seen with pH-stat acid-base management [11]. Furthermore, data are lacking on whether the jugular desaturation is accom- panied by elevated jugular bulb CO ...
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delivery a n d cognitive outcome [1] speak against the assertion that m e a n arterial pressure should be increased in all patients during rewarming. Although rewarming does appear to be a high-risk period for cerebral ischemia, it is also a high-risk period for embolization (aortic cross-clamp removal, placement and removal of partial aortic clamps, and the return to pulsatility). Arbitrarily increasing CBF during periods of increased embolization may produce results counter to those expected, as seen with pH-stat acid-base m a n a g e m e n t [11]. Furthermore, data are lacking on whether the jugular desaturation is accompanied by elevated jugular bulb CO 2 and hydrogen ion concentrations indicating hypoperfusion, or whether there are alternative explanations such as reperfusion-generated production of free radicals that may or may not be reversed by increasing CBF. We believe that the future for preventing neurologic sequelae is likely to come from a monitoring technology that identifies those patients whose CBF does not meet oxygen need. This is probably best detected by continuous monitoring of venous saturation, although some advocate other devices such as quantitative electroencephalography or near-infrared spectroscopy. The causes of jugular bulb desaturafion involve a host of factors, only one of which is the balance of CBF to cerebral oxygen consumption. Although we agree with Dr Mutch that maintaining perfusion pressure during normothermic CPB may be easy and potentially warranted in elderly and diabetic patients, it may not be completely benign, and we cannot agree that there is substantial evidence that it will "help decrease the incidence and severity of cognitive dysfunction" in all patients. We wish that the solution to this problem were so simple.
Mark F. Newman, MD Narda D. Croughwell, CRNA Joseph G. Reves, MD Department of Anesthesiology Duke University Medical Center Box 3094 Durham, NC 27710 References 1. N e w m a n MF, Croughwell ND, Blumenthal JA, et al. Effect of aging on cerebral autoregulation during cardiopulmonary bypass: Association with postoperative cognitive dysfunction. Circulation 1994;90(Suppl 2):293-9. 2. Mutch WAC, Sutton IR, Teskey JM, Cheang MS, Thomson IR. Cerebral pressure-flow relationship during cardiopulmonary bypass in the dog at normothermia and moderate hypothermia. J Cereb Blood Flow Metab 1994;14:510-8. 3. N e w m a n MF, Kramer D, Sanderson I, et al. Differential age effects of m e a n arterial pressure and rewarming on cognitive dysfunction after cardiopulmonary bypass. Anesth Analg (in press). 4. Govier AV, Reves JG, McKay RD, et al. Factors and their influence on regional cerebral blood flow during nonpulsatile cardiopulmonary bypass. Ann Thorac Surg 1984;38:592600. 5. Ellis RJ, Wisniewski A, Pott R, Calhoun C, Loucks P, Wells MR. Reduction of flow rate and arterial pressure at moderate hypothermia does not result in cerebral dysfunction. J Thorac Cardiovasc Surg 1980;79:173-80. 6. Slogoff S, Reul GJ, Keats AS, et al. Role of perfusion pressure and flow in major organ dysfunction after cardiopulmonary bypass. A n n Thorac Surg 1984;50:911-8. 7. Treasure T, Smith PL, N e w m a n S, et al. Impairment of cerebral function following cardiac a n d other major surgery. Eur J Cardiothorac Surg 1989;3:216-21. 8. Schell RM, Kern FH, Greeley WJ, et al. Cerebral blood flow and metabolism during cardiopulmonary bypass. Anesth Analg 1993;76:849-65.
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9. Bashein G, Townes BD, Nessly ML, et al. A randomized study of carbon dioxide m a n a g e m e n t during hypothermic cardiopulmonary bypass. Anesthesiology 1990;72:7-15. 10. Prough DS, Stump DA, Troost BT. Paco 2 m a n a g e m e n t during cardiopulmonary bypass: intriguing physiologic rationale, convincing clinical data, evolving hypothesis? Anesthesiology 1990;72:3-6. 11. Murkin JM, Martzke JS, Buchan AM, Bentley C, Wong CJ. A randomized study of the influence of perfusion technique and pH m a n a g e m e n t strategy in 316 patients undergoing coronary artery bypass surgery. 2. Neurological and cognitive outcomes. J Thorac Cardiovasc Surg (in press).
