Comparison of Single versus Multidose Blood Cardioplegia in Arterial Switch Procedures

Transcription

1 Comparison of Single versus Multidose Blood Cardioplegia in Arterial Switch Procedures Serafin Y. DeLeon, M.D., Farouk S. Idriss, M.D., Michel N. Ilbawi, M.D., C. Elise Duffy, M.D., D. Woodrow Benson, Jr., M.D., and Carl L. Backer, M.D. ABSTRACT Fifty-three patients with transposition of the great arteries and Taussig-Bing anomaly undergoing an arterial switch procedure were divided into two groups. Group 1 (N = 32) received multidose cardioplegia injected initially into the aortic root and subsequently into the coronary artery orifices and Group 2 (N = 211, single-dose cardioplegia injected into the aortic root. The mean aortic cross-clamp and bypass times were generally longer in Group 1 compared with Group 2. Group 1 patients with simple transposition undergoing primary repair (N = 15) had an aortic cross-clamp time of 80 f 8 minutes and a bypass time of 203 f 27 minutes versus minutes (p < 0.001) and 170 f 15 minutes (p < 0.01), respectively, for similar patients in Group 2 (N = 10). Group 1 patients with simple transposition undergoing staged repair (N = 7) had an aortic cross-clamp time of 71 f 6 minutes and a bypass time of 201 f 24 minutes versus 66 f 4 minutes (p = not significant [NS]) and 226 f 25 minutes (p = NS), respectively, for Group 2 (N = 6). In Group 1 patients with complex transposition (N = lo), the aortic bypass time was 79 f 12 minutes and the bypass time was 261 f 40 minutes versus minutes (p < 0.05) and minutes (p < 0.11, respectively, for Group 2 (N = 5). Early mortality was 16% (5/32) in Group 1; there were no early deaths in Group 2. One patient died of an occluded left coronary artery attributed to catheter trauma. Late mortality was 11% (3/27) in Group 1 and 5% (1/21) in Group 2. In Group 1, postoperative ST-T wave changes developed in 37% (10/27) compared with 5% (1/21) in Group 2. The postoperative myocardial performance determined echocardiographically by systolic increase in septal and posterior wall thickness, fractional shortening, and left ventricular enddiastolic dimensions was comparable in the two groups. We conclude that the administration of a single dose of cold blood cardioplegia into the aortic root, along with topical and systemic hypothermia, is a simple and effective method of myocardial protection in infants and young children undergoing the arterial switch procedure. From the Divisions of Cardiovascular-Thoracic Surgery and Cardiology, The Children s Memorial Hospital, and the Departments of Surgery and Pediatrics, Northwestern University Medical School, Chicago, IL. Accepted for publication Nov 30, Address reprint requests to Dr. DeLeon, Division of Cardiovascular- Thoracic Surgery, The Children s Memorial Hospital, 2300 Children s Plaza, Chicago, IL Successful anatomical correction in infants and children with transposition of the great arteries by the so-called arterial switch procedure has been reported by several centers [l-71. The procedure, however, requires prolonged aortic cross-clamping because of the need for coronary artery transfer along with the switching of the great arteries. The ideal method of myocardial protection during this period of aortic cross-clamping has not been addressed. Corno and colleagues [8] found that myocardial protection of neonatal hearts is best achieved by intermittent infusion of blood cardioplegia. In the arterial switch procedure, there are some technical problems associated with direct infusion of cardioplegic solution into tiny coronary orifices. Encountering these difficulties, we have adopted a single-dose blood cardioplegia for our arterial switch procedures. To determine whether a single dose of blood cardioplegia is as effective as the intermittent-dose technique for myocardial protection, we analyzed our experience. Material and Methods In the last four years, we have performed 53 arterial switch procedures in our institution. The patients were divided into two groups. Group 1 (N = 32) had multidose cardioplegia and Group 2 (N = 21), single-dose cardioplegia. In Group 1, 22 patients had simple transposition. Fifteen of them had primary repair, and 7 had a staged procedure (pulmonary artery banding or systemic-pulmonary artery shunt or both followed by arterial switch procedure). Our technique of staging has been previously reported [9]. In 1 patient, coarctation of the aorta was repaired at the initial operation. Ten patients had complex transposition (ventricular septal defect, 7, and Taussig-Bing anomaly, 3); 3 underwent primary repair, and 7 had pulmonary artery banding followed by the arterial switch procedure. In 2 patients, coarctation