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Eur J Cardiothorac Surg 2002;22:328-329
© 2002 Elsevier Science NL
Letter to the Editor |
Abteilung für Thorax- und Kardiovaskularchirurgie, Herzzentrum NRW, Ruhr-Universität Bochum, Georgstrasse 11, D-32545 Bad Oeynhausen, Germany
Received 15 March 2002; accepted 12 April 2002.
* Corresponding author. Tel.: +49-5731-97-1235; fax: +49-5731-97-1300
e-mail: kminami{at}hdz-nrw.de
We congratulate Pedro E. Antunes for his results after usage of the staged approach for carotid and coronary disease [1]. They compare quite well to the results of other groups using this policy.
However, the staged approach operating first on the carotid artery bears a considerable risk for the myocardium. In fact, the rate of 3.6% myocardial infarctions (MI) seen after the carotid endarterectomy in the described population reflects the reason why the staged approach has been abandoned by many centers. The overview given in Table 3 of the discussed article confirms that these considerations are not purely theoretical and not limited to the presented study: the mean MI rate for the populations that underwent staged operations amounts to 5.8%. The average rate for MI of 2.2% and a maximum of 2.5% resulting from Table 5 shows that using the combined approach is less threatening for the heart.
The ‘combined approach’ is not a standardized procedure performed uniformly in all centers. Most authors report that they do the carotid endarterectomy under different grades of preparation for the cardiopulmonary bypass applied for the immediately following CABG procedure. The most advanced preparation is present when cardiopulmonary bypass is already installed for the carotid endarterectomy. We favor this variation in order to achieve optimal protection for both organs, brain and heart, by hemodilution, hypothermia and blood pressure control. In 2000, we described [2] the results obtained from a large series of 340 patients consecutively operated using cardiopulmonary bypass for both procedures. The rates for MI (0.6%) and stroke (3.2%) reflect the advantages mainly for the heart, but also for stroke prevention, of this strategy.
We consider such a series worthy of mention in a summary of series reporting results of concomitant carotid and coronary operations, as in Table 5 of Antunes' article. The results of the Bad Oeynhausen study [2] are even more noteworthy for a comparison of methods since the patients were sicker (concomitant operations were not excluded, 45.6 vs. 26% had symptomatic carotid artery disease) than the patients of the discussed article.
The four (out of 77) cases of unstable angina described by Antunes (of which two patients had urgent CABG) could as well be used to reason against the staged approach, since their fate is not bad luck, but the well explainable consequence of exposing patients with known significant coronary heart disease to the risk of carotid artery revascularization without optimal myocardial protection.
Although we are not forced to obey only economical constraints, the cost aspect might well be considered if no medical reason contradicts it. The article of Daily [3] underlines that a significant cost reduction can be achieved by doing the combined procedure.
Concluding, we agree with the author concerning the statement that good results are possible with the staged approach. But the results that we obtained with the combined approach using cardiopulmonary bypass for both procedures were more beneficial for the patients.
References
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