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Ann Thorac Surg 2004;78:1514-1515
© 2004 The Society of Thoracic Surgeons

Correspondence

Reply

Christian Lund, MD, Per K. Hol, MD, Runar Lundblad, MD, PhD, Erik Fosse, MD, PhD, Kjetil Sundet, PhD, Bjørn Tennøe, MD, Rainer Brucher, PhD, David Russell, MD, PhD

Department of Neurology, Rikshospitalet University Hospital, 0027 Oslo, Norway

christian.lund{at}rikshospitalet.no

To the Editor:

We thank Dr Whitaker for his interest and comments regarding our study [1] and appreciate the opportunity to comment on his remarks. We used a heparin-coated (Duraflo II; Baxter) circuit in all patients having an on-pump procedure and 25-µm arterial line filters (DII AF-1025 Gold) in all patients. The Duraflo II coating also reduces the inflammatory response, as we [2, 3] have demonstrated in previous studies. Alpha-stat strategy is used routinely for pH correction at our hospital, as was the case in this study. Patients in both groups had Swan-Ganz catheters and continuous monitoring of cardiac output, which allowed optimal volume substitution at all times during operation. In most instances, cardiac output was maintained unchanged during off-pump surgical procedures, even when the surgical team was operating on the posterior coronary vessels. Arrhythmias occurred in a few patients because of cardiac ischemia [4], but this event was exceptional.

Although multifrequency transcranial Doppler can differentiate solid from gaseous microemboli, this is possible only when there are limited numbers of microemboli [5]. It is very difficult to carry out an exact classification of all microemboli during operation because of analysis difficulties when multiple clusters of microemboli enter the middle cerebral artery simultaneously. We do record blood flow velocities in the middle cerebral artery during all operations. However, velocity (V) measurements alone do not give a precise estimation of blood flow (F), as we cannot, for example, always maintain a constant insonation angle during the entire operation. We also do not know the cross-sectional area (A) of the middle cerebral artery under study, ie, F = A x V. In an attempt to overcome this problem, we are currently developing frequency-weighted Doppler power measurements [6].

The main aim of our study was to compare cerebral microembolization during off-pump and on-pump operations. A more detailed report of the neuropsychological and neuroradiological findings with a 12-month follow-up in a larger patient population is in preparation.

References

  1. Lund C, Hol PK, Lundblad R, et al. Comparison of cerebral embolization during off-pump and on-pump coronary artery bypass surgery. Ann Thorac Surg. 2003;76:765–770[Abstract/Free Full Text]
  2. Øvrum E, Fosse E, Mollnes TE, et al. Complete heparin-coated cardiopulmonary bypass and low heparin dose reduce complement and granulocyte activation. Eur J Cardio-thorac Surg. 1996;10:54–60[Abstract]
  3. Moen O, Høgasen K, Fosse E, et al. Attenuation of changes in leukocyte surface markers and complement activation with heparin-coated cardiopulmonary bypass. Ann Thorac Surg. 1997;63:105–111[Abstract/Free Full Text]
  4. Lund C, Lundblad R, Fosse E, et al. Ventricular fibrillation during off-pump coronary artery bypass grafting: transcranial Doppler and clinical findings. Cerebrovasc Dis. 2001;12:139–141[Medline]
  5. Russell D, Brucher R. Online automatic discrimination between solid and gaseous cerebral microemboli with the first multifrequency transcranial Doppler. Stroke. 2002;33:1975–1980[Abstract/Free Full Text]
  6. Russell D, Brucher R. Assessment of the effect of nitroglycerine and sumatriptan on MCA cross-section area and blood flow using TCD [Abstract]. Cerebrovasc Dis. 2003;16(Suppl 2):25

Related Article

Apparent Reduction of Cerebral Microemboli During Off-Pump Operations
Donald C. Whitaker
Ann. Thorac. Surg. 2004 78: 1513-1514. [Extract] [Full Text] [PDF]




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