- Email: [email protected]
Wondrous Oxygenation During Awake Upper Airway Surgery
Ann Thorac Surg 2011;91:1306 –12
CORRESPONDENCE
References
Carlos A.C. Pedra, MD, PhD
1. Barbetakis N, Asteriou C, Tsilikas C. Treatment of myxedema coma after major thoracic surgery (letter). Ann Thorac Surg 2011;91:1310. 2. Yuan Y, Hu Y, Xie T, Zhao Y. Myxedema coma after esophagectomy. Ann Thorac Surg 2010;90:295–7.
Catheterization Laboratory for Congenital Heart Diseases Instituto Dante Pazzanese de Cardiologia 04012-180 - São Paulo, Brazil
1311
References
We want to congratulate Dr Green and colleagues [1] for their expertise to deal with this difficult clinical situation. The use of cardiac septal occluders for closure of airway fistulas has led to two ongoing trials at our institution. One trial for closure of bronchopleural fistulas using a metallic occluder [2]. The second trial for closure of tracheoesophageal fistulas using an alternative model of this device [3]. Although the double-disk metallic septal occluder used by Green and colleagues [1] has good stability after being deployed, it has a high profile, and it protrudes into the lumen of the airway or the esophagus, as demonstrated in Figure 3 of Green and colleagues’ [1] article. We reported the use of this model of device, the Occlutech Figulla ASD N Occluder (International Occlutech AB, Helsingborg, Sweden) with good results for closing a total bronchopleural fistula [4]. Different from the tracheoesophageal fistulas, the bronchopleural fistula is at the distal portion of the bronchus, so the high profile of the prosthesis is not a problem. Alternatively, we have used a Gore Helex Septal occluder (W.L. Gore & Associates, Inc, Flagstaff, AZ) for closing a benign tracheoesophageal fistula. This prosthesis model is not metallic and it flattens along the organs walls making less protrusion at the lumens of the trachea or the esophagus [5]. Although more work is necessary to establish what is the best way to endoscopically treat these difficult conditions, we would like to congratulate Dr Green and colleagues [1] for their valuable contribution.
We would like to thank Dr Evelinda Trindade for her assistance with the English language.
Miguel L. Tedde, MD, PhD Helio Minamoto, MD, PhD Thoracic Surgery Department Heart Institute (InCor) and Hospital das Clinicas of São Paulo Medical School 05403-900 - São Paulo, Brazil e-mail: [email protected] Paulo R. Scordamaglio, MD Ascedio Rodrigues, MD Eduardo G.H. Moura, MD, PhD Respiratory Endoscopy Service Endoscopy Unit Hospital das Clinicas of São Paulo Medical School 05403-000 - São Paulo, Brazil © 2011 by The Society of Thoracic Surgeons Published by Elsevier Inc
Dr Pedra discloses that he has financial relationships with AGA Medical USA and W.L. Gore & Associates.
