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Letters to the Editor |
Department of Cardiac Surgery, Ludwig-Maximilians University of Munich, Germany
Received 6 February 2008; accepted 7 February 2008.
* Corresponding author. Address: Department of Cardiac Surgery, Herzklinik der Universität München, Wolkerweg 16, 81375 München, Germany. Tel.: +49 89 7097 1844; fax: +49 89 7097 1848. (Email: lamm{at}lrz.uni-muenchen.de).
Key Words: Coronary
We thank the Editor for giving us the opportunity to reply to McGoldrick and White's letter to the Editor [1].
There is indeed a basis supporting a causal relationship between sealant use and graft thrombosis.
Free thrombin is undoubtedly deleterious when reaching the circulation system.
In vitro tests done to shed light on the thrombin release as a parameter of non-reacting components and its dependence on the application technique show that there is a release of thrombin into the supernatant for at least 120 h after application even when Duploject application was used [2]. Some studies also indicate that there may be even more-free thrombin when the sealant is used in surface temperatures below 37 °C. It may be added that free thrombin may easily reach the circulation system via a sucker when the heart-lung machine is in operation. Marek et al. studied the effects of topically applied thrombin containing fibrin sealant to the survival of epigastric free flaps in a rat model. Their results suggest that the use of thrombin-based fibrin sealant is detrimental to flap survival especially when applied to venous anastomoses [3]. Dascombe et al. were able to demonstrate an increased platelet adhesion in the luminal surface of term human placenta vessels when thrombin-based fibrin glue was applied to the adventitial surface of an intact vessel or an anastomosis. Furthermore, they were able to detect thrombin intraluminally as early as 1 min following glue formation. For the remainder of the perfusion constant thrombin diffusion rates were maintained [4]. Additionally, Sinauridze et al., studying the dynamics of clot formation in a two-compartment chamber designed to allow free diffusion of thrombin into nonstirred plasma or fibrinogen solution, made the observation that clot weight increased throughout the experiment (sometimes 20–24 h) when the thrombin concentrations were extremely low [5]. Finally, it is known that the saphenous vein response to thrombin is vasoconstriction as opposed to the relaxation in internal mammary arteries.
Considering these publications, we believe that there is a basis supporting a causal relationship between sealant use and graft thrombosis. We however cannot see a rationale for McGoldrick and White's plea for Tisseel usage in 100% of CABG cases. Unfortunately, we are not aware which broader study the authors are referring to. We believe that such a study comparing two matched CABG groups with a 100% usage of Tisseel in one group would add crucial information to the debate and cannot be reduced to statements such as, ‘... Our results may inform this debate ...’ or ‘... The mortality was low in both groups, which were matched for age, sex, risk factors and isolated coronary surgery ...’. We, therefore, encourage McGoldrick and White to publish their study so that it may be discussed adequately. Until such time, we still see a potential warning signal in the data published so far and would not advocate a Tissucol use in 100% of all cases as recommended by the authors.
References
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