Coronary Artery Bypass Operation A f t e r Pneumonectomy To the Editor: We read with interest the recent article " O p e n Heart Operation After Pneumonectomy" by Medalion and associates [1]; we also performed a coronary artery bypass operation on a patient who presented in December 1994 for unstable angina 20 years after cancer-related left pneumonectomy. The patient was a 63-year-old m a n with severe proximal left anterior descending and circumflex arterial lesions. He had diabetes mellitus controlled with oral antidiabetics. Pulmonary function tests showed 36% of predicted value (1.09 L) for forced expiratory volume in 1 second, 36% of predicted value (1.36 L) for forced vital capacity, and 29% of predicted value (33 L) for maximal voluntary ventilation, revealing severe obstructive and restrictive respiratory failure. Preoperative arterial oxygen tension was 68.1 m m Hg, without nasal oxygen therapy, arterial carbon dioxide tension was 35.6 m m Hg, and arterial oxygen saturation was 94.2%. Preoperative hemodynamic values were as follows: pulmonary artery pressure, 28/11 m m Hg; pulmonary capillary wedge pressure, 8 m m Hg; right ventricular pressure, 35/1 m m Hg; and central venous pressure, 7 m m Hg. The patient underwent coronary artery bypass grafting with left internal thoracic artery to left anterior descending coronary artery, and a saphenous vein graft to the first obtuse marginal artery. Mediastinal tissues were excessively adhered to each other, and adherences were partly relieved under cardiopulmonary bypass. W e a n i n g from cardiopulmonary bypass was achieved by 10 ~ g . k g 1. min ~ dopamine infusion. Aortic cross-clamping and cardiopulmonary bypass times were 52 and 121 minutes. Early postoperative pressures were as follows: arterial blood pressure, 110/80 m m Hg; pulmonary artery pressure, 31/12 m m Hg; pulmonary capillary wedge pressure, 9 m m Hg; and central venous pressure, 8 m m Hg. Fifteen minutes after admission to the postoperative intensive care unit, pulmonary artery pressure increased and arterial hypotension developed. Internal resuscitation was done, the sternum was left open, and intraaortic balloon p u m p i n g was administered via the left femoral artery. Eight hours later the sternum was closed. Twenty-four hours later the intraaortic balloon p u m p was removed, and the patient was extubated 36 hours postoperatively. Eight hours after the extubation, rightsided pneumothorax developed, requiring chest tube insertion and underwater seal drainage. On the sixth day, the patient underwent another operation because of mediastinitis and sternal detachment. Staphylococcus aureus was identified from the mediastinal cultures. The patient died with septic shock on the 12th day. Here we presented our experience with a patient who underwent left pneumonectomy and coronary artery bypass grafting. In conclusion, we can say that open heart operation after pneumonectomy does not present great technical problems
© 1995 by The Society of Thoracic Surgeons 0003-4975/95/$9.50
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relating to the operation, but the postoperative outcome may be tedious. Thus, patient selection regarding pulmonary function must be done very carefully.
Percutaneous Transthoracic Needle Biopsy of the Lung
M. Murat Demirta~, MD Hacz Akar, MD Mehmet Kaplan, MD Sabri Da~,sah, MD
It may be a settled question to some, And excuse me if I appear just a little dumb, But I think that the needle biopsy of the lung Is a procedure that is often overdone.
Ahmet ~elebi Mah, Siimbiilzade Sok No. 20/3, CIskiidar-IstanbuI Turkey
What's the problem? You may ask; This all has been settled in the past. Well, not in my little neck of the woods; The procedure is done more often than it should.
Reference 1. Medalion B, Elami A, Milgalter E, Merin G. O p e n heart operation after pneumonectomy. A n n Thorac Surg 1994;58: 882-4.