Wondrous Oxygenation During Awake Upper Airway Surgery To the Editor: We congratulate Dr Macchiarini and his team to their remarkable article [1]. Their work seems to present the long-desired solution for upper airway surgery. Fortunately, The Annals of Thoracic Surgery also published the discussion of the presentation during The 45th Annual Meeting of The Society of Thoracic Surgeons in that Dr Lanuti from Boston commented that the respiratory effort is depressed with the described regimen. He also asked if the field was insuflated with oxygen or if the O2 tension in the room was increased. Macciarini’s answer was: “You don’t need to. The only thing that you need to do is to ask the patient to stay awake [. . .] and say, ‘Please breathe deeply.’ and you will see that the trachea moves and takes oxygen from below.” When deep breathing increases Pao2 then PaCO2 has to decrease. In contrast, Table 3 shows that the Pao2 increases intraoperatively during resection and reconstruction from 118 ⫾ 15 mm Hg to 132 ⫾ 9 mm Hg, but Paco2 also increased from 42 ⫾ 5 mm Hg to 58 ⫾ 10 mm Hg. Perhaps the Paco2 values were obtained before, and the Pao2 values after waking up the patients. If these values were measured in the same blood sample, then this relatively elevated Paco2 indicates a pronounced hypoventilation and a simultaneous improvement of oxygenation under such a degree of depressed respiratory efforts is only possible when the Pio2 is increased. 0003-4975/$36.00
MISCELLANEOUS
Broncoscopic Closure of Tracheoesophageal Fistulas To the Editor:
1. Green DA, Moskowitz WB, Shepherd RW. Closure of a broncho-to-neoesophageal fistula using an Amplatzer Septal Occluder device. Ann Thorac Surg 2010;89:2010 –2. 2. Bronchoscopic closure of bronchopleural fistulas with Occlutech Figulla ASD N Occluder device protocol. http:// clinicaltrials.gov/ct2/show/NCT01153074?term⫽tedde& rank⫽2. Accessed Aug 4, 2010. 3. Endoscopic closure of tracheoesophageal fistulas with occluder device (TEFGore Helex) Protocol. http://clinicaltrials. gov/ct2/show/NCT01153061?term⫽tedde&rank⫽1. Accessed Aug 4, 2010. 4. Tedde ML, Scordamaglio PR, Minamoto H, Figueiredo VR, Pedra CC, Jatene FB. Endobronchial closure of total bronchopleural fistula with Occlutech Figulla ASD N device. Ann Thorac Surg 2009;88:e25– 6. 5. Scordamaglio PR, Tedde ML, Minamoto H, Pedra CA, Jatene FB. Endoscopic treatment of tracheobronchial tree fistulas using atrial septal defect occluders: preliminary results. J Bras Pneumol 2009;35:1156 – 60.
1312
BOOK REVIEW
Ann Thorac Surg 2011;91:1312
Medical School Hanover Carl-Neuberg-Str. 1 Hannover, 30623 Germany e-mail: [email protected]
patient, then the airway cannot provide breathing, and therefore the patient cannot obviously eliminate carbon dioxide. We manage this by the hyperoxic oxygenation method until the anastomosis has been completed and accept permissive hypercapnia. This simple surgical step explains the issue raised by Dr Raymondos.
Reference
Paolo Macchiarini, MD, PhD
1. Macchiarini P, Rovira I, Ferrarello, S. Awake upper airway surgery. Ann Thorac Surg 2010;89:387–91.
Department of General Thoracic and Regenerative Surgery and Intrathoracic Transplantation Careggi University Hospital Florence Florence, Italy e-mail: [email protected]
Konstantinos Raymondos, MD Bernard Panning, MD
Reply To the Editor: We appreciate the comments of Drs Raymondos and Panning [1] on the raising partial pressures of arterial carbon dioxide and oxygen values during airway resection [2]. As carefully detailed, and as any health professional dealing with airway operations knows, you need to resect the diseased airway during tracheal operations. Well, if you need to resect the trachea in an awake
References 1. Raymondos K, Panning B. Wondrous oxygenation during awake upper airway surgery (letter). Ann Thorac Surg 2011; 91:1311-2. 2. Macchiarini P, Rovira I, Ferrarello S. Awake upper airway surgery. Ann Thorac Surg 2010;89:387–91.
