- Email: [email protected]
Septal myocardial infarction: A complication of coronary artery stay sutures
400
CORRESPONDENCE
Ann Thorac Surg 1993;56395402
Papillary Polypoid Lesion in the TracheobronchialTrees
Complete Removal
Incomplete Removal
Neoplasma
Non-IntensiveFollow-up]
IIntensive Follow-up
Fig I . Flow chart shows the treatment strategy for papillary polypoid lesion (squamous cell papilloma and inflammatory polyp) in the tracheobronchial trees. (* The criteria were described in the previous review 111: If the tumor is not wide-based, the location is clearly visualized on endoscopy, and the patient's status is not compromised, endoscopic management is selected. lf the tumor is wide-based, the location is poorly visualized on endoscopy, or the patient's status is compromised, surgical management is selected.)
bronchus, which portion was easily managed by endoscopy, and the tumor was not wide-based. In terms of actuarial event-free rate of the endoscopically and surgically managed groups in the previous review [l], there was no significant difference between the groups. Furthermore, endoscopic management is improving, so more tracheobronchial tumors will be managed endoscopically in the future. On the other hand, in the reviewed 16 surgically managed patients, there was no death directly related to operation. Additionally, some patients underwent surgical resection for an inflammatory polyp without any complications [3, 41. I therefore believe that there is no reason to hesitate to use surgical management of benign polypoid lesions in the tracheobronchial trees. I would like to propose the following regimen for treating bronchial papillary polypoid lesion (Fig 1). First, a definite diagnosis should be made by histologic examination of biopsy specimen. Then, if the tumor is diagnosed as a squamous cell papilloma, the tumor should be managed according to the criteria described in the previous review. If the diagnosis is an inflammatory polyp, bronchoscopic removal should be tried if the tumor location and shape are suitable for endoscopic treatment and the patient's condition is not compromised. Surgical resection should be selected if endoscopic management is considered difficult. If the tumor is diagnosed as an inflammatory polyp after complete removal by endoscopy, intensive follow-up should not be recommended. If the tumor is diagnosed as a neoplasm, intensive follow-up is necessary. If the tumor is incompletely removed and diagnosed as a neoplasm, surgical resection should be performed immediately. If the diagnosis is inflammatory polyp, intensive follow-up is necessary.
Yoshifumi Naka, M D Department of Surgery Osaka Police Hospital 10-31, Kitayamacho, Tennoji-ku Osaka 543, japan
References 1. Naka Y, Nakao K, Hamaji Y, Nakahara M, Tsujimoto M, Nakahara K. Solitary squamous cell papilloma of the trachea. Ann Thorac Surg 1993;55:189-93. 2. Spencer H, Dail DH, Arneaud J. Non-invasive bronchial epithelial papillary tumors. Cancer 1980;45:1486-97. 3. Freant LJ, Sawyers JL. Benign bronchial polyps and papillomas. Ann Thorac Surg 1971;11:46&7. 4. Vontz FK, Vitsky BH. Giant bronchial polyp treated by emergency thoracotomy. Chest 1974;661024.
Septa1 Myocardial Infarction: A Complication of Coronary Artery Stay Sutures To the Editor: Coronary artery stay sutures are used for exposure and to reduce bleeding, especially for coronary artery anastomoses performed on the beating heart. In his discussion of a report by Pfister and associates, Dr Gundry [ l ] emphasizes the risks of using such stay sutures, which may lead to coronary artery stenoses. This report highlights another type of injury probably induced by a coronary artery stay suture. A 59-year-old man with complete occlusion of his left anterior descending and right coronary arteries as well as a 70% stenosis of his circumflex coronary artery underwent coronary artery bypass grafting with cardiopulmonary bypass support, left ventricular venting, and cold blood cardioplegic arrest. The left internal mammary artery was anastomosed to the left anterior descending artery, which measured 1.3 mm, and saphenous vein grafts were placed to the obtuse marginal branch of the circumflex artery and to the right coronary artery. To control backbleeding coronary stay sutures were used. Tachycardia and rising left atrial pressures prompted the use of an intraaortic balloon pump after weaning from bypass support. The postoperative electrocardiograms showed new ST-segment elevation in leads V, to V, in addition to the preexisting poor R-wave progression, which was known to be the result of a remote anteroseptal myocardial infarction. The intraaortic balloon pump was removed on the first postoperative day, and the patient recovered uneventfully. The serum creatine kinase level peaked at 499 units (MB fraction, 17 units) less than 20 hours postoperatively. A left internal mammary artery angiogram on the fourth postoperative day demonstrated a patent left internal mammary artery to left anterior descending artery anastomosis and an area of intraseptal hemorrhage (Fig 1). The patient continued to do well. Several follow-up echocardiograms showed the interventricular septum to be intact and the left ventricular function to be unchanged from the baseline preoperative study. Four weeks postoperatively an exercise electrocardiogram was unremarkable, and the patient returned to work subsequently. We strongly believe that our routine use of coronary artery stay sutures was the cause of this complication. It is conceivable that one of the sutures injured a septa1 artery leading to a small hemorrhagic myocardial infarction. Despite left ventricular venting, back-bleeding via collaterals can be a nuisance. Methods to deal with back-bleeding include intracoronary balloons, continuous irrigation of the anastomotic site [2], suction, or the application of a gas jet [3]. No systematic studies to determine the potential damaging effects of these techniques exist, and new methods should be evaluated with care [4].
