Ann Thorac Surg 1993;56:1001-6

CORRESPONDENCE 1003

leagues that routine postoperative enzyme assays are of limited value if reinfusion techniques are used. Enzyme elevations in blood could mislead the diagnosis of myocardial injury in pa- tients undergoing coronary artery bypass grafting and of intra- vascular hemolysis in patients undergoing valve replacement. We agree that when using reinfusion techniques, measurements of enzyme levels should be withheld in the immediate postoper- ative period.

Ruggero De Paulis, M D Carlo Bassano, M D Alessandro Ricci, M D Guglielmo M . Actis Dato, M D Luigi Chiariello, M D

Department of Cardiac Surgery Tor Vergata University of Rome European Hospital Via Portuense, 700 00249 Rome, Ztaly

References 1. Wahl GW, Feins RH, Alfieres G, Bixby K. Reinfusion of shed

blood after coronary operation causes elevation of cardiac enzyme levels. Ann Thorac Surg 1992;53:625-7.

2. Sobel BE. Cardiac enzymes and other macromolecular mark- ers of myocardial injury. In: Hurst JW, Logue BR, Rackley CE, et al, eds. The heart. Arteries and veins. Rew York: McGraw- Hill, 1985:897-8.

3. Graeber GM, Cafferty PJ, Wolf RE, Cohen DJ, Zajtchuk R. Creatine kinase and lactate dehydrogenase in the muscles encountered during median sternotomy and in the myocar- dium of the cardiac chambers. J Thorac Cardiovasc Surg 1985;89:700-5.

Congenital Aortic Stenosis and Patent Ductus Arteriosus in the Adult To the Editor:

We read with great interest the article by Glower and colleagues [ l ] and recently encountered a similar problem in a 24-year-old male patient. The patient was clinically suspected to have patent ductus arteriosus with aortic stenosis. The chest roentgenogram and electrocardiogram were suggestive of clinical diagnosis. The echocardiography showed the presence of a large aneurysmal hypertensive patent ductus arteriosus and a localized membrane 1 cm below the aortic valve with a peak and mean gradient of 118 and 72 mm Hg, respectively. The cardiac catheterization and angiographic findings were systemic pulmonary artery pressure, pulmonary-to-systemic blood flow of 3231, large aneurysmal patent ductus arteriosus, localized subaortic stenosis with a gradient of 125 mm Hg, and trivial aortic regurgitation.

Conventional cardiopulmonary bypass was instituted after median sternotomy. Immediately, the patent ductus arteriosus was blocked with a Fogarty catheter passed through a pulmonary arteriotomy. The patient was cooled down to 22T, and the ductus was closed with a Gelseal patch (gelatin-coated Dacron patch; Vascutek, Inc, Scotland) using 5-0 Prolene (Ethicon, Som- erville, NJ) as continuous running over-and-over suture. The subaortic membrane was excised under cardioplegic arrest. The patient was discharged on the eighth postoperative day.

In contrast to the case reported by Glower and colleagues [l], our case was diagnosed on echocardiography, and cardiac cath- eterization confirmed the diagnosis. We differ with Glower and colleagues and recommend management of patent ductus arteri- osus and aortic stenosis in one stage. With our unpublished experience of five pediatric cases of patent ductus arteriosus and

aortic stenosis, we did not have any difficulty in the present case and recommend median sternotomy for managing patent ductus arteriosus and aortic stenosis. In our case compared with the cases reviewed by Glower and colleagues, the aortic valve was preserved. The postoperative echocardiogram performed on the seventh postoperative day showed absence of any gradient.

Arun K . Bhutani, MCh Kesava Dev, MCh Moosekunhi M . Koppala, MCh Madan M . Maddali, M D Kurudarnannil A . Abraham, DM Komarakshi R. Balakrishnan, MCh Rajesh N. Desai, MCh

Southern Railway Headquarters Hospital Ayanavaram, Perarnbur Madras 600 023, lndia

Reference 1. Glower DD, Bashore TM, Spritzer CE. Congenital aortic

stenosis and patent ductus arteriosus in the adult. Ann Thorac Surg 1992;54:368-71.

Reply To the Editor:

Bhutani and colleagues are to be congratulated on the fine results in their patient. We agree that their patient and indeed our patient presented previously were best managed with repair of the aortic stenosis and the patent ductus arteriosus in a single- stage operation. Choice of a single-stage procedure or two-staged operation should clearly be individualized to each particular patient. Our statement that a staged repair is the procedure of choice is perhaps more applicable to those adult patients with a ductus arteriosus complicated by calcification, atherosclerosis, or sufficiently large size to make safe repair of the ductus difficult through a median sternotomy. Thus, we agree that our patient and the patient of Bhutani and colleagues were best managed by a single-stage procedure. Whether the single-stage or two-staged approach will be most appropriate for the majority of adult patients awaits further data regarding the frequency of uncom- plicated versus complicated ductal anatomy in adults with com- bined aortic stenosis and patent ductus arteriosus.

Donald D . Glower, M D Thomas M . Bashore, M D Charles E . Spritzer, M D

Duke University Medical Center Box 3852 Durham, NC 27720

Need for Aprotinin Use Notification To the Editor:

Use of aprotinin has been widely demonstrated as highly effec- tive in reducing blood loss and blood transfusion after open heart operations [l]. Since the first experiences when aprotinin was suggested for those patients undergoing open heart operations with high bleeding risks [2], its effectiveness in platelet protection and in antifibrinolytic activity during and after extracorporeal circulation led many cardiac surgeons to use aprotinin even in patients undergoing elective primary open heart operations.

As a consequence of this, a large population of patients exposed to aprotinin are likely to develop sensitization to this