Fig 1). On surgical exploration, it was discovered that the device had penetrated the posterior rectus sheath and peritoneum, and was free in the peritoneal cavity. A section of distended small bowel was entangled in the leads. The posterior rectus fascia and surrounding tissue appeared to be of normal quality. Intraoperative testing demonstrated the leads to be fully functional but the device would not cardiovert the patient at 30 J. As this particular device was under recall by the manufacturer, it was replaced with a similar unit. This generator 0003-4975/95l$9.50
CORRESPONDENCE
785
tomosis is being done there is no myocardial ischemia because retrograde warm blood is being infused continuously. By the time we finish the proximal anastomoses, the heart usually regains a good r h y t h m on its own, a n d once the aortic clamp is released, in most instances we are ready to come off bypass. With this method, the use of inotropes is rare a n d defibrillation is hardly ever necessary. As stated, the advantage of our technique rests in the fact that as soon as the distal anastomoses are done the myocardium is no longer ischemic and is perhaps more uniformly perfused by warm blood through the retrograde cannula. Therefore, there is a discrepancy in all our cases between ischemic time and clamp time. Once again, it was very nice to read Aranki and associates' article, which seems to support the basic philosophy of a single-clamp technique.
Department of Cardiac Surgery Brigham and Women's Hospital 75 Francis St Boston, MA 02115
Shantikumar K. Gandhi, MD
References
Cardiovascular and Thoracic Surgery Kansas Heart Institute, PA 833 Garfield Topeka, KS 66606
1. Aranki SF, Rizzo RJ, Adams DH, et al. Single-clamp technique: an important adjunct to myocardial and cerebral protection in coronary operation. A n n Thorac Surg 1994;58: 296 -303. 2. Becker H, Vinten-Johansen J, Buckberg GD, Follette DM, Robertson JM. Critical importance of ensuring cardioplegic delivery with coronary stenoses. J Thorac Cardiovasc Surg 1981;82:507-15. 3. Weisel RD, Hoy FB, Baird RJ, et al. Improved myocardial protection during a prolonged cross-clamp period. A n n Thorac Surg 1983;36:664-74. 4. Guyton RA. Myocardial protection as an integral part of overall operative strategy. Preoperative preparation a n d planning for optimal results. In: Chitwood WR, ed. Myocardial preservation: clinical applications. Philadelphia: Hanley and Belfus, 1988:279-89.
Reference 1. Aranki SF, Rizzo RJ, Adams DH, et al. Single-clamp technique: an important adjunct to myocardial and cerebral protection in coronary operation. A n n Thorac Surg 1994;58: 296-303.
Reply To the Editor: We appreciate Dr G a n d h i ' s kind comments regarding our recent report on the single-clamp technique [1]. It is interesting to know that more surgeons are using this technique than generally perceived. Doctor G a n d h i makes two very important points. He is focusing his comments mainly on the myocardial protection aspect of this technique, which we believe to be extremely important a n d is underestimated. Considering the higher frequency of cardiac complications after coronary artery bypass grafting as compared with cerebral complications it is obvious that the greatest impact of this technique would be in its contribution to myocardial protection. In the presence of critical coronary artery stenosis, there is an inevitable n o n h o m o g e n e o u s cooling and distribution of cardioplegia to ischemic myocardial zones that require it most. By sequentially constructing the distal and proximal anastomoses, and by adding retrograde delivery of cardioplegia, an even distribution and better protection is achieved. However, the most critical phase is after removal of the clamp. Using the single-clamp technique the heart is revascularized totally and is able to meet the maximal oxygen d e m a n d imposed by the reactive hyperemia that follows global ischemia. In the conventional technique of constructing the proximal anastomoses, after removal of the clamp this period constitutes, in our opinion, an "unprotected ischemia t i m e " because the heart is still critically ischemic, hyperemic, a n d no longer hypothermic. Experimental [2] and clinical studies [3] cited in our article support these observations. In a review of myocardial protection, Guyton [4] advocates the use of the single-clamp technique for the following scenarios: in the presence of severe proximal coronary stenoses, for acute myocardial ischemia, in the presence of poor left ventricular function, a n d for all coronary reoperations. These scenarios describe the type of patients that we are seeing in the current era of coronary surgery. © 1995 by The Society of Thoracic Surgeons
The second important point that Dr Gandhi makes relates to the route of cardioplegia delivery. W h e n antegrade cardioplegia alone is used it is important to perform the distal and proximal anastomoses sequentially to improve cardioplegia delivery. On the other hand, w h e n antegrade/retrograde delivery is used, the order of anastomosis construction becomes less important. Retrograde sinus perfusion with oxygenated blood during construction of the proximal anastomoses is a logical m e t h o d to reduce the duration of ischemia.
