- Email: [email protected]
Long-term preservation of isolated heart
Ann Thorac Surg 2001;71:397– 404
CORRESPONDENCE
403
Reply To the Editor: We greatly appreciate Dr Tovar’s comments and his addition of references. There are several minimally invasive routes available to achieve ectopic parathyroid resection and it is difficult to compare them adequately. As noted in our manuscript, we feel that thoracoscopy has many advantages in our hands, which include excellent visualization and control along with short hospital stay and few postoperative complications. Familiarity with the multiple choices of access should allow all surgeons to make informed decisions for their patients. Cristina Medrano, MD Rodney J. Landreneau, MD Theresa M. Boley, MSN Tilitha Shawgo, RN Anthony Grasch, PA-C Stephen R. Hazelrigg, MD Fig 2. Thymus gland containing a large parathyroid adenoma in the left lower pole removed through a transcervical approach. (Reprinted with permission from Tovar [2].)
sured 3.5 cm in maximum diameter (Fig 2). The patient met the criteria normally used for an outpatient procedure but was kept in the hospital overnight to monitor calcium levels. Although my report did not appear in an Index Medicus journal and was published after Medrano and associates submitted their article for publication, in it I quoted and referenced a subxiphoid approach [3] published in 1995, and an anterior mediastinal access [4] published in 1991 for resection of mediastinal ectopic parathyroid adenomas. In addition, in the same article I mentioned that in 1976, Freeman and associates [5] referred to transcervical thymectomy as an integral part of neck exploration for hyperparathyroidism. I congratulate Medrano and coauthors for bringing to our attention this interesting topic, their elegant management, and superb results. Eduardo A. Tovar, MD Department of Cardiothoracic Surgery University of California, Irvine Medical Center 100 E Valencia Mesa Dr, Suite 301 Fullerton, CA 92835 e-mail: [email protected].
References 1. Medrano C, Hazelrigg SR, Landreneau RJ, Boley TM, Shawgo T, Grasch A. Thoracoscopic resection of ectopic parathyroid glands. Ann Thorac Surg 2000;69:221–3. 2. Tovar EA. Transcervical resection of an aorticopulmonary window parathyroid tumor. Surg Rounds 1999;22:638– 40. 3. Wei JP, Gadacz TR, Weisner LF, Burke GJ. The subxiphoid laparoscopic approach for resection of mediastinal parathyroid adenoma after successful localization with TC-99msestamibi radionuclide scan. Surg Laparosc Endosc 1995;5: 402– 6. 4. Schlinkert RT, Whitaker MD, Argueta R. Resection of select mediastinal parathyroid adenomas through an anterior mediastinotomy. Mayo Clinic Proc 1991;66:1110–3. 5. Freeman JB, Sherman BM, Mason EE. Transcervical thymectomy—an integral part of neck exploration for hyperparathyroidism. Arch Surg 1976;111:359– 64. © 2001 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
Southern Illinois University School of Medicine PO Box 19638 Springfield, IL e-mail: [email protected].
