- Email: [email protected]
What Should Be the Systolic Cardiac Output in Aorta?
Ann Thorac Surg 2017;103:1679–82
CORRESPONDENCE
1681
Reference 1. Khelil N, Sleilaty G, Palladino M, et al. Surgical anatomy of the aortic annulus: landmarks for external annuloplasty in aortic valve repair. Ann Thorac Surg 2015;99:1220–7.
Reply To the Editor:
Congratulations to the authors for this valuable study [1]. They have put tremendous effort into the aortic valve bypass (AVB) technique. We have some concerns about this technique used in surgical treatment of severe aortic stenosis. Obviously, the duration of diastole is almost twofold that of systole. Bypassing the ascending aorta, aortic arch, and initial segment of the descending aorta with the AVB technique may have adverse results in terms of hypoperfusion. Are the authors eager to plan a simulation [2] in which the systolic cardiac output was three times (i.e., 3 5 L) of the usual cardiac output? Ismail Yurekli, MD Mert Kestelli, MD Habib Cakir, MD Nihan Karakas Yesilkaya, MD Izmir Ataturk Education and Research Hospital 6436 sok 82/3 35540 Karsiyaka-Izmir, Turkey Basin Sitesi, 35360, Izmir, Turkey email: [email protected]
References 1. Brown JW, Boyd JH, Patel PM, et al. Transcatheter aortic valve replacement versus aortic valve bypass: a comparison of outcomes and economics. Ann Thorac Surg 2016;101:49–54; discussion 54–5. 2. Kestelli M, Yilik L, Ozs€ oyler I, et al. Experimental study of a multiplaned mechanical aortic valve using bovine aorta. Int Heart J 2005;46:133–8.
Emmanuel Lansac, MD, PhD Department of Cardiac Surgery Institut Mutualiste Montsouris 42 Blvd Jourdan Paris 75014, France email: [email protected] Isabelle Di Centa, MD ˇ
Vascular Surgery Unit, Hopital Foch Suresnes, France
References 1. Yurekli I, Kestelli M, Cakir H, Peker I. Regarding surgical anatomy of the aortic annulus (letter). Ann Thorac Surg 2017;103:1680–1. 2. Khelil N, Sleilaty G, Palladino M, et al. Surgical anatomy of the aortic annulus: landmarks for external annuloplasty in aortic valve repair. Ann Thorac Surg 2015;99: 1220–7. 3. Lansac E, Di Centa I, Sleilaty G, et al. Long-term results of external aortic ring annuloplasty for aortic valve repair. Eur J Cardiothorac Surg 2016;50:350–60. 4. Anderson R. Defining the enigmatic annulus of the aortic valve. Eur J Cardiothorac Surg 2016;49:101–2. 5. Sievers HH, Hemmer G, Beyersdorf F, et al. The everyday used nomenclature of the aortic root components: the tower of Babel? Eur J Cardiothorac Surg 2012;41:478–82. 6. de Kerchove L, Jashari R, Boodhwani M, et al. Surgical anatomy of the aortic root: implication for valve-sparing reimplantation and aortic valve annuloplasty. J Thorac Cardiovasc Surg 2015;149:425–33. Ó 2017 by The Society of Thoracic Surgeons Published by Elsevier Inc.
