514
LElTERS
TO THE EDITOR
Administration of aprotinin intraoperatively appears to result in better preservation of fibronectin levels during cardiopulmonary bypass. Though the mechanism of action of aprotinin in the preservation of fibronectin remains unclear, it is proposed that it probably exerts an inhibiting effect on proteolytic enzymes by forming an aprotinin-proteinase complex. The clinical implications of the higher leve1 of fibronectin achieved during cardiopulmonary bypass by the intraoperative use of aprotonin need further evaluation. Dhafir M. Al Khudairi, FFARCS (I) A.M. Mehrun Zuleika, FFARCS {I) Wïlliam Sawyer MB, ChB
Riyadh Cardiac Centre Armed Forces Hospita1 Riyadh, Kingdom of Saudi Arabia REFERENCES
1. Pourrat E, Sie PM, Besrez X: Changes in plasma fibronectin levels after cardiac and pulmonary surgery: Role of cardiopulmonary bypass. Stand J Thor Cardiovasc Surg 19:63-67,1985 2. Grotta AW, Carsons S, Abrams L, et al: Fibronectin levels during cardiopulmonary bypass. NY State J Med 87:493-496, 1987 3. Michiolic J, Graninger W, Have1 M, et al: Plasma fibronectin,
Sickle
Cel1 Trait,
albumin, IgM and total protein during cardiopulmonary Thorac Cardiovasc Surgeon 33:176-178,1985
bypass.
4. Haniuda M, Morinoto M, Sugmoya A, et al: Suppressive effect of ulanistatin on plasma fibronectin depression after cardiac surgery. Ann Thorac Surg 45171.173,1988
Open Heart
Surgery,
and SVO,
To the Editor:
A 59-year-old woman with sickle cel1 trait (SCT) was scheduled for atria1 septal defect closure plus tricuspid valve plication at this institution. She was asymptomatic for SCT, total hemoglobin was 13.2 g %, and the value of HbS was 30%, so we did not perform any preoperative exchange transfusion. We based our intraoperative management on widely accepted directions,’ ie, avoidance of hypothermia, hypoxia, acidosis, and venous stasis. Induction of cardioplegic arrest was achieved with warm cardioplegic solution, followed by cold cardioplegia, extracorporeal circuit was primed with packed red cells (800 mL) plus mannitol and Ringer’s solution. During extracorporeal circulation systemic temperature was kept at 34°C. In order to continuously monitor mixed venous oxygen saturation (SvOz) we inserted, through the right internal jugular vein, a fiberoptic thermodilution catheter (Opticath, Abbott Laboratories, North Chicago, IL) after proper calibration. SvOz turned out to be higher than normal in the right atrium and pulmonary artery due to the left-to-right shunt, but, surprisingly, SvOz was very high (95%) even in the superior vena cava with the catheter tip 2 cm beyond the end of the introducer sheath. Our suspicion of an undiagnosed anomalous pulmonary venous connection was, a few minutes later, confirmed by the surgeon after sternal spread and visual inspection of the heart. The surgical strategy was modified after this unexpected finding but, nevertheless, the perioperative course was uneventful. HbS decreased during cardiopulmonary bypass to 24%. In conclusion, though the anesthetic management of patients with SCT during cardiopulmonary bypass and the use of SvOz as a real-time index of tissue oxygenation do not deserve any further comment, being well-documented clinical entities, we would like to point out, in this case, the usefulness of SvOz as a diagnostic tool for the diagnosis of intracardiac shunts. P. Ceriana, M. Maurelli, A. Locatelli, T. Bianchi, G. Chiaudani, M.P. Maua, A. Pagnin, REFERENCES
Department of Cardiac Anesthesia IRCCS Policlinico San Matteo
1. Hensley FA Jr, Martin DE: The practice of cardiac anesthesia. Boston, MA, Little, Brown, 1990, pp 248-249
Radiographic
Pulmonary
Abnormalities
MD MD MD MD MD MD MD
Pavia, Italy
After Pediatrie
Cardiac
Surgery
To the Editor:
We have read with interest the recent article by Jain et al1 describing radiographic pulmonary abnormalities in adult cardiac surgical patients. We wish to report a common postoperative finding in our pediatrie cardiac surgical patient