REVIEW OF RECENT BOOKS Open Heart: The Radical Surgeons Who Revolutionized Medicine by David K.C. Cooper, MD 2010, New York, Kaplan Publishing 431 pp, illustrated, $26.99 ISBN: 978-1-60714-490-8 Reviewed by W. Gerald Rainer, MD, MS (Surg), Denver, Colorado
MISCELLANEOUS
Dr David Cooper’s book is yet another account chronicling the exploits and lives of certain pioneers in cardiac surgery some 50 to 60⫹ years after revolutionary breakthroughs occurred that forever changed surgery of the heart, not only from a technical standpoint, but also from the perspective of bold approaches to new and previously unexplored methods. Cooper approaches his topic chronologically beginning with Robert Gross and Clarence Crafoord (circa 1938 to 1944) and ending with Willem Kolff, Michael DeBakey, Denton Cooley, and William DeVries (era of the artificial heart). The author has gathered his material from a variety of sources including personal interviews with the main characters, interviews with trainees or close associates, and, in some cases, from accounts of individual opinions (some third-hand) based upon sometime vaguely documented personal assessments. As I have spent my career coincident with most of the years covered in this book, perhaps I have been mesmerized by the spectacular accomplishments of these surgeons so that even though I have been aware of all of the faults in this book’s account, I have never felt that
© 2011 by The Society of Thoracic Surgeons Published by Elsevier Inc
public exposure of these character flaws would be helpful in understanding the challenges of the time. The book is a relatively easy read in spite of a modicum of repetition. In an attempt at quasi-balanced insight into the personal lives of the principal players, the author concentrates heavily on foibles, shortcomings, and misadventures during and after enormously productive careers. This is done with such broad strokes as to seemingly apply equally to all pioneering cardiac surgeons of the time. In spite of considerable discussion of personal shortcomings, to the author’s credit, in some cases he includes expressions of opinions contrary to the critical portraits painted by others (vis-à-vis, Hufnagel’s, Bartlett’s, and Kirklin’s complimentary comments about Gross [pp 22–24]; also Gott’s comments supportive of Lillehei [p 205]). Along with a few editorial errors (eg, Sun Valley, Colorado (sic) [p 261]), a major gaffe is the statement on page 199 when describing the role of the founder of Medtronic Corporation, the section begins with “The story of the late (sic) Earl Bakken . . . .” This is not in keeping with his healthy appearance in the photograph sent with his Christmas card in December 2010. Although “OPEN HEART” is written with an apparent factual approach and with unfettered candor, undue emphasis on individual character flaws at a time of a tumultuous and highly productive revolution in thoracic surgery detracts from the courage and vision of such pioneering individuals and their phenomenal accomplishments.
Ann Thorac Surg 2011;91:1312 • 0003-4975/$36.00 doi:10.1016/j.athoracsur.2011.01.049
CORRESPONDENCE
References
Carlos A.C. Pedra, MD, PhD
1. Barbetakis N, Asteriou C, Tsilikas C. Treatment of myxedema coma after major thoracic surgery (letter). Ann Thorac Surg 2011;91:1310. 2. Yuan Y, Hu Y, Xie T, Zhao Y. Myxedema coma after esophagectomy. Ann Thorac Surg 2010;90:295–7.
Catheterization Laboratory for Congenital Heart Diseases Instituto Dante Pazzanese de Cardiologia 04012-180 - São Paulo, Brazil
1311
References
We want to congratulate Dr Green and colleagues [1] for their expertise to deal with this difficult clinical situation. The use of cardiac septal occluders for closure of airway fistulas has led to two ongoing trials at our institution. One trial for closure of bronchopleural fistulas using a metallic occluder [2]. The second trial for closure of tracheoesophageal fistulas using an alternative model of this device [3]. Although the double-disk metallic septal occluder used by Green and colleagues [1] has good stability after being deployed, it has a high profile, and it protrudes into the lumen of the airway or the esophagus, as demonstrated in Figure 3 of Green and colleagues’ [1] article. We reported the use of this model of device, the Occlutech Figulla ASD N Occluder (International Occlutech AB, Helsingborg, Sweden) with good results for closing a total bronchopleural fistula [4]. Different from the tracheoesophageal fistulas, the bronchopleural fistula is at the distal portion of the bronchus, so the high profile of the prosthesis is not a problem. Alternatively, we have used a Gore Helex Septal occluder (W.L. Gore & Associates, Inc, Flagstaff, AZ) for closing a benign tracheoesophageal fistula. This prosthesis model is not metallic and it flattens along the organs walls making less protrusion at the lumens of the trachea or the esophagus [5]. Although more work is necessary to establish what is the best way to endoscopically treat these difficult conditions, we would like to congratulate Dr Green and colleagues [1] for their valuable contribution.
