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Eur J Cardiothorac Surg 2006;29:861
© 2006 Elsevier Science NL
Letter to the Editor |
Cardiac Surgical Research/Cardiothoracic Surgery, The Rayne Institute, Guy's & St Thomas’ NHS Foundation Trust, St Thomas’ Hospital, London SE1 7EH, UK
Received 20 January 2006; accepted 23 January 2006.
* Corresponding author. Tel.: +44 20 7261 0157; fax: +44 20 7928 0658. (Email: david.chambers{at}kcl.ac.uk).
Key Words: Intermittent cross-clamp • Fibrillation • Cardioplegia • Preconditioning • Myocardial protection
We thank Dr Mishra for his perceptive and insightful comments [1] concerning both our recent study published in EJCTS [2] on intermittent cross-clamp fibrillation (ICCF) and the provocative editorial comment that accompanied the article [3], and we are pleased that he found them interesting. Dr Mishra makes some very valid points in his letter concerning the use of ICCF; certainly at St Thomas’ Hospital the technique is used relatively routinely by a number of surgeons with excellent results. Our initial study concerning the protective effect of ICCF [4] was prompted by a belief (by one of us) that cardioplegia should be more protective than ICCF; however, to our surprise, it was demonstrated that ICCF had an intrinsic protective effect equivalent to multidose cardioplegia (at least under our experimental conditions with similar extent of ischaemic injury). In the discussion, we speculated that preconditioning might be a factor involved in this protection, but the study was not designed to investigate that mechanism of action; hence, our recent study where this question was specifically addressed [2] and demonstrated to be the case. In his Editorial [3], Dr Vaage comments that although our study supports previous beliefs of surgeons that ICCF must involve a preconditioning mechanism of protection, nevertheless the technique should probably be abandoned. This would avoid the potential danger of an increased incidence of stroke or neurologic injury due to repeated cross-clamping of the atherosclerotic aorta in the older patient population currently undergoing revascularisation surgery. Whilst we concede that this may be a problem in older patients, it must be relatively easy at the time of surgery to determine whether the aorta is suitable for multiple cross-clamp or whether cardioplegia should be used. The increasing and routine use of transoesophageal echo during cardiac surgery will allow further identification and characterisation of the atherosclerotic status of the ascending aorta to assist decisions on use of protective technique. The technique of ICCF is used in a considerable number of patients requiring revascularisation at St Thomas’ Hospital, and the incidence of stroke is no higher than other centres. We suggest that the main concern with the ICCF technique relates to problem patients requiring extended ischaemic periods, which will test the protective efficacy of ICCF. We recently showed [5] that exacerbation of myocardial injury caused by increasing episodes of ICCF could be attenuated by administration of a sodium–hydrogen exchange inhibitor throughout the ischaemia and reperfusion episodes, and similar drug treatment may be useful when inexperienced registrars are learning this technique. Hence, we agree with both viewpoints; surgeons should be aware of the limitations of the technique and be prepared to tailor their technique to the specific patient as presented, but any technique should not be abandoned out of hand because of perceived problems that have not necessarily been shown to occur in a clinical situation.
References
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