- Email: [email protected]
Repair of Ebstein's Anomaly
1826
CORRESPONDENCE
On Decreasing Distal Endothelial Damage After Intracoronary Shunt Insertion To the Editor: We read with interest the article by Hangler and colleagues [1] about the morphologic effects of intracoronary shunts on the coronary endothelial layer in the human beating heart. They have also described coronary lesions secondary to snare application in patients before heart transplantation and at scanning electron microscopy focal endothelial denudation, microthrombosis, and atherosclerotic plaque rupture [2]. We have reported a case of early multifocal stenosis at sites of coronary snaring after beating heart coronary artery surgery in a diabetic patient [3]. Our group has already shown that shunts caused a severe endothelial dysfunction, which can lead to acute spasm, thrombosis, or chronic intimal hyperplasia. Indeed, shunting to obtain hemostasis and a satisfactory intracoronary flow requires a snug fit that is systematically associated with a denudation and endothelial dysfunction [4]. Intracoronary shunts are associated with different disadvantages depending on their mismatch to the target coronary artery. The morphologic study of Hangler and colleagues [1] confirms our experimental findings. We have recently proposed a new type of intracoronary shunt called the “Monoshunt” to avoid distal endothelial damage of the target coronary artery [5]. The Monoshunt has a distal undersized flexible portion that avoids rubbing on the endothelial layer and prevents occurrence of the endothelial dysfunction in the distal run-off while ensuring adequate hemostasis [6]. The perfect hemostatic systems for off-pump coronary artery bypass surgery, in terms of efficacy and particularly of safety, has not been discovered. Use of coronary hemostatic devices must always be guided by the concern of inducing as little trauma as possible with soft surgical handling and knowledge of potential complications. Roland G. Demaria, MD, PhD Louis P. Perrault, MD, PhD MISCELLANEOUS
Department of Surgery and Research Center Montreal Heart Institute 5000 Belanger St E Montreal, PQ, H1T 1C8, Canada e-mail: [email protected].
References 1. Hangler HB, Pfaller K, Ruttmann E, et al. Effects of intracoronary shunts on coronary endothelial coating in the human beating heart. Ann Thorac Surg 2004;77:776 – 80. 2. Hangler HB, Pfaller K, Antretter H, Dapunt OE, Bonatti JO. Coronary endothelial injury after local occlusion on the human beating heart. Ann Thorac Surg 2001;71:122–7. 3. Demaria RG, Fortier S, Carrier M, Perrault LP. Early multifocal stenosis after coronary artery snaring during off-pump coronary artery bypass in a patient with diabetes. J Thorac Cardiovasc Surg 2001;122:1044 –5. 4. Demaria RG, Fortier S, Malo O, Carrier M, Perrault LP. Influence of intracoronary shunt size on coronary endothelial function during OPCAB. Heart Surg Forum 2003;6:160 – 8. 5. Izutani H, Gill IS. Acute graft failure caused by an intracoronary shunt in minimally invasive direct coronary artery bypass grafting. J Thorac Cardiovasc Surg 2003;125:723– 4. 6. Demaria RG, Malo O, Carrier M, Perrault LP. The Monoshunt: a new intracoronary shunt design to avoid distal endothelial dysfunction during off-pump coronary artery bypass (OPCAB). Int Cardiovasc Thorac Surg 2003;2:281– 6. © 2005 by The Society of Thoracic Surgeons Published by Elsevier Inc
Ann Thorac Surg 2005;79:1824 –30
Mitral Valve Repair To the Editor: The article by Fasol and colleagues [1] made interesting reading. Several innovative methods have been used for posterior annuloplasty and remodeling of the mitral valve using a C-shaped device. The original description came from Cooley and colleagues [2]. We adapted this technique, but we used thick Teflon felt (C-R Bard Inc, Tempe, AZ) instead [3, 4]. Another commercially available product for this type of repair is the Cosgrove ring. The authors would have done well to credit Cooley and colleagues [2] for their original description, as well as to refer to a large series of published data on this type of repair, which is quite popular. The authors deserve to be congratulated on producing yet another new device for a well established technique. Arkalgud Sampath Kumar, MS, MCh All India Institute of Medical Sciences Department of CTVS, CT Centre AIIMS, Ansari Nagar New Delhi 110 029, India e-mail: [email protected]
References 1. Meinhart J, Deutsch M, Binder T. Mitral valve repair with the Colvin–Galloway future band. Ann Thorac Surg 2004;77: 1985– 8. 2. Cooley DA, Frazier OH, Norman JC. Mitral leaflet prolapse: surgical treatment using a posterior annular collar prosthesis. Cardiovasc Dis Bull Tex Heart Inst 1976;3:438 – 43. 3. Sampath Kumar A, Kumar RV, Shrivastava S, Venugopal P, Sood AK, Gopinath N. Mitral valve reconstruction: early results of a modified Cooley technique. Tex Heart Inst J 1992;19:107–11. 4. Choudhary SK, Talwar S, Dubey B, Chopra A, Saxena A, Sampath Kumar A. Mitral valve repair in a predominantly rheumatic population: long-term results. Tex Heart Inst J 2001;28:8 –15.