We would like to thank Dr Evelinda Trindade for her assistance with the English language.
Miguel L. Tedde, MD, PhD Helio Minamoto, MD, PhD Thoracic Surgery Department Heart Institute (InCor) and Hospital das Clinicas of São Paulo Medical School 05403-900 - São Paulo, Brazil e-mail: [email protected] Paulo R. Scordamaglio, MD Ascedio Rodrigues, MD Eduardo G.H. Moura, MD, PhD Respiratory Endoscopy Service Endoscopy Unit Hospital das Clinicas of São Paulo Medical School 05403-000 - São Paulo, Brazil © 2011 by The Society of Thoracic Surgeons Published by Elsevier Inc
Dr Pedra discloses that he has financial relationships with AGA Medical USA and W.L. Gore & Associates.
Wondrous Oxygenation During Awake Upper Airway Surgery To the Editor: We congratulate Dr Macchiarini and his team to their remarkable article [1]. Their work seems to present the long-desired solution for upper airway surgery. Fortunately, The Annals of Thoracic Surgery also published the discussion of the presentation during The 45th Annual Meeting of The Society of Thoracic Surgeons in that Dr Lanuti from Boston commented that the respiratory effort is depressed with the described regimen. He also asked if the field was insuflated with oxygen or if the O2 tension in the room was increased. Macciarini’s answer was: “You don’t need to. The only thing that you need to do is to ask the patient to stay awake [. . .] and say, ‘Please breathe deeply.’ and you will see that the trachea moves and takes oxygen from below.” When deep breathing increases Pao2 then PaCO2 has to decrease. In contrast, Table 3 shows that the Pao2 increases intraoperatively during resection and reconstruction from 118 ⫾ 15 mm Hg to 132 ⫾ 9 mm Hg, but Paco2 also increased from 42 ⫾ 5 mm Hg to 58 ⫾ 10 mm Hg. Perhaps the Paco2 values were obtained before, and the Pao2 values after waking up the patients. If these values were measured in the same blood sample, then this relatively elevated Paco2 indicates a pronounced hypoventilation and a simultaneous improvement of oxygenation under such a degree of depressed respiratory efforts is only possible when the Pio2 is increased. 0003-4975/$36.00
MISCELLANEOUS
Broncoscopic Closure of Tracheoesophageal Fistulas To the Editor:
1. Green DA, Moskowitz WB, Shepherd RW. Closure of a broncho-to-neoesophageal fistula using an Amplatzer Septal Occluder device. Ann Thorac Surg 2010;89:2010 –2. 2. Bronchoscopic closure of bronchopleural fistulas with Occlutech Figulla ASD N Occluder device protocol. http:// clinicaltrials.gov/ct2/show/NCT01153074?term⫽tedde& rank⫽2. Accessed Aug 4, 2010. 3. Endoscopic closure of tracheoesophageal fistulas with occluder device (TEFGore Helex) Protocol. http://clinicaltrials. gov/ct2/show/NCT01153061?term⫽tedde&rank⫽1. Accessed Aug 4, 2010. 4. Tedde ML, Scordamaglio PR, Minamoto H, Figueiredo VR, Pedra CC, Jatene FB. Endobronchial closure of total bronchopleural fistula with Occlutech Figulla ASD N device. Ann Thorac Surg 2009;88:e25– 6. 5. Scordamaglio PR, Tedde ML, Minamoto H, Pedra CA, Jatene FB. Endoscopic treatment of tracheobronchial tree fistulas using atrial septal defect occluders: preliminary results. J Bras Pneumol 2009;35:1156 – 60.
1312
BOOK REVIEW
Ann Thorac Surg 2011;91:1312
Medical School Hanover Carl-Neuberg-Str. 1 Hannover, 30623 Germany e-mail: [email protected]
patient, then the airway cannot provide breathing, and therefore the patient cannot obviously eliminate carbon dioxide. We manage this by the hyperoxic oxygenation method until the anastomosis has been completed and accept permissive hypercapnia. This simple surgical step explains the issue raised by Dr Raymondos.