Long-term Preservation of Isolated Heart To the Editor: We read with interest the article by Ou and associates in the November 1999 issue of The Annals of Thoracic Surgery [1]. In this study, Ou and coworkers show that the levels of adenosine triphosphate (ATP) in St. Thomas’ solution (ST)-treated and University of Wisconsin solution (UW)-treated hearts at 25°C were lower than for corresponding groups at 4°C ( p ⬍ 0.01). The ATP concentration was not significantly different in UW and ST hearts at 4°C. After storage at 25°C, the level was lower in the UW group than in the ST group ( p ⬍ 0.05). Consequently, UW at higher temperatures is not favorable for storage of the heart. We have previously published a partly similar study [2]. A lot of experimental studies have claimed that UW is significantly superior to ST in long-term preservation under hypothermic conditions. However, other studies point out that UW is inferior to ST [3]. There is also a plethora of research comparing the results of adding various pharmacological agents into the solutions. Besides these discussions, we have performed this study in order to improve the long- and short-term storage quality of the UW and ST solutions. In our study, four different solutions (UW, ST, and their modifications by pentoxyfillin [Ptx]) are investigated with regard to adenine nucleotide catabolism in the short- and long-term storage of cardiac explant. The four solutions are compared in the following groups: 1) ST vs UW; 2) ST vs ST ⫹ Ptx; 3) UW vs UW ⫹ Ptx; and 4) ST ⫹ Ptx vs UW ⫹ Ptx. Cobays of the same gender and age were heparinized and their hearts were excised under anesthesia. The hearts were perfused and transmural myocardial biopsies were taken after 10 minutes and 1, 3, 6, and 12 hours. Energy Charge Ratio (ECR) was calculated on the basis of adenosine triphosphate (ATP), adenosine diphosphate (ADP), and adenosine monophosphate (AMP) values. Consequently, in the long-term preservation of isolated cobay heart under hypothermic conditions, UW has been found to be significantly superior to ST ( p ⬍ 0.05). The addition of Ptx to ST displays a preserving effect on ATP levels in the tissue after 1, 3, and 6 hours. This result can be explained by the finding that Ptx is the inhibitor 0003-4975/01/$20.00
404
CORRESPONDENCE
of 5⬘ nucleotidase; it decreases the effect of cytokine production and increases the effect of prostaglandin synthesis. However, UW solution and Ptx do not appear to be a suitable combination for preserving ATP contents under hypothermic conditions. ¨ zyazıcıog˘lu, MD Ahmet O Azman Ates¸, MD Ibrahim Yekeler, MD Department of Cardiovascular Surgery Atatu¨rk University School of Medicine 25240 Erzurum, Turkey e-mail: [email protected].
Ann Thorac Surg 2001;71:397– 404
References 1. Ou R, Gavin JB, Esmore DS, et al. Increased temperature reduces the protective effect of University of Wisconsin solution in the heart. Ann Thorac Surg 1999;68:1628–35. ¨ zyazıcıog˘lu A, Ceviz M, Yekeler I, et al. Long-term preser2. O vation of isolated cobay heart with the solution of University ¨ TD of Wisconsin, St. Thomas’ II and their modifications. AU 1996;28:220–5. 3. Choong YS, Gavin JB. Functional recovery of hearts after cardioplegia and storage in University of Wisconsin and in St. Thomas’ Hospital solutions. J Heart Lung Transplant 1991;10: 537– 46.
REVIEW OF RECENT BOOKS Key Topics in Thoracic Surgery Edited by A.G. Casson, MB, ChB, FRCSC, and M.R. Johnston, MD, FRCSC Oxford, United Kingdom, BIOS Scientific Publishers, Ltd, 1999 296 pp, illustrated, £22.95 ISBN: 185996155X Reviewed by Nicholas J. Demos, MD This text in the ever-expanding field of general thoracic surgery consists of 80, small, easy-reading chapters designed as a “ . . . quick reference for senior medical students . . . and other postgraduate trainees. . . .” Compare it for instance with the 2000 5th edition of the Shields text, General Thoracic Surgery, Fifth Edition (Philadelphia, PA: Lippincott Williams & Wilkins) consisting of 2,500 pages, which “should be used when further detail is needed. . . .” At the end of each three- to six-page chapter, suggested further reading and cross references to other chapters of the text are very helpful indeed. The chapters on achalasia, adult respiratory distress syndrome, anesthesia, bronchoscopy, antireflux surgery, and Barrett’s esophagus are the little jewels of the book written by recognized master surgeons and anesthetists. However, mention could have been made in the text and in the index of emergency complications of gastroesophageal reflux such as serious hemorrhage, since the house officers reading this book are the first doctors faced with such emergencies. Moreover, a few more details and references might have been given on the stapled, uncut gastroplasty and fundoplication for hiatal hernia, about which a three-decade follow-up has now been available (Demos NJ, Dis Esoph, 1999;12:14) with rather good results. The procedure has been the procedure of choice with surgeons in the Mayo Clinic, Montreal, and in Europe. The chapter on chylothorax is an excellent pre´cis of this uncommon but important subject. The word “symphysis” could
