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Ann Thorac Surg 2003;76:661
© 2003 The Society of Thoracic Surgeons
a Cardiothoracic Surgery, University Hospital, Coimbra 3000, Portugal
To the Editor:
We have read with great interest the article by Raco and coworkers [1]. We congratulate the authors for the good results of their coronary surgery using a technique that is gaining increasing acceptance by many units throughout the world.
Hypothermic ventricular fibrillation, with or without intermittent aortic cross-clamping, was used in the earliest days of coronary surgery for ischemic heart disease, but most surgeons now use one of several forms of cardioplegia for myocardial protection during coronary artery bypass graft (CABG). There is no doubt that cardioplegia affords protection to the myocardium, as revealed unequivocally by an endless number of reports dealing with its numerous variations. However, this does not mean that noncardioplegic methods, which are still used by many, result in a lesser protection. The safety and efficacy of these methods have been demonstrated in primary and reoperative CABG, as well as in higher risk patients. Besides, the concept of ischemic preconditioning appears to support intermittent ischemic arrest.
We used cardioplegia for myocardial protection during CABG until about 1990. Since then, we have sequentially used intermittent aortic cross-clamping, initially, and more recently, ventricular fibrillation without aortic occlusion. We now have accumulated an experience of more than 5500 patients who underwent isolated CABG using these methods, with a perioperative mortality of 1.0% for all corners. There was no major reason to move to cardioplegic techniques, other than for simplicity. We now prefer noncardioplegic methods, not only because they are safe and efficient but also because they are more versatile and allow greater operative flexibility. The technique is easy to perform and is reproducible by less experienced surgeons and trainers. In previous reports, we demonstrated that noncardioplegic methods afford good myocardial protection and operating conditions with excellent applicability, even in patients with severe left ventricular dysfunction [2], and discussed the basic operative principles and technical aspects related to the method of intermittent aortic cross-clamping [3]. In the latter work, we found that patients operated on with intermittent cross-clamping had better clinical outcomes and lower requirements for inotropic support, when compared with those operated on using cardioplegia.
Since 1992 we have been using ventricular fibrillation, without aortic occlusion, with success for primary and reoperative CABG, for resection of left ventricular aneurysms, and for closure of ischemic ventricular septal defects. The main reason for changing from intermittent aortic cross-clamping was simplicity, as we learned to obtain good local control and operating conditions, and because it potentially avoids embolic consequences of manipulating the aorta. We have recently studied risk factors for cerebrovascular accidents in a series of 4567 patients submitted to isolated CABG with hypothermic ventricular fibrillation with or without periods of aortic cross-clamping [4]. In a multivariable analysis, we found that the number of periods of aortic cross-clamping was an independent risk variable for a perioperative cerebrovascular accident (odds ratio of 1.3 for each period of cross-clamping). This study adds evidence to the superiority of the fibrillation technique over intermittent cross-clamping of the aorta, in terms of neurologic protection, and we strongly recommend it to the authors.
References
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