CORRESPONDENCE
Ann Thorac Surg 1992;54:12449
Fig 2. Clinical course of plasma free hemoglobin (Hb) level.
replacement for failing bioprostheses. Two Carbomedics prostheses were employed. Again clinical signs of hemolysis with LDH levels up to 2,670 IU and a plasma free hemoglobin level of 53 mg/dL were detected. An echocardiogram showed a small mitral paravalvular leak and borderline ventricular function. The use of 400 mg of pentoxifylline three times daily eliminated the signs of hemolysis. Seven months postoperatively the patient is well. A 43-year-old man underwent redo mitral and aortic valve replacement for failing bioprostheses, and two Medtronic-Hall valves were used. There was an early onset of hemolysis (LDH, 6,600 IU; plasma free hemoglobin, 135 mg/dL) and the echocardiogram showed a small paravalvular aortic leak with a hypertrophied, well-contracting left ventricle. We started using 400 mg of pentoxifylline three times daily, which reduced the hematological signs of hemolysis (LDH, 2,800 IU; plasma free hemoglobin, 69 mg/dL). The addition of 20 mg of propranolol three times daily completely cured the hemolysis. Six months after operation the patient is asymptomatic. We think that the use of pentoxifylline can be effective in the treatment of mechanical hemolysis after cardiac operations. If pentoxifylline does not completely correct hemolysis, the use of propranolol should bc considered as hernodynamic conditions permit.
1247
advantage of use of pentoxifylline (Trental) for intravascular hemolysis after prosthetic valve insertion. They reported 4 patients, 3 of whom had signs of paraprosthetic valve leakage. All 4 patients clinically showed a regression of hemolysis after pentoxifylline administration. Additionally, 2 patients received propranolol. None of them underwent reoperation for paraprosthetic valve leakage. However, our experience regarding intravascular hemolysis due to paraprosthetic valve leakage after insertion of St. Jude Medical prostheses [2] was quite different. One of 9 patients died of multiorgan failure and the other 8 patients needed reoperation to repair paraprosthetic leakages. Our 4 patients did receive pentoxifylline for the purpose of alleviating the hemolysis but showed no improvement. One patient showed a transient improvement of hemolysis after propranolol administration as we reported. Although not all patients who have paraprosthetic valve leakage demonstrated severe intravascular hemolysis due to mechanical trauma to erythrocytes, we believe that patients with a small leakage in Dacron-cuffed St. Jude Medical mitral prostheses usually suffer intractable intravascular hemolysis and need reoperation. Propranolol or pentoxifylline sometimes reduces the degree of hemolysis and shortens the period of natural healing of hemolysis. We, however, like to emphasize that such agents never substitute for reparative operation.
Yutaka Okita, M D Shigehito Miki, M D Department of Cardiovascular Surgey Tenri Hospital 200 Mishima, Tenri, Nara Japan 632 References 1. Okita Y, Miki S, Kusuhara K, Ueda Y, Tahata T, Yamanaka K. Propranolol for intractable hemolysis after open heart operation. Ann Thorac Surg 1991;52:1158-60. 2. Okita Y, Miki S, Kusuhara K, et al. Intractable hemolysis caused by perivalvular leakage following mitral valve replacement with St. Jude Medical prostheses. Ann Thorac Surg 1988;46:89-92.
- -
Cardiac Trauma To the Editor:
Alessandro Golino, M D Paolo Stassano, M D Nicola Spampinato, M D
We read with interest the article by Knott-Craig and associates [ l ] and congratulate them on a succinct article with excellent results. We thank them for citing one of our previous publications on the subject [2]. We are compelled, however, to correct Knott-Craig and associates regarding the mortality figures they attributed to our article. As reported in our publication [2], the overall survival from all penetrating cardiac injuries was 53.6% (60 of 112). This included a 20% to 25% survival in patients who were "in extremis" (physiologic index, 15 and 20). In their current article [l], Knott-Craig and associates incorrectly state that our mortality for patients requiring emergency room thoracotomy was "almost loo%.''We have consistently obtained a survival of 25% to 30% with emergency room thoracotomy [ 2 4 ] even in patients who had no vital signs on admission but who had some sign of life in transit to the hospital. It is also noteworthy that our reports had dealt with both stab and gunshot wounds of the heart. Knott-Craig and associates have included only stab wounds, which are known to have a more favorable prognosis. Because the paper was entitled "Penetrating cardiac trauma . . . ," we wonder why gunshot wounds were excluded.
