CORRESPONDENCE
Bjork-Shiley Strut Fracture and Disc Escape To the Editor: I found the article by Hendel [ l ] concerning the method of disc retrieval of an escaped Bjork-Shiley disc secondary to strut fracture interesting. Another method that we describe for retrieval of a fractured Bjork-Shiley disc is to extend the sternotomy incision down to the umbilicus. Usually the disc will lodge either at the aortic bifurcation or at the takeoff of the inferior mesenteric artery. At this point the disc can be palpated, then a small aortotomy made with removal of the disc 121. This event certainly carries a high mortality rate, and as of yet very few people survive the event. I think that the key to survival is prompt diagnosis and treatment.
Stanley K. Lochridge, M D Alabama Heart Institute Baptist Medical Center Montclair 800 Montclair Road - Suite 270 Birmingham, A L 35213
References 1. Hendel PN. Bjork-Shiley strut fracture and disc escape: literature review and a method of disc retrieval. Ann Thorac Surg 1989;47:436-40. 2. Gaos CM, Tiller JP, Lochridge SK. Successful replacement of a fractured Bjork-Shiley aortic valve prosthesis. J Cardiovasc Surg 1988;29:106-8.
Internal Mammary Artery Grafts To the Editor: Vander Salm and associates [ l ] have drawn attention to the optimal route for the internal mammary artery as a conduit for coronary artery bypass grafting. We too have mostly used the shortest routings as described. We disagree, however, with the last of their three conclusions, stating that no routing can be conceived to revascularize more than two coronary beds with two internal mammary arteries. In our institution we have experience in several patients with the following construction:
1. Right internal mammary artery taken down as a skeletonized vessel (to increase length) through a pericardial incision immediately anterior to the right phrenic nerve and through the transverse sinus to the diagonal and left anterior descending coronary arteries. 2. Left internal mammary artery through a pericardial incision to anterolateral, obtuse, and marginal branches ending on the posterior descending coronary artery. Using this particular method we have been able to perform complete arterial revascularization with up to six distal anastomoses (right internal mammary artery, 2; left, 4). Therefore, we cannot agree with the conclusions reached by Vander Salm and associates; moreover, we think that complete arterial revascularization is frequently possible using both internal mammary arteries, even in extensive coronary artery disease.
A. Brute1 de la Rivikre, M D
1. 1. A. M . T . Defauw, M D
R. P. H . M . Hamerlijnck, M D P. 1. Knaepen, M D H . A. van Swieten, M D F . E . E . Vermeulen, M D Department of Cardiothorucic Surgery St. Antonius Hospital Nieuwegein, the Netherlands 0 1990 by The Society of Thoracic Surgeons
Reference 1. Vander Salm TJ, Chowdhary S, Okike ON, Pezzella AT, Pasque MK. Internal mammary artery grafts: the shortest route to the coronary arteries. Ann Thorac Surg 1989;47421-7.
Reply
To the Editor:
Doctor de la Riviere and colleagues have clearly redemonstrated the inadvisability of authors using absolute negatives such as “never” or “no.” Not only have they proved our statement “no conceivable frugality of IMA routing can allow the revascularization of more than two coronary beds” incorrect; they have also demonstrated greater imagination and surgical fortitude than we in their remarkable achievement of revascularizing all three coronary beds with in situ internal mammary artery grafts using as many as six distal anastomoses. Although one could theoretically question the ability of two internal mammary artery grafts to supply the flow needs of the entire myocardium, if the results in the patients whom they describe are good, those results should speak for themselves. I congratulate them on their impressive operative achievements.
Thomas 1. Vander Salm, M D Department of Surgery University of Massachusetts Medical Center 55 Lake Ave North Worcester, M A 01655
Tetracycline Pleurodesis for Persistent Air Leak To the Editor: I read the article by Almassi and Haasler [l] on chemical pleurodesis in the presence of persistent air leak with interest, and would like to share my experience with this procedure. Over the last 2 years, I have performed tetracycline pleurodesis (TP) for persistent air leak on 4 patients. Tetracycline pleurodesis was done because these 4 patients were considered poor candidates for operation. The severity of air leak was graded by its occurrence: present infrequently with cough (grade l), present every time with cough (grade 2), present with few spontaneous breaths (grade 3), present with every spontaneous breath (grade 4). The method in brief was as follows. The chest tube was taken off suction, and the tube was clamped distally. Under sterile precautions, lidocaine (250 mg, 1%solution), saline solution (20 mL), and tetracycline hydrochloride (2,000 mg, 50 mg/mL) were then injected separately at five-minute intervals. The chest tube was held up for five minutes, the distal clamp was removed, and the tube was left off suction for four hours. Severity of pain was assessed after the procedure. A check was made four hours later for the presence of air leak, and the chest tube was reattached to suction. If, 24 hours later, the air leak was not observed, the chest tube was clamped and a chest roentgenogram was obtained. The chest tube was removed if full expansion of lung was confirmed by the radiograph. The description and results of TP in these 4 patients are summarized in Table 1. Tetracycline pleurodesis was successful in closing persistent air leak in 2 patients. In the first patient, decrease in air leak was noted within four hours, and air leak was absent after 24 hours. In the second patient, even though the air leak was infrequent, clamping of the chest tube resulted in reaccumulation of pneumothorax and lung collapse. Persistent right upper lobe pneumothorax in this patient resolved within 24 hours of TP. In the 2 patients with acquired immunodeficiency Ann Thorac Surg 1990;49:166-70
0003-4975/90/$3.50
Bjork-Shiley Strut Fracture and Disc Escape To the Editor: I found the article by Hendel [ l ] concerning the method of disc retrieval of an escaped Bjork-Shiley disc secondary to strut fracture interesting. Another method that we describe for retrieval of a fractured Bjork-Shiley disc is to extend the sternotomy incision down to the umbilicus. Usually the disc will lodge either at the aortic bifurcation or at the takeoff of the inferior mesenteric artery. At this point the disc can be palpated, then a small aortotomy made with removal of the disc 121. This event certainly carries a high mortality rate, and as of yet very few people survive the event. I think that the key to survival is prompt diagnosis and treatment.