© 2001 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
have been used to describe pleural obliteration instead of “synthesis” (page 55, line 14). Mention could also have been made of the role of gastrointestinal hormones in the treatment of chylothorax. The last chapter dealing with Video-Assisted Thoracic Surgery fails to mention hiatal hernioplasty as a possibility. The chapters on congenital bronchopulmonary anomalies are again a good summary. The authors could have stimulated the imagination of the young readers by mentioning the unified concept of the theory of development of these abnormalities. The several chapters on reflux stress the importance and value of an esophagram and gastrointestinal x-rays which are all but forgotten by gastroenterologists. The chapter on pectus excavatum could have mentioned the simple strut elevation, Nuss procedure, performed in recent years. Excellent coverage is given on esophageal cancer staging and treatment. Even though the subject is frequently depressing, we are frequently called upon to palliate the patient’s symptoms. Quality of life could be stressed a bit more. The high incidence of post-resection gastroesophageal and oral reflux and aspiration, up to 65% in the Chinese, Boston and Mayo Clinic experiences, could have been dealt with and methods mentioned to prevent it, such as the intercostal pedicle procedure (Dis Esoph 1995;8:142) with which we now have a three-decade-long experience. The chapter on lung cancer chemotherapy is the very first of ten chapters on lung cancer probably heralding a depressing outlook. Lung transplantation, surgery for emphysema, mediastinal tumors, corrosive esophageal injury and cricopharyngeal disorders are succinctly covered. Even though this text is written for young students and house officers to whom I wholeheartedly recommend it, I plan to consult it myself as a quick reference. Jersey City, New Jersey
Ann Thorac Surg 2001;71:404 • 0003-4975/01/$20.00 PII S0003-4975(00)02383-3
CORRESPONDENCE
403
Reply To the Editor: We greatly appreciate Dr Tovar’s comments and his addition of references. There are several minimally invasive routes available to achieve ectopic parathyroid resection and it is difficult to compare them adequately. As noted in our manuscript, we feel that thoracoscopy has many advantages in our hands, which include excellent visualization and control along with short hospital stay and few postoperative complications. Familiarity with the multiple choices of access should allow all surgeons to make informed decisions for their patients. Cristina Medrano, MD Rodney J. Landreneau, MD Theresa M. Boley, MSN Tilitha Shawgo, RN Anthony Grasch, PA-C Stephen R. Hazelrigg, MD Fig 2. Thymus gland containing a large parathyroid adenoma in the left lower pole removed through a transcervical approach. (Reprinted with permission from Tovar [2].)
sured 3.5 cm in maximum diameter (Fig 2). The patient met the criteria normally used for an outpatient procedure but was kept in the hospital overnight to monitor calcium levels. Although my report did not appear in an Index Medicus journal and was published after Medrano and associates submitted their article for publication, in it I quoted and referenced a subxiphoid approach [3] published in 1995, and an anterior mediastinal access [4] published in 1991 for resection of mediastinal ectopic parathyroid adenomas. In addition, in the same article I mentioned that in 1976, Freeman and associates [5] referred to transcervical thymectomy as an integral part of neck exploration for hyperparathyroidism. I congratulate Medrano and coauthors for bringing to our attention this interesting topic, their elegant management, and superb results. Eduardo A. Tovar, MD Department of Cardiothoracic Surgery University of California, Irvine Medical Center 100 E Valencia Mesa Dr, Suite 301 Fullerton, CA 92835 e-mail: [email protected].