Department of Cardiac Surgey Second Medical School University of Naples 5, via S . Pansini 80131 Naples Italy Reference 1. Okita Y, Miki S , Kusuhara K, Ueda Y, Tahata T, Yamanaka K. Propranolol for intractable hemolysis after open heart operation. Ann Thorac Surg 1991;52:1158-60.
Reply
To the Editor:
We thank Dr Golino and associates for their comments regarding our article [l]. In their letter, they have drawn attention to an
1248
CORRESPONDENCE
Ann Thorac Surg 1992;54: 1 2 6 9
Finally, Knott-Craig and associates add another descriptive term, "critically unstable," to the already long list of narrative titles used to describe the clinical status of the patients. "Fatal," "moribund," "in extremis," "lifeless," and "agonal" are only a few examples of this listing. As underscored by Trinkle [5], a more objective clinical description of the patients should improve the evaluation of different series in terms of management strategies and their results.
Rao R . lvatu y , M D Michael Rohman, M D Department of Surgery Lincoln Hospital 234 E 149th St Bronx, NY 10451
References 1. Knott-Craig CJ, Dalton RP, Rossouw GJ, Barnard PM. Penetrating cardiac trauma: management strategy based on 129 surgical emergencies over 2 years. Ann Thorac Surg 1992;53: 10069. 2. Ivatury RR, Nallathambi MN, Rohman M, Stahl WM. Penetrating cardiac trauma. Quantifying the severity of anatomic and physiologic injury. Ann Surg 1987;205:61-6. 3. Ivatury RR, Shah PM, Ito K, Ramirez-Schon G, Suarez F, Rohman M. Emergency room thoracotomy for the resuscitation of patients with "fatal" penetrating injuries of the heart. Ann Thorac Surg 1981;32:377-85. 4. Ivatury RR, Rohman M, Steichen FM, Gunduz Y , Nallathambi M, Stahl WM. Penetrating cardiac injuries: twenty-year experience. Am Surg 1987;53:310-7. 5. Trinkle JK. Penetrating heart wounds: difficulty in evaluating clinical series [Editorial]. Ann Thorac Surg 1984;38:181-2.
Reply
To the Editor:
My colleagues and I thank Drs Ivatury and Rohman for their kind comments regarding our article, and recognize the important contributions they have made through the years on the same subject. Their contention with the mortality rates for emergency room thoracotomy relates to our statement that "our results . . . [54% mortality] also compare favorably with the mortality rate in similar reports, which range from almost 100% to 26%." Three references were given [l-31, and the mortality rates in these references are 71%, 92%, and 62%, respectively. Second, the 129 patients described in our article represent a consecutive series without any exclusions, as clearly stated in the article. The fact that there were no gunshot wounds among these patients attests to the patterns and instruments of violence in this community, where gunshot wounds are very uncommon. Finally, we share Ivatury and Rohman's opinion that the variety of terminologies describing patients with penetrating trauma makes comparisons difficult. However, accurate clear clinical descriptions of the patient's condition, as portrayed in our article, separated into easily identifiable groups probably make the interpretation of the data as simple as referring to reference tables as suggested by Ivatury and Rohman.
References 1. Ivatury RR, Nallathambi MN, Rohman M, Stahl WM. Penetrating cardiac trauma. Quantifying the severity of anatomic and physiologic injury. Ann Surg 1987;205:61-6. 2. Moore EE, Moore JB, Galloway AC, Eiseman 8. Post-injury thoracotomy in the emergency department: a critical evaluation. Surgery 1979;86:590-8. 3. Attar S, Suter CM, Hankins JR, Sequeira A, McLaughlin JS. Penetrating cardiac injuries. Ann Thorac Surg 1991;51:711-6.