Repair of Ebstein’s Anomaly To the Editor: I read with great interest the report by Drs Wu and Huang [1] on their procedure for Ebstein’s anomaly. The incorporation of the abnormal septal and posterior leaflets in the repair is ingenious and innovative. The description of the lesion in 1 patient in whom the diagnosis was confirmed at operation was as follows: “Half of the septal leaflet near to the antero-septal commissure was severely hypoplastic, which made this area to be absent from valve tissue. The remainder of the septal leaflet was displaced 1.5 cm from the annulus.” On the basis of our experience, which is shared by others, my colleagues and I [2] find the anatomy to be different: the surface area of the septal leaflet is severely reduced with short chordae or a linear attachment to the septum. The displacement is minimal near the anteroseptal commissure and maximal where the posteroseptal commissure is supposed to be situated. The displacement is between 3 and 7 cm, and the leaflet tissue reaches the apex of the right ventricle in severe cases. The posterior leaflet is absent or severely reduced in 40% of our patients. In such situations, mobilization of the septal leaflet appears an impossible challenge. The leaflet extension technique could probably be useful, but the durability 0003-4975/05/$30.00
Ann Thorac Surg 2005;79:1824 –30
of fresh nonpreserved autologous pericardium needs to be confirmed. In 1980, Carpentier and colleagues [2], demonstrated that the anterior leaflet has restricted motion, which is a major factor in tricuspid incompetence [3]. In our practice, the reduced motion of the anterior leaflet has to be treated to obtain a competent tricuspid valve. I would be interested to know how the authors solve the problem of reduced mobility of the anterior leaflet. The right ventricular wall resection is a major contribution. It appears to be safe and to produce excellent results. Sylvain Marc Chauvaud, MD Department of Cardiovascular Surgery Hôpital Européan Georges Pompidou 20, Rue Leblanc 75015 Paris, France e-mail: [email protected]
References 1. Wu Q, Huang Z. A new procedure for Ebstein’s anomaly. Ann Thorac Surg 2004;77:470 – 6. 2. Carpentier A, Chauvaud S, Mace L, et al. A new reconstructive operation for Ebstein’s anomaly of the tricuspid valve. J Thorac Cardiovasc Surg 1988;96:92–101. 3. Chauvaud S, Berrebi A, d’Attellis N, Mousseaux E, Hernigou A, Carpentier A. Ebstein’s anomaly: repair based on functional analysis. Eur J Cardio-thorac Surg 2003;23:525–31.
