Ann Thorac Surg 2008;86:1052-1053. doi:10.1016/j.athoracsur.2008.04.034
© 2008 The Society of Thoracic Surgeons
Correspondence
Reply
Christopher Rao, MBBS, BSa,
Thanos Athanasiou, PhD, FETCSa,
Joanna Chikwe, FRCSb
a Department of Biosurgery and Surgical Technology, Imperial College London, St. Mary's Hospital, London, W2 1NY England
b Department of Cardiothoracic Surgery, Mount Sinai Hospital, One Gustave L. Levy Place, New York, NY 10029
(Email: christopher.rao{at}imperial.ac.uk; tathan5253{at}aol.com; chikwe{at}gmail.com).
To the Editor:
We appreciate the thoughtful response of Dr Odell [1] to our article [2]. Odell highlights a case report [3] and an animal study [4], suggesting that deformation of intracoronary stents may occur intraoperatively from routine manipulation of the heart. Although neither study was identified by our review of the literature, this putative mechanism fits well within the paradigm we propose to explain the increased mortality and morbidity observed in patients with prior intracoronary stents who subsequently undergo elective coronary artery bypass grafting [5, 6]. Within this paradigm, we divide the possible mechanisms into three types (Table 1). First, intrinsic pathophysiology consists of the factors that predispose patients to coronary artery bypass surgery after previous stenting. Second, acquired pathophysiology represents the direct results of prior coronary artery stenting. Finally, we list potential technical sequelae resulting from previous coronary stents. It is not possible from available data to determine which of these mechanisms are primarily responsible for the adverse outcomes we have outlined. Therefore, we have designed a prospective exploratory study (ie, the Surgery After Stenting [SAS] trial) to specifically identify the dominant processes to better inform selection of initial revascularization strategy in patients that are likely to need eventual coronary artery bypass surgery.
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Table 1 Proposed Mechanisms of Adverse Outcomes After Elective Coronary Artery Bypass Surgery in Patients With Prior Intracoronary Stents
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References
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- Odell JA. Coronary artery bypass grafting after previous stenting is associated with compromised long-term efficacy (letter) Ann Thorac Surg 2008;86:1052.[Free Full Text]
- Rao C, Stanbridge RL, Chikwe J, et al. Does previous percutaneous coronary stenting compromise the long-term efficacy of subsequent coronary artery bypass surgery?. A microsimulation study. Ann Thorac Surg 2008;85:501-507.[Abstract/Free Full Text]
- Tovar EA, Blau N, Borsari A, Landa DW, Packer JM. Severe deformity of a Palmaz-Schatz stent after normal surgical manipulation Ann Thorac Surg 1997;63:220-221.[Abstract/Free Full Text]
- Tovar EA, Borsari A. Effects of surgical manipulation on coronary stents: should surgical strategy be altered? Ann Thorac Surg 1997;63:37-40.[Abstract/Free Full Text]
- Thielmann M, Leyh R, Massoudy P, et al. Prognostic significance of multiple previous percutaneous coronary interventions in patients undergoing elective coronary artery bypass surgery Circulation 2006;114(1 Suppl):I441-I447.[Medline]
- Thielmann M, Neuhauser M, Knipp S, et al. Prognostic impact of previous percutaneous coronary intervention in patients with diabetes mellitus and triple-vessel disease undergoing coronary artery bypass surgery J Thorac Cardiovasc Surg 2007;134:470-476.[Abstract/Free Full Text]
Related Article
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Coronary Artery Bypass Grafting After Previous Stenting is Associated With Compromised Long-Term Efficacy
- John A. Odell
Ann. Thorac. Surg. 2008 86: 1052.
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