References 1. Medrano C, Hazelrigg SR, Landreneau RJ, Boley TM, Shawgo T, Grasch A. Thoracoscopic resection of ectopic parathyroid glands. Ann Thorac Surg 2000;69:221–3. 2. Tovar EA. Transcervical resection of an aorticopulmonary window parathyroid tumor. Surg Rounds 1999;22:638– 40. 3. Wei JP, Gadacz TR, Weisner LF, Burke GJ. The subxiphoid laparoscopic approach for resection of mediastinal parathyroid adenoma after successful localization with TC-99msestamibi radionuclide scan. Surg Laparosc Endosc 1995;5: 402– 6. 4. Schlinkert RT, Whitaker MD, Argueta R. Resection of select mediastinal parathyroid adenomas through an anterior mediastinotomy. Mayo Clinic Proc 1991;66:1110–3. 5. Freeman JB, Sherman BM, Mason EE. Transcervical thymectomy—an integral part of neck exploration for hyperparathyroidism. Arch Surg 1976;111:359– 64. © 2001 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
Southern Illinois University School of Medicine PO Box 19638 Springfield, IL e-mail: [email protected].
Long-term Preservation of Isolated Heart To the Editor: We read with interest the article by Ou and associates in the November 1999 issue of The Annals of Thoracic Surgery [1]. In this study, Ou and coworkers show that the levels of adenosine triphosphate (ATP) in St. Thomas’ solution (ST)-treated and University of Wisconsin solution (UW)-treated hearts at 25°C were lower than for corresponding groups at 4°C ( p ⬍ 0.01). The ATP concentration was not significantly different in UW and ST hearts at 4°C. After storage at 25°C, the level was lower in the UW group than in the ST group ( p ⬍ 0.05). Consequently, UW at higher temperatures is not favorable for storage of the heart. We have previously published a partly similar study [2]. A lot of experimental studies have claimed that UW is significantly superior to ST in long-term preservation under hypothermic conditions. However, other studies point out that UW is inferior to ST [3]. There is also a plethora of research comparing the results of adding various pharmacological agents into the solutions. Besides these discussions, we have performed this study in order to improve the long- and short-term storage quality of the UW and ST solutions. In our study, four different solutions (UW, ST, and their modifications by pentoxyfillin [Ptx]) are investigated with regard to adenine nucleotide catabolism in the short- and long-term storage of cardiac explant. The four solutions are compared in the following groups: 1) ST vs UW; 2) ST vs ST ⫹ Ptx; 3) UW vs UW ⫹ Ptx; and 4) ST ⫹ Ptx vs UW ⫹ Ptx. Cobays of the same gender and age were heparinized and their hearts were excised under anesthesia. The hearts were perfused and transmural myocardial biopsies were taken after 10 minutes and 1, 3, 6, and 12 hours. Energy Charge Ratio (ECR) was calculated on the basis of adenosine triphosphate (ATP), adenosine diphosphate (ADP), and adenosine monophosphate (AMP) values. Consequently, in the long-term preservation of isolated cobay heart under hypothermic conditions, UW has been found to be significantly superior to ST ( p ⬍ 0.05). The addition of Ptx to ST displays a preserving effect on ATP levels in the tissue after 1, 3, and 6 hours. This result can be explained by the finding that Ptx is the inhibitor 0003-4975/01/$20.00
404
CORRESPONDENCE
of 5⬘ nucleotidase; it decreases the effect of cytokine production and increases the effect of prostaglandin synthesis. However, UW solution and Ptx do not appear to be a suitable combination for preserving ATP contents under hypothermic conditions. ¨ zyazıcıog˘lu, MD Ahmet O Azman Ates¸, MD Ibrahim Yekeler, MD Department of Cardiovascular Surgery Atatu¨rk University School of Medicine 25240 Erzurum, Turkey e-mail: [email protected].
