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Ann Thorac Surg 1996;61:1591-1592
© 1996 The Society of Thoracic Surgeons
U.O. di Cardiochirurgia, Ospedale Cisanello, Via Paradisa 2, 56122 Pisa, Italy
To the Editor:
The article by Mayumi and associates [1] published in the September 1995 issue of The Annals of Thoracic Surgery once again demonstrates the efforts in developing new methods to obtain enlargement of a diminutive aortic annulus in patients undergoing aortic valve replacement. However, the technique described by Mayumi and associates is not new, because it was initially proposed in 1983 by Nunez and colleagues [2] as an alternative to other more popular ones such as those described earlier by Nicks and colleagues [3] or Manouguian and Seybold-Epting [4]. When compared with such techniques, the method described by Nunez and colleagues [2] has the clear advantages of allowing a real enlargement of the aortic annulus without opening the left atrium and without distorting the mitral valve. My colleagues and I have used this simplified technique at the University of Padova in the past and reported the preliminary results in a series of 18 patients operated on between 1984 and 1990 [5]. The results obtained were gratifying; we were able to achieve insertion of a prosthesis two sizes larger than the native annulus in most cases with a low rate of complications. I continue to favor this technique whenever I believe that enlargement of the aortic annulus is mandatory to insert a prosthesis of adequate size because I believe it is simple, reproducible, and effective. The article by Mayumi and associates [1] contributes to further popularize this technique without, however, giving proper credit to previous publications.
References
Department of Cardiovascular Surgery, National Kyushu Medical Center Hospital, 1-8-1 Jigyohama, Chuo-ku, Fukuoka 810, Japan
To the Editor:
Recently, we published an article entitled ``Simplified Manouguian's Aortic Annular Enlargement for Aortic Valve Replacement'' in this journal [1]. The technique involves an incision from the top of the commissure between the noncoronary cusp and left coronary cusp through the interventricular fibrous trigone like the so-called Manouguian's aortic enlarging method [2, 3], but both the anterior mitral leaflet and the left atrial roof are preserved intact.
With regard to the letter from Dr Bortolotti, I heartily apologize to Dr Bortolotti and his colleagues and to Dr Nunez and his colleagues for not citing their excellent works [4, 5], which definitely preceded ours. This is simply because we did not find their publications due to the lack of availability in our institution of the journals in which they have published their articles, not because we have purposely ignored them. I hope they understand.
In addition, soon after we had published our article in The Annals, I also found a letter written by Dr D. Rastan in the April 1995 issue of The Journal of Thoracic and Cardiovascular Surgery [6]. The letter strongly claimed that the original concept and operations of the aortic annular enlargement associated with or without mitral valve replacement were originated by Dr H. Rastan [7, 8], not by Dr Manouguian, and therefore the title of the article, ``Eleven-Year Follow-up Study for Aortic or Aortic-Mitral Anulus-Enlarging Procedure by Manouguian's Technique,'' by my colleagues, Kawachi, Tominaga, and Tokunaga [9], should be corrected.
Soon after Manouguian's publications in 1979 [2, 3], the method was examined in animals and in autopsy cases, and then used for patients at the Division of Cardiovascular Surgery, Kyushu University Hospital, by Dr Tokunaga. Doctor Tokunaga's first clinical case of double-valve replacement using the method was done on a patient with rheumatic aortic and mitral stenosis in January 1980. Thereafter, Dr Tokunaga refined the original Rastan-Manouguian's aortic annular enlarging method as a method for double-valve replacement with no mortality. The long-term follow-up results of 15 patients (single aortic, 7; double aortic and mitral, 8) were published by Kawachi and associates in 1992 [9]. The doctors led by Dr Tokunaga became familiar with this technique at his division. The results were generally satisfactory, as reported previously [9], but all of the young doctors who assisted Dr Tokunaga's operations noticed the complexity and resulting prolonged aortic cross-clamp time of the operations.
Our first case of the simplified aortic annular enlargement method was done by me in April 1994 [1]. I must disclose, however, that exactly similar operations had also been independently done before April 1994 at both Iizuka Hospital, Iizuka City, Fukuoka, Japan, led by Dr Jiro Tanaka, and Kyushu Kosei Nenkin Hospital, Kitakyushu City, Fukuoka, led by Dr Akira Sese, both of whom were previously led by Dr Tokunaga. This fact was revealed after the galley proof of our article had been already sent back to The Annals.
Again I extend my sincere apology to all of these important surgeons. Whoever the credit belongs to, the simplified aortic annular enlarging method is convenient for aortic valve replacement.
References
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