Reply
CORRESPONDENCE
1827
freed some parts of the muscle, which connected to the anterior papillary muscle to lengthen the muscle. We suggest that Ebstein’s anomaly may be better divided into three pathologic types, which has some advantage in the surgical treatment for the anomaly. Type A (no downward displacement of anterior leaflet with septal and post leaflets anomaly) and type B (less than 1/3 of the anterior leaflet displaced downward, with septal and post leaflets anomaly) are both eligible for the new procedure to avoid the valve replacement. Type C (more than 1/3 of the anterior leaflet displaced downward and is severe hypoplasty, with septal and post leaflets anomaly, and right outflow tract stenosis often can be seen in this type) may need a Glenn procedure, 11/2 ventricle correction, total cave-pulmonary vein connection (TCPC), or heart transplantation. The anterior leaflet situation usually correlates to the size of the atrialized ventricle, the degree of the tricuspid regurgitation, and function of the right ventricle. Thanks again for your interest. I hope my team and I can meet you in the near future to share your experience. Qing-yu Wu, MD Department of Cardiovascular Surgery 1st Hospital affiliated to Tsinghua University No. 6 Jiuxianqiao 1st Road, Chaoyang District Beijing, China 100016 e-mail: [email protected]
Reference 1. Wu Q, Huang Z. A new procedure for Ebstein’s anomaly. Ann Thorac Surg 2004;77:470 – 6.
To the Editor:
© 2005 by The Society of Thoracic Surgeons Published by Elsevier Inc
Patent Ductus Arteriosus in Neonates and New Approaches To the Editor: The publication by Vicente and colleagues [1] describes an original approach to patent ductus arteriosus (PDA) closure in premature neonates. Although PDA treatment has historically been a field in which pediatric surgery and cardiology have pioneered new techniques, we believe that the reported surgical procedure does not offer clear advantages. Very low birth weight (⬍ 1,500 g) infants are an extremely fragile group of patients, and concerns about morbidity of our therapeutic acts are particularly important [2]. A thoracotomy is always an invasive act, even if performed with a minimally invasive intent. Muscle cutting, rib spreading, and lung manipulation are components of the dorsal approach; besides, it is performed close to the spine, the hinge of the thoracic cage. We fear that posterior incision can augment the risk of complications such as scoliosis, rib deformities, and shoulder dysfunction [2]. Blunt dissection by q-tips does not warrant pleural integrity: actually “parietal pleural lacerations” were said to be “common” in the article [1]. Thus it is logical to suppose the occurrence of pneumothorax, but incidence and techniques of drainage are not reported. Another drawback is the prone position of the patient with potential problems of airway control, endotracheal tube displacement, management of perfusion, and monitoring lines. It was not reported where the operation was performed, but transfer to the operating room of such patients who are frequently unstable, in addition to temperature management can be very demanding. Last year The Annals of Thoracic Surgery published a consistent experience of a video-assisted thoracoscopic clipping of the PDA 0003-4975/05/$30.00
MISCELLANEOUS
Thank you very much for your very kind comments and interest in my article [1]. I wish to clarify some details in response to your letter. I agree with your description about the anatomy of the septal and posterior leaflets; we see the same in our patients. There is a mistake in my article: “Half of the septal leaflet near to the antero-septal commissure was severely hypoplastic, which made this area without valve tissue. The remainder of the septal leaflet was displaced 1.5 cm from the annulus” should be changed to: “Half of the septal leaflet near the postseptal commissure was severely hypoplastic, which made this area without valve tissue. The remainder of the septal leaflet was displaced 1.5 cm from the annulus.” As you said mobilization of the septal leaflet appears to be an impossible challenge; therefore, we detached the base of the septal leaflet to use that as some chordae tendinea or as part of the leaflet extension. As you know, there is no material better than fresh autologous pericardium. Glutaraldehyde-treated pericardium is too inflexible to preserve function of the rebuilt leaflet. What is more, we have experience that fresh autologous pericardium produced good results in mitral valve repair; therefore we believe that fresh autologous pericardium should be satisfactory for leaflet function in the tricuspid valve, which is under lower stress than the mitral valve. Furthermore, the septal leaflet is not as important as the anterior leaflet. In my article, we did not discuss the hypoplastic anterior leaflet, but we do think the anterior leaflet is the most important part to maintain normal function of the tricuspid valve. For anterior leaflet adhesion, we usually detached the free edge of the adherent leaflet, using the posterior or septal leaflet tissue to form “new chordae tendinea.” We transferred this to the free edge of the anterior leaflet, to rebuild the anterior leaflet, or we
