- Email: [email protected]
Penetrating injury of the innominate artery
CORRESPONDENCE
Ann Thorac Surg
365
1992;53:3W
minutes. The level in the reservoir would rise with the addition of dilute blood, commensurate with administrationof cerebroplegia in the antegrade group. We did not observe this phenomenon in the retrograde group. We speculate that there was much more resistance to the efflux of retrograde cerebroplegia (carotid arteries to aortic arch to descending aorta to femoral artery to arterial line to impeller pump) into the arterial line. Although the jugular venous perfusion pressure was kept very low in the retrograde group, we suspect that the pressure in the brachiocephalic vessels was significantly greater than zero (unlike Ueda and associates‘patients with an open aortic arch). For this reason we believe that the diminution in the transcerebral pressure gradient led to cerebral edema. We would urge that the report by Ueda and associates be interpreted with caution. It is unclear whether their patients received barbituates before circulatory arrest or had external cranial cooling as is common practice in North America. The mean circulatory arrest time for their patients was only 35.6 minutes. This is well within the 45-minute time frame that has been shown to produce satisfactory results in similar patients without brain perfusion [2,3]. What is more, Ueda and associates perfused the brain through the jugular vein with unadulterated pump blood. Unfortunately even in the absence of circulatory arrest, clinical and subclinical neurologic injury occurs with cardiopulmonary bypass [4, 51. We believe that for true cerebroplegia to be established, the brain should be perfused with a solution that will preserve metabolic function of the brain and return the electrochemical processes of the brain back to baseline after a protracted period of circulatory arrest. More work is needed to achieve this end.
Michael D . Crittenden, M D Division of Cardiothoracic and Vascular Surgery Howard University Hospital 2041 Georgia Ave, N W , Suite 4B04 Washington, DC 20060
References 1. Ueda Y, Miki S, Kusuhara K, Okita Y, Tahata T, Yamanaka K. Surgical treatment of aneurysm or dissection involving the ascending aorta and aortic arch, utilizing circulatory arrest and retrograde cerebral perfusion. J Cardiovasc Surg 1990;31: 553-8. 2. Ergin MA, OConnor J, Guinto R, Griep RB. Experience with profound hypothermia and circulatory arrest in the treatment of aneurysms of the aortic arch: aortic arch replacement for acute aorch dissecions. J Thorac Cardiovasc Surg 1982;M 647-55. 3. Griepp RB, Stinson EB, Hollingsworth JF, Buehler D. Prosthetic replacement of the aortic arch. J Thorac Cardiovasc Surg 1975;701051-63. 4. Newman SP. The incidence and nature of neuropsychological morbidity following cardiac surgery. Perfusion 1989;4:93-100. 5. Clarkson PM, MacArthur BA, Barratt-Boyes BG, Whitlock Rh4, Neutze JM. Developmental progress following cardiac surgery in infancy using profound hypothermia and circulatory arrest. Circulation 1980;62:85561.
Single Venous Cannulation for Valve Operations To the Editor: In a Letter to the Editor published in The Annals of Thoracic Surgery [l], Drs Balasundaram and Duran referred to a recently published article in which the authors were unaware that a technical innovation had been described 9 years earlier. Dr Balasundaram
and associates [2] published an article concerning single venous cannulation for valve operations. I hasten to point out that this technical advance was first published in 1959 by Blanco and co-workers [3]. The original article described in great detail a major contribution to surgical technique, including clinical experience from 1957. The 1950s may appear prehistoric to a new generation of cardiac surgeons, but I am delighted to call attention to a scientific contribution made 31 years ago.
George Robinson, M D Division of Cardiothoracic Surgery St. Luke’slRoosevelt Hospital Center New York, NY 10025
References 1. Balasundaram S, Duran CMG. Mitral prosthetic replacement in small left atria. Ann Thorac Surg 1991;51:1046. 2. Balasundaram S, Vega JL, Duran CMG. Single venous cannulation through the right atrium for venous return in valve operations. Ann Thorac Surg 1991;51:506-7. 3. Blanco G, Oca C, Baltar ER, Nichols HT, Bailey CP. Single catheter gravity drainage of the right atrium or right ventricle during total cardiac bypass. Dis Chest 1959;35:554-60.
