Invited Commentary

Abstract

Among the voluminous advice and instruction given to graduating medical students, perhaps none is more familiar than the phrase, primum non nocere, which is translated as “first, do no harm.” This injunction, which is often attributed to Hippocrates, is violated daily by pediatric cardiac surgeons. Proof of this is encountered in the postoperative intensive care unit, where our patients virtually all “require” continuous infusions of inotropic drugs that they did not need before the operation. In severe cases, patients may emerge from the operating room with open sternotomy incisions, and some may even require temporary mechanical cardiac support. Happily for most patients, these deleterious effects of the operation are temporary and are reversed within a few days, when the benefit of the intervention finally begins to overwhelm its physiologic cost. Nonetheless, an enormous amount of effort has been devoted to minimization of iatrogenic harm during pediatric cardiac operations, with the emergence of such concepts as myocardial “protection” and improved whole-body homeostasis during cardiopulmonary bypass. To this end, several French centers have recently advocated the avoidance of hypothermia during bypass and cardioplegia and have reported excellent results with such an approach [1Durandy Y. Hulin S. Intermittent warm blood cardioplegia in the surgical treatment of congenital heart disease: clinical experience with 1400 cases.J Thorac Cardiovasc Surg. 2007; 133: 241-246Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar, 2Pouard P. Mauriat P. Ek F. et al.Normothermic cardiopulmonary bypass and myocardial cardioplegic protection for neonatal arterial switch operation.Eur J Cardiothorac Surg. 2006; 30: 695-699Crossref PubMed Scopus (62) Google Scholar]. The study by Belli and colleagues [3Belli E. Roussin R. Ly M. et al.Anomalous origin of the left coronary artery from the pulmonary artery associated with severe left ventricular dysfunction: results in normothermia.Ann Thorac Surg. 2010; 90: 856-861Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar] adds to this body of literature by describing outcomes for 21 patients with anomalous origin of the left coronary artery from the pulmonary artery and severely impaired ventricular function (shortening fraction <0.15), who underwent reimplantation of the anomalous left coronary into the aorta. This was accomplished with normothermic cardiopulmonary bypass and intermittent warm antegrade sanguineous cardioplegia. Early survival in the group was excellent (20 of 21), and there have been no late deaths. No patient required mechanical support after the operation, although 16 patients were managed with delayed sternal closure. One patient required transcatheter stent placement in the reimplanted left coronary artery for early stenosis and has undergone additional percutaneous angioplasty of the left main coronary artery. There were no operations on the mitral valve concomitant with or subsequent to the original coronary operation. Ventricular function and mitral valve function have both either improved or normalized in nearly all patients. The authors conclude that repair of anomalous origin of the left coronary artery from the pulmonary artery performed with normothermic bypass and cardioplegia is safe and effective in this particularly vulnerable population, even in the setting of severe left ventricular dysfunction. The authors are to be congratulated for truly superb results, but unfortunately, their study was not designed to answer the question of whether their approach is superior to the more commonly used hypothermic conduct of bypass and myocardial protection. The outcomes in the present study were achieved in patients with severe left ventricular dysfunction, and thus the approach the authors have taken seems to have neutralized such dysfunction as a risk factor in patients with anomalous origin of the left coronary artery from the pulmonary artery. However, the absence of a control group does not allow for such a conclusion to be regarded as definitive. The authors have, nonetheless, certainly answered whether or not a normothermic approach is safe in these sickest of patients. It is, and we must thank them for providing our community with the equipoise mandatory to allow a definitive randomized trial between normothermic and hypothermic approaches. Anomalous Origin of the Left Coronary Artery From the Pulmonary Artery Associated With Severe Left Ventricular Dysfunction: Results in NormothermiaThe Annals of Thoracic SurgeryVol. 90Issue 3PreviewRepair of anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) carries a high risk of operation, particularly in those with poor left ventricular function. In this study, we assessed the outcomes of patients who presented with severe preoperative left ventricular dysfunction (shortening fraction <15%) who underwent the repair under normothermic bypass. Full-Text PDF