of the aorta was repaired at the initial operation. One patient had an intervening systemic-pulmonary artery shunt. In Group 2, 16 patients had simple transposition (intact ventricular septum) and underwent either primary repair (N = 10) or staged repair (N = 6). Five patients had complex transposition (transposition of the great arteries with ventricular septal defect, 4, or Taussig-Bing anomaly, 1) [lo]; 2 had primary repair and 3, pulmonary artery banding followed by the arterial switch procedure. Patients in Group 1 with simple transposition who had primary repair had a mean age and weight comparable with those of Group 2 patients (Group 1, 8.2 days 548 Ann Thorac Surg 45:54%553, May Copyright by The Society of Thoracic Surgeons

2 549 DeLeon et al: Single versus Multidose Cardioplegia in Arterial Switch Table 1. Early (Hospital) Deaths Patient Time of No., Age Diagnosis Repaidcardioplegia Death Cause Autopsy Findings 6,3 mo Taussig-Bing anomaly Staged/multidose POD 1 LCO Subendocardial infarction 14, 14 d Simple transposition Primary/multidose POD 7 LCO Occluded LCA, transmural infarctions 18, 7 d Simple transposition Primary/multidose POD 7 Unknown Multiple subendocardial hemorrhages, LV 29, 17 d Complex transposition Primaryimultidose Intraop LCO Myocardial infarctions, LV 32, 30 mo Simple transposition Staged/multidose Intraop LCO Diffuse myocardial necrosis POD = postoperative day; LCO = low cardiac output; LCA = left coronary artery; LV = left ventricle. and 3.5 kg; Group 2, 8.3 days and 3.7 kg). However, for patients with simple transposition who had staged repair, the mean age and weight were different in the two groups (Group 1, 11.8 months and 7 kg; Group 2, 5.5 months and 3.6 kg). In patients with complex transposition, the mean age and weight were also different (Group 1, 12.8 months and 6 kg; Group 2, 5.3 months and 5.4 kg). Surgical Proced ure Our surgical technique for the arterial switch procedure has been reported [ll, 121 and is reviewed here only briefly. Under cardiopulmonary bypass and deep hypothermia (18" to 22"C), and after closure of the atrial and ventricular septa1 defects if present, the aorta was crossclamped and cold blood cardioplegia (8" to l0t) was given through a No. 14 or 16 intracatheter using the Gish Biomedical Cardioplegia System Model CPS-1000 (Gish Biomedical, Inc., 2350 S Pullman Ave, Santa Ana, CA 92705). The cardioplegic solution was prepared by filling the cardioplegia pump reservoir with the cardiopulmonary bypass perfusate and adding 20 mg of KCl, 3 gm of mannitol, 200 pg of nitroglycerin, and 12.5 gm of albumin per liter. The pressure in the line was monitored and kept at or lower than 100 mm Hg. Ice slush was also applied topically to the heart. In Group 1 patients, the aortic transection, coronary artery transfer, and aortic reanastomosis were accomplished after an initial cardioplegia dose, calculated at 400 ml/m2, was administered into the aortic root followed with similar doses given at 15-minute intervals directly into the coronary orifices using either a 3.5F Argyle feeding tube (Sherwood Medical, St. Louis, MO 63103) or 4.2F Broviac pediatric single-lumen catheter (Evermed, Inc., 100 Sockanosett Crossroad, Cranston, RI 02920). In Group 2 patients, a similar procedure of aortic transection, coronary artery transfer, and aortic reanastomosis was performed following the administration into the root of the aorta of a single dose of cardioplegia, also calculated at 400 mum2. In both groups, the aortic cross-clamp was released after coronary artery transfer and completion of the aortic anastomosis. The pulmonary artery reconstruction was accomplished during rewarming. Results The differences in aortic cross-clamp and bypass times, mortality, postoperative development of an abnormal electrocardiogram, and ventricular contractility determined by echocardiography were compared in both groups. Aortic Cross-Clamp and Bypass Times For patients with simple transposition undergoing primary repair, the mean aortic cross-clamp time for Group 1 (multidose cardioplegia) was longer, 80? 