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Eur J Cardiothorac Surg 2006;29:860
© 2006 Elsevier Science NL
Letter to the Editor |
Department of Cardiothoracic Surgery, 16 Alexandra Parade, Glasgow Royal Infirmary, Glasgow G31 2ER, UK
Received 21 December 2005; accepted 23 January 2006.
* Tel.: +44 141 5645206/2114731; fax: +44 141 2114845. (Email: mishrapk_25{at}yahoo.com).
Key Words: Fibrillatory arrest • Myocardial protection • Cardioplegic arrest
I read with great interest recent article by Fujii et al. [1] where they have discussed role of intermittent cross-clamp fibrillatory arrest for myocardial protection. The editorial comment, which follows, was highly informative and makes an interesting reading. I would like to add a few comments.
Myocardial protection has remained an enigma. Young trainees do get baffled when one senior consultant says that cardioplegic arrest is better and fibrillatory arrest is a thing of the past, but the very next day he/she finds another surgeon (might be a junior consultant) producing excellent clinical outcome using the same fibrillatory arrest technique. Does greying hairs necessarily indicate better wisdom? Is the technique wrong or the person using it is not aware about the advantages and limitations of the technique?
Over the last few decades, life expectancy has increased far beyond 70 years. Obviously, repeated clamping and declamping of the aorta is to be avoided in octogenarians as the editorial comment rightly points out. I am afraid while pointing out the deficiencies of a particular technique we should be highlighting the advantages associated with it as well.
Alhan et al. [2] emphasised that intermittent fibrillatory arrest is as effective as cardioplegic technique in low-risk cases of coronary artery bypass grafting. They provided ultrastructural evidence of efficacy of fibrillatory arrest technique in myocardial protection. We also need to revisit the article by Bonchek et al. [3] where they have described their experience of 3000 patients with fibrillatory arrest technique. They had 29% patients who were more than 70 years of age. They reported good results and recommended it for high-risk patients as well.
Patients with pre-existing conduction blocks are at high risk of progression of their conduction defects with cardioplegia [4]. Fibrillatory arrest technique would be of distinct advantage in these patients [4,5]. In patients with permanent pacemakers, the fibrillatory arrest technique inhibits the pacemaker during cross clamping as a direct result of induced electrical fibrillation (kopppula). During the construction of the proximal anastomosis the pacemaker will keep the heart beating (koppula). There will not be a need for our cardiology colleagues to come to theatre to sort it out.
Cold cardioplegic technique has limitations in patients with cold agglutinins the incidence of which is high in developing countries [5]. Fibrillatory arrest technique can be an excellent substitute providing good myocardial protection and the core body temperature can be kept at 37 °C without any deleterious effects. The literature describes various complicated techniques in such patients which are really uncalled for only if we could get rid of the scepticism surrounding the fibrillatory arrest technique.
Fibrillatory arrest is a low-cost versatile technique. Hopefully this article by Fujii et al. [1] will attract the attention of cardiothoracic surgeons and rejuvenate interest. Agreed it is an old wine in new bottle. A new bottle does not necessarily mean that we should drink the wine. At the same time are we justified in discarding the bottle or the wine without even tasting it?
References
This article has been cited by other articles:
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  D. J. Chambers and M. Fujii Reply to Mishra Eur. J. Cardiothorac. Surg., May 1, 2006; 29(5): 861 - 861. [Full Text] [PDF]
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