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Eur J Cardiothorac Surg 2003;23:138
© 2003 Elsevier Science NL

Letter to the Editor

Reply to Protopapas

Department of Otolaryngology Head and Neck Surgery, American University of Beirut, Beirut, Lebanon

Received 4 October 2002; received in revised form 4 October 2002; accepted 17 October 2002.

* Tel.: +961-1-350-000 ext. 5470; fax: +961-1-744-464
e-mail: hb03{at}aub.edu.lb

Key Words: Complication • Coronary bypass • Internal mammary artery • Internal thoracic artery • Outcome • Vocal cord paralysis

The author has raised two concerns: One regarding the possible increase in recurrent laryngeal nerve injury with the upcoming evolution in cardiothoracic surgery, where the internal thoracic artery is completely harvested bilaterally thus exposing both recurrent laryngeal nerves, second whether this potential increase in risk warrants further prospective evaluation in view of the medico legal implications.

Regarding the first concern, no doubt that bilateral usage of the internal thoracic artery for total arterial coronary revascularization can theoretically increase the incidence of vocal cord paralysis since both recurrent laryngeal nerves are exposed and dissected during the surgery. However, no study has compared the outcome of unilateral versus bilateral vocal cord paralysis in unilateral versus bilateral dissection of the mammary arteries following open heart surgery, most likely in view of the very small incidence [1].

Regarding the second concern, no study has confirmed the exact etiology behind the paralysis or paresis of the vocal cords following open heart surgery. Injury to the recurrent laryngeal nerve has been suspected but the exact mechanism of injury has never been specified or drawn, and this is mainly due to the difficulty in determining the site of injury and also due to the spontaneous recovery after few months [2]. True, dissection of the Internal thoracic artery at the level of the subcalvian artery can expose the recurrent laryngeal nerve, however dissection and exposure of the recurrent laryngeal nerve are not enough to incriminate the harvesting of these vessels as an increase in the risk of vocal cord paralysis knowing that other mechanisms of injury such as traction on the major vessels and sternotomy are as likely to be responsible for the insult [3–5]. Hence I do not believe that this evolution in Cardiothoracic surgery should prompt the surgeons to change their technique nor to have medico-legal concerns. Maybe it will be informative to do a comparative study between two groups of open heart surgery patients operated on and anesthesized by the same team, whereby in one group one mammary artery is harvested and in the other two are harvested. If the results show that the incidence of vocal cord paralysis is higher in the second group, maybe further evaluation of the harvesting technique should be evaluated.

References

1. Shafei H., El Kholy A., Azmy S. Vocal cord dysfunction after cardiac surgery. An overlooked complication. Eur J Cardiothorac Surg 1997;11(3):564-566.[Abstract]
2. Tewari P., Aggarwal S.K. Combined left-sided recurrent laryngeal and phrenic nerve palsy after coronary artery operation. Ann Thorac Surg 1996;61(6):1721-1723.[Abstract/Free Full Text]
3. Martin-Hirsch D.P., Newbegin C.J.R. Right vocal cord paralysis as a result of central venous catheterization. J Laryngol Otol 1995;109:1107-1108.[Medline]
4. Hahn F.W., Jr, Maertin J.T., Lillie J.L. Vocal cord paralysis with endotracheal tube intubation. Arch Otolaryngol 1970;92:226-229.[Medline]
5. Tiche L.L. Causes of recurrent laryngeal nerve paralysis. Arch Otolaryngol 1976;102:259-261.[Abstract]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Hamdan, A. L. Search for Related Content PubMed Articles by Hamdan, A. L. Related Collections Coronary disease