8 minutes compared with 64 & 6 minutes for Group 2 (single-dose cardioplegia (p < 0.001, unpaired Student t test). In addition, the bypass time was significantly longer for Group 1 patients (mean, minutes) compared with Group 2 patients (mean, minutes) ( p < 0.01). For patients with simple transposition having staged repair, Group 1 also had a longer mean aortic cross-clamp time ( minutes) compared with Group 2 (66 k 4 minutes) ( p = not significant [NS]). The mean bypass time, however, was shorter for Group 1 patients ( minutes) compared with Group 2 patients ( minutes) (p = NS). The patients with complex transposition who had multidose cardioplegia (Group 1) also had longer mean aortic cross-clamp and bypass times compared with similar Group 2 patients (aortic cross-clamp time, minutes versus minutes, p < 0.05; bypass time, minutes versus minutes, p < 0.1). Early Deaths There were no early deaths (hospital deaths) among the 21 patients receiving single-dose cardioplegia (Group 2). In patients receiving multidose cardioplegia (Group l), there were 5 early deaths, a mortality of 16% (5/32) (Table 1). One patient with simple transposition who had primary repair died following complete occlusion of the left coronary artery due to intimal disruption attributed to catheter trauma during administration of cardioplegia. Another patient with simple transposition undergoing primary repair, who appeared to be doing well, died suddenly on the seventh postoperative day. Autopsy revealed multiple areas of subendocardial hemorrhage. The 3 other patients died of low cardiac output

3 550 The Annals of Thoracic Surgery Vol45 No 5 May 1988 Table 2. Late Deaths Patient Postoperative Cause and No., Age Diagnosis Repair/Cardioplegia Electrocardiogram Time of Death Autopsy Findings 8, 13 d Complex transposition Primary/multidose J. T-111, avf Died of LCO at reop for Myocardial fibrosis J. ST-Vl-V6 PS at 3 yr 26, 8 mo Simple transposition Staged/multidose J. T-aVL, V,-V, Died with URI at 2 mo Myocardial fibrosis 27, 18 mo Simple transposition Staged/multidose & T-11, Ill, avf, Died with URI at 3 mo Myocardial fibrosis 46, 1 mo Simple transposition Stagedlsingle dose No ST-T changes Died at 3 mo of possible Not done tracheostomy complications.1 = inverted; LCO = low cardiac output; PS = pulmonary stenosis; URI = upper respiratory tract infection. v1-v6 either intraoperatively or in the immediate postoperative period. Autopsy on all 3 patients revealed extensive myocardial injury sufficient to explain the low-output postoperative state. Late Deaths In Group 1, there were 3 late deaths (following hospital discharge) (Table 2). Two patients died 2 months and 3 months following a staged repair for simple transposition. Both were being treated for upper respiratory tract infections. Each of these patients had postoperative electrocardiographic changes suggestive of myocardial injury, and autopsy revealed areas of myocardial fibrosis in both patients. The third patient, who also had postoperative ST-T wave changes, died of low cardiac output following reoperation for pulmonary stenosis three years later. There was 1 late death in Group 2, a patient with simple transposition of the great arteries and Goldenhar s syndrome (cleft lip and palate). This patient could not be weaned from the ventilator following pulmonary artery banding and underwent an arterial switch procedure 25 days after banding. Following the arterial switch procedure, he was weaned from ventilator support and was discharged from the hospital with a tracheostomy because of subglottic stenosis. The patient died suddenly at home of possible tracheostomy-related complications 3 months later. No autopsy was performed. Electrocardiography We examined electrocardiograms made an average of 6.9 months following operation for evidence of inversion, flattening, or depression of the ST segment and T wave in the standard and chest leads, evidence suggestive of myocardial injury. Ten of 11 patients in whom major ST-T wave changes developed in the chest leads had changes in the standard leads (Table 3). No Q waves suggestive of transmural infarction were seen in any of the patients. One patient (5%, 1/21) in Group 2 had postoperative ST-T wave changes compared with 10 patients in Group 1 (37%, 10/27). Three of these Group 1 patients died late and constituted 75% (3/4) of the late deaths in the series. Echocardiography M-mode and two-dimensional echocardiographic studies were performed at days postoperatively in Group 1 and days postoperatively in Group 2 (p = NS). The appearance of reduced septal motion postoperatively was a frequent finding but seemed likely to be due to residual right ventricular hypertrophy rather than ischemic injury, as systolic thickening was maintained. While a generalized reduction in left ventricular free wall motion was noted in a few patients, hypokinesia or akinesia restricted to the posteroinferior or anterolateral walls was not seen. Because of the difficulty in quantifying septal motion, the variables of septal and posterior wall percent systolic thickening, fractional shortening, and percent predicted left ventricular enddiastolic dimension corrected for weight were chosen for comparison between the two groups [13]. These results are presented in Table 4. Twenty-five patients