Cooper, G.J.

Underwood, M.J.

Elsevier - Publisher Connector 

10 2 2 Letters to the Editor 
The Journal of Thoracic and 
Cardiovascular Surgery 
May 1995 
3. Nazari S, Trazzi R, Moncalvo F, et al. A new method 
for separate lung ventilation. J TaORAC CARDIOVASC 
SVR6 1988;95:133-8. 
4. Trazzi R, Nazari S. Clinical experience with a new right 
sided endobronchial tube in left main bronchus ur- 
gery. J Cardiothorac Anaesth 1989;3:461-4. 
12/8/59955 
Reply to the Editor: 
I appreciate the research into the area of bronchial 
blockade done by Drs. Fontana and Nazari. When I first 
began to design the Univent tube (Fuji Systems Corpora- 
tion, Tokyo, Japan), my objectives were to create an 
endobronchial tube that was easy to place by clinicians not 
used to such procedures, a device that could ventilate the 
patient's lungs adequately without adding to gas flow 
resistance, and a device that could easily support he use 
of a fiberoptic bronchoscope. I believe the Univent tube 
has achieved these goals. 
My original etter to the Editor 1 explained to surgeons 
the various ways the Univent tube could make lee (in the 
operating room) easier for rhein. 
The types of cases Drs. Fontana and Nazari describe 
are not easy, especially when using a new and perhaps 
unfamiliar device. For these reasons I did not indicate the 
use of Univent tubes for tracheal, carinal, or main-stem 
bronchial resections. I have anecdotal reports of these 
cases being performed with the bronchial umen of the 
Univent tube being used as a "jet stylet," ventilating the 
nonsurgical lung by means of high-frequency jet ventila- 
tion with the blocker cuff deflated to allow for escaping 
gases. These cases were performed by anesthesiologists 
and surgeons well versed in the use of the Univent tube 
and advanced surgical ventilation techniques. 
For the Univent tube to be used properly, as with all 
medical devices, it is wise to start on the easier and more 
routine cases to gain experience. The Univent tube will 
accept standard-sized fiberoptic bronchoscopes for visual- 
ization and placement of the bronchial blocker. If the 
instruction manual is followed, right-sided placement of 
the blocker is safe and simple to perform. 
I designed the Univent tube to simplify the concept of 
the endotracheal tube and balloon occlusion catheter 
technique for lung separation. The tube described by 
Drs. Fontana and Nazari seems to reintroduce the 
difficulties of Fogarty catheters for the surgeon/anes- 
thesiologist. 
Hiroshi Inoue, MD 
First Department of Surgery 
School of Medicine 
Tokai University 
Isehara, Kanagawa 259-1L Japan 
REFERENCE 
1. Inoue H. Univent endotracheal tube: twelve-year ex- 
perience [Letter]. J THORAC CARDIOVASC SURG 1994; 
107:1171-2. 
12/8/61688 
Aprotinin and vein graft occlusion after coronary 
artery bypass 
To the Editor: 
We were interested to read the article by Havel and 
colleagues (J THORAC CARDIOVASC SURG 1994;107:807- 
10), which concluded that aprotinin significantly reduced 
postoperative bleeding without influencing early vein graft 
patency in a series of 45 patients undergoing coronary 
artery bypass. The number of patients in this study is 
inadequate, however, to make any conclusion regarding 
the effect aprotinin may have on the early patency of 
coronary vein gratis. 
The most appropriate method of statistical analysis of 
data concerning vein graft patency has frequently been 
debated, but it seems clear that comparison of rein graft 
patency rates by distal anastomoses alone is inadequate. 
Many factors may influence early graft occlusion, and 
recent studies that have compared the patency and occlu- 
sion of distal anastomoses within patients have shown that 
these are dependent events. 1 It is therefore important 
when investigating the effect of a single variable on vein 
graft patency that a comparison be made of the proportion 
of patients with at least one occluded graft. This important 
