Carreras-Costa, Francesc

Corno, Antonio

Kocica, Mladen J.

Torrent-Guasp, Francisco

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[2] Bo¨hme W. U¨ber den aktiven Anteil des Herzens and der Fo¨rderung desVenenblutes. Ergebn Physiol 1936;38:252–338.[3] Henein MJ, Gibson DG. Long-axis function in disease. Heart 1999;81:229–31.[4] Brutsaert DL, Sys SU. Relaxation and diastole of the heart. Physiol Rev1989;69:1228–315.[5] Lunkenheimer PP, Redmann K, Florek J, Fassnacht U, Cryer CW,Wu¨bbeling F, Niederer P, Anderson RH. The forces generated withinthe musculature of the left ventricular wall. Heart 2004;90:200–7.* Tel.: þ49-251-8356256; fax: þ49-251-8356257.E-mail address: redmann@uni-muenster.de (P.P. Lunkenheimer).doi:10.1016/j.ejcts.2004.05.024Reply to the Letter to the EditorReply to LunkenheimerFrancisco Torrent-Guaspa, Mladen J. Kocicab,*,1Antonio Cornoc, Francesc Carreras-CostadaDenia, Alicante, SpainbClinic for Cardiac Surgery,Institute for Cardiovascular Diseases,UC Clinical Centre of Serbia,8th Kosta Todorovic St., 11000 Belgrade,Serbia and MontenegrocDepartment of Cardiovascular Surgery,Centre Hospitalier Universitaire Vaudois (CHUV),Lausanne, SwitzerlanddDepartment of Cardiology, Cardiac Imaging Unit,Hospital Sant Pau, Barcelona, SpainReceived 15 May 2004; accepted 18 May 2004; Available online17 July 2004Keywords: Ventricle; Anatomy; Myocardium; PhysiologyIt was a real pleasure to see your Letter to the Editor,because of many reasons. First, it is always good to knowthat our work [1] is attracting your interest so strongly. Wethank you. Then, it is very interesting to follow yourevolution [2], switching from the valuable participation in adevelopment of the ventricular myocardial band concept, tothe position of its passionate critic. Finally, it is againpleasure to find out, that your calls for denial of suchconcept, do not always find a ‘desirable’ echo in a scientificworld [3].Examining elctrophysiological and functional data, inorder to test the hypothesis of activation sequence in theventricular myocardium, James Cox (coauthor) and hisassociates, calculated the delivery of the impulse throughoutthe ventricular band. They have very carefully plotted outhow the electrical impulse is delivered to the myocardium,by the specialized conduction system, and correlated thosefindings with the velocities of conduction in thin and thickareas of the heart. It came out that impulse deliveryprecisely mimicked predicted sequence of activation. Thesame was true for other researchers applying differentinvestigational methods, mentioned in our article (i.e.Fourier analyses of ventricular MUGA scans, MRI-basedmathematical modeling) [1]. The results obtained fromthose studies, initiated by the evidence of the ventricularmyocardial band, not only provided a solid experimentalground for present publication [1], but also for manyother researches derived from this new morpho-functionalconcept [3].Careful readers may also find a precise concordancebetween the context and references cited in our article [1].Thus, they can notice, for example, that some conclusionsgiven by Henein and Gibson are not interpreted, buttransferred from the their valuable original work onventricular long axis [4]. It is not our misunderstanding,but our disagreement with proposed influence of the atrialmuscle on generating ventricular suction force, by abruptupward movement of the entire ventricular base. The sameis true for the excellent Brutsaert’s review [5]. There is nosuch place in our article [1] arguing with Brutsaert’sexplanations of different loading conditions influence onisolated myocardial fiber activation. On the contrary, wehave emphasized this well-known fact several times,explaining dynamic changes of the ‘hemoskeleton’ andtheir significant influences on the ventricular performance.Therefore, the sources of your conclusion about “delayedshortening activity as a typical behaviour of the ascendinglimb” would remain a secret for us, but definitively, they donot belong to our article [1].Beyond your personal, undoubtedly benevolent, con-cerns, the readers may also be aware of the some otheropinions, declaring that: “This model is an example of anemphasis that relates fiber architecture to chamber shapeand mechanics and has implications for improved under-standing of electrical, electromechanical and mechanicaldeterminants of cardiac function” [3].We are quite confident that you had carefully read ourarticle [1], but if you could, in addition, participate onthe NIH-NHLBI 2002 Workshop: ‘Form and Function:New Views on Development, Diseases and Therapies forthe Heart’, you probably wouldn’t miss some importantfacts.References[1] Torrent-Guasp F, Kocica MJ, Corno A, Komeda M, Cox J, Flotats A,Ballester-Rodes M, Carreras-Costa F. Systolic ventricular filling. Eur JCardiothorac Surg 2004;25:376–86.