in Group 1 (78%) and 15 (71%) in Group 2 had echocardiographic studies available for analysis. The percent fractional shortening appeared better, although not significantly so (p < 0.25), in Group 2. The other variables were comparable in both groups. Comment Several methods of myocardial protection during intracardiac operation in infants and children have been reported. Lamberti and colleagues [ 141 obtained good results in 88 infants and children undergoing intracardiac operation using topical hypothermia (mortality, 5.6%), which appeared to be more effective in smaller hearts because of their greater surface area. Bove and Stammers [15], who also found that the immature myocardium had a greater tolerance for ischemia than did the mature heart, suggested that the role of cardioplegic solution in protecting the neonatal heart during cardiac operations when deep hypothermia is used may be of lesser importance than in the older patient. Schachner and associates [16] found that the addition of potassium crystalloid cardioplegia afforded better myocardial protection in infants undergoing intracardiac procedures compared with the use of profound hypothermia and circulatory arrest alone. Their patients who

4 t DeLeon et al: Single versus Multidose Cardioplegia in Arterial Switch Table 3. Hospital Survivors with Postoperative ST-T Wave Changes Patient No., Age Postoperative at Repair Diagnosis RepairiCardioplegia Electrocardiogram Final Outcome Comment 3, 10 d 4, 12 d 8, 13 d 11, 7 d 20, 3 yr Complex TGA Complex TGA Primary/multidose 4 T-I, avl, v,-v, Primaryimultidose Flat T-I, avl J T-V,-V, Primaryimultidose T-111, avf Died of LCO at 4 ST-V,-V, reop for PS at 3 yr Primary/multidose 4 ST-I, avl, V,V, Stagedimultidose 4 T-I, avl, Difficulty coming off CPB Difficulty coming off CPB at initial op Autopsy: myocardial fibrosis 22, 9 d 25, 10 mo 26, 8 mo 27, 18 mo 30, 5 mo 38, 13 d Complex TGA Primary/multidose Stagedimultidose Stagedimultidose Staged/multidose Staged/multidose Primaryisingle dose v1-v6 Flat T-I 4 T-aVL, V,-V, 4 T-V,-V6 1 T-aVL, V,-V, 4 T-11, 111, avf, vrv, 5 T-111, avf, V1-Vs J T-aVL, V,-V, Died with at 2 mo Died with at 3 mo JRI JRI Had PVCs Autopsy: myocardial fibrosis Autopsy: myocardial fibrosis Had PVCs TGA = transposition of the great arteries;.1 = inverted; CPB = cardiopulmonary bypass; LCO = low cardiac output; PS = pulmonary stenosis; PVCs = premature ventricular contractions; URI = upper respiratory tract infection. Table 4. Echocardiographic Assessment of Postoperative Left Ventricular Function Group 1 Group 2 (Multidose) (Single Dose) Variable Calculation (N = 25) (N = 15) p Value % Systolic thickening of inter- Systolic - diastolic thickness/ 42 f NS ventricular septum diastolic thickness % Systolic thickening of LV Systolic - diastolic thickness/ 61 f C 17 NS posterior wall diastolic thickness % Predicted LVEDD LVEDD/predicted LVEDD 107 f NS % Fractional shortening LVEDD - LVESDiLVEDD 34 & 6 36 f 9 NS Predicted LVEDD = (natural log weight) (131. NS = not significant; LV = left ventricular; LVEDD = left ventricular end-diastolic dimension; LVESD = left ventricular end-systolic dimension. received potassium cardioplegia had fewer arrhythmias, plasma creatine kinase isoenzymes, and ultrastructural myocardial changes. Crawford and colleagues [ 171 also reported good results (mortality, 5%) in 60 consecutive infants and children undergoing correction of congenital heart conditions using intermittent potassium crystalloid cardioplegia. Bull and co-workers [18] did not find a significant difference in mortality between children having systemic hypothermia (25 C) and intermittent aortic cross-clamping, and those having systemic hypothermia and intermittent crystalloid cardioplegia infusion. However, they noted that mortality appeared to increase sharply after about 65 minutes of ischemia in patients having systemic hypothermia and intermittent aortic cross-clamping compared with 85 minutes of ischemia in patients receiving intermittent crystalloid cardioplegia. More recently, Corno and colleagues [8] compared topical hypothermia and crystalloid and blood cardioplegia for the protection of ischemic neonatal piglet hearts. They found that the best myocardial protection as measured by functional recovery was obtained in the group receiving intermittent cold blood cardioplegia with potassium and normal calcium level. Although it appears that intermittent cold blood cardioplegia with potassium and normal calcium level appears the best method for myocardial protection in infants and young children, its

