CORRESPONDENCE
Esophageal Perforation To the Editor: I read with interest the excellent review entitled “Esophageal perforation: a continuing challenge,” by W. G. Jones I1 and Robert J. Ginsberg, published in The Annals of Thoracic Surgery [l]. Dr Jones and Dr Ginsberg quoted our article [2] as having 61 cases of esophageal perforations with an overall mortality of 30%. We have reported 64 cases of esophageal perforations, including 2 cases that were treated nonoperatively because the perforations were contained: one was a cervical perforation due to a foreign body, and the other was diagnosed immediately after a rigid esophagoscopy with biopsy of a peptic stricture. Both patients survived. An additional patient had an abdominal perforation that was closed primarily, but was excluded from Table 3 because the latter compared cervical versus thoracic operations. The third patient also survived. The overall mortality was 28% (18164). Although this is a small difference from that reported in Dr Jones and Dr Ginsberg’s review, nevertheless it is important. Safuh Attar, M D Division of Thoracic and Cardiovascular Surgery University of Ma y l a n d Hospital 22 S Greene St Baltimore, M D 21201
References 1. Jones WG 11, Ginsberg RJ. Esophageal perforation: a continuing challenge. Ann Thorac Surg 1992;53:534-43. 2. Attar S, Hankins JR, Suter CM, et al. Esophageal perforation: a therapeutic challenge. Ann Thorac Surg 1990;50:459.
Reply
To the Editor:
We thank Dr Attar for his letter regarding our review on esophageal perforation. In our review of the article by Attar and associates, the 3 additional cases that Dr Attar mentioned were indeed not included in the preparation of data for Table 1. Thus, as he has stated, the tabulated mortality should indeed be 18/64 (28%) rather than the 18/61 (30%) that we quoted. We apologize to Dr Attar and his associates for this error and appreciate his efforts in its correction.
William G. Jones 11, M D Robert 1. Ginsberg, M D The New York Hospital-Cornell Medical Center 525 E 68th St New York, N Y 10021
Ross’ First Homograft Replacement of the Aortic Valve To the Editor: I read with interest the article by Hopkins and associates [I]. Their report took me back 30+ years when I was working on the aortic homograft and the heterologous aortic valve. At that time I was unaware of the experimental work of Gross, Lam [2], and Heimbecker. It was Murray’s [3] successful clinical use of placing the homograft in the descending aorta that prompted me to devise the method of placing the aortic valve in the ”subcoronary position” [4]. Once I realized this was a feasible clinical proposition, I phoned Donald Ross at Guy‘s Hospital and described the 0 1992 by The Society of Thoracic Surgeons
method to him. He expressed considerable interest and mentioned it to Lord Brock-his chief at that time-who also considered it possible. During the same conversation I asked R o s s who was doing far more open heart valve operations than I w a s t o let me know if and when he proposed inserting a freeze-dried homologous aortic valve into the “subcoronary position.” As reported by Hopkins and associates [l], Ross had started collecting a bank of freeze-dried valves and luckily, as it subsequently turned out, he was forced to insert a valve in the orthotopic position with a successful outcome [5]. He kindly phoned me after the operation and apologized for not letting me know before the operation, as his hand had been forced! However, Ross was not the first to place an autologous aortic valve in the orthotopic position. This was first achieved by Bill Bigelow and Raymond Heimbecker in 1961 (Bigelow W, Heimbecker R, personal communication, 1987). The patient, sadly, died of an infarct after 24 hours. For the record and history of cardiac surgery, they therefore were the first to insert an aortic homograft in the subcoronary position. Truly, originality is only original when you are the first!
Alfred 1. Gunning, FRCS Department of CardiolThoracic S u r g e y Medical University of South Africa PO Box 124 Medunsa 0204 South Africa
References 1. Hopkins RA, St. Louis J, Corcoran C. Ross’ first homograft replacement of the aortic valve. Ann Thorac Surg 1991;52: 1190-3. 2. Lam CR, Acam HH, Mennell ER. An experimental study of aortic valve homografts. Surg Gynecol Obstet 1952;94:129-35. 3. Murray G. Homologous aortic valve segment transplants as surgical treatment for aortic and mitral insufficiency. Angiology 1956;7:466-71. 4. Duran CG, Gunning AJ. A method for placing a total homologous valve in the “subcoronary position.” Lancet 1962;2: 779-89. 5. Ross DN. Homograft replacement of the aortic valve. Lancet 1962;2:487.
