Ann Thorac Surg 1995;60:59
© 1995 The Society of Thoracic Surgeons
Discussion
 |
Introduction
|
|---|
 Top
 Introduction
|
|---|
See also page 55.
DR DAVIS C. DRINKWATER, JR (Los Angeles, CA): I enjoyed your presentation very much. I wonder if we could look at the data another way and infer that because these stenoses occurred in the Prolene suture group in the first 15 months, they were related to a learning curve, a technical aspect, that might have changed over the two periods? I think that because of the two time periods, you really cannot say that polydioxanone makes the total difference, although many of us have adopted its use.
DR HAWKINS: Yes, I agree. What really stimulated this is what you brought up at the very end of your statement, and that is that many of us use absorbable suture for both coarctation and total anomalous pulmonary venous connection without any firm data to justify this. Many people have reported excellent results with a continuous polypropylene suture. You are correct in saying the operative mortality rate was higher early in the experience, and there definitely was evidence of a learning curve. The same group of surgeons used the identical technique during the period of the study, but I am on very thin ice to conclude that the change in suture is the only factor involved in the lower incidence of late pulmonary venous obstruction. There are many factors involved, and that is why one cannot conclude absorbable suture is the only factor related to our low incidence of late pulmonary venous obstruction since 1989. This study is an attempt to look carefully at the incidence of pulmonary venous obstruction using polydioxanone suture. The only way to truly settle this is with some type of a randomized trial, which will probably never be done.
DR JOHN E. MAYER, JR (Boston, MA): I wonder whether or not you looked at any of the other variables in your study that have been thought by some investigators to be associated with late pulmonary venous obstruction. Certainly when the data from my institution was examined, the two variables that came out as risk factors for late pulmonary venous obstruction were presence of heterotaxy syndrome and size of the individual pulmonary veins measured preoperatively by echocardiography. Can you tell us what other data you considered?
DR HAWKINS: We did not see any increased incidence in the patients with heterotaxy syndrome; in fact, none of the patients with heterotaxy had evidence of late pulmonary venous obstruction. We did not look at the size of the common pulmonary vein preoperatively. I think that it may be a factor in late pulmonary venous obstruction, and it certainly is a factor in whether repair should even be attempted. If the patient has a 1-mm or a 2-mm common pulmonary vein, is this really a patient who is going to have a successful outcome? Others have emphasized that patients with preoperative obstruction or with the infracardiac type of total anomalous pulmonary venous connection have a higher incidence of pulmonary venous obstruction. We did not see a correlation of these with late obstruction. In fact, 4 of the 5 patients who had late pulmonary venous obstruction had supracardiac forms.