Surgery of Aortic Dissections With GRF Glue To the Editor: Stimulated by the excellent results of Bachet and co-workers [l], who introduced gelatin-resorcin-formol glue into the surgery of aortic dissections, we have used the glue since 1991. Our technique is similar to the procedure described by Laas and coworkers [2], and our results are comparable [3, 41: We used gelatin-resorcin-formol glue in 7 patients with type A dissections and in 5 patients with type B dissections without complications. Teflon felts were never necessary. In all type A dissections a preoperatively diagnosed severe aortic incompetence could be repaired by refixating the valve commissures only. An aortic valve replacement was never necessary. We recommend some technical details that seem to be advantageous: We do not protect the internal lumen of the aorta during the fixation of the glue with a sponge. Instead we insert a Foley catheter (Blocker catheter) and inflate it up to 50 mL. This method has two advantages: (1) we protect the internal lumen of the aorta, and (2) we apply a constant, very efficient compression on the wall layers, which makes the glue more effective. During the fixation period of the glue, which takes about 5 minutes, a low-flow and low-pressure perfusion is maintained. This helps to avoid air embolism into the carotid arteries, which are not cross-clamped. After the distal anastomosis is completed, the graft is crossclamped and the rewarming period begins, while the second anastomosis is performed (Fig 1). This technique reduces the hypothermia period.
Harald E . Zeplin, M D Department of Thoracic and Cardiovascular Surgery School of Medicine Pacelliallee 4 6400 Fulda Germany
Christopher J. Knott-Craig, M D Section of Thoracic and Cardiovascular Surge y The University of Oklahoma PO Box 26901 920 Stanton Young Blvd South Pavilion 4SP 250 Oklahoma City, OK 73190
Fig 1 . Compression of the aortic wall layers by a Foley catheter after the glue is applied (graft cross-clamped with Crawford clamp).
Ann Thorac Surg 1992;54:12449
Fig 2. Clinical course of plasma free hemoglobin (Hb) level.
replacement for failing bioprostheses. Two Carbomedics prostheses were employed. Again clinical signs of hemolysis with LDH levels up to 2,670 IU and a plasma free hemoglobin level of 53 mg/dL were detected. An echocardiogram showed a small mitral paravalvular leak and borderline ventricular function. The use of 400 mg of pentoxifylline three times daily eliminated the signs of hemolysis. Seven months postoperatively the patient is well. A 43-year-old man underwent redo mitral and aortic valve replacement for failing bioprostheses, and two Medtronic-Hall valves were used. There was an early onset of hemolysis (LDH, 6,600 IU; plasma free hemoglobin, 135 mg/dL) and the echocardiogram showed a small paravalvular aortic leak with a hypertrophied, well-contracting left ventricle. We started using 400 mg of pentoxifylline three times daily, which reduced the hematological signs of hemolysis (LDH, 2,800 IU; plasma free hemoglobin, 69 mg/dL). The addition of 20 mg of propranolol three times daily completely cured the hemolysis. Six months after operation the patient is asymptomatic. We think that the use of pentoxifylline can be effective in the treatment of mechanical hemolysis after cardiac operations. If pentoxifylline does not completely correct hemolysis, the use of propranolol should bc considered as hernodynamic conditions permit.
