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Letters to the Editor |
a Cardiovascular Surgery Discipline, Federal University of São Paulo, São Paulo, Brazil
b Division of Thoracic and Cardiovascular Surgery, Department of Surgery and Anatomy, Ribeirão Preto Faculty of Medicine, University of São Paulo, Brazil
Received 24 December 2008; accepted 4 February 2009.
* Corresponding author. Address: Rua Borges Lagoa 1080 cj 608, São Paulo SP 04038-002, Brazil. Tel.: +55 11 5572 6309; fax: +55 11 5572 6309. (Email: wjgomes.dcir{at}epm.br).
Key Words: Coronary artery bypass • Off-pump • Postoperative complications
The paper from Sun et al. reporting the incidence of vasoplegic syndrome (VS) after off-pump coronary artery bypass grafting (OPCAB) draws attention to a remarkable change in the postoperative complications related to this procedure [1].
The current increased interest in OPCAB has been guided by a growing body of evidence demonstrating lower incidence of perioperative complications, as compared to the conventional technique, mainly owing to avoidance of cardiopulmonary bypass.
VS was at first thought to be inexorably linked to cardiopulmonary bypass (CPB) use in cardiovascular surgery. However, further studies identified the occurrence of VS in patients who underwent OPCAB, disclosing the multifactorial connections associated with the emergence of this syndrome [2,3].
Although CPB has been associated with an extensive inflammatory response, recent evidence points out that the magnitude of this inflammatory response may not significantly differ between on-pump and off-pump techniques, with divergences limited to qualitative aspects of the activation pathways. The surgical trauma factor, with its systemic repercussion, might be at least as important as CPB [4].
Conversely, the 2.8% reported incidence of VS in OPCAB found in the Sun's paper makes it higher than any other isolated postoperative complication (except atrial fibrillation), ahead of rates of stroke (0.8%), myocardial infarction (0.3%), renal failure (1.9%), and major infections (2.5%). Consequently, this original finding has upgraded VS to one of the commonest complication after OPCAB.
Although the mortality rate in patients developing VS in this series has not been provided, previous reports clearly demonstrated that VS is a risk factor for mortality, with figures as high as 25%.
Once established, the conventional treatment for VS has been hemodynamic support with vasopressor agents; norepinephrine or vasopressin. Methylene blue has been advocated in patients developing catecholamine-resistant VS, and reports have shown promising results, with attenuation of severity and improved outcomes [5]. However, the role of methylene blue for treatment of this singular condition remains yet to be determined.
Therefore, the paper from Sun et al. has the merit of unquestionably establishing VS as a significant postoperative complication following OPCAB. The true incidence of this syndrome in this circumstance and the impact on outcomes remains to be established. Definitely, additional prospective studies aiming to help settle these issues are necessary and much awaited.
Footnotes
The authors of the original paper [1] were invited to comment on this Letter to the Editor but declined the offer.
References
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