Reference
Paolo Macchiarini, MD, PhD
1. Macchiarini P, Rovira I, Ferrarello, S. Awake upper airway surgery. Ann Thorac Surg 2010;89:387–91.
Department of General Thoracic and Regenerative Surgery and Intrathoracic Transplantation Careggi University Hospital Florence Florence, Italy e-mail: [email protected]
Konstantinos Raymondos, MD Bernard Panning, MD
Reply To the Editor: We appreciate the comments of Drs Raymondos and Panning [1] on the raising partial pressures of arterial carbon dioxide and oxygen values during airway resection [2]. As carefully detailed, and as any health professional dealing with airway operations knows, you need to resect the diseased airway during tracheal operations. Well, if you need to resect the trachea in an awake
References 1. Raymondos K, Panning B. Wondrous oxygenation during awake upper airway surgery (letter). Ann Thorac Surg 2011; 91:1311-2. 2. Macchiarini P, Rovira I, Ferrarello S. Awake upper airway surgery. Ann Thorac Surg 2010;89:387–91.
REVIEW OF RECENT BOOKS Open Heart: The Radical Surgeons Who Revolutionized Medicine by David K.C. Cooper, MD 2010, New York, Kaplan Publishing 431 pp, illustrated, $26.99 ISBN: 978-1-60714-490-8 Reviewed by W. Gerald Rainer, MD, MS (Surg), Denver, Colorado
MISCELLANEOUS
Dr David Cooper’s book is yet another account chronicling the exploits and lives of certain pioneers in cardiac surgery some 50 to 60⫹ years after revolutionary breakthroughs occurred that forever changed surgery of the heart, not only from a technical standpoint, but also from the perspective of bold approaches to new and previously unexplored methods. Cooper approaches his topic chronologically beginning with Robert Gross and Clarence Crafoord (circa 1938 to 1944) and ending with Willem Kolff, Michael DeBakey, Denton Cooley, and William DeVries (era of the artificial heart). The author has gathered his material from a variety of sources including personal interviews with the main characters, interviews with trainees or close associates, and, in some cases, from accounts of individual opinions (some third-hand) based upon sometime vaguely documented personal assessments. As I have spent my career coincident with most of the years covered in this book, perhaps I have been mesmerized by the spectacular accomplishments of these surgeons so that even though I have been aware of all of the faults in this book’s account, I have never felt that
© 2011 by The Society of Thoracic Surgeons Published by Elsevier Inc
public exposure of these character flaws would be helpful in understanding the challenges of the time. The book is a relatively easy read in spite of a modicum of repetition. In an attempt at quasi-balanced insight into the personal lives of the principal players, the author concentrates heavily on foibles, shortcomings, and misadventures during and after enormously productive careers. This is done with such broad strokes as to seemingly apply equally to all pioneering cardiac surgeons of the time. In spite of considerable discussion of personal shortcomings, to the author’s credit, in some cases he includes expressions of opinions contrary to the critical portraits painted by others (vis-à-vis, Hufnagel’s, Bartlett’s, and Kirklin’s complimentary comments about Gross [pp 22–24]; also Gott’s comments supportive of Lillehei [p 205]). Along with a few editorial errors (eg, Sun Valley, Colorado (sic) [p 261]), a major gaffe is the statement on page 199 when describing the role of the founder of Medtronic Corporation, the section begins with “The story of the late (sic) Earl Bakken . . . .” This is not in keeping with his healthy appearance in the photograph sent with his Christmas card in December 2010. Although “OPEN HEART” is written with an apparent factual approach and with unfettered candor, undue emphasis on individual character flaws at a time of a tumultuous and highly productive revolution in thoracic surgery detracts from the courage and vision of such pioneering individuals and their phenomenal accomplishments.
Ann Thorac Surg 2011;91:1312 • 0003-4975/$36.00 doi:10.1016/j.athoracsur.2011.01.049