Penetrating Injury of the Innominate Artery To the Editor: In the January 1991 issue of The Annals, McLean and McManus [l] presented a case of penetrating trauma involving the innominate artery. Reported experiences with this kind of vascular injury are very rare. We reported a case of penetrating injury of the innominate artery in 1983 [2]. We had double-ligated this artery during operation but the vessel was found to be recanalized 1 year after operation. The innominate artery was then repaired by using an 8-mm Dacron tube graft interposed between the ascending aorta and the distal end of the innominate artery. A 19-year-old man was brought to our emergency room in profound shock. He had been stabbed 2 hours before. The wound was in the sternal end of the left third intercostal space and extended to the right, beneath the sternum. Chest roentgenogram showed a large left hemothorax and marked widening of the superior mediastinum. Penetrating injury to one of the mediastinal arteries was suspected, and the patient was operated on immediately. A median sternotomy was camed out. There was a large hematoma in the mediastinum. The innominate artery had partially been cut 1 cm above its origin. The active bleeding was controlled with digital compression, and because prolonged attempts to repair the laceration would jeopardize the patient‘s life, the innominate artery was ligated. This procedure was tolerated well by the patient. There was no permanent neurologic deficit; however, right subclavian steal syndrome was present. Because of the long-standing postoperative wound infection, reconstructive intervention could not be done at this stage. When the wound infection subsided the patient was discharged with the suggestion of a second operation for reconstruction of the innominate artery, which was necessary. The patient disappeared for a long period of time, however. One year later he showed up and he had no complaints. There were no limitations in his physical activity, even during exercise. Finding of the right radial and carotid pulses was surprising. Retrograde angio-
366
Ann Thorac Surg 1992;53:3&3-8
CORRESPONDENCE
Fig 1 . Angiogram shows recanalization of the ligated innominate artery (arrow). graphic examination showed the recanalization of the ligated innominate artery (Fig 1). In the second operation two silk sutures, used in the original ligation of the innominate artery, were found to have cut through the wall and lay within a small aneurysmal sac. This part of the innominate artery was excised, and the origin of the innominate artery at the aorta was sutured. An 8-mm Dacron prosthesis was interposed between the ascending aorta and the distal end of the innominate artery.
Having performed close to 200 open heart cases with this new form of myocardial protection, I reviewed the last 100 cases of nonredo, isolated aortocoronary bypass grafting done using cold intermittent blood cardioplegia, as well as 100 cases of warm continuous retrograde blood cardioplegia. Comparison studies showed no significant difference in the surgical outcome of these two groups, as indicated in Table 1. All deaths involved male patients, age 62 and 60 years in the warm cardioplegia group and 66 years in the cold cardioplegia group. The first patient died 19 days postoperatively of a sudden pulmonary embolus, after an initially difficult time due to chronic obstructive pulmonary disease that required 5 days on ventilatory support. The second underwent uneventful triple aortocoronary bypass grafting; after an initially stable postoperative period, the patient became hypotensive with low cardiac output that could not be reversed, and the patient died in a low cardiac output state due to ischemic cardiomyopathy. At the autopsy all grafts were found to be patent and no localized infarct was seen; extensive myocardial fibrosis and generalized ischemic myocardium were found. The last patient died late. Having undergone a laparotomy for control of gastrointestinal bleeding, the patient suffered a pulmonary embolus the day after discharge from the hospital. Although there was no major difference in the outcome of these two small groups of patients, we have been very pleased with the degree of myocardial protection provided by the use of continuous warm blood cardioplegia, particularly with the retrograde infusion. It appears to provide good ventricular myocardial distribution and does not necessitate the use of multiple lines and cannulas attached to the newly placed grafts, which is particularly advantageous for those of us who do distal anastomoses first. I should note, however, that during the initial phases of adaptation to this technique we noticed an unusual number of patients with postoperative atrial fibrillation and, although we did not document this problem in numbers, this impression was shared by all four cardiac surgeons. At the time, we were using continuous cardioplegia flows between 50 and 150 mWmin and could see the presence of persistent P waves on the electrocardiographic monitor throughout the period of ventricular arrest.
