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Ann Thorac Surg 2000;70:1450
© 2000 The Society of Thoracic Surgeons

Correspondence

Reply

Scott D. Lick, MD, Paul S. Brown, MD, Mark Kurusz CCP, Roger A. Vertrees, PhD, Christopher K. McQuitty, MD, William E. Johnston, MD

a Room 6.120, John Sealy Hospital, Galveston, TX, USA 77555-0528

e-mail: slick.utmb.edu

To the Editor

Doctor Allen’s concerns are appreciated. His group has done the large-animal groundwork showing the benefits of controlled reperfusion, and should be applauded.

First, we chose to leave the left atrial clamp closed during the entire 10 minutes because we do not consider the pulmonary graft to be truly deaired during controlled reperfusion. During controlled reperfusion, tidal volumes are intentionally small, allowing thorough distribution of the low-pressure, low-volume reperfusate (ie, to prevent West zone I hypoperfusion). Only after the pulmonary artery is unclamped, the graft perfused under normal physiologic flow and pressure, and the airspaces are fully expanded, do we consider it safe to open the left atrial clamp. We acknowledge that in their studies of swine, Dr Allen and coworkers noted no signs of air embolus. However, they did no neurohistolopathological examinations, and did no survival studies, and thus could not conduct postoperative neurologic testing. We do not consider these acute studies in swine enough evidence to go against our clinical intuition that a more thorough deairing is required.

Second, we cannot comment directly on the hemodynamic stability of their swine model. We did not perform any large-animal studies using controlled reperfusion. However, our clinical experience with amino acid-enriched cardioplegia is that it can make patients hypotensive. We reckoned that withdrawal of arterial blood simultaneous with left atrial influx of: (1) Buckberg-based solution, (2) washout of postischemic lung metabolites and any residual lung preservative, and (3) potential air emboli (as described above) could potentially lead to hypotension. Hence, we created the reservoir perfusion protocol as described.

It is likely that if controlled reperfusion becomes widely practiced, others will think of more ingenious and elegant techniques. All variants, however, will be indebted to Dr Allen and his colleagues.


Related Article

Controlled pulmonary reperfusion: what is the optimal method of delivery?
Bradley S. Allen
Ann. Thorac. Surg. 2000 70: 1449-1450. [Extract] [Full Text] [PDF]




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