CORRESPONDENCE
On Decreasing Distal Endothelial Damage After Intracoronary Shunt Insertion To the Editor: We read with interest the article by Hangler and colleagues [1] about the morphologic effects of intracoronary shunts on the coronary endothelial layer in the human beating heart. They have also described coronary lesions secondary to snare application in patients before heart transplantation and at scanning electron microscopy focal endothelial denudation, microthrombosis, and atherosclerotic plaque rupture [2]. We have reported a case of early multifocal stenosis at sites of coronary snaring after beating heart coronary artery surgery in a diabetic patient [3]. Our group has already shown that shunts caused a severe endothelial dysfunction, which can lead to acute spasm, thrombosis, or chronic intimal hyperplasia. Indeed, shunting to obtain hemostasis and a satisfactory intracoronary flow requires a snug fit that is systematically associated with a denudation and endothelial dysfunction [4]. Intracoronary shunts are associated with different disadvantages depending on their mismatch to the target coronary artery. The morphologic study of Hangler and colleagues [1] confirms our experimental findings. We have recently proposed a new type of intracoronary shunt called the “Monoshunt” to avoid distal endothelial damage of the target coronary artery [5]. The Monoshunt has a distal undersized flexible portion that avoids rubbing on the endothelial layer and prevents occurrence of the endothelial dysfunction in the distal run-off while ensuring adequate hemostasis [6]. The perfect hemostatic systems for off-pump coronary artery bypass surgery, in terms of efficacy and particularly of safety, has not been discovered. Use of coronary hemostatic devices must always be guided by the concern of inducing as little trauma as possible with soft surgical handling and knowledge of potential complications. Roland G. Demaria, MD, PhD Louis P. Perrault, MD, PhD MISCELLANEOUS
Department of Surgery and Research Center Montreal Heart Institute 5000 Belanger St E Montreal, PQ, H1T 1C8, Canada e-mail: [email protected].
References 1. Hangler HB, Pfaller K, Ruttmann E, et al. Effects of intracoronary shunts on coronary endothelial coating in the human beating heart. Ann Thorac Surg 2004;77:776 – 80. 2. Hangler HB, Pfaller K, Antretter H, Dapunt OE, Bonatti JO. Coronary endothelial injury after local occlusion on the human beating heart. Ann Thorac Surg 2001;71:122–7. 3. Demaria RG, Fortier S, Carrier M, Perrault LP. Early multifocal stenosis after coronary artery snaring during off-pump coronary artery bypass in a patient with diabetes. J Thorac Cardiovasc Surg 2001;122:1044 –5. 4. Demaria RG, Fortier S, Malo O, Carrier M, Perrault LP. Influence of intracoronary shunt size on coronary endothelial function during OPCAB. Heart Surg Forum 2003;6:160 – 8. 5. Izutani H, Gill IS. Acute graft failure caused by an intracoronary shunt in minimally invasive direct coronary artery bypass grafting. J Thorac Cardiovasc Surg 2003;125:723– 4. 6. Demaria RG, Malo O, Carrier M, Perrault LP. The Monoshunt: a new intracoronary shunt design to avoid distal endothelial dysfunction during off-pump coronary artery bypass (OPCAB). Int Cardiovasc Thorac Surg 2003;2:281– 6. © 2005 by The Society of Thoracic Surgeons Published by Elsevier Inc
Ann Thorac Surg 2005;79:1824 –30
Mitral Valve Repair To the Editor: The article by Fasol and colleagues [1] made interesting reading. Several innovative methods have been used for posterior annuloplasty and remodeling of the mitral valve using a C-shaped device. The original description came from Cooley and colleagues [2]. We adapted this technique, but we used thick Teflon felt (C-R Bard Inc, Tempe, AZ) instead [3, 4]. Another commercially available product for this type of repair is the Cosgrove ring. The authors would have done well to credit Cooley and colleagues [2] for their original description, as well as to refer to a large series of published data on this type of repair, which is quite popular. The authors deserve to be congratulated on producing yet another new device for a well established technique. Arkalgud Sampath Kumar, MS, MCh All India Institute of Medical Sciences Department of CTVS, CT Centre AIIMS, Ansari Nagar New Delhi 110 029, India e-mail: [email protected]
References 1. Meinhart J, Deutsch M, Binder T. Mitral valve repair with the Colvin–Galloway future band. Ann Thorac Surg 2004;77: 1985– 8. 2. Cooley DA, Frazier OH, Norman JC. Mitral leaflet prolapse: surgical treatment using a posterior annular collar prosthesis. Cardiovasc Dis Bull Tex Heart Inst 1976;3:438 – 43. 3. Sampath Kumar A, Kumar RV, Shrivastava S, Venugopal P, Sood AK, Gopinath N. Mitral valve reconstruction: early results of a modified Cooley technique. Tex Heart Inst J 1992;19:107–11. 4. Choudhary SK, Talwar S, Dubey B, Chopra A, Saxena A, Sampath Kumar A. Mitral valve repair in a predominantly rheumatic population: long-term results. Tex Heart Inst J 2001;28:8 –15.
