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Thermodilution catheter-induced endobronchial hemorrhage with pulmonary hypertension
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Ann Thorac Surg 1991;52:12044
CORRESPONDENCE
prokinetic domperidone (Motilium; Janssen Pharmaceutica) appeared to have little objective efficacy, although symptomatic improvement was reported [3]. Our data suggest that the interposed stomach appears to retain its gastric identity rather than acting as an inert conduit and remains a satisfactory method of reconstruction after esophagectomy for both benign and malignant esophageal disease [4].
Alan G. Casson, MB, ChB John Powe, M D Richard Inculet, M D Richard Finley, M D Departments of Surgery and Nuclear Medicine University of Western Ontario Victoria Hospital London, Ont, Canada
References 1. Morton KA, Karwande SV, Davis K, Datz FL, Lynch RE. Gastric emptying after gastric interposition for cancer of the esophagus of hypopharynx. Ann Thorac Surg 1991;51:759-63. 2. Powe JE, Casson AG, Inculet RI, Laurin N, Finley RJ. Functional evaluation of gastric interposition following total esophagectomy. J Nucl Med 1990;31(Suppl):775. 3. Casson AG, Powe JE, Inculet RI, Finley R. Efficacy of domperidone (Motilium) on modifying function of the interposed stomach following total esophagectomy. Gastroenterology 1989;98(Suppl):A335. 4. Casson AG, Powe J, Inculet R, Finley R. Functional results of gastric interposition following total esophagectomy. Clin Nucl Med (in press).
Surgical Management of Carcinoid Heart Disease To the Editor: In their recent report on the surgical management of carcinoid heart disease, Fetherston and Davis [ l ] suggest that mechanical tricuspid valve replacement be performed in patients with the carcinoid syndrome because of the ”theoretical potential” for carcinoid heart disease to recur on bioprosthetic valve leaflets. Recently, we have reported just such a case [2], in which recurrent carcinoid plaque on a Hancock porcine prosthesis contributed to failure of the valve and eventually led to reoperation. We also are aware of at least one postmortem study demonstrating that carcinoid plaque can develop on bioprosthetic valves [3]. We therefore agree with the recommendations of Fetherston and Davis that mechanical tricuspid valve replacement be considered in patients with carcinoid heart disease, particularly for those individuals at low risk for anticoagulation failure.
Paul M . Ridker, M D Frederick J. Schoen, M D , PhD Division of Cardiology and Department of Pathology Brigham and Women’s Hospital Boston, M A 02146
References 1. Fetherston GJ, Davis BB. Surgical management of carcinoid heart disease. Ann Thorac Surg 1991;51:4934. 2. Ridker PM, Chertow GM, Karlson EW, Neish AS, Schoen FJ. Bioprosthetic tricuspid valve stenosis associated with extensive plaque deposition in carcinoid heart disease. Am Heart J 1991;121:1835-8. 3. Schoen FJ, Hausner RJ, Howell JF, Beazly HL, Titus JL. Porcine heterograft valve replacement in carcinoid heart disease. J Thorac Cardiovasc Surg 1981;81:100-5.
Thermodilution Catheter-Induced Endobronchial Hemorrhage With Pulmonary Hypertension To the Editor: Various techniques have been described to control severe endobronchial hemorrhage caused by Swan-Ganz catheter injury to the distal pulmonary artery. The method of endobronchial blockade under direct vision described by Dr Purut and his colleagues [I] is a precise and reliable technique in patients with normal pulmonary artery pressure undergoing coronary artery operation. However, in patients with pulmonary hypertension this technique should be employed with great caution. We recently performed a reoperation of mitral valve replacement and tricuspid valve repair on a 78-year-old woman with preoperative pulmonary artery pressure of 60/30 mm Hg. Blood issuing through the endotracheal tube was noticed immediately after operation. A chest roentgenogram showed a triangular shadow of segmental consolidation on the left side. Bronchoscopy was performed, and the bleeding from the lingular segment of the left upper lobe was arrested using a Fogarty balloon catheter. Postoperatively, systolic pulmonary artery pressure was maintained less than 40 mm Hg. The patient’s hemodynamic status deteriorated in the first 24 hours after operation, and a chest roentgenogram showed increasing opacity on the left side. A chest drain was inserted, and about 2,000 mL of blood was drained. The patient was reoperated on for left upper lobectomy as the bleeding continued. The patient died 48 hours postoperation due to severely compromised hemodynamic status. In patients with pulmonary hypertension, endobronchial blockade can lead to increased intralobar pressure due to continued bleeding and eventual rupture of the lobe. Alternate methods such as selective embolization of the bleeding artery or local injection of vasoconstrictors through the bronchoscope may be of value in this situation to avoid this fatal complication.
Pasala S . Ravichandran, M D Stephen P. Kelly, M D Jeffrey S . Swanson, M D Cindy L. Fessler, BS Albert Starr, M D The Heart Institute at St. Vincent Hospital and Medical Center 9155 SW Barnes Rd, Suite 236 Portland, O R 97225
Reference 1. Purut CM, Scott SM, Parham JV, Smith PK. Intraoperative management of severe endobronchial hemorrhage. Ann Thorac Surg 1991;51:30&7.