Can Takosubo Syndrome in the Setting of Pericardiocentesis Be Prevented? To the Editor: I enjoyed reading the report by Belluschi and colleagues [1] about the 69-year old man who experienced Takotsubo syndrome (TTS) after pericardiocentesis for a pericardial effusion with tamponade, 6 months after aortic valve repair and ascending aorta replacement. There are no details about periprocedural blood pressure (BP) or heart rate (HR) rise, or symptoms of anxiety experienced by the patient, suggestive of a heightened sympathetic autonomic function, which could have ushered in the TTS. One wonders whether b-blockade, sedation, or both (eg, with benzodiazepines or propofol) could prevent the occasional emergence of TTS in patients undergoing pericardiocentesis. Other authors have emphasized “the importance of careful clinical evaluation (altered HR and dyspnea) in suspecting acute left ventricular dysfunction after initial clinical improvement with pericardial aspiration” [2]. The authors state that their patient had experienced pericardiocentesis-triggered TTS, rather than pericardial decompression syndrome (PDS), which they excluded in their patient “because pulmonary edema and cardiogenic shock were absent” [1]. PDS is thought to be “a well-defined but rather underreported complication of pericardial drainage [3, 4]. In addition, in the present case [1], “the clinical pattern of initial improvement followed by deterioration” instead of an “onset of biventricular impairment immediately post procedure” as in PDS [2] bespeaks TTS. However, the comprehensive review carried out by Ayoub and 0003-4975/$36.00
MISCELLANEOUS
We thank Yurekli and colleagues for their letter [1] on our article [2]. However, assumptions on dynamic anatomy, aneurysm formation, and leaflet deterioration are not supported by any references from the literature and do not correspond to our experience with long-term results of external aortic ring annuloplasty for aortic valve repair [3]. Furthermore, Yurekli and colleagues refer to a nonflexible external aortic annuloplasty, which is not the aortic ring we illustrate in our work. Indeed, we use an expansible (so flexible) aortic ring annuloplasty (Fig 1 of Khelil and colleagues) [2]. The purpose of Khelil and colleagues’s [2] article is to describe anatomical landmarks of the subvalvular plane for an external aortic annuloplasty; dynamic anatomy is not discussed and is beyond the scope of this anatomical work [2]. We do not agree with consideration on anatomic annulus, which is the term widely accepted in literature, particularly by Anderson [4] and Sievers and colleagues [5], who suggest use of the term aortic “annulus” to describe the ring (or plane) joining the three nadirs of the semilunar leaflet attachments. Three-dimensional figures are scale drawings showing the subvalvular dissection plane line and the schematic 3-dimensional aortic annular view from the each cusps as could be seen in a flaccid heart, which was also the finding of de Kerchove and colleagues [6].
What Should Be the Systolic Cardiac Output in Aorta? To the Editor:
CORRESPONDENCE
1681
Reference 1. Khelil N, Sleilaty G, Palladino M, et al. Surgical anatomy of the aortic annulus: landmarks for external annuloplasty in aortic valve repair. Ann Thorac Surg 2015;99:1220–7.
Reply To the Editor:
Congratulations to the authors for this valuable study [1]. They have put tremendous effort into the aortic valve bypass (AVB) technique. We have some concerns about this technique used in surgical treatment of severe aortic stenosis. Obviously, the duration of diastole is almost twofold that of systole. Bypassing the ascending aorta, aortic arch, and initial segment of the descending aorta with the AVB technique may have adverse results in terms of hypoperfusion. Are the authors eager to plan a simulation [2] in which the systolic cardiac output was three times (i.e., 3 5 L) of the usual cardiac output? Ismail Yurekli, MD Mert Kestelli, MD Habib Cakir, MD Nihan Karakas Yesilkaya, MD Izmir Ataturk Education and Research Hospital 6436 sok 82/3 35540 Karsiyaka-Izmir, Turkey Basin Sitesi, 35360, Izmir, Turkey email: [email protected]
References 1. Brown JW, Boyd JH, Patel PM, et al. Transcatheter aortic valve replacement versus aortic valve bypass: a comparison of outcomes and economics. Ann Thorac Surg 2016;101:49–54; discussion 54–5. 2. Kestelli M, Yilik L, Ozs€ oyler I, et al. Experimental study of a multiplaned mechanical aortic valve using bovine aorta. Int Heart J 2005;46:133–8.