1247
advantage of use of pentoxifylline (Trental) for intravascular hemolysis after prosthetic valve insertion. They reported 4 patients, 3 of whom had signs of paraprosthetic valve leakage. All 4 patients clinically showed a regression of hemolysis after pentoxifylline administration. Additionally, 2 patients received propranolol. None of them underwent reoperation for paraprosthetic valve leakage. However, our experience regarding intravascular hemolysis due to paraprosthetic valve leakage after insertion of St. Jude Medical prostheses [2] was quite different. One of 9 patients died of multiorgan failure and the other 8 patients needed reoperation to repair paraprosthetic leakages. Our 4 patients did receive pentoxifylline for the purpose of alleviating the hemolysis but showed no improvement. One patient showed a transient improvement of hemolysis after propranolol administration as we reported. Although not all patients who have paraprosthetic valve leakage demonstrated severe intravascular hemolysis due to mechanical trauma to erythrocytes, we believe that patients with a small leakage in Dacron-cuffed St. Jude Medical mitral prostheses usually suffer intractable intravascular hemolysis and need reoperation. Propranolol or pentoxifylline sometimes reduces the degree of hemolysis and shortens the period of natural healing of hemolysis. We, however, like to emphasize that such agents never substitute for reparative operation.
Yutaka Okita, M D Shigehito Miki, M D Department of Cardiovascular Surgey Tenri Hospital 200 Mishima, Tenri, Nara Japan 632 References 1. Okita Y, Miki S, Kusuhara K, Ueda Y, Tahata T, Yamanaka K. Propranolol for intractable hemolysis after open heart operation. Ann Thorac Surg 1991;52:1158-60. 2. Okita Y, Miki S, Kusuhara K, et al. Intractable hemolysis caused by perivalvular leakage following mitral valve replacement with St. Jude Medical prostheses. Ann Thorac Surg 1988;46:89-92.
- -
Cardiac Trauma To the Editor:
Alessandro Golino, M D Paolo Stassano, M D Nicola Spampinato, M D
We read with interest the article by Knott-Craig and associates [ l ] and congratulate them on a succinct article with excellent results. We thank them for citing one of our previous publications on the subject [2]. We are compelled, however, to correct Knott-Craig and associates regarding the mortality figures they attributed to our article. As reported in our publication [2], the overall survival from all penetrating cardiac injuries was 53.6% (60 of 112). This included a 20% to 25% survival in patients who were "in extremis" (physiologic index, 15 and 20). In their current article [l], Knott-Craig and associates incorrectly state that our mortality for patients requiring emergency room thoracotomy was "almost loo%.''We have consistently obtained a survival of 25% to 30% with emergency room thoracotomy [ 2 4 ] even in patients who had no vital signs on admission but who had some sign of life in transit to the hospital. It is also noteworthy that our reports had dealt with both stab and gunshot wounds of the heart. Knott-Craig and associates have included only stab wounds, which are known to have a more favorable prognosis. Because the paper was entitled "Penetrating cardiac trauma . . . ," we wonder why gunshot wounds were excluded.
Department of Cardiac Surgey Second Medical School University of Naples 5, via S . Pansini 80131 Naples Italy Reference 1. Okita Y, Miki S , Kusuhara K, Ueda Y, Tahata T, Yamanaka K. Propranolol for intractable hemolysis after open heart operation. Ann Thorac Surg 1991;52:1158-60.
Reply
To the Editor:
We thank Dr Golino and associates for their comments regarding our article [l]. In their letter, they have drawn attention to an
1248
CORRESPONDENCE
Ann Thorac Surg 1992;54: 1 2 6 9
Finally, Knott-Craig and associates add another descriptive term, "critically unstable," to the already long list of narrative titles used to describe the clinical status of the patients. "Fatal," "moribund," "in extremis," "lifeless," and "agonal" are only a few examples of this listing. As underscored by Trinkle [5], a more objective clinical description of the patients should improve the evaluation of different series in terms of management strategies and their results.
Rao R . lvatu y , M D Michael Rohman, M D Department of Surgery Lincoln Hospital 234 E 149th St Bronx, NY 10451
References 1. Knott-Craig CJ, Dalton RP, Rossouw GJ, Barnard PM. Penetrating cardiac trauma: management strategy based on 129 surgical emergencies over 2 years. Ann Thorac Surg 1992;53: 10069. 2. Ivatury RR, Nallathambi MN, Rohman M, Stahl WM. Penetrating cardiac trauma. Quantifying the severity of anatomic and physiologic injury. Ann Surg 1987;205:61-6. 3. Ivatury RR, Shah PM, Ito K, Ramirez-Schon G, Suarez F, Rohman M. Emergency room thoracotomy for the resuscitation of patients with "fatal" penetrating injuries of the heart. Ann Thorac Surg 1981;32:377-85. 4. Ivatury RR, Rohman M, Steichen FM, Gunduz Y , Nallathambi M, Stahl WM. Penetrating cardiac injuries: twenty-year experience. Am Surg 1987;53:310-7. 5. Trinkle JK. Penetrating heart wounds: difficulty in evaluating clinical series [Editorial]. Ann Thorac Surg 1984;38:181-2.
