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Ann Thorac Surg 2002;73:1691-1692
© 2002 The Society of Thoracic Surgeons

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Correspondence

Open heart surgery and abdominal aortic aneurysm: reply

^a Department of Cardiovascular Surgery, University Federico II of Naples, Via Pansini, 5, 80131 Naples, Italy
^b Bristol Heart Institute, Bristol Royal Infirmary, Marlborough St, Bristol BS2 8HW, UK

e-mail: r.ascione{at}bristol.ac.uk

To the Editor

We thank Drs Economopoulos and Iliopoulos for their valuable comments on our study [1]. Despite a rather large literature published over the last two decades, the surgical treatment of combined coronary and abdominal disease is still controversial.

Our report [1] was intended to examine the influence of cardiopulmonary bypass and cardioplegic arrest on early and late clinical outcome in patients undergoing a one-stage surgical procedure. Drs Economopoulos and Iliopoulos seem to have reservations regarding the surgical strategy followed in our on-pump series, particularly the adverse hemodynamic effects imposed on the myocardium by suprarenal aortic clamping during abdominal surgical intervention. They wrote that "it has been documented that this maneuver causes serious and adverse alterations in diastolic and systolic myocardial function." In support of their concerns, they refer to studies by Westaby [2], Mohr [3], and their colleagues. However, we looked carefully at the content of these reports and could not find any evidence to support what, therefore, remains an assumption. The fact is that myocardial injury to a revascularized heart after suprarenal aortic clamping is still unknown, and a dedicated study is needed to clarify this aspect.

In our on-pump series, the decision-making process was not uncritical. Rather, it took into account more than a single risk factor, as one would expect in the strategic management of such high-risk patients. Once we were assured of satisfactory hemodynamics, the decision to close the chest was aimed at minimizing the potential risks of mediastinal infection from protracted exposure of the thoracic cavity and open communication with the abdominal cavity and of excessive bleeding with the partial reversal of heparin sodium. Furthermore, decisions also were made with the goal of minimizing subsystem organ dysfunction related to prolonged cardiopulmonary bypass time. Confidence in doing so was based on the improved tolerance of what was now a revascularized heart to the increase in afterload after suprarenal aortic clamping. We think that this was a more than appropriate strategy.

Our results were obtained in patients operated on between March 1990 and February 1995 and were comparable to those reported in the literature [2, 3]. Since then, we have gained further experience in this field as a result of our continued efforts to improve the treatment of patients with combined coronary and abdominal vascular disease. To this end, we started to use off-pump coronary artery bypass grafting during 1995 and now have one of the largest series in the literature.

References

1. Ascione R., Iannelli G., Lim K.H.H., Imura H., Spampinato N. One-stage coronary and abdominal aortic operation with or without cardiopulmonary bypass: early and midterm follow-up. Ann Thorac Surg 2001;72:768-775.[Abstract/Free Full Text]
2. Westaby S., Parry A., Grebenik C.R., Pillai R., Lamont P. Combined cardiac and abdominal aortic aneurysm operations. The dual operation on cardiopulmonary bypass. J Thorac Cardiovasc Surg 1992;104:990-995.[Abstract]
3. Mohr F.W., Falk V., Autschbach R., et al. One-stage surgery of coronary arteries and abdominal aorta in patients with impaired left ventricular function. Circulation 1995;91:379-385.[Abstract/Free Full Text]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Raimondo Ascione Nicola Spampinato Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Ascione, R. Articles by Spampinato, N. Search for Related Content PubMed Articles by Ascione, R. Articles by Spampinato, N. Related Collections Coronary disease Related Article