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Ann Thorac Surg 2003;76:973
© 2003 The Society of Thoracic Surgeons

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Correspondence

Reply

^a Department of Cardiovascular Surgery, National Kanazawa Hospital, 1-1 Shimoishibikicho, Kanazawa, 920-8650, Japan

e-mail: matumoto{at}kinbyou.hosp.go.jp

To the Editor:

We thank Dr Masroor and colleagues for responding to our article [1] and for their thoughtful comments.

As we stated in our paper, retrograde coronary sinus (CS) perfusion, as a method of myocardial preservation, is not novel. In 1956, Lillehei [2] first reported a clinical case of aortic valve surgery using this technique (perfusion flow was 125 mL/min). We proved the efficacy and safety of this technique through the use of near-infrared spectroscopy monitoring and the measurements of cardiac enzymes.

We agree with their comment about the myocardial protection of the beating heart surgery. Cardiac dysfunction may be caused by myocardial edema intrinsic to the diastolic state of the arrested heart [3]. Therefore, cardioplegic arrest techniques will inevitably produce some degree of myocardial edema and reperfusion injury. In contrast, keeping the heart beating results in less myocardial edema and better cardiac function [4]. Thus, we also believe that the on-pump beating heart surgery allows for less myocardial damage and minimizes the risk of ischemia-reperfusion.

However, we have a different opinion about the perfusion technique. They recommend the simultaneous ante/retro perfusion, and it is theoretically acceptable for us. But, we have no information about the clinical data from them regarding whether simultaneous retro/ante perfusion is superior to our method. If they want to demonstrate the efficacy of simultaneous retro/ante perfusion, they need to show the comparable clinical data. If their clinical results are almost equal to ours, we do not favor the more complex method. And they stated that direct cannulation to the coronary ostia is used for aortic procedure. We avoid the procedure because the disadvantages of direct antegrade perfusion include risk of injury and postcannulation ostial stenosis of the coronary arteries, and interruption of surgical procedures. And when coronary revascularization is also performed, the retrograde CS perfusion technique does not require the specially designed perfusion method that they documented.

Besides, our experimental study in swine indicates that the optimal CS perfusion flow is 7 mL/kg/min; 5 mL/kg/min or lower perfusion flow frequently induces ventricular fibrillation due to hypoperfusion. Their lowest limit perfusion flow of 250 mL/min may be below the safe level. We believe that higher perfusion flow (>300 mL/min) maintains beating of the heart and appropriate pH, and allows effective delivery of substrates and removal of acid metabolites.

We think their technique is also a good surgical option that promotes more homogeneous oxygenated blood distribution. However, following our excellent clinical data, we favor retrograde CS perfusion because it is simpler than the simultaneous ante/retro perfusion technique.

References

1. Matsumoto Y., Watanabe G., Endo M., et al. Efficacy and safety of on-pump beating heart surgery for valvular disease. Ann Thorac Surg 2002;74:678-683.[Abstract/Free Full Text]
2. Lillehei C.W., DeWall R.A., Gott V.L., Varco R.L. The direct vision correction of calcific aortic stenosis by means of a pump-oxygenator and retrograde coronary sinus perfusion. Dis Chest 1956;30:123-131.[Medline]
3. Misare B.D., Krukenkamp B.D., Lazer Z.P., Levitsky S.L. Recovery of postischemic contractile function is depressed by antegrade warm continuous blood cardioplegia. Ann Thorac Surg 1993;105:37-44.
4. Mehlhorn U., Allen S.J., Adamus D.L., Davis K.L., Gogola G.R., Warters R.D. Cardiac surgical conditions induced by ß-blockade: effect on myocardial fluid balance. Ann Thorac Surg 1996;62:143-150.[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 Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Matsumoto, Y. Search for Related Content PubMed Articles by Matsumoto, Y. Related Collections Valve disease