515
LETTERS TO THE EDITOR
population. Following surgical correction of tetralogy of Fallot there is a 35% to 40% incidence of right upper lobe atelectasis, which usually becomes evident on the chest roentgenogram 6 to 10 hours postoperatively. The same incidence of postoperative right upper lobe atelectasis is seen in our children with Down syndrome after repair of an AV canal. In each case, malposition or temporary displacement of the nasotracheal tube was excluded. The orifice of the right upper lobe bronchus is generally found on the lateral side of the right main bronchus just below the carina. We wish to raise the question whether certain congenital malformations would predispose these children to right upper lobe atelectasis. An aberrant right upper lobe bronchus leaving the trachea above the carina could explain our findings. Hubert Böhrer, MD Alfons Bach, MD Johann Motsch, MD
REFERENCE
Department of Anesthesia University of Heidelberg Heidelberg, Germany
1. Jain U, Rao TLK, Kleinman BS, et al: Radiographic pulmonary abnormalities after different types of cardiac surgery. J Cardiothorac Vast Anesth 5:592-595,199l
Combination
of Pancuronium
and Vecuronium
To the Editor:
1 was interested to read the article “Hemodynamic Responses to Pancuronium and Vecuronium During High-Dose Fentanyl Anesthesia for Coronary Artery Bypass Grafting.“’ The authors have compared pancuronium and vecuronium, which have different effects on cardiovascular parameters, namely pancuronium has a propensity to increase heart rate and arterial blood pressure, and vecuronium, though associated with marked cardiovascular stability, does not counter the bradycardia in a narcotic-based anesthetic. These differences in clinical characteristics offer some advantage in combining the two drugs in clinical practice. It appears logica1 to mix pancuronium and vecuronium in an attempt to minimize the cardiac stimulation due to pancuronium at the same time preventing bradycardia associated with the use of vecuronium. We combined pancuronium and vecuronium in a 1:l concentration and found that the margin of safety in terms of myocardial Oz supply/demand can be increased when the pancuronium-vecuronium mixture is used rather than when pancuronium is used alone.2 K. Muralidhar, MD
Department of Anaesthesiology B.M. Birla Heart Research Centre Calcutta, India REFERENCES
1. Paulissian R, Mahdi M, Joseph NJ, et al: Hemodynamic Responses to Pancuronium and Vecuronium during high-dose Fentanyl anesthesia for Coronary artery bypass grafting. J Cardiothorac Vast Anesth 5:120-125,199l.
2. Muralidhar K, Bhanumurthy S: Pancuronium and Vecuronium mixture for coronary artery bypass grafting. J Anesth Clin Pharmacol6:5-9,199O.
LElTERS
TO THE EDITOR
Administration of aprotinin intraoperatively appears to result in better preservation of fibronectin levels during cardiopulmonary bypass. Though the mechanism of action of aprotinin in the preservation of fibronectin remains unclear, it is proposed that it probably exerts an inhibiting effect on proteolytic enzymes by forming an aprotinin-proteinase complex. The clinical implications of the higher leve1 of fibronectin achieved during cardiopulmonary bypass by the intraoperative use of aprotonin need further evaluation. Dhafir M. Al Khudairi, FFARCS (I) A.M. Mehrun Zuleika, FFARCS {I) Wïlliam Sawyer MB, ChB
Riyadh Cardiac Centre Armed Forces Hospita1 Riyadh, Kingdom of Saudi Arabia REFERENCES
1. Pourrat E, Sie PM, Besrez X: Changes in plasma fibronectin levels after cardiac and pulmonary surgery: Role of cardiopulmonary bypass. Stand J Thor Cardiovasc Surg 19:63-67,1985 2. Grotta AW, Carsons S, Abrams L, et al: Fibronectin levels during cardiopulmonary bypass. NY State J Med 87:493-496, 1987 3. Michiolic J, Graninger W, Have1 M, et al: Plasma fibronectin,
Sickle
Cel1 Trait,
albumin, IgM and total protein during cardiopulmonary Thorac Cardiovasc Surgeon 33:176-178,1985
bypass.