CORRESPONDENCE
Ann Thorac Surg 1993;56395-402
Fig 1 . Left internal mammary artery (LIMA) graft (double arrow) to the left anterior descending artery (LAD) (single arrow) with intact anastomosis and retrograde pow into the proximal LAD. (SE = septal extravasa tion.)
401
ideal to prevent undesirable complications when a second sternotomy becomes necessary, many surgeons leave the pericardium open to avoid the development of cardiac tamponade, or because its closure induces systemic hypotension or elevated central venous pressure. Recently, Hunter and associates [ l ] proved adverse hemodynamic effects of pericardial closure soon after open heart operations in adult patients by comparing the hemodynamic indices before pericardial closure, soon after pericardial closure, and after removal of the pericardial suture 1.5 to 2 hours later while the chest remained closed. In the past, I have encountered several infants in whom acute cardiac failure developed, indistinguishable from that caused by cardiac tamponade, several hours after a relatively simple operation such as closure of the ventricular septal defect. Emergency sternal reopening in the intensive care unit only proved that the heart was distended, but the removal of the pericardial stitches dramatically improved the patients’ hemodynamic condition and subsequent postoperative course. Since then, I have adopted the following procedure as a safety measure to prevent such unexpected incidents for the past 15 years (Fig 1): When primary pericardial closure seems to be tolerated, a heavy polypropylene suture of 3-0 or 2-0 is passed through the skin over the anterior neck with a small piece of a Nelaton tube as an anchor in one end. Then, the stitch is passed through the pericardium with a continuous horizontal mattress suture downward until about 1cm proximal to the diaphragmatic surface, and then passed outward through the skin of the upper abdominal wall. Then it is anchored to another piece of a Nelaton tube. Care is taken not to pull the stitch too tightly. A drain tube is inserted into the posterior pericardial space through the small opening of the lowest portion of the pericardial incision. Another drain tube is placed substernally. The sternum and the rectus abdominis muscles are closed in the usual manner. Should there be signs suggestive of acute distention of the heart such as
We have become much more restrictive with the use of coronary stay sutures since.
Fred H. Splittgerber, M D Carmine Minale, M D Department of Cardiothoracic and Vascular Surgery Wuppertal City Hospital Klinikum Barmen Heusnerstrasse D-5600 Wuppertal 2 Germany
References 1. Gundry SR. Discussion of Pfister AJ, Zaki MS, Garcia JM, et al. Coronary artery bypass without cardiopulmonary bypass. Ann Thorac Surg 1992;54:1092. 2. Lichtenstein SV, Abel JG, Slutsky AS. Warm retrograde cardioplegia. J Thorac Cardiovasc Surg 1992;104:374-80. 3. Teoh KHT, Panos AL, Harmantas AH, Lichtenstein SV, Salerno TA. Optimal visualization of coronary artery anastomoses by gas jet. Ann Thorac Surg 1991;52:564. 4. Poulton TJ. Visualization of coronary artery anastomoses by gas jet [Letter]. Ann Thorac Surg 1992;54:59&-9.
Adverse Hemodynamic Effects of Pericardial Closure Soon After an Open Heart Operation To the Editor: Controversy exists as to whether the pericardium should be closed after an open heart operation. Although primary closure is
Small Nelaton
- Heavy polypropylene suture
1 Sternum-
Diaphragm-
Drain tube for pericardial space Drain tube for substernal space Fig 1 . Safety procedure for pericardial closure.