Table 1. Comparison of the Two Groups
Acar Tokcan, M D Department of Cardiovascular Surgery Cukurova University Medical Faculty 01330 BalcalilAdana, Turkey
References 1. McLean TR, McManus RP. Penetrating trauma involving the innominate artery. Ann Thorac Surg 1991;51:11M. 2. Tokcan A, Salih OK, GekirdekG A, Yeniocak A. [Penetrating injury of the innominate artery]. GATA Bulteni 1983;25: 1235-45.
Retrograde Continuous Warm Blood Cardioplegia
To the Editor:
I read with interest the report from Salemo and associates [l] on the technique and pitfalls of retrograde continuous warm blood cardioplegia. After verbal reports from members of the group at St. Michael's Hospital in Toronto, our group began using continuous warm blood cardioplegia in the spring of 1990 and have become quite comfortable with the technique.
Variable
Warm Continuous Blood Cardioplegia
Cold Intermittent Blood Cardioplegia
p Value
~
No. of Patients Maletfemale Average no. of grafts Av. ischemic time per graft Average age (y) Operation Elective Urgent Emergency Intraaortic balloon Pump Deaths Atrial fibrillation NS = not sigruficant.
100 84/16 3.4 15 min 21 s
3.43 14 min 10 s
NS NS NS <0.01
59.96
62.68
<0.025
25 67 8 3 (1preop)
23 74 2 4 (1preop)
NS NS NS
2
1
NS
7
5
NS
100 8Ot20
NS
Ann Thorac Surg
365
1992;53:3W
minutes. The level in the reservoir would rise with the addition of dilute blood, commensurate with administrationof cerebroplegia in the antegrade group. We did not observe this phenomenon in the retrograde group. We speculate that there was much more resistance to the efflux of retrograde cerebroplegia (carotid arteries to aortic arch to descending aorta to femoral artery to arterial line to impeller pump) into the arterial line. Although the jugular venous perfusion pressure was kept very low in the retrograde group, we suspect that the pressure in the brachiocephalic vessels was significantly greater than zero (unlike Ueda and associates‘patients with an open aortic arch). For this reason we believe that the diminution in the transcerebral pressure gradient led to cerebral edema. We would urge that the report by Ueda and associates be interpreted with caution. It is unclear whether their patients received barbituates before circulatory arrest or had external cranial cooling as is common practice in North America. The mean circulatory arrest time for their patients was only 35.6 minutes. This is well within the 45-minute time frame that has been shown to produce satisfactory results in similar patients without brain perfusion [2,3]. What is more, Ueda and associates perfused the brain through the jugular vein with unadulterated pump blood. Unfortunately even in the absence of circulatory arrest, clinical and subclinical neurologic injury occurs with cardiopulmonary bypass [4, 51. We believe that for true cerebroplegia to be established, the brain should be perfused with a solution that will preserve metabolic function of the brain and return the electrochemical processes of the brain back to baseline after a protracted period of circulatory arrest. More work is needed to achieve this end.