Stanley K. Lochridge, M D Alabama Heart Institute Baptist Medical Center Montclair 800 Montclair Road - Suite 270 Birmingham, A L 35213
References 1. Hendel PN. Bjork-Shiley strut fracture and disc escape: literature review and a method of disc retrieval. Ann Thorac Surg 1989;47:436-40. 2. Gaos CM, Tiller JP, Lochridge SK. Successful replacement of a fractured Bjork-Shiley aortic valve prosthesis. J Cardiovasc Surg 1988;29:106-8.
Internal Mammary Artery Grafts To the Editor: Vander Salm and associates [ l ] have drawn attention to the optimal route for the internal mammary artery as a conduit for coronary artery bypass grafting. We too have mostly used the shortest routings as described. We disagree, however, with the last of their three conclusions, stating that no routing can be conceived to revascularize more than two coronary beds with two internal mammary arteries. In our institution we have experience in several patients with the following construction:
1. Right internal mammary artery taken down as a skeletonized vessel (to increase length) through a pericardial incision immediately anterior to the right phrenic nerve and through the transverse sinus to the diagonal and left anterior descending coronary arteries. 2. Left internal mammary artery through a pericardial incision to anterolateral, obtuse, and marginal branches ending on the posterior descending coronary artery. Using this particular method we have been able to perform complete arterial revascularization with up to six distal anastomoses (right internal mammary artery, 2; left, 4). Therefore, we cannot agree with the conclusions reached by Vander Salm and associates; moreover, we think that complete arterial revascularization is frequently possible using both internal mammary arteries, even in extensive coronary artery disease.
A. Brute1 de la Rivikre, M D
1. 1. A. M . T . Defauw, M D
R. P. H . M . Hamerlijnck, M D P. 1. Knaepen, M D H . A. van Swieten, M D F . E . E . Vermeulen, M D Department of Cardiothorucic Surgery St. Antonius Hospital Nieuwegein, the Netherlands 0 1990 by The Society of Thoracic Surgeons
Reference 1. Vander Salm TJ, Chowdhary S, Okike ON, Pezzella AT, Pasque MK. Internal mammary artery grafts: the shortest route to the coronary arteries. Ann Thorac Surg 1989;47421-7.
Reply
To the Editor:
Doctor de la Riviere and colleagues have clearly redemonstrated the inadvisability of authors using absolute negatives such as “never” or “no.” Not only have they proved our statement “no conceivable frugality of IMA routing can allow the revascularization of more than two coronary beds” incorrect; they have also demonstrated greater imagination and surgical fortitude than we in their remarkable achievement of revascularizing all three coronary beds with in situ internal mammary artery grafts using as many as six distal anastomoses. Although one could theoretically question the ability of two internal mammary artery grafts to supply the flow needs of the entire myocardium, if the results in the patients whom they describe are good, those results should speak for themselves. I congratulate them on their impressive operative achievements.
Thomas 1. Vander Salm, M D Department of Surgery University of Massachusetts Medical Center 55 Lake Ave North Worcester, M A 01655
Tetracycline Pleurodesis for Persistent Air Leak To the Editor: I read the article by Almassi and Haasler [l] on chemical pleurodesis in the presence of persistent air leak with interest, and would like to share my experience with this procedure. Over the last 2 years, I have performed tetracycline pleurodesis (TP) for persistent air leak on 4 patients. Tetracycline pleurodesis was done because these 4 patients were considered poor candidates for operation. The severity of air leak was graded by its occurrence: present infrequently with cough (grade l), present every time with cough (grade 2), present with few spontaneous breaths (grade 3), present with every spontaneous breath (grade 4). The method in brief was as follows. The chest tube was taken off suction, and the tube was clamped distally. Under sterile precautions, lidocaine (250 mg, 1%solution), saline solution (20 mL), and tetracycline hydrochloride (2,000 mg, 50 mg/mL) were then injected separately at five-minute intervals. The chest tube was held up for five minutes, the distal clamp was removed, and the tube was left off suction for four hours. Severity of pain was assessed after the procedure. A check was made four hours later for the presence of air leak, and the chest tube was reattached to suction. If, 24 hours later, the air leak was not observed, the chest tube was clamped and a chest roentgenogram was obtained. The chest tube was removed if full expansion of lung was confirmed by the radiograph. The description and results of TP in these 4 patients are summarized in Table 1. Tetracycline pleurodesis was successful in closing persistent air leak in 2 patients. In the first patient, decrease in air leak was noted within four hours, and air leak was absent after 24 hours. In the second patient, even though the air leak was infrequent, clamping of the chest tube resulted in reaccumulation of pneumothorax and lung collapse. Persistent right upper lobe pneumothorax in this patient resolved within 24 hours of TP. In the 2 patients with acquired immunodeficiency Ann Thorac Surg 1990;49:166-70
0003-4975/90/$3.50