Inadequacy, Mortality, and Thoracoscopy To the Editor: We appreciate that the editorial board felt that our case report [1] and the report by Fry and colleagues [2] describing tumor implantations after video-assisted thoracic resections were of sufficient importance to dedicate an editorial written by Drs Allen a n d Pairolero on the subject [3]. Doctors Allen and Pairolero unfortunately misinterpreted or misread one point, which requires clarification. Nowhere in our article did we state or imply that a thoracoscopic approach was chosen because our patient was too debilitated to undergo an open procedure. Her co-morbidities were listed to highlight why a video-assisted thoracic surgical procedure was selected as an "initial" diagnostic procedure. Further pulmonary resection was planned if the lesion on frozen section was a bronchogenic primary tumor. Their inaccurate comments detract somewhat from the important point that we and Dr Fry and colleagues were raising: thoracoscopic procedures must be used with great caution w h e n dealing with suspected intrathoracic malignancies. Severe local and potentially lethal complications may result. It behooves us to communicate openly and freely with our surgical colleagues, especially w h e n new techniques are being used and procedurerelated complications are identified.
Garrett L. Walsh, MD Jonathan C. Nesbitt, MD Department of Thoracic and Cardiovascular Surgery The University of Texas MD Anderson Cancer Center Texas Medical Center 1515 Holcombe Blvd Houston, TX 77030 References 1. Walsh GL, Nesbitt JC. Tumor implants after thoracoscopic resection of a metastatic sarcoma. A n n Thorac Surg 1995;59: 215-6. 2. Fry WA, Siddiqui A, Pensler JM, Mostafavi H. Thoracoscopic implantation of cancer with a fatal outcome. A n n Thorac Surg 1995;59:42-5. 3. Allen MS, Pairolero PC. Inadequacy, mortality, and thoracoscopy [Editorial]. A n n Thorac Surg 1995;59:6.
To the Editor:
Now wouldn't everything be just wonderful If, whenever we see a solitary pulmonary nodule, With a small-gauge transthoracic needle so fast, We could diagnose with certainty any suspicious mass. But much to our chagrin a n d to be quite fair, A benign diagnosis from the needle is extremely rare. So with an operable patient with an SPN, As far as I'm concerned, needle biopsy is not necessarily in. Please don't get me wrong and jump to conclusions; I really don't have any grand delusions, To think that I could change the way things are done By spouting a few words in rhyme somewhat in fun. Needle biopsies can be quite benefitting, Especially in the correct clinical setting. With a superior sulcus tumor, for instance, You need a diagnosis before radiotherapy will commence. With multiple lesions of the lungs the yield is great; A needle biopsy can help predict the patient's fate. In this diagnostic instance, that's all you need, And major surgery can be avoided, and all are pleased. The problem comes in the operable patient with the SPN. He's sent to the radiologist to have a needle put in. Please tell me what is going to change? W h e n negative or positive, surgery should be arranged. The often quoted reason which I've heard said, If it's small cell carcinoma you treat with drugs instead. To most thoracic surgeons I need not declare, Peripheral small cell tumors are very rare. And, if and w h e n small cells are found, A surgical approach would still be sound. T1 small cell lesions really do quite well; After resection the prognosis is swell. And in half the cases in which small cells are called, Histologic sections reveal no small cells at all. So a wary eye the surgeon must retain W h e n aspirated small cells from the lung are named. Other proponents have noted operative time saved; It's true, that some OR minutes may be waived, But excisional biopsies take little time to perform; While waiting for the frozen, dissection should be the norm. And what are the true percentages of complications, Pneumothoraces, hemoptysis, and other negations? Needle tract tumors carry very little fear; However, I've seen two in the last 10 years. But the most important problem that I see Concerning percutaneous transthoracic needle biopsy Is that the experience of the thoracic surgeon Can be completely left out of the decision equation.
© 1995 by The Society of Thoracic Surgeons 0003-4975/95/$9.50