5 552 The Annals of Thoracic Surgery Vol45 No 5 May 1988 application in arterial switch procedures is difficult because of the need for direct injection into tiny coronary orifices. To our knowledge, no one has used multidose cardioplegia in the arterial switch procedure. Jatene and colleagues [2] reported use of systemic hypothermia (20 C), release of the aortic cross-clamp after the transfer of the aorta and left coronary artery for myocardial reperfusion, and reclamping of the aorta for the right coronary artery anastomosis. Yacoub and colleagues [19, 201 and Kreutzer and associates [21] used profound hypothermia and circulatory arrest, and Castaneda and colleagues [3] employed one dose of cardioplegic solution infused into the root of the aorta in addition to systemic hypothermia (20 C) and circulatory arrest. The latter reported a 7% mortality and the development of new Q waves suggesting postoperative infarction in 7 of 14 patients (50%). Kanter and colleagues [4] initially used systemic (20 C) and topical hypothermia and crystalloid cardioplegia, also administered into the aortic root. Subsequently, they changed to profound hypothermia (15 C) and circulatory arrest without cardioplegia. They reported an overall mortality of 26.7%. Quaegebeur and co-workers [5], using systemic hypothermia (17" to 19OC) and singledose crystalloid cardioplegia, reported an early mortality of 17%. The number of deaths appeared significant only after 120 minutes of cross-clamping. Late postoperative left ventricular function assessed electrocardiographically was normal in 97% of their patients. Pacific0 and colleagues [22] were the only ones we could find who used blood cardioplegia in addition to systemic hypothermia (20" to 26 C). Their report concerned 6 patients. In the arterial switch procedure, as in various other operations for congenital heart disease, it is difficult to define the exact cause of death because of the variety and complexity of the defects. In our series, although all early deaths occurred in patients who received multidose cardioplegia infused directly into the coronary orifice and who showed postmortem evidence of myocardial injury, only 1 death could be directly attributed to the method of cardioplegia administration. Increasing experience also has to be considered in comparing results in the two groups. Since the multidose cardioplegia technique was used early in the series, it can be argued that the longer aortic cross-clamp and bypass times, the higher mortality, and the higher incidence of electrocardiographic abnormalities in the multidose cardioplegia group could be expected. However, intermittent administration of cardioplegia will inevitably prolong the procedure. In addition, the patients who sustained electrocardiographic abnormalities and those who died were evenly distributed among the 32 patients who had multidose cardioplegia. Based on aortic cross-clamp and bypass times, operative mortality, electrocardiographic evidence of myocardial injury, and echocardiographic measures of myocardial function, we conclude that single-dose is as good as or better than multidose blood cardioplegia in infants and young children undergoing the arterial switch procedure. Research supported in part by the A. C. Buehler Foundation, Park Ridge, IL. References 1. Yacoub MH: The case for anatomic correction of transposition of the great arteries. J Thorac Cardiovasc Surg 78:3, Jatene AD, Fontes VF, Souza LCB, et al: Anatomic correction of transposition of the great arteries. J Thorac Cardiovasc Surg 83:20, Castaneda AR, Norwood WI, Jonas RA, et al: Transposition of the great arteries and intact ventricular septum: anatomical repair in the neonate. Ann Thorac Surg38:438, Kanter KR, Anderson RH, Lincoln C, et al: Anatomic correction for complete transposition and double outlet right ventricle. J Thorac Cardiovasc Surg 90:690, Quaegebeur JM, Rohmer J, Ottenkamp J, et al: The arterial switch operation: an eight-year experience. J Thorac Cardiovasc Surg 92:361, Lecompte Y, Zannini L, Hazan E, et al: Anatomic correction of transposition of the great arteries: new technique without use of a prosthetic conduit. J Thorac Cardiovasc Surg 82:629, Freedom RM, Culham JAG, Olley PM, et al: Anatomic correction of transposition of the great arteries: pre- and postoperative cardiac catheterization, with angiocardiography in five patients. Circulation 63:905, Corno AF, Bethencourt DM, Laks H, et al: Myocardial protection in the neonatal heart: a comparison of topical hypothermia and crystalloid and blood cardioplegic solutions. J Thorac Cardiovasc Surg 93:163, Ilbawi MN, Idriss FS, DeLeon SY, et al: Preparation of the left ventricle for anatomical correction in patients with simple transposition of the great arteries: surgical guidelines. J Thorac Cardiovasc Surg 