CORRESPONDENCE
Ann Thorac Surg 1993;56395402
Papillary Polypoid Lesion in the TracheobronchialTrees
Complete Removal
Incomplete Removal
Neoplasma
Non-IntensiveFollow-up]
IIntensive Follow-up
Fig I . Flow chart shows the treatment strategy for papillary polypoid lesion (squamous cell papilloma and inflammatory polyp) in the tracheobronchial trees. (* The criteria were described in the previous review 111: If the tumor is not wide-based, the location is clearly visualized on endoscopy, and the patient's status is not compromised, endoscopic management is selected. lf the tumor is wide-based, the location is poorly visualized on endoscopy, or the patient's status is compromised, surgical management is selected.)
bronchus, which portion was easily managed by endoscopy, and the tumor was not wide-based. In terms of actuarial event-free rate of the endoscopically and surgically managed groups in the previous review [l], there was no significant difference between the groups. Furthermore, endoscopic management is improving, so more tracheobronchial tumors will be managed endoscopically in the future. On the other hand, in the reviewed 16 surgically managed patients, there was no death directly related to operation. Additionally, some patients underwent surgical resection for an inflammatory polyp without any complications [3, 41. I therefore believe that there is no reason to hesitate to use surgical management of benign polypoid lesions in the tracheobronchial trees. I would like to propose the following regimen for treating bronchial papillary polypoid lesion (Fig 1). First, a definite diagnosis should be made by histologic examination of biopsy specimen. Then, if the tumor is diagnosed as a squamous cell papilloma, the tumor should be managed according to the criteria described in the previous review. If the diagnosis is an inflammatory polyp, bronchoscopic removal should be tried if the tumor location and shape are suitable for endoscopic treatment and the patient's condition is not compromised. Surgical resection should be selected if endoscopic management is considered difficult. If the tumor is diagnosed as an inflammatory polyp after complete removal by endoscopy, intensive follow-up should not be recommended. If the tumor is diagnosed as a neoplasm, intensive follow-up is necessary. If the tumor is incompletely removed and diagnosed as a neoplasm, surgical resection should be performed immediately. If the diagnosis is inflammatory polyp, intensive follow-up is necessary.
Yoshifumi Naka, M D Department of Surgery Osaka Police Hospital 10-31, Kitayamacho, Tennoji-ku Osaka 543, japan
References 1. Naka Y, Nakao K, Hamaji Y, Nakahara M, Tsujimoto M, Nakahara K. Solitary squamous cell papilloma of the trachea. Ann Thorac Surg 1993;55:189-93. 2. Spencer H, Dail DH, Arneaud J. Non-invasive bronchial epithelial papillary tumors. Cancer 1980;45:1486-97. 3. Freant LJ, Sawyers JL. Benign bronchial polyps and papillomas. Ann Thorac Surg 1971;11:46&7. 4. Vontz FK, Vitsky BH. Giant bronchial polyp treated by emergency thoracotomy. Chest 1974;661024.
Septa1 Myocardial Infarction: A Complication of Coronary Artery Stay Sutures To the Editor: Coronary artery stay sutures are used for exposure and to reduce bleeding, especially for coronary artery anastomoses performed on the beating heart. In his discussion of a report by Pfister and associates, Dr Gundry [ l ] emphasizes the risks of using such stay sutures, which may lead to coronary artery stenoses. This report highlights another type of injury probably induced by a coronary artery stay suture. A 59-year-old man with complete occlusion of his left anterior descending and right coronary arteries as well as a 70% stenosis of his circumflex coronary artery underwent coronary artery bypass grafting with cardiopulmonary bypass support, left ventricular venting, and cold blood cardioplegic arrest. The left internal mammary artery was anastomosed to the left anterior descending artery, which measured 1.3 mm, and saphenous vein grafts were placed to the obtuse marginal branch of the circumflex artery and to the right coronary artery. To control backbleeding coronary stay sutures were used. Tachycardia and rising left atrial pressures prompted the use of an intraaortic balloon pump after weaning from bypass support. The postoperative electrocardiograms showed new ST-segment elevation in leads V, to V, in addition to the preexisting poor R-wave progression, which was known to be the result of a remote anteroseptal myocardial infarction. The intraaortic balloon pump was removed on the first postoperative day, and the patient recovered uneventfully. The serum creatine kinase level peaked at 499 units (MB fraction, 17 units) less than 20 hours postoperatively. A left internal mammary artery angiogram on the fourth postoperative day demonstrated a patent left internal mammary artery to left anterior descending artery anastomosis and an area of intraseptal hemorrhage (Fig 1). The patient continued to do well. Several follow-up echocardiograms showed the interventricular septum to be intact and the left ventricular function to be unchanged from the baseline preoperative study. Four weeks postoperatively an exercise electrocardiogram was unremarkable, and the patient returned to work subsequently. We strongly believe that our routine use of coronary artery stay sutures was the cause of this complication. It is conceivable that one of the sutures injured a septa1 artery leading to a small hemorrhagic myocardial infarction. Despite left ventricular venting, back-bleeding via collaterals can be a nuisance. Methods to deal with back-bleeding include intracoronary balloons, continuous irrigation of the anastomotic site [2], suction, or the application of a gas jet [3]. No systematic studies to determine the potential damaging effects of these techniques exist, and new methods should be evaluated with care [4].