Reply
To the Editor:
My colleagues and I thank Drs Ivatury and Rohman for their kind comments regarding our article, and recognize the important contributions they have made through the years on the same subject. Their contention with the mortality rates for emergency room thoracotomy relates to our statement that "our results . . . [54% mortality] also compare favorably with the mortality rate in similar reports, which range from almost 100% to 26%." Three references were given [l-31, and the mortality rates in these references are 71%, 92%, and 62%, respectively. Second, the 129 patients described in our article represent a consecutive series without any exclusions, as clearly stated in the article. The fact that there were no gunshot wounds among these patients attests to the patterns and instruments of violence in this community, where gunshot wounds are very uncommon. Finally, we share Ivatury and Rohman's opinion that the variety of terminologies describing patients with penetrating trauma makes comparisons difficult. However, accurate clear clinical descriptions of the patient's condition, as portrayed in our article, separated into easily identifiable groups probably make the interpretation of the data as simple as referring to reference tables as suggested by Ivatury and Rohman.
References 1. Ivatury RR, Nallathambi MN, Rohman M, Stahl WM. Penetrating cardiac trauma. Quantifying the severity of anatomic and physiologic injury. Ann Surg 1987;205:61-6. 2. Moore EE, Moore JB, Galloway AC, Eiseman 8. Post-injury thoracotomy in the emergency department: a critical evaluation. Surgery 1979;86:590-8. 3. Attar S, Suter CM, Hankins JR, Sequeira A, McLaughlin JS. Penetrating cardiac injuries. Ann Thorac Surg 1991;51:711-6.
Surgery of Aortic Dissections With GRF Glue To the Editor: Stimulated by the excellent results of Bachet and co-workers [l], who introduced gelatin-resorcin-formol glue into the surgery of aortic dissections, we have used the glue since 1991. Our technique is similar to the procedure described by Laas and coworkers [2], and our results are comparable [3, 41: We used gelatin-resorcin-formol glue in 7 patients with type A dissections and in 5 patients with type B dissections without complications. Teflon felts were never necessary. In all type A dissections a preoperatively diagnosed severe aortic incompetence could be repaired by refixating the valve commissures only. An aortic valve replacement was never necessary. We recommend some technical details that seem to be advantageous: We do not protect the internal lumen of the aorta during the fixation of the glue with a sponge. Instead we insert a Foley catheter (Blocker catheter) and inflate it up to 50 mL. This method has two advantages: (1) we protect the internal lumen of the aorta, and (2) we apply a constant, very efficient compression on the wall layers, which makes the glue more effective. During the fixation period of the glue, which takes about 5 minutes, a low-flow and low-pressure perfusion is maintained. This helps to avoid air embolism into the carotid arteries, which are not cross-clamped. After the distal anastomosis is completed, the graft is crossclamped and the rewarming period begins, while the second anastomosis is performed (Fig 1). This technique reduces the hypothermia period.
Harald E . Zeplin, M D Department of Thoracic and Cardiovascular Surgery School of Medicine Pacelliallee 4 6400 Fulda Germany
Christopher J. Knott-Craig, M D Section of Thoracic and Cardiovascular Surge y The University of Oklahoma PO Box 26901 920 Stanton Young Blvd South Pavilion 4SP 250 Oklahoma City, OK 73190
Fig 1 . Compression of the aortic wall layers by a Foley catheter after the glue is applied (graft cross-clamped with Crawford clamp).