4. Haniuda M, Morinoto M, Sugmoya A, et al: Suppressive effect of ulanistatin on plasma fibronectin depression after cardiac surgery. Ann Thorac Surg 45171.173,1988
Open Heart
Surgery,
and SVO,
To the Editor:
A 59-year-old woman with sickle cel1 trait (SCT) was scheduled for atria1 septal defect closure plus tricuspid valve plication at this institution. She was asymptomatic for SCT, total hemoglobin was 13.2 g %, and the value of HbS was 30%, so we did not perform any preoperative exchange transfusion. We based our intraoperative management on widely accepted directions,’ ie, avoidance of hypothermia, hypoxia, acidosis, and venous stasis. Induction of cardioplegic arrest was achieved with warm cardioplegic solution, followed by cold cardioplegia, extracorporeal circuit was primed with packed red cells (800 mL) plus mannitol and Ringer’s solution. During extracorporeal circulation systemic temperature was kept at 34°C. In order to continuously monitor mixed venous oxygen saturation (SvOz) we inserted, through the right internal jugular vein, a fiberoptic thermodilution catheter (Opticath, Abbott Laboratories, North Chicago, IL) after proper calibration. SvOz turned out to be higher than normal in the right atrium and pulmonary artery due to the left-to-right shunt, but, surprisingly, SvOz was very high (95%) even in the superior vena cava with the catheter tip 2 cm beyond the end of the introducer sheath. Our suspicion of an undiagnosed anomalous pulmonary venous connection was, a few minutes later, confirmed by the surgeon after sternal spread and visual inspection of the heart. The surgical strategy was modified after this unexpected finding but, nevertheless, the perioperative course was uneventful. HbS decreased during cardiopulmonary bypass to 24%. In conclusion, though the anesthetic management of patients with SCT during cardiopulmonary bypass and the use of SvOz as a real-time index of tissue oxygenation do not deserve any further comment, being well-documented clinical entities, we would like to point out, in this case, the usefulness of SvOz as a diagnostic tool for the diagnosis of intracardiac shunts. P. Ceriana, M. Maurelli, A. Locatelli, T. Bianchi, G. Chiaudani, M.P. Maua, A. Pagnin, REFERENCES
Department of Cardiac Anesthesia IRCCS Policlinico San Matteo
1. Hensley FA Jr, Martin DE: The practice of cardiac anesthesia. Boston, MA, Little, Brown, 1990, pp 248-249
Radiographic
Pulmonary
Abnormalities
MD MD MD MD MD MD MD
Pavia, Italy
After Pediatrie
Cardiac
Surgery
To the Editor:
We have read with interest the recent article by Jain et al1 describing radiographic pulmonary abnormalities in adult cardiac surgical patients. We wish to report a common postoperative finding in our pediatrie cardiac surgical patient
515
LETTERS TO THE EDITOR
population. Following surgical correction of tetralogy of Fallot there is a 35% to 40% incidence of right upper lobe atelectasis, which usually becomes evident on the chest roentgenogram 6 to 10 hours postoperatively. The same incidence of postoperative right upper lobe atelectasis is seen in our children with Down syndrome after repair of an AV canal. In each case, malposition or temporary displacement of the nasotracheal tube was excluded. The orifice of the right upper lobe bronchus is generally found on the lateral side of the right main bronchus just below the carina. We wish to raise the question whether certain congenital malformations would predispose these children to right upper lobe atelectasis. An aberrant right upper lobe bronchus leaving the trachea above the carina could explain our findings. Hubert Böhrer, MD Alfons Bach, MD Johann Motsch, MD
REFERENCE
Department of Anesthesia University of Heidelberg Heidelberg, Germany
1. Jain U, Rao TLK, Kleinman BS, et al: Radiographic pulmonary abnormalities after different types of cardiac surgery. J Cardiothorac Vast Anesth 5:592-595,199l
Combination
of Pancuronium
and Vecuronium
To the Editor:
1 was interested to read the article “Hemodynamic Responses to Pancuronium and Vecuronium During High-Dose Fentanyl Anesthesia for Coronary Artery Bypass Grafting.“’ The authors have compared pancuronium and vecuronium, which have different effects on cardiovascular parameters, namely pancuronium has a propensity to increase heart rate and arterial blood pressure, and vecuronium, though associated with marked cardiovascular stability, does not counter the bradycardia in a narcotic-based anesthetic. These differences in clinical characteristics offer some advantage in combining the two drugs in clinical practice. It appears logica1 to mix pancuronium and vecuronium in an attempt to minimize the cardiac stimulation due to pancuronium at the same time preventing bradycardia associated with the use of vecuronium. We combined pancuronium and vecuronium in a 1:l concentration and found that the margin of safety in terms of myocardial Oz supply/demand can be increased when the pancuronium-vecuronium mixture is used rather than when pancuronium is used alone.2 K. Muralidhar, MD
Department of Anaesthesiology B.M. Birla Heart Research Centre Calcutta, India REFERENCES
1. Paulissian R, Mahdi M, Joseph NJ, et al: Hemodynamic Responses to Pancuronium and Vecuronium during high-dose Fentanyl anesthesia for Coronary artery bypass grafting. J Cardiothorac Vast Anesth 5:120-125,199l.
2. Muralidhar K, Bhanumurthy S: Pancuronium and Vecuronium mixture for coronary artery bypass grafting. J Anesth Clin Pharmacol6:5-9,199O.