CORRESPONDENCE
Ann Thorac Surg 1993;56395-402
Fig 1 . Left internal mammary artery (LIMA) graft (double arrow) to the left anterior descending artery (LAD) (single arrow) with intact anastomosis and retrograde pow into the proximal LAD. (SE = septal extravasa tion.)
401
ideal to prevent undesirable complications when a second sternotomy becomes necessary, many surgeons leave the pericardium open to avoid the development of cardiac tamponade, or because its closure induces systemic hypotension or elevated central venous pressure. Recently, Hunter and associates [ l ] proved adverse hemodynamic effects of pericardial closure soon after open heart operations in adult patients by comparing the hemodynamic indices before pericardial closure, soon after pericardial closure, and after removal of the pericardial suture 1.5 to 2 hours later while the chest remained closed. In the past, I have encountered several infants in whom acute cardiac failure developed, indistinguishable from that caused by cardiac tamponade, several hours after a relatively simple operation such as closure of the ventricular septal defect. Emergency sternal reopening in the intensive care unit only proved that the heart was distended, but the removal of the pericardial stitches dramatically improved the patients’ hemodynamic condition and subsequent postoperative course. Since then, I have adopted the following procedure as a safety measure to prevent such unexpected incidents for the past 15 years (Fig 1): When primary pericardial closure seems to be tolerated, a heavy polypropylene suture of 3-0 or 2-0 is passed through the skin over the anterior neck with a small piece of a Nelaton tube as an anchor in one end. Then, the stitch is passed through the pericardium with a continuous horizontal mattress suture downward until about 1cm proximal to the diaphragmatic surface, and then passed outward through the skin of the upper abdominal wall. Then it is anchored to another piece of a Nelaton tube. Care is taken not to pull the stitch too tightly. A drain tube is inserted into the posterior pericardial space through the small opening of the lowest portion of the pericardial incision. Another drain tube is placed substernally. The sternum and the rectus abdominis muscles are closed in the usual manner. Should there be signs suggestive of acute distention of the heart such as
We have become much more restrictive with the use of coronary stay sutures since.
Fred H. Splittgerber, M D Carmine Minale, M D Department of Cardiothoracic and Vascular Surgery Wuppertal City Hospital Klinikum Barmen Heusnerstrasse D-5600 Wuppertal 2 Germany
References 1. Gundry SR. Discussion of Pfister AJ, Zaki MS, Garcia JM, et al. Coronary artery bypass without cardiopulmonary bypass. Ann Thorac Surg 1992;54:1092. 2. Lichtenstein SV, Abel JG, Slutsky AS. Warm retrograde cardioplegia. J Thorac Cardiovasc Surg 1992;104:374-80. 3. Teoh KHT, Panos AL, Harmantas AH, Lichtenstein SV, Salerno TA. Optimal visualization of coronary artery anastomoses by gas jet. Ann Thorac Surg 1991;52:564. 4. Poulton TJ. Visualization of coronary artery anastomoses by gas jet [Letter]. Ann Thorac Surg 1992;54:59&-9.
Adverse Hemodynamic Effects of Pericardial Closure Soon After an Open Heart Operation To the Editor: Controversy exists as to whether the pericardium should be closed after an open heart operation. Although primary closure is
Small Nelaton
- Heavy polypropylene suture
1 Sternum-
Diaphragm-
Drain tube for pericardial space Drain tube for substernal space Fig 1 . Safety procedure for pericardial closure.