Repair of Ebstein’s Anomaly To the Editor: I read with great interest the report by Drs Wu and Huang [1] on their procedure for Ebstein’s anomaly. The incorporation of the abnormal septal and posterior leaflets in the repair is ingenious and innovative. The description of the lesion in 1 patient in whom the diagnosis was confirmed at operation was as follows: “Half of the septal leaflet near to the antero-septal commissure was severely hypoplastic, which made this area to be absent from valve tissue. The remainder of the septal leaflet was displaced 1.5 cm from the annulus.” On the basis of our experience, which is shared by others, my colleagues and I [2] find the anatomy to be different: the surface area of the septal leaflet is severely reduced with short chordae or a linear attachment to the septum. The displacement is minimal near the anteroseptal commissure and maximal where the posteroseptal commissure is supposed to be situated. The displacement is between 3 and 7 cm, and the leaflet tissue reaches the apex of the right ventricle in severe cases. The posterior leaflet is absent or severely reduced in 40% of our patients. In such situations, mobilization of the septal leaflet appears an impossible challenge. The leaflet extension technique could probably be useful, but the durability 0003-4975/05/$30.00
Ann Thorac Surg 2005;79:1824 –30
of fresh nonpreserved autologous pericardium needs to be confirmed. In 1980, Carpentier and colleagues [2], demonstrated that the anterior leaflet has restricted motion, which is a major factor in tricuspid incompetence [3]. In our practice, the reduced motion of the anterior leaflet has to be treated to obtain a competent tricuspid valve. I would be interested to know how the authors solve the problem of reduced mobility of the anterior leaflet. The right ventricular wall resection is a major contribution. It appears to be safe and to produce excellent results. Sylvain Marc Chauvaud, MD Department of Cardiovascular Surgery Hôpital Européan Georges Pompidou 20, Rue Leblanc 75015 Paris, France e-mail: [email protected]
References 1. Wu Q, Huang Z. A new procedure for Ebstein’s anomaly. Ann Thorac Surg 2004;77:470 – 6. 2. Carpentier A, Chauvaud S, Mace L, et al. A new reconstructive operation for Ebstein’s anomaly of the tricuspid valve. J Thorac Cardiovasc Surg 1988;96:92–101. 3. Chauvaud S, Berrebi A, d’Attellis N, Mousseaux E, Hernigou A, Carpentier A. Ebstein’s anomaly: repair based on functional analysis. Eur J Cardio-thorac Surg 2003;23:525–31.
