Carrel, Thierry

Englberger, Lars

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Letters to the Editor / European Journal of Cardio-thoracic Surgery 27 (2005) 174–178 177[3] Alderman EL, Levy JH, Rich JB, Nili M, Vidne B, Schaff H, Uretzky G,Pettersson G, Thiis JJ, Hantler C, Chaitman B, Nadel A. Analyses ofcoronary graft patency after aprotinin use: results from the InternationalMulticenter Aprotinin Graft Patency Experience (IMAGE) trial. J ThoracCardiovasc Surg 1998;116(5):716–30.*Corresponding author. Tel.: C44 1642 850 850x4242/Bleep1613; fax: C44 114 273 1361.E-mail address: vivshriv@yahoo.comdoi:10.1016/j.ejcts.2004.09.022Reply to the Letter to the EditorReply to Shrivastava and AkowuahLars Englberger, Thierry Carrel*Clinic for Cardiovascular Surgery,University Hospital (Inselspital), Berne, SwitzerlandReceived 26 September 2004; accepted 27 September 2004; Available online2 November 2004Keywords: Clopidogrel; Antiplatelet therapy; Coronary artery bypass grafting;Blood loss; AprotininAs Shrivastava and Akowuah note, in our observationalstudy [1] we only recorded clodidogrel use within threedays prior to surgery indiscriminately if it was stopped 1,2 or 3 days prior to surgery. However, onset of action canbe expected within hours (especially if a loading dose isadministered) and once established in therapy effects arepresent for the lifespan of platelets. We thereforeappreciate the point if the mean time clopidogrel hasbeen stopped before surgery in the no clopidogrel groupwas less than 7 days. Although this was not recorded forstudy purpose (which is a limitation) clinical practiceallows to suggest that the majority of patients in the noclopidogrel group have had no clopidogrel at all. In bothgroups a comparable number of patients were on aspirin(37.3% in the clopidogrel group vs. 41.5% in the noclopidogrel group, PZns).A recent meta-analysis of randomized clinical trials [2]points out clearly, that concerns about perioperativemyocardial infarction (early graft closure) linked to aproti-nin use are limited in evidence. This is in accordance to ourclinical experience. It has been recognized early thataprotinin is also efficient for the reduction of blood lossafter CPB in a low-dose protocol [3]. We use it routinely inthe pump-prime dose (two million KIU) also in patients whoare not at an increased risk of bleeding supplemented by thehigh dose protocol in patients are at risk.As a next point Shrivastava and Akowuah presume apossible bias due to different practice among the surgeons inour unit. However, this can be ruled out by the fact that inthe respect of interest (stopping of clopidogrel beforesurgery) our surgical group is very homogenous. Additionally,the continental system of a surgical unit in a universityhospital differs from the consultant-system practiced in UK.Finally we agree that further clinical trials arewelcomed in this field, especially including specificmeasurements of platelet function. In addition, factorsreducing perioperative bleeding complications (e.g. apro-tinin and other antifibrinolytics) have to be evaluated forpatients operated under ongoing clopidogrel therapy.References[1] Englberger L, Faeh B, Berdat PA, Eberli F, Meier B, Carrel T. Impact ofclopidogrel in coronary artery bypass grafting. Eur J Cardiothorac Surg2004;26:96–101.[2] Sedrakysn A, Treasure T, Elefteriades JA. Effect of aprotinin on clinicaloutcomes in coronary artery bypass graft surgery: a systematic review andmeta-analysis of randomized clinical trials. J Thorac Cardiovasc Surg2004;128:442–8.[3] Carrel T, Bauer E, Laske A, von Segesser L, Turina M. Low-dose aprotininalso allows reduction of lood loss after cardiopulmonary bypass. J ThoracCardiovasc Surg 1991;102:801–2.*Corresponding author. Tel.: C41 31 632 2375; fax: C41 31 632 4443.E-mail address: thierry.carrel@insel.chdoi:10.1016/j.ejcts.2004.09.023Letter to the EditorCoronary grafts flow and cardiac pacing modalities: theimportance of the cardiac resynchronisation trialsMichael Poullis*, Michael ShackclothDepartment of Cardiothoracic Surgery, Cardiothoracic Center, BroadgreenHospital, Thomas Drive, Liverpool L14 3PE, UKReceived 11 July 2004; accepted 3 September 2004; Available online18 October 2004Keywords: Cardiac; Pacing; PhysiologyD’Ancona et al. present important information oncoronary graft flow and optimal pacing techniques [1].Optimal cardiovascular haemodynamics in the marginalpostoperative patient may enhance graft patency. This haspreviously been shown in patients who require intra-aorticballoon pump support [2].A number of important points, however, needclarification.First, no mention of