Reply
To the Editor:
My colleagues and I have read with great interest the letter by Mr Gunning concerning the contribution by Drs Bigelow and Heimbecker. I agree that history is best served by such accuracy, and certainly it appears that these individuals deserve the credit for the first placement of the homologous aortic valve in the orthotopic position in a human. Mr Gunning’s clarification is all the more important because as far as I am aware, there is no other record in the international literature of this case. Because their patient died, I believe that Mr Ross deserves credit for the first successful placement of a homograft aortic valve in the orthotopic position in a human. I am intrigued that it was Mr Gunning’s experimental work on technique that was generously shared with Mr Ross that allowed the successful clinical insertion. Mr Ross himself admitted that he had not performed such a procedure in an animal. This to me is a most significant aspect of this historical vignette. It underscores the importance of the informal network that those of us involved in reconstructive cardiac Ann Thorac Surg 1992;54:809-16
0003-4975/92/$5.00
Esophageal Perforation To the Editor: I read with interest the excellent review entitled “Esophageal perforation: a continuing challenge,” by W. G. Jones I1 and Robert J. Ginsberg, published in The Annals of Thoracic Surgery [l]. Dr Jones and Dr Ginsberg quoted our article [2] as having 61 cases of esophageal perforations with an overall mortality of 30%. We have reported 64 cases of esophageal perforations, including 2 cases that were treated nonoperatively because the perforations were contained: one was a cervical perforation due to a foreign body, and the other was diagnosed immediately after a rigid esophagoscopy with biopsy of a peptic stricture. Both patients survived. An additional patient had an abdominal perforation that was closed primarily, but was excluded from Table 3 because the latter compared cervical versus thoracic operations. The third patient also survived. The overall mortality was 28% (18164). Although this is a small difference from that reported in Dr Jones and Dr Ginsberg’s review, nevertheless it is important. Safuh Attar, M D Division of Thoracic and Cardiovascular Surgery University of Ma y l a n d Hospital 22 S Greene St Baltimore, M D 21201
References 1. Jones WG 11, Ginsberg RJ. Esophageal perforation: a continuing challenge. Ann Thorac Surg 1992;53:534-43. 2. Attar S, Hankins JR, Suter CM, et al. Esophageal perforation: a therapeutic challenge. Ann Thorac Surg 1990;50:459.
Reply
To the Editor:
We thank Dr Attar for his letter regarding our review on esophageal perforation. In our review of the article by Attar and associates, the 3 additional cases that Dr Attar mentioned were indeed not included in the preparation of data for Table 1. Thus, as he has stated, the tabulated mortality should indeed be 18/64 (28%) rather than the 18/61 (30%) that we quoted. We apologize to Dr Attar and his associates for this error and appreciate his efforts in its correction.
William G. Jones 11, M D Robert 1. Ginsberg, M D The New York Hospital-Cornell Medical Center 525 E 68th St New York, N Y 10021
Ross’ First Homograft Replacement of the Aortic Valve To the Editor: I read with interest the article by Hopkins and associates [I]. Their report took me back 30+ years when I was working on the aortic homograft and the heterologous aortic valve. At that time I was unaware of the experimental work of Gross, Lam [2], and Heimbecker. It was Murray’s [3] successful clinical use of placing the homograft in the descending aorta that prompted me to devise the method of placing the aortic valve in the ”subcoronary position” [4]. Once I realized this was a feasible clinical proposition, I phoned Donald Ross at Guy‘s Hospital and described the 0 1992 by The Society of Thoracic Surgeons
method to him. He expressed considerable interest and mentioned it to Lord Brock-his chief at that time-who also considered it possible. During the same conversation I asked R o s s who was doing far more open heart valve operations than I w a s t o let me know if and when he proposed inserting a freeze-dried homologous aortic valve into the “subcoronary position.” As reported by Hopkins and associates [l], Ross had started collecting a bank of freeze-dried valves and luckily, as it subsequently turned out, he was forced to insert a valve in the orthotopic position with a successful outcome [5]. He kindly phoned me after the operation and apologized for not letting me know before the operation, as his hand had been forced! However, Ross was not the first to place an autologous aortic valve in the orthotopic position. This was first achieved by Bill Bigelow and Raymond Heimbecker in 1961 (Bigelow W, Heimbecker R, personal communication, 1987). The patient, sadly, died of an infarct after 24 hours. For the record and history of cardiac surgery, they therefore were the first to insert an aortic homograft in the subcoronary position. Truly, originality is only original when you are the first!
Alfred 1. Gunning, FRCS Department of CardiolThoracic S u r g e y Medical University of South Africa PO Box 124 Medunsa 0204 South Africa
References 1. Hopkins RA, St. Louis J, Corcoran C. Ross’ first homograft replacement of the aortic valve. Ann Thorac Surg 1991;52: 1190-3. 2. Lam CR, Acam HH, Mennell ER. An experimental study of aortic valve homografts. Surg Gynecol Obstet 1952;94:129-35. 3. Murray G. Homologous aortic valve segment transplants as surgical treatment for aortic and mitral insufficiency. Angiology 1956;7:466-71. 4. Duran CG, Gunning AJ. A method for placing a total homologous valve in the “subcoronary position.” Lancet 1962;2: 779-89. 5. Ross DN. Homograft replacement of the aortic valve. Lancet 1962;2:487.
Reply
To the Editor:
My colleagues and I have read with great interest the letter by Mr Gunning concerning the contribution by Drs Bigelow and Heimbecker. I agree that history is best served by such accuracy, and certainly it appears that these individuals deserve the credit for the first placement of the homologous aortic valve in the orthotopic position in a human. Mr Gunning’s clarification is all the more important because as far as I am aware, there is no other record in the international literature of this case. Because their patient died, I believe that Mr Ross deserves credit for the first successful placement of a homograft aortic valve in the orthotopic position in a human. I am intrigued that it was Mr Gunning’s experimental work on technique that was generously shared with Mr Ross that allowed the successful clinical insertion. Mr Ross himself admitted that he had not performed such a procedure in an animal. This to me is a most significant aspect of this historical vignette. It underscores the importance of the informal network that those of us involved in reconstructive cardiac Ann Thorac Surg 1992;54:809-16
0003-4975/92/$5.00