Ann Thorac Surg 2001;71:397– 404
References 1. Ou R, Gavin JB, Esmore DS, et al. Increased temperature reduces the protective effect of University of Wisconsin solution in the heart. Ann Thorac Surg 1999;68:1628–35. ¨ zyazıcıog˘lu A, Ceviz M, Yekeler I, et al. Long-term preser2. O vation of isolated cobay heart with the solution of University ¨ TD of Wisconsin, St. Thomas’ II and their modifications. AU 1996;28:220–5. 3. Choong YS, Gavin JB. Functional recovery of hearts after cardioplegia and storage in University of Wisconsin and in St. Thomas’ Hospital solutions. J Heart Lung Transplant 1991;10: 537– 46.
REVIEW OF RECENT BOOKS Key Topics in Thoracic Surgery Edited by A.G. Casson, MB, ChB, FRCSC, and M.R. Johnston, MD, FRCSC Oxford, United Kingdom, BIOS Scientific Publishers, Ltd, 1999 296 pp, illustrated, £22.95 ISBN: 185996155X Reviewed by Nicholas J. Demos, MD This text in the ever-expanding field of general thoracic surgery consists of 80, small, easy-reading chapters designed as a “ . . . quick reference for senior medical students . . . and other postgraduate trainees. . . .” Compare it for instance with the 2000 5th edition of the Shields text, General Thoracic Surgery, Fifth Edition (Philadelphia, PA: Lippincott Williams & Wilkins) consisting of 2,500 pages, which “should be used when further detail is needed. . . .” At the end of each three- to six-page chapter, suggested further reading and cross references to other chapters of the text are very helpful indeed. The chapters on achalasia, adult respiratory distress syndrome, anesthesia, bronchoscopy, antireflux surgery, and Barrett’s esophagus are the little jewels of the book written by recognized master surgeons and anesthetists. However, mention could have been made in the text and in the index of emergency complications of gastroesophageal reflux such as serious hemorrhage, since the house officers reading this book are the first doctors faced with such emergencies. Moreover, a few more details and references might have been given on the stapled, uncut gastroplasty and fundoplication for hiatal hernia, about which a three-decade follow-up has now been available (Demos NJ, Dis Esoph, 1999;12:14) with rather good results. The procedure has been the procedure of choice with surgeons in the Mayo Clinic, Montreal, and in Europe. The chapter on chylothorax is an excellent pre´cis of this uncommon but important subject. The word “symphysis” could
© 2001 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
have been used to describe pleural obliteration instead of “synthesis” (page 55, line 14). Mention could also have been made of the role of gastrointestinal hormones in the treatment of chylothorax. The last chapter dealing with Video-Assisted Thoracic Surgery fails to mention hiatal hernioplasty as a possibility. The chapters on congenital bronchopulmonary anomalies are again a good summary. The authors could have stimulated the imagination of the young readers by mentioning the unified concept of the theory of development of these abnormalities. The several chapters on reflux stress the importance and value of an esophagram and gastrointestinal x-rays which are all but forgotten by gastroenterologists. The chapter on pectus excavatum could have mentioned the simple strut elevation, Nuss procedure, performed in recent years. Excellent coverage is given on esophageal cancer staging and treatment. Even though the subject is frequently depressing, we are frequently called upon to palliate the patient’s symptoms. Quality of life could be stressed a bit more. The high incidence of post-resection gastroesophageal and oral reflux and aspiration, up to 65% in the Chinese, Boston and Mayo Clinic experiences, could have been dealt with and methods mentioned to prevent it, such as the intercostal pedicle procedure (Dis Esoph 1995;8:142) with which we now have a three-decade-long experience. The chapter on lung cancer chemotherapy is the very first of ten chapters on lung cancer probably heralding a depressing outlook. Lung transplantation, surgery for emphysema, mediastinal tumors, corrosive esophageal injury and cricopharyngeal disorders are succinctly covered. Even though this text is written for young students and house officers to whom I wholeheartedly recommend it, I plan to consult it myself as a quick reference. Jersey City, New Jersey
Ann Thorac Surg 2001;71:404 • 0003-4975/01/$20.00 PII S0003-4975(00)02383-3