[2] Torrent-Guasp F, Zarco P, Lunkenheimer PP, Aragoncillo P, Farina J,Streeter DD, Ramon C. Nuevos conceptos sobre la estructuramiocardica ventricular. In: Torrent-Guasp F, Zarco P, LunkenheimerPP, Aragoncillo P, Farina J, Streeter DD, Ramon C, editors. Estructuray mecanica del corazon. Barcelona: Grass Ediciones; 1987. p. 34–87.[3] Buckberg GD, Weisfeldt ML, Ballester M, Beyar R, Burkhoff D,Coghlan HC, Doyle M, Epstein ND, Gharib M, Ideker RE, Ingels NB,Letters to the Editor / European Journal of Cardio-thoracic Surgery 26 (2004) 660–665 663LeWinter MM, McCulloch AD, Pohost GM, Reinlib RJ, Sahn DJ,Spinale FG, Spotnitz HM, Sopko G, Torrent-Guasp F, Shapiro EP. Leftventricular form and function: scientific priorities and strategicplanning for development of new views of disease. Circulation 2004;in press.[4] Henein MJ, Gibson DG. Long-axis function in disease. Heart 1999;81:229–31.[5] Brutsaert DL, Sys SU. Relaxation and diastole of the heart. Physiol Rev1989;69:1228–315.* Corresponding author. Tel.:þ381-11-3670609; fax:þ381-11-3610880.E-mail address: kocica@sezampro.yu (M.J. Kocica).1URL: E-mail address: www.ctsnet.org/home/mkocicadoi:10.1016/j.ejcts.2004.05.023Letter to the EditorBiological effects of coronary surgery: role of surgicaltrauma and CPBAldo Cannata, Paolo Biglioli,Elena Tremoli, Alessandro Parolari*Department of Cardiac Surgery,Centro Cardiologico Fondazione Monzino IRCCSand University of Milan,Milan, ItalyReceived 17 May 2004; accepted 28 May 2004Keywords: Coronary surgeryWe did read with interest the Letter to the Editor fromDr Raja in the May issue of the EJCTS [1]. Hecommented the prospective randomised study, comparingoff-pump and on-pump CABG, by Wehlin recentlypublished in the EJCTS [2]. Moreover, he quoted asreference a review paper about the same topic from ourgroup [3]. Here we would make some comments about thecontents expressed by Dr Raja. First, quoting the reviewpaper from our group, he stated that excessive shear stressduring CPB may cause damage to blood constituents,activation of the inflammatory response, platelet activationand it may contribute to endothelial injury. We recognizethat the shear stress may have a potential role in thepathophysiology of the CPB. Nevertheless, we have topoint out that our literature review did not investigate theevidences about the relationships between shear stress andCPB [3]. Moreover, we also recognize that the CPB mayelicit the inflammatory response by means of severalpathways. However, the evidences emerged from theavailable literature comparing on-pump surgery to off-pump surgery, including even major thoracic andabdominal surgery, suggest that CPB may have a limitedrole in inflammatory and hemostatic derangements duringthe perioperative period. Moreover, such role seems to belimited to the final steps of the operation and the veryearly postoperative hours [3]. On the other side, it is likelythat the trauma to the tissue, imposed by the surgicalprocedure, may be the more consistent source of pro-inflammatory and pro-coagulant mediators during theentire perioperative period. In our opinion, the obser-vations from Wehlin and colleagues are a furtherconfirmation of this hypothesis [2].References[1] Raja SG. The dark side of cardiopulmonary bypass. Eur J CardiothoracSurg 2004;25:906.[2] Wehlin L, Vedin J, Vaage J, Lundahl J. Activation of complement andleukocyte receptors during on- and off pump coronary artery bypasssurgery. Eur J Cardiothorac Surg 2004;25:35–42.[3] Biglioli P, Cannata A, Alamanni F, Naliato M, Porqueddu M, ZanobiniM, Tremoli E, Parolari A. Biological effects of off-pump vs. on-pumpcoronary artery surgery: focus on inflammation, hemostasis andoxidative stress. Eur J Cardiothorac Surg 2003;24:260–9.* Corresponding author. Address: Department of Cardiac Surgery, CentroCardiologico Fondazione Monzino IRCCS, via Parea, 4, 20138 Milan,Italy. Tel.: þ39-02-58-00-2558; fax: þ39-02-58-01-1194.E-mail address: alessandro.parolari@ccfm.it (A. Parolari).doi:10.1016/j.ejcts.2004.05.047Reply to the Letter to the EditorReply to Cannata et al.Trauma or no trauma, cardiopulmonary bypass is the majorcontributor to inflammatory response after cardiac surgeryShahzad G. RajaDepartment of Cardiac Surgery,Royal Liverpool Children’s NHS Trust, Alder Hey Hospital,Eaton Road, Liverpool L12 2AP, UKReceived 27 May 2004; accepted 28 May 2004; Available online26 June 2004Keywords: Cardiopulmonary bypass; Systemic inflammation; CoronarysurgeryIn an era of evidence based medicine, Cannata andcolleagues’ views that cardiopulmonary bypass (CPB) mayhave a limited role in inflammatory and hemostaticderangements during the perioperative period and that thetrauma to the tissue, imposed by the surgical procedure, maybe the more consistent source of pro-inflammatory andpro-coagulant mediators during the entire perioperativeperiod seem a bit naive and contrary to available robustevidence from a large number of randomized controlledtrials (RCTs).Letters to the Editor / European Journal of Cardio-thoracic Surgery 26 (2004) 660–665664

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