pre or postoperative intra-ventri-cular conduction defects are mentioned. Patients with leftbundle branch block are significantly better cardiovascularlyafter the specific pacing of the lateral aspect of the leftventricle [3]. This has been shown in the cardiac resynchro-nisation trials [4,5]. However D’Ancona et al. just mention‘two ventricular pacing wires were placed in each patient’,making no mention of the anatomical placement of theelectrodes.Second, recommending an optimal A-V delay of 175 msis potentially non safe practice. Personnel experience ofaltering A-V delay in A-V sequential paced patients, whilemonitoring cardiac indices via Swan-Ganz catheter read-ings shows that inter patient variability in optimal A-Vpacing delay is quite high. This fact is demonstrated bytheir figure 1, which shows as the A-V delay is increasedfrom 100 to 175 ms, at least six of the ten patients hadLetters to the Editor / European Journal of Cardio-thoracic Surgery 27 (2005) 174–178178decreased mean graft flow! This fact has already beenreported in the literature [3].References[1] D’Ancona G, Hargrove M, Hinchion J, Ramesh BC, Chughtai JZ, Anjum MN,O’Donnell A, Aherne T. Coronary grafts flow and cardiac pacingmodalities: how to improve perioperative myocardial perfusion. EurJ Cardiothorac Surg 2004;26(1):85–8.[2] Tahan SR, Geha AS, Hammond GL, Cohen LS, Langou RA. Bypass surgeryfor left main coronary artery disease. Reduced perioperative myocardialinfarction with preoperative intra-aortic balloon counterpulsation. BrHeart J 1980;43(2):191–8.[3] Auricchio A, Stellbrink C, Block M, Sack S, Vogt J, Bakker P, Klein H,Kramer A, Ding J, Salo R, Tockman B, Pochet T, Spinelli J. Effect of pacingchamber and atrioventricular delay on acute systolic function of pacedpatients with congestive heart failure. The Pacing Therapies forCongestive Heart Failure Study Group. The Guidant Congestive HeartFailure Research Group. Circulation 1999;99(23):2993–3001.[4] Young JB, Abraham WT, Smith AL, Leon AR, Lieberman R, Wilkoff B,Canby RC, Schroeder JS, Liem LB, Hall S, Wheelan K, Multicenter InSyncICD Randomized Clinical Evaluation (MIRACLE ICD) Trial Investigators.Combined cardiac resynchronization and implantable cardioversiondefibrillation in advanced chronic heart failure: the MIRACLE ICD Trial.J Am Med Assoc 2003;289(20):2685–94.[5] Philippon F. Cardiac resynchronization therapy: device-based medicinefor heart failure. J Card Surg 2004;19(3):270–4.*Corresponding author. Tel./fax: C44 151 228 1616.E-mail address: mpoullis@hotmail.comdoi:10.1016/j.ejcts.2004.09.005Reply to the Letter to the EditorReply to Poullis and ShackclothIntraoperative graft flow measurement and pacing mod-alitiesGiuseppe D’Ancona*Department of CT Surgery, Cork University Hospital,Wilton, Cork, IrelandReceived 31 August 2004; accepted 3 September 2004; Available online18 October 2004Keywords: TTFM; DDD pacing; VVI pacingWe have read with interest Dr Poullis letter and wethank him for his timely comments. We are well awarethat, as specified by Dr Poullis, and demonstrated inprevious literature, optimal cardiovascular hemodynamicsin the marginal postoperative patient may enhance graftpatency or better improve myocardial perfusion. In realityour study, differently from any other published in theliterature, including the resynchronization trials mentionedby Dr Poullis, did not focus on the mere hemodynamicparameter changes resulting from different pacing mod-alities but did center on the immediate changes inintraoperative coronary graft flows as measured by transittime technique and as resulting from different pacingtechniques.Ventricular pacing wires were routinely placed in theright ventricle and right atrium and graft flows weremeasured during DDD and VVI pacing and at different A-Vdelays. Patients with preoperative atrio-ventricular orintraventricular conduction anomalies were specificallyexcluded from the study.Although we do believe that DDD pacing can signifi-cantly improve coronary grafts flow when compared toVVI pacing, we do agree that it is difficult to indicate thebest A-V delay. The inter patient high variability inoptimal A-V pacing delay is not a secret and can be easilydeducted in the second part of our study where statisticalsignificance was not achieved. In this regard we areextending our analysis to a larger group of patients withthe aim to better define a specific range of A-V delaysthat may significantly allow for optimal flows in newlyconstructed coronary grafts.*Tel./fax: C353 21 4546400.E-mail address: rgea@hotmail.comdoi:10.1016/j.ejcts.2004.09.004

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