Sary F. Aranki, MD Lawrence H. Cohn, MD
Isolated Bilateral Coronary Ostial Stenosis W i t h Complete Obstruction of the Left Main A r t e r y To the Editor: We noted in the case report by Frierson a n d associates [1] that isolated bilateral ostial coronary stenosis due to atheromatous aortic disease is extremely rare, with only 6 cases reported in the literature. Isolated bilateral ostial stenosis is probably more frequently found in aortitis syndromes such as Takayasu's arteritis and syphilis, with a few case reports in orientals [2-4]. We would like to add the case of a 31-year-old Indian m a n who presented to us with class II dyspnea and angina on exertion. He was a smoker and had no other risk factor for atherosclerotic heart disease. There was no history of syphilis or tuberculosis. O n examination he h a d a pulse rate of 80 beats/ min; the pulse was felt equally at all pulse points. His blood pressure was 120/70 m m Hg. No other abnormality was detected. He h a d a normal cholesterol level (3.4 mmol/L), a n d serologic tests for syphilis were negative. Chest roentgenogram showed a normal heart shadow with no chamber enlargement, and electrocardiogram showed Q waves in leads V1-V3, T depression in leads I and avL, a n d fiat ST in leads V4-V6. A treadmill test was done using the Bruce protocol. He achieved 4 metabolic equivalents with ST depression of more than 2 m m in leads II, III, aVF, V5, a n d V6 with recovery in 4 minutes. Echocardiography showed a left ventricular ejection fraction of 0.47 and a fractional shortening of 0.24, mild aortic regurgitation, a n d trivial mitral regurgitation. Coronary angiogram showed a good-sized, well-contracfing left ventricle. Right coronary artery showed a 95% ostial stenosis (Fig 1), a n d the left coronary ostium was completely obstructed with retrograde filling from the right coronary artery (Fig 2). 0003-4975/95/$9.50
786
CORRESPONDENCE
Ann Thorac Surg 1995;59:784-94
accounting for 0.06% of patients having coronary angiograms [5]. Our patient had isolated bilateral coronary ostial stenosis with complete obstruction of the left coronary ostium and 95% ostial stenosis of the right coronary artery with no risk factors for atherosclerosis or aortitis syndromes. In spite of his severe disease he had only class II symptoms.
Adarsh Subrahmanyam Koppula, MCh Moosekunhi M. Koppalla, MCh Kurudamannil A. Abraham, MD Komarakshi Rajagopal Balakrishnan, MCh Department of Cardiovascular Surgery Southern Railway Headquarters Hospital Madras-600 023 India References
Fig 1. Right coronary sinus injection in left anterior oblique projection shows 95% right ostial stenosis with a normal right coronary artery distally.
He was operated on with a left internal mammary artery graft to the left anterior descending artery and a saphenous vein graft to the right coronary artery. He had an uneventful recovery, and follow-up at 3 months showed him to be free of angina. Complete obstruction of the left main coronary artery is rare,
Fig 2. Right coronary injection in left anterior oblique view shows normal fight coronary artery and retrograde filling of left main coronary artery up to its origin. © 1995 by The Society of Thoracic Surgeons
1. Frierson JH, Duke DJ, Berney BW, Molloy TA, Dimas AP. Isolated bilateral ostial coronary artery stenoses. Ann Thorac Surg 1993;55:993-4. 2. Tanaka K, Mizutani T, Yada I, Yuasa H, Kusagawa M. Aortocoronary bypass grafting for bilateral coronary ostial stenosis caused by Takayasu's aortitis [Letter]. J Thorac Cardiovasc Surg 1990;99:948-9. 3. Takei M, Sasaki Y, Suyama K, et al. Surgically treated case of complete obstruction of the left main coronary artery caused by Takayasu's arteritis. Am Heart J 1993;126:458-9. 4. Nakashima H, Takahara A, Yoshioka M. A case of left coronary obstruction due to syphilitic aortitis. Kokyu To Junkan 1991;39:831-5. 5. Zimmern SH, Rogers WJ, Bream PR, et al. Total occlusion of the left main coronary artery: the Coronary Artery Surgery Study (CASS) experience. Am J Cardiol 1982;49:2003-10.
Intraperitoneal Migration of an AICD Generator Placed in a Posterior Rectus Pocket To the Editor: The automatic implantable cardioverter defibrillator (AICD) has become a common therapeutic option for malignant cardiac rhythm disturbances. A small percentage of patients in whom these devices are implanted will complain of persistent discomfort or suffer a generator box migration or erosion. To minimize the risk of these complications, authors have described placing the generator in the properitoneal space [1]. Recently in this journal Habal and associates [2] advocated the use of a pocket posterior to the rectus muscle. We wish to report a patient who sut~ered a complication from an AICD generator implanted in this position. The patient was an 80-year-old man who underwent placement of a CPI Ventak 1600 (Cardiac Pacemakers, Inc, St. Paul MN) AICD device for a ventricular tachycardic arrest. The procedure was performed at an outside hospital well experienced in cardiac procedures. Nine months later he presented to his internist with migrating abdominal pain. A rectal mass was detected on physical examination, and a computed tomographic scan was obtained. The latter demonstrated the AICD generator in the patient's pelvis (Fig 1). On surgical exploration, it was discovered that the device had penetrated the posterior rectus sheath and peritoneum, and was free in the peritoneal cavity. A section of distended small bowel was entangled in the leads. The posterior rectus fascia and surrounding tissue appeared to be of normal quality. Intraoperative testing demonstrated the leads to be fully functional but the device would not cardiovert the patient at 30 J. As this particular device was under recall by the manufacturer, it was replaced with a similar unit. This generator 0003-4975/95l$9.50