1122
CORRESPONDENCE
Reply To the Editor: We thank Drs Gursoy, Hokenek, and Bakuy [1] for their interest in our study that demonstrated the superior vasodilating effect of fasudil on internal thoracic artery (ITA) graft in coronary artery bypass grafting (CABG) [2]. The concentration of fasudil (0.9 mg/dL or 2.67 mmol/L) that we used for dilating the ITA graft was determined based on our previous basic research of fasudil on the radial artery graft [3]. In our present clinical study on the ITA graft, we injected fasudil locally into the lumen of the graft. Since we did not use intravenous injection, the half-life of fasudil (30 minutes) is not an issue. Preventing spasm of the ITA graft immediately after harvesting is very important for the success of subsequent anastomoses and CABG. Fasudil exhibits this effect adequately. However, the purpose of administering fasudil is not to maintain the graft in a state of excessive dilatation. In our department, we have used fasudil routinely as an arterial graft dilating agent in over 300 cases of CABG. We have not encountered any complication attributable to graft spasm, or any complication associated with use of fasudil. Our clinical experience has proven that fasudil is safe and useful clinically as a vasodilating agent for arterial grafts in CABG. Go Watanabe, MD, PhD Department of General and Cardiothoracic Surgery Kanazawa University Graduate School of Medical Science Kanazawa, 13-1 Takara-machi, Kanazawa 920-8640, Japan e-mail: [email protected]
References 1. Gursoy M, Hokenek F, Bakuy V. Therapeutic options against internal thoracic artery spasm (letter). Ann Thorac Surg 2014;97:1121. 2. Watanabe G, Noda Y, Takagi T, Tomita S, Yamaguchi S, Kiuchi R. Fasudil is a superior vasodilator for the internal thoracic artery in coronary surgery. Ann Thorac Surg 2013;96: 543–7. 3. Takagi T, Okamoto Y, Tomita S, et al. Intraradial administration of fasudil inhibits augmented Rho kinase activity to effectively dilate the spastic radial artery during coronary artery bypass grafting surgery. J Thorac Cardiovasc Surg 2011;142:e59–65.
MISCELLANEOUS
Should We Prone Cardiac Surgery Patients With Acute Respiratory Distress Syndrome? To the Editor: In March, Stephens and associates [1] provided a review of the acute respiratory distress syndrome (ARDS). Recently, Gu erin and colleagues [2] demonstrated an absolute risk reduction of 16.8% for 28-day mortality among ARDS patients (PO2/FiO2 150) who received 16 hours of proning per day. That means for every 6 ARDS patients treated, 1 death might be prevented at 28 days. The 28-day mortality rate (23.6%) is one of the lowest mortality rates reported for patients with ARDS in randomized trials, as is the absolute risk reduction. A single trial should be interpreted with caution. Previous trials of prone positioning in ARDS did not improve mortality [3]. The population studied by the Gu erin group consisted predominantly of patients with pneumonia and 80% had sepsis; that differs from most cardiac surgery patients. Proning poses challenges for cardiac surgery patients. Cardiac Ó 2014 by The Society of Thoracic Surgeons Published by Elsevier Inc
Ann Thorac Surg 2014;97:1120–5
output might be adversely affected and turning patients might be risky. Cardiac surgery patients are at jeopardy for destabilizing their sternum, tearing bypass grafts, and developing sternal infections. Pacing leads and pleural or mediastinal tubes could also dislodge. Our literature review identified three trials of prone positioning in cardiac surgery patients. Maillet and colleagues [4] studied 16 patients and found improved oxygenation. In 5 patients, pressure ulcers developed, and in 2, wound infections. Brussel and coworkers [5] studied 10 patients whose oxygenation improved; 4 patients had facial edema and 5 had chest wall and forehead bruising. Eremenko and colleagues [6] compared 36 prone patients against 36 supine controls. The intervention group had lower mortality, fewer arrhythmias, and improved oxygenation. The Gu erin study [2] offers hope for ARDS patients. However, further randomized trials are needed to delineate its safety and efficacy before prone positioning can be recommended for cardiac surgery patients. Michael Mazzeffi, MD, MPH Peter Rock, MD, MBA Department of Anesthesiology University of Maryland School of Medicine 22 S Greene St, Rm S11C00 Baltimore, MD 21217 e-mail: [email protected]