Reply
CORRESPONDENCE
1827
freed some parts of the muscle, which connected to the anterior papillary muscle to lengthen the muscle. We suggest that Ebstein’s anomaly may be better divided into three pathologic types, which has some advantage in the surgical treatment for the anomaly. Type A (no downward displacement of anterior leaflet with septal and post leaflets anomaly) and type B (less than 1/3 of the anterior leaflet displaced downward, with septal and post leaflets anomaly) are both eligible for the new procedure to avoid the valve replacement. Type C (more than 1/3 of the anterior leaflet displaced downward and is severe hypoplasty, with septal and post leaflets anomaly, and right outflow tract stenosis often can be seen in this type) may need a Glenn procedure, 11/2 ventricle correction, total cave-pulmonary vein connection (TCPC), or heart transplantation. The anterior leaflet situation usually correlates to the size of the atrialized ventricle, the degree of the tricuspid regurgitation, and function of the right ventricle. Thanks again for your interest. I hope my team and I can meet you in the near future to share your experience. Qing-yu Wu, MD Department of Cardiovascular Surgery 1st Hospital affiliated to Tsinghua University No. 6 Jiuxianqiao 1st Road, Chaoyang District Beijing, China 100016 e-mail: [email protected]
Reference 1. Wu Q, Huang Z. A new procedure for Ebstein’s anomaly. Ann Thorac Surg 2004;77:470 – 6.
To the Editor:
© 2005 by The Society of Thoracic Surgeons Published by Elsevier Inc
Patent Ductus Arteriosus in Neonates and New Approaches To the Editor: The publication by Vicente and colleagues [1] describes an original approach to patent ductus arteriosus (PDA) closure in premature neonates. Although PDA treatment has historically been a field in which pediatric surgery and cardiology have pioneered new techniques, we believe that the reported surgical procedure does not offer clear advantages. Very low birth weight (⬍ 1,500 g) infants are an extremely fragile group of patients, and concerns about morbidity of our therapeutic acts are particularly important [2]. A thoracotomy is always an invasive act, even if performed with a minimally invasive intent. Muscle cutting, rib spreading, and lung manipulation are components of the dorsal approach; besides, it is performed close to the spine, the hinge of the thoracic cage. We fear that posterior incision can augment the risk of complications such as scoliosis, rib deformities, and shoulder dysfunction [2]. Blunt dissection by q-tips does not warrant pleural integrity: actually “parietal pleural lacerations” were said to be “common” in the article [1]. Thus it is logical to suppose the occurrence of pneumothorax, but incidence and techniques of drainage are not reported. Another drawback is the prone position of the patient with potential problems of airway control, endotracheal tube displacement, management of perfusion, and monitoring lines. It was not reported where the operation was performed, but transfer to the operating room of such patients who are frequently unstable, in addition to temperature management can be very demanding. Last year The Annals of Thoracic Surgery published a consistent experience of a video-assisted thoracoscopic clipping of the PDA 0003-4975/05/$30.00
MISCELLANEOUS
Thank you very much for your very kind comments and interest in my article [1]. I wish to clarify some details in response to your letter. I agree with your description about the anatomy of the septal and posterior leaflets; we see the same in our patients. There is a mistake in my article: “Half of the septal leaflet near to the antero-septal commissure was severely hypoplastic, which made this area without valve tissue. The remainder of the septal leaflet was displaced 1.5 cm from the annulus” should be changed to: “Half of the septal leaflet near the postseptal commissure was severely hypoplastic, which made this area without valve tissue. The remainder of the septal leaflet was displaced 1.5 cm from the annulus.” As you said mobilization of the septal leaflet appears to be an impossible challenge; therefore, we detached the base of the septal leaflet to use that as some chordae tendinea or as part of the leaflet extension. As you know, there is no material better than fresh autologous pericardium. Glutaraldehyde-treated pericardium is too inflexible to preserve function of the rebuilt leaflet. What is more, we have experience that fresh autologous pericardium produced good results in mitral valve repair; therefore we believe that fresh autologous pericardium should be satisfactory for leaflet function in the tricuspid valve, which is under lower stress than the mitral valve. Furthermore, the septal leaflet is not as important as the anterior leaflet. In my article, we did not discuss the hypoplastic anterior leaflet, but we do think the anterior leaflet is the most important part to maintain normal function of the tricuspid valve. For anterior leaflet adhesion, we usually detached the free edge of the adherent leaflet, using the posterior or septal leaflet tissue to form “new chordae tendinea.” We transferred this to the free edge of the anterior leaflet, to rebuild the anterior leaflet, or we