Michael D . Crittenden, M D Division of Cardiothoracic and Vascular Surgery Howard University Hospital 2041 Georgia Ave, N W , Suite 4B04 Washington, DC 20060
References 1. Ueda Y, Miki S, Kusuhara K, Okita Y, Tahata T, Yamanaka K. Surgical treatment of aneurysm or dissection involving the ascending aorta and aortic arch, utilizing circulatory arrest and retrograde cerebral perfusion. J Cardiovasc Surg 1990;31: 553-8. 2. Ergin MA, OConnor J, Guinto R, Griep RB. Experience with profound hypothermia and circulatory arrest in the treatment of aneurysms of the aortic arch: aortic arch replacement for acute aorch dissecions. J Thorac Cardiovasc Surg 1982;M 647-55. 3. Griepp RB, Stinson EB, Hollingsworth JF, Buehler D. Prosthetic replacement of the aortic arch. J Thorac Cardiovasc Surg 1975;701051-63. 4. Newman SP. The incidence and nature of neuropsychological morbidity following cardiac surgery. Perfusion 1989;4:93-100. 5. Clarkson PM, MacArthur BA, Barratt-Boyes BG, Whitlock Rh4, Neutze JM. Developmental progress following cardiac surgery in infancy using profound hypothermia and circulatory arrest. Circulation 1980;62:85561.
Single Venous Cannulation for Valve Operations To the Editor: In a Letter to the Editor published in The Annals of Thoracic Surgery [l], Drs Balasundaram and Duran referred to a recently published article in which the authors were unaware that a technical innovation had been described 9 years earlier. Dr Balasundaram
and associates [2] published an article concerning single venous cannulation for valve operations. I hasten to point out that this technical advance was first published in 1959 by Blanco and co-workers [3]. The original article described in great detail a major contribution to surgical technique, including clinical experience from 1957. The 1950s may appear prehistoric to a new generation of cardiac surgeons, but I am delighted to call attention to a scientific contribution made 31 years ago.
George Robinson, M D Division of Cardiothoracic Surgery St. Luke’slRoosevelt Hospital Center New York, NY 10025
References 1. Balasundaram S, Duran CMG. Mitral prosthetic replacement in small left atria. Ann Thorac Surg 1991;51:1046. 2. Balasundaram S, Vega JL, Duran CMG. Single venous cannulation through the right atrium for venous return in valve operations. Ann Thorac Surg 1991;51:506-7. 3. Blanco G, Oca C, Baltar ER, Nichols HT, Bailey CP. Single catheter gravity drainage of the right atrium or right ventricle during total cardiac bypass. Dis Chest 1959;35:554-60.
Penetrating Injury of the Innominate Artery To the Editor: In the January 1991 issue of The Annals, McLean and McManus [l] presented a case of penetrating trauma involving the innominate artery. Reported experiences with this kind of vascular injury are very rare. We reported a case of penetrating injury of the innominate artery in 1983 [2]. We had double-ligated this artery during operation but the vessel was found to be recanalized 1 year after operation. The innominate artery was then repaired by using an 8-mm Dacron tube graft interposed between the ascending aorta and the distal end of the innominate artery. A 19-year-old man was brought to our emergency room in profound shock. He had been stabbed 2 hours before. The wound was in the sternal end of the left third intercostal space and extended to the right, beneath the sternum. Chest roentgenogram showed a large left hemothorax and marked widening of the superior mediastinum. Penetrating injury to one of the mediastinal arteries was suspected, and the patient was operated on immediately. A median sternotomy was camed out. There was a large hematoma in the mediastinum. The innominate artery had partially been cut 1 cm above its origin. The active bleeding was controlled with digital compression, and because prolonged attempts to repair the laceration would jeopardize the patient‘s life, the innominate artery was ligated. This procedure was tolerated well by the patient. There was no permanent neurologic deficit; however, right subclavian steal syndrome was present. Because of the long-standing postoperative wound infection, reconstructive intervention could not be done at this stage. When the wound infection subsided the patient was discharged with the suggestion of a second operation for reconstruction of the innominate artery, which was necessary. The patient disappeared for a long period of time, however. One year later he showed up and he had no complaints. There were no limitations in his physical activity, even during exercise. Finding of the right radial and carotid pulses was surprising. Retrograde angio-
366
Ann Thorac Surg 1992;53:3&3-8
CORRESPONDENCE
Fig 1 . Angiogram shows recanalization of the ligated innominate artery (arrow). graphic examination showed the recanalization of the ligated innominate artery (Fig 1). In the second operation two silk sutures, used in the original ligation of the innominate artery, were found to have cut through the wall and lay within a small aneurysmal sac. This part of the innominate artery was excised, and the origin of the innominate artery at the aorta was sutured. An 8-mm Dacron prosthesis was interposed between the ascending aorta and the distal end of the innominate artery.