Emmanuel Lansac, MD, PhD Department of Cardiac Surgery Institut Mutualiste Montsouris 42 Blvd Jourdan Paris 75014, France email: [email protected] Isabelle Di Centa, MD ˇ
Vascular Surgery Unit, Hopital Foch Suresnes, France
References 1. Yurekli I, Kestelli M, Cakir H, Peker I. Regarding surgical anatomy of the aortic annulus (letter). Ann Thorac Surg 2017;103:1680–1. 2. Khelil N, Sleilaty G, Palladino M, et al. Surgical anatomy of the aortic annulus: landmarks for external annuloplasty in aortic valve repair. Ann Thorac Surg 2015;99: 1220–7. 3. Lansac E, Di Centa I, Sleilaty G, et al. Long-term results of external aortic ring annuloplasty for aortic valve repair. Eur J Cardiothorac Surg 2016;50:350–60. 4. Anderson R. Defining the enigmatic annulus of the aortic valve. Eur J Cardiothorac Surg 2016;49:101–2. 5. Sievers HH, Hemmer G, Beyersdorf F, et al. The everyday used nomenclature of the aortic root components: the tower of Babel? Eur J Cardiothorac Surg 2012;41:478–82. 6. de Kerchove L, Jashari R, Boodhwani M, et al. Surgical anatomy of the aortic root: implication for valve-sparing reimplantation and aortic valve annuloplasty. J Thorac Cardiovasc Surg 2015;149:425–33. Ó 2017 by The Society of Thoracic Surgeons Published by Elsevier Inc.
Can Takosubo Syndrome in the Setting of Pericardiocentesis Be Prevented? To the Editor: I enjoyed reading the report by Belluschi and colleagues [1] about the 69-year old man who experienced Takotsubo syndrome (TTS) after pericardiocentesis for a pericardial effusion with tamponade, 6 months after aortic valve repair and ascending aorta replacement. There are no details about periprocedural blood pressure (BP) or heart rate (HR) rise, or symptoms of anxiety experienced by the patient, suggestive of a heightened sympathetic autonomic function, which could have ushered in the TTS. One wonders whether b-blockade, sedation, or both (eg, with benzodiazepines or propofol) could prevent the occasional emergence of TTS in patients undergoing pericardiocentesis. Other authors have emphasized “the importance of careful clinical evaluation (altered HR and dyspnea) in suspecting acute left ventricular dysfunction after initial clinical improvement with pericardial aspiration” [2]. The authors state that their patient had experienced pericardiocentesis-triggered TTS, rather than pericardial decompression syndrome (PDS), which they excluded in their patient “because pulmonary edema and cardiogenic shock were absent” [1]. PDS is thought to be “a well-defined but rather underreported complication of pericardial drainage [3, 4]. In addition, in the present case [1], “the clinical pattern of initial improvement followed by deterioration” instead of an “onset of biventricular impairment immediately post procedure” as in PDS [2] bespeaks TTS. However, the comprehensive review carried out by Ayoub and 0003-4975/$36.00
MISCELLANEOUS
We thank Yurekli and colleagues for their letter [1] on our article [2]. However, assumptions on dynamic anatomy, aneurysm formation, and leaflet deterioration are not supported by any references from the literature and do not correspond to our experience with long-term results of external aortic ring annuloplasty for aortic valve repair [3]. Furthermore, Yurekli and colleagues refer to a nonflexible external aortic annuloplasty, which is not the aortic ring we illustrate in our work. Indeed, we use an expansible (so flexible) aortic ring annuloplasty (Fig 1 of Khelil and colleagues) [2]. The purpose of Khelil and colleagues’s [2] article is to describe anatomical landmarks of the subvalvular plane for an external aortic annuloplasty; dynamic anatomy is not discussed and is beyond the scope of this anatomical work [2]. We do not agree with consideration on anatomic annulus, which is the term widely accepted in literature, particularly by Anderson [4] and Sievers and colleagues [5], who suggest use of the term aortic “annulus” to describe the ring (or plane) joining the three nadirs of the semilunar leaflet attachments. Three-dimensional figures are scale drawings showing the subvalvular dissection plane line and the schematic 3-dimensional aortic annular view from the each cusps as could be seen in a flaccid heart, which was also the finding of de Kerchove and colleagues [6].
What Should Be the Systolic Cardiac Output in Aorta? To the Editor: