CORRESPONDENCE
Ann Thorac Surg 1991;52: 12048
1207
Fig 1. Hammersmith prosthesis: ring and disc. The arrow indicates the site of wear.
In December 1990 her condition suddenly deteriorated, she became dyspneic and listless, and she also started having palpitations. She volunteered an interesting observation of not being able to hear the clicking of the prosthetic valve. Clinically she had signs of mild tricuspid stenosis with gross regurgitation, and prosthetic clicks were not audible. Echocardiographic examination suggested a thrombosed prosthesis causing stenosis with regurgitation. Chest roentgenogram showed mild cardiomegaly. On January 17, 1991, she underwent reoperation. After institution of routine cardiopulmonary bypass, a vent was placed in the left ventricle through the right superior pulmonary vein. At normothermia and with the heart beating, the right atrium was opened. To my amazement I could not see the disc in the prosthetic ring. There was no clot or thrombus in the right atrial cavity. I removed the prosthetic ring but could not find the disc in the right ventricular cavity. Palpation of the main pulmonary artery revealed the presence of a hard object which, when removed after pulmonary arteriotomy, was found to be the disc of the Hammersmith valve. The disc was embedded in the main pulmonary artery with mild fibrous reaction around it. It is unlikely that it was dislodged during initial manipulation and cannulation of the heart. Pulmonary arteriotomy was closed with 6-0 continuous Prolene (Ethicon, Somerville, NJ). A size 33 Carbomedics mechanical prosthesis was sutured in place with sixteen interrupted 2-0 Ethibond (Ethicon) sutures. The patient made an uneventful postoperative recovery and was discharged from the hospital on January 28,1991. She was reviewed 6 weeks later when her condition was satisfactory. She was in sinus rhythm with a substantial improvement in her symptoms at this early stage. The preoperative echocardiograms were reviewed without revealing operative details. The issue of when the disc actually slipped out of the ring, although now of academic interest only, could not be resolved. However, inspection of the prosthesis (Fig 1) shows, as observed previously [4], wear of the polypropylene material at the site of the contact between the short leg of the disc and the valve ring from where the disc escapes very easily. Clearly, the long-term surgical results of tricuspid valve replacement in Ebstein’s anomaly in careful hands are most gratifying. It is equally interesting that the Hammersmith valve, which is now obsolete, has given 24 years of good life to this patient. Perhaps the choice of the prosthesis, when replacing the
tricuspid valve, does not make much difference in achieving good long-term results.
P. Raj Behl, M S , FRCS
Regional Cardiothoracic Centre Freeman Hospital Freeman Rd Newcastle upon Tyne, NE7 7DN Great Britain
References 1. Kirklin JK. Christiaan Barnards contribution to the surgical treatment of Ebstein’s malformation. Ann Thorac Surg 1991; 51:147-51. 2. Behl PR, Blesovsky A. Ebstein’s anomaly: sixteen years’ experience with valve replacement without plication of the right ventricle. Thorax 1984;39:%13. 3. Barnard CN, Schrire V. Surgial correction of Ebstein’s malformation with prosthetic tricuspid valve. Surgery 1963;54:302-8. 4. Shaw TRD, Gunstensen J, Turner RWD. Sudden mechanical malfunction of the Hammersmith mitral valve prostheses due to wear of polypropylene. J Thorac Cardiovasc Surg 1974;67: 579-83.
Gastric Emptying After Gastric Pull-up To the Editor: We read with interest the paper by Morton and associates [I], who used radionuclide transit studies to evaluate function of the interposed stomach after total esophagectomy in 14 patients. Although we concur with their results, that gastric emptying is dependent on position, studies performed at our institution on 35 patients reconstructed in a similar manner [2] have indicated the following additional findings: (1)patterns of spontaneous emptying of the vagotomized intrathoracic stomach are complex, and mean percentage radionuclide clearances at 30 minutes are comparable with emptying of the normal intraabdominal stomach; (2) there appears to be very little correlation between subjective symptoms (dysphagia, early satiety, reflux) and objective findings as measured by radionuclide transit studies; and (3) attempts at modifying function of the interposed stomach using the gastric
1208
Ann Thorac Surg 1991;52:12044
CORRESPONDENCE
prokinetic domperidone (Motilium; Janssen Pharmaceutica) appeared to have little objective efficacy, although symptomatic improvement was reported [3]. Our data suggest that the interposed stomach appears to retain its gastric identity rather than acting as an inert conduit and remains a satisfactory method of reconstruction after esophagectomy for both benign and malignant esophageal disease [4].
Alan G. Casson, MB, ChB John Powe, M D Richard Inculet, M D Richard Finley, M D Departments of Surgery and Nuclear Medicine University of Western Ontario Victoria Hospital London, Ont, Canada
References 1. Morton KA, Karwande SV, Davis K, Datz FL, Lynch RE. Gastric emptying after gastric interposition for cancer of the esophagus of hypopharynx. Ann Thorac Surg 1991;51:759-63. 2. Powe JE, Casson AG, Inculet RI, Laurin N, Finley RJ. Functional evaluation of gastric interposition following total esophagectomy. J Nucl Med 1990;31(Suppl):775. 3. Casson AG, Powe JE, Inculet RI, Finley R. Efficacy of domperidone (Motilium) on modifying function of the interposed stomach following total esophagectomy. Gastroenterology 1989;98(Suppl):A335. 4. Casson AG, Powe J, Inculet R, Finley R. Functional results of gastric interposition following total esophagectomy. Clin Nucl Med (in press).
Surgical Management of Carcinoid Heart Disease To the Editor: In their recent report on the surgical management of carcinoid heart disease, Fetherston and Davis [ l ] suggest that mechanical tricuspid valve replacement be performed in patients with the carcinoid syndrome because of the ”theoretical potential” for carcinoid heart disease to recur on bioprosthetic valve leaflets. Recently, we have reported just such a case [2], in which recurrent carcinoid plaque on a Hancock porcine prosthesis contributed to failure of the valve and eventually led to reoperation. We also are aware of at least one postmortem study demonstrating that carcinoid plaque can develop on bioprosthetic valves [3]. We therefore agree with the recommendations of Fetherston and Davis that mechanical tricuspid valve replacement be considered in patients with carcinoid heart disease, particularly for those individuals at low risk for anticoagulation failure.
Paul M . Ridker, M D Frederick J. Schoen, M D , PhD Division of Cardiology and Department of Pathology Brigham and Women’s Hospital Boston, M A 02146
References 1. Fetherston GJ, Davis BB. Surgical management of carcinoid heart disease. Ann Thorac Surg 1991;51:4934. 2. Ridker PM, Chertow GM, Karlson EW, Neish AS, Schoen FJ. Bioprosthetic tricuspid valve stenosis associated with extensive plaque deposition in carcinoid heart disease. Am Heart J 1991;121:1835-8. 3. Schoen FJ, Hausner RJ, Howell JF, Beazly HL, Titus JL. Porcine heterograft valve replacement in carcinoid heart disease. J Thorac Cardiovasc Surg 1981;81:100-5.
Thermodilution Catheter-Induced Endobronchial Hemorrhage With Pulmonary Hypertension To the Editor: Various techniques have been described to control severe endobronchial hemorrhage caused by Swan-Ganz catheter injury to the distal pulmonary artery. The method of endobronchial blockade under direct vision described by Dr Purut and his colleagues [I] is a precise and reliable technique in patients with normal pulmonary artery pressure undergoing coronary artery operation. However, in patients with pulmonary hypertension this technique should be employed with great caution. We recently performed a reoperation of mitral valve replacement and tricuspid valve repair on a 78-year-old woman with preoperative pulmonary artery pressure of 60/30 mm Hg. Blood issuing through the endotracheal tube was noticed immediately after operation. A chest roentgenogram showed a triangular shadow of segmental consolidation on the left side. Bronchoscopy was performed, and the bleeding from the lingular segment of the left upper lobe was arrested using a Fogarty balloon catheter. Postoperatively, systolic pulmonary artery pressure was maintained less than 40 mm Hg. The patient’s hemodynamic status deteriorated in the first 24 hours after operation, and a chest roentgenogram showed increasing opacity on the left side. A chest drain was inserted, and about 2,000 mL of blood was drained. The patient was reoperated on for left upper lobectomy as the bleeding continued. The patient died 48 hours postoperation due to severely compromised hemodynamic status. In patients with pulmonary hypertension, endobronchial blockade can lead to increased intralobar pressure due to continued bleeding and eventual rupture of the lobe. Alternate methods such as selective embolization of the bleeding artery or local injection of vasoconstrictors through the bronchoscope may be of value in this situation to avoid this fatal complication.
Pasala S . Ravichandran, M D Stephen P. Kelly, M D Jeffrey S . Swanson, M D Cindy L. Fessler, BS Albert Starr, M D The Heart Institute at St. Vincent Hospital and Medical Center 9155 SW Barnes Rd, Suite 236 Portland, O R 97225
Reference 1. Purut CM, Scott SM, Parham JV, Smith PK. Intraoperative management of severe endobronchial hemorrhage. Ann Thorac Surg 1991;51:30&7.
Ann Thorac Surg 1991;52: 12048
1207
Fig 1. Hammersmith prosthesis: ring and disc. The arrow indicates the site of wear.
In December 1990 her condition suddenly deteriorated, she became dyspneic and listless, and she also started having palpitations. She volunteered an interesting observation of not being able to hear the clicking of the prosthetic valve. Clinically she had signs of mild tricuspid stenosis with gross regurgitation, and prosthetic clicks were not audible. Echocardiographic examination suggested a thrombosed prosthesis causing stenosis with regurgitation. Chest roentgenogram showed mild cardiomegaly. On January 17, 1991, she underwent reoperation. After institution of routine cardiopulmonary bypass, a vent was placed in the left ventricle through the right superior pulmonary vein. At normothermia and with the heart beating, the right atrium was opened. To my amazement I could not see the disc in the prosthetic ring. There was no clot or thrombus in the right atrial cavity. I removed the prosthetic ring but could not find the disc in the right ventricular cavity. Palpation of the main pulmonary artery revealed the presence of a hard object which, when removed after pulmonary arteriotomy, was found to be the disc of the Hammersmith valve. The disc was embedded in the main pulmonary artery with mild fibrous reaction around it. It is unlikely that it was dislodged during initial manipulation and cannulation of the heart. Pulmonary arteriotomy was closed with 6-0 continuous Prolene (Ethicon, Somerville, NJ). A size 33 Carbomedics mechanical prosthesis was sutured in place with sixteen interrupted 2-0 Ethibond (Ethicon) sutures. The patient made an uneventful postoperative recovery and was discharged from the hospital on January 28,1991. She was reviewed 6 weeks later when her condition was satisfactory. She was in sinus rhythm with a substantial improvement in her symptoms at this early stage. The preoperative echocardiograms were reviewed without revealing operative details. The issue of when the disc actually slipped out of the ring, although now of academic interest only, could not be resolved. However, inspection of the prosthesis (Fig 1) shows, as observed previously [4], wear of the polypropylene material at the site of the contact between the short leg of the disc and the valve ring from where the disc escapes very easily. Clearly, the long-term surgical results of tricuspid valve replacement in Ebstein’s anomaly in careful hands are most gratifying. It is equally interesting that the Hammersmith valve, which is now obsolete, has given 24 years of good life to this patient. Perhaps the choice of the prosthesis, when replacing the
tricuspid valve, does not make much difference in achieving good long-term results.
P. Raj Behl, M S , FRCS
Regional Cardiothoracic Centre Freeman Hospital Freeman Rd Newcastle upon Tyne, NE7 7DN Great Britain
References 1. Kirklin JK. Christiaan Barnards contribution to the surgical treatment of Ebstein’s malformation. Ann Thorac Surg 1991; 51:147-51. 2. Behl PR, Blesovsky A. Ebstein’s anomaly: sixteen years’ experience with valve replacement without plication of the right ventricle. Thorax 1984;39:%13. 3. Barnard CN, Schrire V. Surgial correction of Ebstein’s malformation with prosthetic tricuspid valve. Surgery 1963;54:302-8. 4. Shaw TRD, Gunstensen J, Turner RWD. Sudden mechanical malfunction of the Hammersmith mitral valve prostheses due to wear of polypropylene. J Thorac Cardiovasc Surg 1974;67: 579-83.
Gastric Emptying After Gastric Pull-up To the Editor: We read with interest the paper by Morton and associates [I], who used radionuclide transit studies to evaluate function of the interposed stomach after total esophagectomy in 14 patients. Although we concur with their results, that gastric emptying is dependent on position, studies performed at our institution on 35 patients reconstructed in a similar manner [2] have indicated the following additional findings: (1)patterns of spontaneous emptying of the vagotomized intrathoracic stomach are complex, and mean percentage radionuclide clearances at 30 minutes are comparable with emptying of the normal intraabdominal stomach; (2) there appears to be very little correlation between subjective symptoms (dysphagia, early satiety, reflux) and objective findings as measured by radionuclide transit studies; and (3) attempts at modifying function of the interposed stomach using the gastric
1208
Ann Thorac Surg 1991;52:12044
CORRESPONDENCE
prokinetic domperidone (Motilium; Janssen Pharmaceutica) appeared to have little objective efficacy, although symptomatic improvement was reported [3]. Our data suggest that the interposed stomach appears to retain its gastric identity rather than acting as an inert conduit and remains a satisfactory method of reconstruction after esophagectomy for both benign and malignant esophageal disease [4].
Alan G. Casson, MB, ChB John Powe, M D Richard Inculet, M D Richard Finley, M D Departments of Surgery and Nuclear Medicine University of Western Ontario Victoria Hospital London, Ont, Canada
References 1. Morton KA, Karwande SV, Davis K, Datz FL, Lynch RE. Gastric emptying after gastric interposition for cancer of the esophagus of hypopharynx. Ann Thorac Surg 1991;51:759-63. 2. Powe JE, Casson AG, Inculet RI, Laurin N, Finley RJ. Functional evaluation of gastric interposition following total esophagectomy. J Nucl Med 1990;31(Suppl):775. 3. Casson AG, Powe JE, Inculet RI, Finley R. Efficacy of domperidone (Motilium) on modifying function of the interposed stomach following total esophagectomy. Gastroenterology 1989;98(Suppl):A335. 4. Casson AG, Powe J, Inculet R, Finley R. Functional results of gastric interposition following total esophagectomy. Clin Nucl Med (in press).
Surgical Management of Carcinoid Heart Disease To the Editor: In their recent report on the surgical management of carcinoid heart disease, Fetherston and Davis [ l ] suggest that mechanical tricuspid valve replacement be performed in patients with the carcinoid syndrome because of the ”theoretical potential” for carcinoid heart disease to recur on bioprosthetic valve leaflets. Recently, we have reported just such a case [2], in which recurrent carcinoid plaque on a Hancock porcine prosthesis contributed to failure of the valve and eventually led to reoperation. We also are aware of at least one postmortem study demonstrating that carcinoid plaque can develop on bioprosthetic valves [3]. We therefore agree with the recommendations of Fetherston and Davis that mechanical tricuspid valve replacement be considered in patients with carcinoid heart disease, particularly for those individuals at low risk for anticoagulation failure.
Paul M . Ridker, M D Frederick J. Schoen, M D , PhD Division of Cardiology and Department of Pathology Brigham and Women’s Hospital Boston, M A 02146
References 1. Fetherston GJ, Davis BB. Surgical management of carcinoid heart disease. Ann Thorac Surg 1991;51:4934. 2. Ridker PM, Chertow GM, Karlson EW, Neish AS, Schoen FJ. Bioprosthetic tricuspid valve stenosis associated with extensive plaque deposition in carcinoid heart disease. Am Heart J 1991;121:1835-8. 3. Schoen FJ, Hausner RJ, Howell JF, Beazly HL, Titus JL. Porcine heterograft valve replacement in carcinoid heart disease. J Thorac Cardiovasc Surg 1981;81:100-5.
Thermodilution Catheter-Induced Endobronchial Hemorrhage With Pulmonary Hypertension To the Editor: Various techniques have been described to control severe endobronchial hemorrhage caused by Swan-Ganz catheter injury to the distal pulmonary artery. The method of endobronchial blockade under direct vision described by Dr Purut and his colleagues [I] is a precise and reliable technique in patients with normal pulmonary artery pressure undergoing coronary artery operation. However, in patients with pulmonary hypertension this technique should be employed with great caution. We recently performed a reoperation of mitral valve replacement and tricuspid valve repair on a 78-year-old woman with preoperative pulmonary artery pressure of 60/30 mm Hg. Blood issuing through the endotracheal tube was noticed immediately after operation. A chest roentgenogram showed a triangular shadow of segmental consolidation on the left side. Bronchoscopy was performed, and the bleeding from the lingular segment of the left upper lobe was arrested using a Fogarty balloon catheter. Postoperatively, systolic pulmonary artery pressure was maintained less than 40 mm Hg. The patient’s hemodynamic status deteriorated in the first 24 hours after operation, and a chest roentgenogram showed increasing opacity on the left side. A chest drain was inserted, and about 2,000 mL of blood was drained. The patient was reoperated on for left upper lobectomy as the bleeding continued. The patient died 48 hours postoperation due to severely compromised hemodynamic status. In patients with pulmonary hypertension, endobronchial blockade can lead to increased intralobar pressure due to continued bleeding and eventual rupture of the lobe. Alternate methods such as selective embolization of the bleeding artery or local injection of vasoconstrictors through the bronchoscope may be of value in this situation to avoid this fatal complication.
Pasala S . Ravichandran, M D Stephen P. Kelly, M D Jeffrey S . Swanson, M D Cindy L. Fessler, BS Albert Starr, M D The Heart Institute at St. Vincent Hospital and Medical Center 9155 SW Barnes Rd, Suite 236 Portland, O R 97225
Reference 1. Purut CM, Scott SM, Parham JV, Smith PK. Intraoperative management of severe endobronchial hemorrhage. Ann Thorac Surg 1991;51:30&7.