Having performed close to 200 open heart cases with this new form of myocardial protection, I reviewed the last 100 cases of nonredo, isolated aortocoronary bypass grafting done using cold intermittent blood cardioplegia, as well as 100 cases of warm continuous retrograde blood cardioplegia. Comparison studies showed no significant difference in the surgical outcome of these two groups, as indicated in Table 1. All deaths involved male patients, age 62 and 60 years in the warm cardioplegia group and 66 years in the cold cardioplegia group. The first patient died 19 days postoperatively of a sudden pulmonary embolus, after an initially difficult time due to chronic obstructive pulmonary disease that required 5 days on ventilatory support. The second underwent uneventful triple aortocoronary bypass grafting; after an initially stable postoperative period, the patient became hypotensive with low cardiac output that could not be reversed, and the patient died in a low cardiac output state due to ischemic cardiomyopathy. At the autopsy all grafts were found to be patent and no localized infarct was seen; extensive myocardial fibrosis and generalized ischemic myocardium were found. The last patient died late. Having undergone a laparotomy for control of gastrointestinal bleeding, the patient suffered a pulmonary embolus the day after discharge from the hospital. Although there was no major difference in the outcome of these two small groups of patients, we have been very pleased with the degree of myocardial protection provided by the use of continuous warm blood cardioplegia, particularly with the retrograde infusion. It appears to provide good ventricular myocardial distribution and does not necessitate the use of multiple lines and cannulas attached to the newly placed grafts, which is particularly advantageous for those of us who do distal anastomoses first. I should note, however, that during the initial phases of adaptation to this technique we noticed an unusual number of patients with postoperative atrial fibrillation and, although we did not document this problem in numbers, this impression was shared by all four cardiac surgeons. At the time, we were using continuous cardioplegia flows between 50 and 150 mWmin and could see the presence of persistent P waves on the electrocardiographic monitor throughout the period of ventricular arrest.
Table 1. Comparison of the Two Groups
Acar Tokcan, M D Department of Cardiovascular Surgery Cukurova University Medical Faculty 01330 BalcalilAdana, Turkey
References 1. McLean TR, McManus RP. Penetrating trauma involving the innominate artery. Ann Thorac Surg 1991;51:11M. 2. Tokcan A, Salih OK, GekirdekG A, Yeniocak A. [Penetrating injury of the innominate artery]. GATA Bulteni 1983;25: 1235-45.
Retrograde Continuous Warm Blood Cardioplegia
To the Editor:
I read with interest the report from Salemo and associates [l] on the technique and pitfalls of retrograde continuous warm blood cardioplegia. After verbal reports from members of the group at St. Michael's Hospital in Toronto, our group began using continuous warm blood cardioplegia in the spring of 1990 and have become quite comfortable with the technique.
Variable
Warm Continuous Blood Cardioplegia
Cold Intermittent Blood Cardioplegia
p Value
~
No. of Patients Maletfemale Average no. of grafts Av. ischemic time per graft Average age (y) Operation Elective Urgent Emergency Intraaortic balloon Pump Deaths Atrial fibrillation NS = not sigruficant.
100 84/16 3.4 15 min 21 s
3.43 14 min 10 s
NS NS NS <0.01
59.96
62.68
<0.025
25 67 8 3 (1preop)
23 74 2 4 (1preop)
NS NS NS
2
1
NS
7
5
NS
100 8Ot20
NS