point has been made previously, emphasizing the fact that 
individual gratis within a patient are unlikely to behave 
independently. 2 Taking this into account, we have calcu- 
lated that assuming 25% of patients in the control group 
would have one occluded graft or more (from pooled 
data), 290 patients per treatment group would be required 
for a 50% reduction in the risk of occlusion to be detected, 
specifying an alpha error of 5% (two-sided) and a beta 
error of 10%. This is in keeping with the statistical 
estimates of some of the recently published trials regard- 
ing the effect of antiplatelet agents on vein graft occlu- 
sion.3, 4 
Another article published recently addressing the issue 
of aprotinin and vein graft patency found no difference in 
patency rates between treatment and control groups (as 
assessed by ultrafast computed tornography) but con- 
cluded that despite randomizing 216 patients, the num- 
bers were too small to make firm statistical conclusions. » 
The comparison of occlusion rates in 15 patients per 
treatment group as performed by Havel and associates i
therefore inappropriate. Larger trials will have to be 
performed before we can be convinced of their conclu- 
sion. 
M. J. Underwood, MD a 
G. J. Cooper, MD b 
Departments of Cardiac Surgery 
Bristol Royal Infirmary a
Bristol, United Kingdom 
The Brook Hospital b 
London, United Kingdom 
REFERENCES 
1. Sanz G, Pajaron A, Alegria E, et al. Prevention of early 
aortocoronary b pass occlusion by low-dose aspirin and 
dipyridamole. Circulation 1990;82:765-73. 
2. Henderson WG, Moritz T, Goldman S, et al. The 
statistical analysis of graft patency data in a clinical trial 
The Journal of Thoracic and 
Cardiovascular Surgery 
Volume 109, Number 5 
Letters to the Editor 1 0 2 3 
of antiplatelet agents following coronary artery bypass 
grafting. Controlled Clin Trials 1988;9:189-205. 
3. Rajah SM, Nair U, Rees M, et al. Effects of antiplatelet 
therapy with indobufen or aspirin-dipyridamole n graft 
patency one year after coronary artery bypass grafting. J 
THORAC CAm3IOVASC SUR6 1994;107:1146-53. 
4. Van der Meer J, Hillege HL, Kootstra G J, et al. 
Prevention of one-year vein-graft occlusion after aor- 
tocoronary-bypass surgery: a comparison of low-dose 
aspirin, low-dose aspirin plus dipyridamole, and oral 
anticoagulants. Lancet 1993;342:257-64. 
5. Lemmer JH, Stanford W, Bonney SL, et al. Aprotinin 
for coronary bypass operations: efficacy, safety, and 
influence on early saphenous vein graft patency. J
THORAC CARDIOVASC SURG 1994;107:543-53. 
12/8/59361 
Supernumerary heart valves 
To the Editor: 
The report by Barbero-Marcial and associates 1 on the 
surgical treatment of congenital mitral stenosis is a signifi- 
cant contribution. Their patient 7, showing an accessory or 
supernumerary valve that should not be confused with any 
type of double-orifice mitral valve, is of special interest. My 
colleagues and 12 reported the pathologic description of a 
similar anomaly some years ago; in our case, imperforate 
Ebstein's anomaly of the tricuspid valve was present, and the 
supemumerary valve was hypoplastic and connected a cham- 
ber situated posterior to the left atrium, which could be a 
part of the coronary sinus, with the left ventricle. As in the 
case reported by Barbero-Marcial nd coworkers, our case 
showed a single papillary muscle that received all the chor- 
dae tendineae of the supernumerary valve and was covered 
by the posterior leaßet of the left atrioventricular valve. 
Diagnosis in our case might also have been made through a
left ventriculotomy, if the anomaly had been at all suspected. 
Resection of the atrial wall, as done in the case of Barbero- 
Marcial, would have produced a communication of the 
coronary sinus and the right atrium with the left atrium, 
although of relatively small size. Closure of this communica- 
tion would have been necessary to achieve complete correc- 
