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Ann Thorac Surg 1999;68:2386-2387
© 1999 The Society of Thoracic Surgeons
a Department of Thoracic and Cardiovascular Surgery, The University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX 77030, USA
e-mail: rsmythe{at}notes.mdacc.tmc.edu
To the Editor
We thank Drs Shimakowa and Urschel and colleagues for their comments and interest in our manuscript [1]. We would agree with Dr Urschel that the option to rapidly reinstitute cardiopulmonary bypass, if necessary, should be emphasized. Hopefully, with an open sternum and a bypass unit in the room, this would be possible if the algorithm we presented was not successful. The initial goals, however, should still be to maintain a patent airway and wean cardiopulmonary bypass if possible as further surgical treatment may be obviated. A more critical examination of the case presented by Shimokawa and associates is advised, however, as this conveniently provides opportunity to review and emphasize these important points made in our manuscript.
When massive hemorrhage was encountered, a flexible bronchoscope was introduced and the bleeding was localized to one lung. Although this instrument may rarely allow for the localization of bleeding in some cases of massive or exsanguinating hemoptysis, it has little value in establishment of an airway. If the operative endeavors were unsuccessful, the rigid scope would have been useful in maintenance of the airway as cardiopulmonary bypass was weaned. Lung resections on cardiopulmonary bypass may certainly be performed, but the mortality is much higher, as we discussed [2, 3]. Interestingly, the authors recommend avoiding manual compression of the lungs in an effort to dislodge distal thromboemboli. Shouldn’t multiple firings of a stapling device across lung parenchyma while on bypass be discouraged as well? Finally, a word of caution regarding localization of bleeding sources in this situation by visual and manual inspection of the lung. The authors state that several scarred lesions of pulmonary infarction were found and resected. Were these "scarred lesions" likely to be acute? The source or sources of hemorrhage could have been anywhere in the lung, and not necessarily discernible by inspection of the pleural surface. What would the authors have done if all lesions were resected and bleeding continued? This would have been likely to result in a pneumonectomy, which even without cardiopulmonary bypass can result in up to 30% mortality when performed for acute hemoptysis [4]. Our original algorithm regarding the scenario of massive or exsanguinating hemoptysis on cardiopulmonary bypass would have been appropriate in this case [1].
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