Ann Thorac Surg 1991;52:12044
CORRESPONDENCE
prokinetic domperidone (Motilium; Janssen Pharmaceutica) appeared to have little objective efficacy, although symptomatic improvement was reported [3]. Our data suggest that the interposed stomach appears to retain its gastric identity rather than acting as an inert conduit and remains a satisfactory method of reconstruction after esophagectomy for both benign and malignant esophageal disease [4].
Alan G. Casson, MB, ChB John Powe, M D Richard Inculet, M D Richard Finley, M D Departments of Surgery and Nuclear Medicine University of Western Ontario Victoria Hospital London, Ont, Canada
References 1. Morton KA, Karwande SV, Davis K, Datz FL, Lynch RE. Gastric emptying after gastric interposition for cancer of the esophagus of hypopharynx. Ann Thorac Surg 1991;51:759-63. 2. Powe JE, Casson AG, Inculet RI, Laurin N, Finley RJ. Functional evaluation of gastric interposition following total esophagectomy. J Nucl Med 1990;31(Suppl):775. 3. Casson AG, Powe JE, Inculet RI, Finley R. Efficacy of domperidone (Motilium) on modifying function of the interposed stomach following total esophagectomy. Gastroenterology 1989;98(Suppl):A335. 4. Casson AG, Powe J, Inculet R, Finley R. Functional results of gastric interposition following total esophagectomy. Clin Nucl Med (in press).
Surgical Management of Carcinoid Heart Disease To the Editor: In their recent report on the surgical management of carcinoid heart disease, Fetherston and Davis [ l ] suggest that mechanical tricuspid valve replacement be performed in patients with the carcinoid syndrome because of the ”theoretical potential” for carcinoid heart disease to recur on bioprosthetic valve leaflets. Recently, we have reported just such a case [2], in which recurrent carcinoid plaque on a Hancock porcine prosthesis contributed to failure of the valve and eventually led to reoperation. We also are aware of at least one postmortem study demonstrating that carcinoid plaque can develop on bioprosthetic valves [3]. We therefore agree with the recommendations of Fetherston and Davis that mechanical tricuspid valve replacement be considered in patients with carcinoid heart disease, particularly for those individuals at low risk for anticoagulation failure.
Paul M . Ridker, M D Frederick J. Schoen, M D , PhD Division of Cardiology and Department of Pathology Brigham and Women’s Hospital Boston, M A 02146
References 1. Fetherston GJ, Davis BB. Surgical management of carcinoid heart disease. Ann Thorac Surg 1991;51:4934. 2. Ridker PM, Chertow GM, Karlson EW, Neish AS, Schoen FJ. Bioprosthetic tricuspid valve stenosis associated with extensive plaque deposition in carcinoid heart disease. Am Heart J 1991;121:1835-8. 3. Schoen FJ, Hausner RJ, Howell JF, Beazly HL, Titus JL. Porcine heterograft valve replacement in carcinoid heart disease. J Thorac Cardiovasc Surg 1981;81:100-5.
Thermodilution Catheter-Induced Endobronchial Hemorrhage With Pulmonary Hypertension To the Editor: Various techniques have been described to control severe endobronchial hemorrhage caused by Swan-Ganz catheter injury to the distal pulmonary artery. The method of endobronchial blockade under direct vision described by Dr Purut and his colleagues [I] is a precise and reliable technique in patients with normal pulmonary artery pressure undergoing coronary artery operation. However, in patients with pulmonary hypertension this technique should be employed with great caution. We recently performed a reoperation of mitral valve replacement and tricuspid valve repair on a 78-year-old woman with preoperative pulmonary artery pressure of 60/30 mm Hg. Blood issuing through the endotracheal tube was noticed immediately after operation. A chest roentgenogram showed a triangular shadow of segmental consolidation on the left side. Bronchoscopy was performed, and the bleeding from the lingular segment of the left upper lobe was arrested using a Fogarty balloon catheter. Postoperatively, systolic pulmonary artery pressure was maintained less than 40 mm Hg. The patient’s hemodynamic status deteriorated in the first 24 hours after operation, and a chest roentgenogram showed increasing opacity on the left side. A chest drain was inserted, and about 2,000 mL of blood was drained. The patient was reoperated on for left upper lobectomy as the bleeding continued. The patient died 48 hours postoperation due to severely compromised hemodynamic status. In patients with pulmonary hypertension, endobronchial blockade can lead to increased intralobar pressure due to continued bleeding and eventual rupture of the lobe. Alternate methods such as selective embolization of the bleeding artery or local injection of vasoconstrictors through the bronchoscope may be of value in this situation to avoid this fatal complication.
Pasala S . Ravichandran, M D Stephen P. Kelly, M D Jeffrey S . Swanson, M D Cindy L. Fessler, BS Albert Starr, M D The Heart Institute at St. Vincent Hospital and Medical Center 9155 SW Barnes Rd, Suite 236 Portland, O R 97225
Reference 1. Purut CM, Scott SM, Parham JV, Smith PK. Intraoperative management of severe endobronchial hemorrhage. Ann Thorac Surg 1991;51:30&7.