References 1. Stephens RS, Shah AS, Whitman GJR. Lung injury and acute respiratory distress syndrome after cardiac surgery. Ann Thorac Surg 2013;95:1122–9. 2. Guerin C, Reignier J, Richard JC, et al. Prone positioning in severe acute respiratory distress syndrome. N Engl J Med 2013;368:2159–68. 3. Gattinoni L, Tognoni G, Pesenti A, et al. Effect of prone positioning on survival of patients with acute respiratory failure. N Engl J Med 2001;345:568–73. 4. Maillet JM, Thierry S, Brodaty D. Prone positioning and acute respiratory distress syndrome after cardiac surgery: a feasibility study. J Cardiothorac Vasc Anesth 2008;22:414–7. 5. Brussel T, Hachenberg T, Roos N, Lemzem H, Konertz W, Lawin P. Mechanical ventilation in the prone position for acute respiratory failure after cardiac surgery. J Cardiothorac Vasc Anesth 1993;7:541–6. 6. Eremenko AA, Egorov VM, Levikov DI. Results of the treatment of cardiac surgery patients with postoperative acute respiratory distress syndrome by prone position pulmonary ventilation. Anesteziol Reanimatol 2000;5:42–5.
Reply To the Editor: We thank Drs Mazzeffi and Rock [1] for their interest in and comments on our review article [2]. We were similarly impressed by the improvement in mortality with prone positioning in severe acute respiratory distress syndrome (ARDS) reported by Guerin and associates [3], which was published after our manuscript. It should be noted that several of the prior studies of prone positioning in ARDS were performed before low tidal volume ventilation became the standard of care [4–6]. In the absence of lung-protective ventilation, prone positioning may indeed not confer any survival benefits. Guerin and colleagues [3] used a low tidal volume strategy in their protocol, for both the prone and the supine 0003-4975/$36.00
CORRESPONDENCE
Reply To the Editor: We thank Drs Gursoy, Hokenek, and Bakuy [1] for their interest in our study that demonstrated the superior vasodilating effect of fasudil on internal thoracic artery (ITA) graft in coronary artery bypass grafting (CABG) [2]. The concentration of fasudil (0.9 mg/dL or 2.67 mmol/L) that we used for dilating the ITA graft was determined based on our previous basic research of fasudil on the radial artery graft [3]. In our present clinical study on the ITA graft, we injected fasudil locally into the lumen of the graft. Since we did not use intravenous injection, the half-life of fasudil (30 minutes) is not an issue. Preventing spasm of the ITA graft immediately after harvesting is very important for the success of subsequent anastomoses and CABG. Fasudil exhibits this effect adequately. However, the purpose of administering fasudil is not to maintain the graft in a state of excessive dilatation. In our department, we have used fasudil routinely as an arterial graft dilating agent in over 300 cases of CABG. We have not encountered any complication attributable to graft spasm, or any complication associated with use of fasudil. Our clinical experience has proven that fasudil is safe and useful clinically as a vasodilating agent for arterial grafts in CABG. Go Watanabe, MD, PhD Department of General and Cardiothoracic Surgery Kanazawa University Graduate School of Medical Science Kanazawa, 13-1 Takara-machi, Kanazawa 920-8640, Japan e-mail: [email protected]
References 1. Gursoy M, Hokenek F, Bakuy V. Therapeutic options against internal thoracic artery spasm (letter). Ann Thorac Surg 2014;97:1121. 2. Watanabe G, Noda Y, Takagi T, Tomita S, Yamaguchi S, Kiuchi R. Fasudil is a superior vasodilator for the internal thoracic artery in coronary surgery. Ann Thorac Surg 2013;96: 543–7. 3. Takagi T, Okamoto Y, Tomita S, et al. Intraradial administration of fasudil inhibits augmented Rho kinase activity to effectively dilate the spastic radial artery during coronary artery bypass grafting surgery. J Thorac Cardiovasc Surg 2011;142:e59–65.