9487, Yacoub MH, Radley-Smith R Anatomic correction of the Taussig-Bing anomaly. J Thorac Cardiovasc Surg 88:380, Idriss FS, Ilbawi MN, DeLeon SY, et al: Transposition of the great arteries with intact ventricular septum: arterial switch in the first month of life. J Thorac Cardiovasc Surg (in press) 12. Idriss FS, Ilbawi MN, DeLeon SY, et al: Arterial switch in simple and complex transposition of the great arteries. J Thorac Cardiovasc Surg 95:29, Gutgesell HP, Paquet M, Duff DF, McNamara DG: Evaluation of left ventricular size and function by echocardiography: results in normal children. Circulation 56:457, Lamberti JJ Jr, Cohn LH, Laks H, et al: Local cardiac hypothermia for myocardial protection during correction of congenital heart disease. Ann Thorac Surg 20446, Bove EL, Stammers AH: Recovery of left ventricular function after hypothermic global ischemia: age-related differences in the isolated working rabbit heart. J Thorac Cardiovasc Surg 91:115, Schachner A, Vladutiu A, Montes M, et al: Myocardial protection in infant open heart surgery. Scand J Thorac Cardiovasc Surg 17:101, 1983

6 553 DeLeon et al: Single versus Multidose Cardioplegia in Arterial Switch 17. Crawford FA Jr, Barnes TY, Heath BJ: Potassium-induced cardioplegia in patients undergoing correction of congenital heart defects. Chest 78316, Bull C, Cooper J, Stark J: Cardioplegic protection of the child s heart. J Thorac Cardiovasc Surg 88:287, Yacoub MH, Radley-Smith R, Hilton CJ: Anatomical correction of complete transposition of the great arteries and ventricular septal defect in infancy. Br Med J 1:1112, Radley-Smith R, Yacoub MH: One stage anatomic correc- tion of simple transposition of the great arteries in neonates (abstract). Circulation 7O:Suppl 2:26, Kreutzer G, Neirotti R, Galindez E, et al: Anatomic correction of transposition of the great arteries. J Thorac Cardiovasc Surg 73:538, Pacific0 AD, Stewart RW, Bargeron LM Jr: Repair of transposition of the great arteries with ventricular septal defect by an arterial switch operation. Circulation 68:Suppl 2:49, 1983 REVIEW OF RECENT BOOKS Improving Results with Coronary Artery Bypass Grafting Edited by Jack G. Copeland and Steven Goldman Philadelphia, Hanley 6 Belfus, pp, illustrated, $78.00 Revimed by Jorge A. Wernly, M. D. This book, the first of a series entitled Cardiac Surgery: State of the Art Reviews is devoted to coronary artery surgery. In thirteen review chapters by recognized authorities in the field, this succinct and concise volume discusses several contemporary topics related to coronary artery surgery, attempting to present the state-of-the-art (1986) of this vast field. The intent to cover such a broad subject is probably the main weakness of this otherwise fine book: the subject of some of the chapters would have deserved the whole volume! Overall the chapters are concise and informative, contain a complete bibliography, and make valuable contributions based on the experience of their authors. I particularly enjoyed the first chapter, Have the Indications for Coronary Bypass Surgery Been Changed by the Coronary Artery Study (CASS)? It is a brief but excellent review of CASS and its repercussion on surgical practice. I felt that there should have been a similarly entitled chapter Have the Indications and Results of Coronary Artery Bypass Surgery Been Changed by Percutaneous Transluminal Coronary Angioplasty (PTCA)? Considering the tre- mendous impact of PTCA on coronary artery bypass surgery, on patients undergoing mycocardial revascularization, and therefore, on surgical results, the chapter that relates to PTCA is too broad and perhaps vague. Four chapters present new information on saphenous vein grafting (technical aspects, use of sequential grafts, factors influencing vein graft patency, and the effect of antiplatelet therapy). These chapters seem excessive, considering the lesser weight given to other equally, if not more important, topics. For instance, the chapter on the indications, use, and results of the internal mammary artery(ies) is brief. More importantly, however, I thought that appropriate emphasis was not given to the significant impact on surgical techniques, perioperative strategies, and clinical results of the growing number of patients requiring repeat aortocoronary bypass grafting. This book is aimed at a selective surgical audience and in general terms has accomplished the objective of gathering a large body of information on the subject and presenting it in a concise and readable fashion. This initial volume of Cardiac Surgery: State of the Art Reviews is of interest and should be very useful for practicing cardiac surgeons and cardiac surgical residents. Albuquerque, NM