Myocardial oxidative stress protection with sevoflurane versus propofol

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Editor, We read with great interest the scientific report by Ballester et al.1 We appreciate the conclusion they have drawn. However, we have several concerns. We would like to know whether coronary sinus injury occurred in their patients. The authors mention that the coronary sinus was catheterised and the catheter remained in situ while the distal coronary anastomoses were performed. Beating heart coronary artery bypass graft surgery involves manipulation of the heart, at times to extreme degrees. Leaving a coronary sinus catheter in situ could damage the coronary sinus. Coronary sinus injury can be difficult to repair and may result in death.2,3 It must have been difficult to manage the correct positioning of the coronary sinus catheter in a beating heart, as it would have repeatedly dislodged either into right atrium (RA) or further into the coronary sinus despite being anchored to the RA wall, thus hampering the venous drainage of the heart. Another concern that we wish to share is that a coronary shunt was not used for the conduct of the anastomosis. We appreciate that this must have been a surgical decision, but in a patient with coronary artery stenosis undergoing beating heart surgery, the degree of metabolic demand and supply mismatch is much higher than in a pleaged heart. A vascular shunt not only aids in conduct of the anastomosis but also ensures the available flow to the distal myocardial tissue in the affected territory.4,5 The authors did not mention if any other means of distal coronary perfusion was used in their patients. Complications observed in absence of distal coronary perfusion should also be described.