Emmert, Maximilian Y.

Falk, Volkmar

Salzberg, Sacha P.

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References[1] Emmert MY, Salzberg SP, Seifert B, Rodriguez H, Plass A, Hoerstrup SP,Gru¨nenfelder J, Falk V. Is off-pump superior to conventional coronary arterybypass grafting in diabetic patients with multivessel disease? Eur J Cardi-othorac Surg 2011;224:233—9.[2] Herlitz J, Malmberg K, Karlson BW, Ryde´n L, Hjalmarson A. Mortality andmorbidity during a five-year follow-up in diabetics with myocardial infarc-Bilateral internal mammary artery usage was not asso-ciated with increased risk for sternal wound infection in ourcohort. In our opinion, this is due to the skeletonised technique[4] of harvest, which is standard at our institution and to theusage of local antibiotic prophylaxis in many patients [5].As stated in our limitations, the study period was quite long,with most on-pump coronary artery bypass grafting (CABG)Letters to the Editor / European Journal of Cardio-thoracic Surgery 40 (2011) 1546—15531550tion. Acta Med Scand 1988;224:31—8.[3] Fava S, Azzopardi J, Agius-Muscat H. Outcome of unstable angina inpatients with diabetes mellitus. Diabet Med 1997;14:209—13.[4] The BARI Investigators. Seven-year outcome in the Bypass AngioplastyRevascularization Investigation (BARI) by treatment and diabetic status. JAm Coll Cardiol 2000;35:1122—9.[5] Abizaid A, Costa MA, Centemero M, Abizaid AS, Legrand VM, Limet RV,Schuler G, Mohr FW, Lindeboom W, Sousa AG, Sousa JE, van Hout B,Hugenholtz PG, Unger F, Serruys PW, Arterial Revascularization TherapyStudy Group. Clinical and economic impact of diabetes mellitus on percu-taneous and surgical treatment of multivessel coronary disease patients:insights from the Arterial Revascularization Therapy Study (ARTS) trial.Circulation 2001;104:533—8.* Corresponding author. Tel.: +44 1895828550; fax: +44 1895828992.E-mail address: drrajashahzad@hotmail.comdoi:10.1016/j.ejcts.2011.03.012Reply to the Letter to the EditorReply to Raja SGMaximilian Y. Emmert *, Volkmar Falk, Sacha P. SalzbergClinic for Cardiac Surgery, University Hospital Zurich, Zurich, SwitzerlandReceived 2 March 2011; accepted 8 March 2011; Available online14 April 2011Keywords: Diabetes; Coronary artery disease; Off-pump; Coronary arterybypass grafting; Surgery; Myocardial revascularisationWe thank Dr Raja for his interest in our manuscript [1].The strategy for management of blood glucose in theperioperative period was performed in a standardisedfashion, according to our institutional standards, and is inline with the recently published guidelines on the perio-perative management of diabetes in cardiac and vascularsurgery [2,3]. In general, perioperative normoglycaemia wasaimed at, and a minimal disturbance of the patients’ habitualblood glucose balance was anticipated. Hypoglycaemia wasavoided whenever possible, whereas hyperglycaemia wasimmediately corrected to a level of 6—10 mmol l1. Theevening before the operation, oral antidiabetics werestopped and only the standard dose of long-acting insulin(the patient was used to) was applied subcutaneously. On theday of operation, also any type of oral antidiabetics wasavoided and no baseline insulin was applied to the patient. Bycontrast, the blood glucose level was measured in the earlymorning and was corrected prior to the operation usingactrapid, if necessary. During the operation, the bloodglucose level was continuously monitored; if it was too high,it was corrected using an actrapid perfusor (1—6 IE h1) and iftoo low, glucose 5% was infused (200 ml h1). After theoperation, the therapy was changed to the habitual settingsas soon as possible.patients being from the early part of the study, whereas mostof OPCAB patients were from the later part of the study period[6]. Therefore, a certain difference was visible with regard tothe choice of grafts, as the usage of arterial grafts or even totalarterial grafting constitutes nowadays the standard of care atour institution for patients under the age of 70 years, whereas,in earlier days, the usage of saphenous vein grafts was acommon approach to revascularise these patients.References[1] Raja SG. Feasibility, safety and efficacy of multivessel off-pump coronaryartery bypass grafting in diabetics. Eur J Cardiothorac Surg 2011;40:1549—50.[2] Joshi GP, Chung F, Vann MA, Ahmad S, Gan TJ, Goulson DT, Merrill DG,Twersky R. Society for Ambulatory Anesthesia consensus statement onperioperative blood glucose management in diabetic patients undergoingambulatory surgery. Anesth Analg 111:1378—87.[3] Wong J, Zoungas S, Wright C, Teede H. Evidence-based guidelines forperioperative management of diabetes in cardiac and vascular surgery.World J Surg 34:500—13.[4] Peterson MD, Borger MA, Rao V, Peniston CM, Feindel CM. Skeletonization ofbilateral internal thoracic artery grafts lowers the risk of sternal infection inpatients with diabetes. J Thorac Cardiovasc Surg 2003;126:1314—9.[5] Nakano J, Okabayashi H, Hanyu M, Soga Y, Nomoto T, Arai Y, Matsuo T, Kai M,Kawatou M. Risk factors for wound infection after off-pump coronary arterybypass grafting: should bilateral internal thoracic arteries be harvested inpatients with diabetes? J Thorac Cardiovasc Surg 2008;135:540—5.[6] Emmert MY, Salzberg SP, Seifert B, Rodriguez H, Plass A, Hoerstrup SP,Grunenfelder J, Falk V. Is off-pump superior to conventional coronaryartery bypass grafting in diabetic patients with multivessel disease? Eur JCardiothorac Surg 2010.* Corresponding author. Address: Department of Cardiovascular Surgery,University Hospital Zurich, Raemi Street 100, 8091 Zurich, Switzerland.Tel.: +41 44 255 1111; fax: +41 44 255 1111.E-mail addresses: maximilian.emmert@usz.ch,maximilian_emmert@web.de (M.Y. Emmert).doi:10.1016/j.ejcts.2011.03.013Letter to the EditorSafety of tranexamic acid in pediatric cardiac surgery:what we do not knowDavid Faraoni *Department of Anesthesiology, Centre Hospitalo-UniversitaireBrugmann — HUDE RF, Brussels, BelgiumReceived 6 February 2011; accepted 7 March 2011; Available online14 April 2011Keywords: Tranexamic acid; Antifibrinolytic therapy; Transfusion; Pediatriccardiac surgery; Congenital heart disease; SeizuresI have read with interest the article of Martin et al. and Iwould like to make some comments [1]. The risks, benefits,

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