tion. 
Supemumerary valves are exceptional nomalies, thus rar 
of mainly pathologic interest, that can be found in different 
14 locations. " Premortem diagnosis is dilficult, knowledge of 
the existence of these anomalies being the first requisite for 
diagnosis. Abnormal recesses in the atria and coronary sinus 
and bizarre communications between chambers should stim- 
ulate a search for supernurnerary valves. Some of them, as 
very nicely shown by Barbero-Marcial nd associates, could 
be physiologically use~tl after repair. Recognition and treat- 
ment of these anomalies would have been almost impossible 
without opening the left ventricle, and this reinforces the 
value of the report by Barbero-Marcial's group. 
Eduardo Otero-Coto, MD, PhD 
Service of Cardiovascular Surgery 
Hospital CEnico Universitario 
Avda. Blasco Ibahez 17 
46010 l/alencia, Spain 
REFERENCES 
1. Barbero-Marcial M, Riso A, DeAlbuquerque AT, Atik 
E, Jatene A. Left ventricular apical approach for the 
surgical treatment of congenital mitral stenosis. J THO- 
RAC CA~DIOVASC SUR6 1993;106:105-1Ö. 
2. Otero-Coto E, Quero M, Deverall PB. Rare anomalies 
of atrioventricular connection: hidden or supernumer- 
ary valves with imperforate right atrioventricular con- 
nection. Int J Cardiol 1984;6:149-56. 
3. Otero-Coto E, Wilkinson JL, Dickinson DF, Rufilan- 
chas JJ, Märquez J. Gross distortion of atrioventricular 
and ventriculo-arterial relations associated with left 
juxtaposition of atrial appendages: bizarre form of 
atrioventricular c iss-cross. Br Heart J 1979;41:486-92. 
4. Gerlis LM, Anderson RH, Dickinson DF. Duplication 
of the left atrioventricular valve in double inlet left 
ventricle: A triple inlet ventricle? Int J Cardiol 
1984;6:157-61. 
12/8/58206 
Reply to the Editor 
We appreciate the comments by Dr. Otero-Coto re- 
garding our article "Left Ventricular Apical Approach for 
the Surgical Treatment of Congenital Mitral Stenosis." 
This technique had been used since 1987 in our institution 
to treat complex types of mitral stenosis uch as parachute 
mitral valve. The removal of the obstruction starts from 
below; the papillary muscle is split, and the chorda is 
divided, resected, or fenestrated. After good visualization 
of the chordal insertion in the ventricular aspect of the 
mitral välve, the commissurotomies are made. 
The patient who prompted the comments by Dr. 
Otero-Coto had a double mitral apparatus with inde- 
pendent mitral anuli. One hypoplastic mitral valve in 
the medial position had a supravalvular ring and joined 
the atrium to the left ventricle, ending in a single 
papillary muscle. The other mitral valve in the lateral 
position was parachute shaped and less hypoplastic, but 
was not connected to the left atrium. A true atrial wall 
separated this valve from the left atrium. Dr. Otero- 
Coto's patient had a similar anomaly with imperforate 
Ebstein's anomaly of the tricuspid valve. The tricuspid 
valve was the supernumerary valve, hypoplastic and 
related posteriorly to the coronary sinus. 
The risk of producing a communication between of the 
coronary sinus and the right atrium after the resection of 
the true atrial wall was not confirmed in out case because 
there was no close relation between this supernumerary 
valve and the coronary sinus. This could be because of its 
predominantly ateral position instead of posterior posi- 
tion. Overall, we agree with Dr. Otero-Coto that the 
resection of atrial wall could, in some cases, produce a 
communication between the coronary sinus and the right 
atrium. 
Miguel Barbero Marcial, MD 
Heart Institute 
University of Säo Paulo 
Caixa Postal 8091 
Säo Paulo, Brazil 
12/8/61481 


Aprotinin and vein graft occlusion after coronary artery bypass 

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Aprotinin and vein graft occlusion after coronary artery bypass

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