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Ann Thorac Surg 1996;61:278-279
© 1996 The Society of Thoracic Surgeons
Department of Cardiovascular Surgery, University of Verona Medical School, Ocm Borgo Trento, Piazzale Stefani 1, 37126 Verona, Italy
To the Editor:
We would like to comment on the recent article by de Haan and associates [1]. Whole blood retransfusion (WBA) returns unwanted activated coagulation factors and hemolytic degradation products [2]. Despite the safe application of WBA during major vascular operations, coagulation disturbances with lethal outcome have been reported [3–5]. The impaired hemostasis after retransfusion of retained blood from the pleural cavity during cardiopulmonary bypass observed by de Haan and co-workers [1] underlines the caution against WBA. Experimental animal studies comparing cell-saving (CS) against WBA demonstrated minor coagulation disturbances and minor hemolysis in the group receiving cell-separated blood [6]. We compared the quality of WBA versus CS blood concerning hemolytic and coagulation parameters in 32 patients undergoing elective abdominal aortic repair.
Disturbances in coagulation hemostasis (D-dimer and fibrin degradation products) were significantly greater in the WBA group (n = 16) compared with the CS group (n = 16) (fibrin degradation products: 166 ± 56 mg/L for WBA versus 66 ± 28 mg/L for CS, p 
0.001; D-dimer: 0.88 ± 0.24 mg/L for WBA versus 0.76 ± 0.18 mg/L for CS, p 0.001 by Mann-Whitney U test). Reinfusion of hemolysed autologous red blood cells is known to be capable of inducing intravascular coagulation in dogs [7]. Levels of hemolytic degradation products in our study were significantly greater in the whole blood retransfusate compared with cell-separated blood (free hemoglobin: 200 ± 115 mmol/L for WBA versus 86 ± 74 mmol/L for CS, p 0.01; lactic dehydrogenase: 9.5 ± 3.83 µkat/L for WBA versus 4 ± 2.07 µkat/L for CS, p 0.001; haptoglobin: 1.0 ± 0.45 g/L for WBA versus <0.41 for CS, p 0.001 by Mann-Whitney U test).
Our results demonstrate that cell-separated blood seems to be of better quality regarding coagulation disturbances and level of hemolytic degradation products. We support de Haan and wall, the infundibular free wall, and the adherent left atrial appendage. All these anatomic structures were resected en bloc in a fashion similar to the harvesting of a pulmonary autograft for the Ross procedure extended, however, to include a large portion of the left atrial appendage and distally to the pulmonary bifurcation. The right ventricle-to-pulmonary artery continuity was reconstructed by interposing a cryopreserved pulmonary homograft.
The procedure was immediately successful, allowing for complete and prompt recovery from the clinical signs. The patient was discharged to a program of adjunctive chemotherapy and continued to be followed up, showing good clinical behavior up to 12 months, when recurrence of both retroperitoneal and intracardiac tumor was detected. The patient refused further treatment and shortly thereafter died. Autopsy was not permitted.
In summary, total survival after the initial surgical treatment was extended to 33 months which, in spite of the need of two major surgical interventions, the inconvenience of the chemotherapy, and frequent clinical examinations, offered good quality of life. In our case, it could be speculated that the more radical approach that we applied at the time of the second intervention should have been used initially, possibly providing a more favorable effect on the natural history of this neoplastic disease.
In conclusion, it seems to us that an aggressive and extended surgical treatment combined with additional chemotherapy is worthwhile and may indeed offer ``significant palliation and an opportunity for increased length of survival.''
References
Division of Cardiothoracic Surgery (h-892), University of California Medical Center, 200 W Arbor Dr, # 8892 San Diego Ca 92103-1990
To the Editor:
I enjoyed reading the account by Drs Mazzucco and Santini of the further follow up of their patient, in whom they had performed an extensive secondary resection.
Doctor Orringer also brought up some important points in his excellent invited commentary on our article [1]. Perhaps the features now to be emphasized as a result of a review of all 7 of these cases are that by the time these patients become symptomatic, the disease is generally bilateral and distal microembolization has probably occurred.
Certainly, this was the case in all 6 patients that we presented. The patients presented in right heart failure with severe pulmonary hypertension, with bilateral and essentially inoperable disease. Palliation presented the only possibility, and although it is true that subsequent survival was ``dismal,'' it certainly was significantly enhanced both in terms of longevity and quality of life.
The lessons to be learned from these cases are that early diagnosis presents the only opportunity for a potential cure with radical resection. By the time the patient presents with bilateral disease and pulmonary hypertension (unfortunately the usual mode of presentation), a cure is unrealistic but maneuvers can be performed to restore pulmonary blood flow at least for a reasonable period of time.
Reference
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