MISCELLANEOUS
Should We Prone Cardiac Surgery Patients With Acute Respiratory Distress Syndrome? To the Editor: In March, Stephens and associates [1] provided a review of the acute respiratory distress syndrome (ARDS). Recently, Gu erin and colleagues [2] demonstrated an absolute risk reduction of 16.8% for 28-day mortality among ARDS patients (PO2/FiO2 150) who received 16 hours of proning per day. That means for every 6 ARDS patients treated, 1 death might be prevented at 28 days. The 28-day mortality rate (23.6%) is one of the lowest mortality rates reported for patients with ARDS in randomized trials, as is the absolute risk reduction. A single trial should be interpreted with caution. Previous trials of prone positioning in ARDS did not improve mortality [3]. The population studied by the Gu erin group consisted predominantly of patients with pneumonia and 80% had sepsis; that differs from most cardiac surgery patients. Proning poses challenges for cardiac surgery patients. Cardiac Ó 2014 by The Society of Thoracic Surgeons Published by Elsevier Inc
Ann Thorac Surg 2014;97:1120–5
output might be adversely affected and turning patients might be risky. Cardiac surgery patients are at jeopardy for destabilizing their sternum, tearing bypass grafts, and developing sternal infections. Pacing leads and pleural or mediastinal tubes could also dislodge. Our literature review identified three trials of prone positioning in cardiac surgery patients. Maillet and colleagues [4] studied 16 patients and found improved oxygenation. In 5 patients, pressure ulcers developed, and in 2, wound infections. Brussel and coworkers [5] studied 10 patients whose oxygenation improved; 4 patients had facial edema and 5 had chest wall and forehead bruising. Eremenko and colleagues [6] compared 36 prone patients against 36 supine controls. The intervention group had lower mortality, fewer arrhythmias, and improved oxygenation. The Gu erin study [2] offers hope for ARDS patients. However, further randomized trials are needed to delineate its safety and efficacy before prone positioning can be recommended for cardiac surgery patients. Michael Mazzeffi, MD, MPH Peter Rock, MD, MBA Department of Anesthesiology University of Maryland School of Medicine 22 S Greene St, Rm S11C00 Baltimore, MD 21217 e-mail: [email protected]
References 1. Stephens RS, Shah AS, Whitman GJR. Lung injury and acute respiratory distress syndrome after cardiac surgery. Ann Thorac Surg 2013;95:1122–9. 2. Guerin C, Reignier J, Richard JC, et al. Prone positioning in severe acute respiratory distress syndrome. N Engl J Med 2013;368:2159–68. 3. Gattinoni L, Tognoni G, Pesenti A, et al. Effect of prone positioning on survival of patients with acute respiratory failure. N Engl J Med 2001;345:568–73. 4. Maillet JM, Thierry S, Brodaty D. Prone positioning and acute respiratory distress syndrome after cardiac surgery: a feasibility study. J Cardiothorac Vasc Anesth 2008;22:414–7. 5. Brussel T, Hachenberg T, Roos N, Lemzem H, Konertz W, Lawin P. Mechanical ventilation in the prone position for acute respiratory failure after cardiac surgery. J Cardiothorac Vasc Anesth 1993;7:541–6. 6. Eremenko AA, Egorov VM, Levikov DI. Results of the treatment of cardiac surgery patients with postoperative acute respiratory distress syndrome by prone position pulmonary ventilation. Anesteziol Reanimatol 2000;5:42–5.
Reply To the Editor: We thank Drs Mazzeffi and Rock [1] for their interest in and comments on our review article [2]. We were similarly impressed by the improvement in mortality with prone positioning in severe acute respiratory distress syndrome (ARDS) reported by Guerin and associates [3], which was published after our manuscript. It should be noted that several of the prior studies of prone positioning in ARDS were performed before low tidal volume ventilation became the standard of care [4–6]. In the absence of lung-protective ventilation, prone positioning may indeed not confer any survival benefits. Guerin and colleagues [3] used a low tidal volume strategy in their protocol, for both the prone and the supine 0003-4975/$36.00
