They also serve who only stand and wait


Letters to the Editor
being used. Monitoring of the ante-

grade selective perfusion pressure,

which we believe to be a critical com-

ponent of assessment of the cerebral

perfusion, might be easier with axillary

cannulation with an arterial pressure

line placed in the right radial artery.

Also, axillary artery cannulation itself

is not very complicated and is usually

done within 30 minutes. Therefore,

we still prefer using the axillary artery

as a cannulation site.

Dr Küçüker and his colleagues have

suggested an excellent and very impor-

tant point: that surgeons should be

aware of those patients whose aortic

dissection extends into those arteries

or whose right axillary artery takes

off aberrantly from the descending

aorta. Careful review of preoperative

imaging will reliably identify an aber-

rant artery and extension of dissection

into the innominate artery. A dissected

axillary artery should be apparent at

the time of direct examination. If the

artery is dissected, we agree that alter-

native cannulation is required. A well

performed side graft anastomosis

should not lead to a pressurized false

lumen, even if the arch is dissected.

Careful clamping of the innominate ar-

tery, after examination of the vessel,

will prevent clamping off of the true

lumen.

Since the publication of the article,

our aortic surgery practice has continued

to expand. The axillary artery cannula-

tion technique remains a reproducible

and reliable method of arterial outflow

in our hands as well as others
2–4

and

will continue to be our choice. However,

it is crucially important to be aware of

the pitfalls suggested by Dr. Küçüker

and others and to use judicious clinical

judgment for each case for its safe and

successful use.
1,5

Hiroo Takayama, MD
Craig R. Smith, MD

Michael E. Bowdish, MD
Allan S. Stewart, MD

Division of Cardiothoracic Surgery
Columbia University

New York, NY
798 The Journal of Thoracic and C
References
1. Tasxdemir O, Saritasx A, Küçüker S, Ozatik MA,

Sener E. Aortic arch repair with right brachial artery

perfusion. Ann Thorac Surg. 2002;73:1837-42.

2. Halkos ME, Kerendi F, Myung R, Kilgo P,

Puskas JD, Chen EP. Selective antegrade cerebral

perfusion via right axillary artery cannulation reduces

morbidity and mortality after proximal aortic surgery.

J Thorac Cardiovasc Surg. 2009;138:1081-9.

3. Etz CD, Plestis KA, Kari FA, Silovitz D, Bodian CA,

Spielvogel D, et al. Axillary cannulation significantly

improves survival and neurologic outcome after ath-

erosclerotic aneurysm repair of the aortic root and as-

cending aorta. Ann Thorac Surg. 2008;86:441-6.

4. Svensson LG, Blackstone EH, Rajeswaran J,

Sabik JF 3rd, Lytle BW, Gonzalez-Stawinski G,

et al. Does the arterial cannulation site for circula-

tory arrest influence stroke risk? Ann Thorac Surg.

2004;78:1274-84.

5. Orihashi K, Sueda T, Okada K, Takahashi S. Com-

pressed true lumen in the innominate artery: a pitfall

of right axillary arterial perfusion in acute aortic dis-

section. J Thorac Cardiovasc Surg. 2009;137:242-3.

doi:10.1016/j.jtcvs.2009.10.026
THEY ALSO SERVE WHO ONLY
STAND AND WAIT
To the Editor:

I read with great interest, and a de-

gree of nostalgia, Dr Kumar’s edito-

rial
1

on the second assistant.

It brought back memories of a time

long ago, when I was young and

thirsty for learning. I spent 18 months

as a Senior House Officer (the most ju-

nior member of the surgical team) in

Southampton, UK, where my only

role in theaters was to harvest a length

of vein and then stand next to the sur-

geon as a second assistant.

Dr Kumar offers great advice on

how to make the most of this time.

As he suggests, I developed my

habit of making notes with illustra-

tions during that time. I still have that

habit and have a large collection of

these handwritten notes and drawings,

to which I refer at times even now.

I would often get bored with the re-

petitive nature of my job of harvesting

vein and closing the leg. During one

such period of boredom, I started using

my left hand (I am right-handed) to do

parts of the procedure. I soon became

adept at using my left hand as well,

a skill that I use on many occasions

now with great advantage.
ardiovascular Surgery c March 2010
Being a second assistant for a long

time can, however, be a source of de-

spair, especially if the opportunities to

open or close the chest or do a top-end

anastomosis do not materialize. ‘‘They

also serve who only stand and waite.’’
2

I would think of Milton.

Being a second assistant also allows

the mind to drift without anybody notic-

ing (at times). Daydreaming can be

a wonderful experience (at times). I

had chosen cardiac surgery to be a top-

notch cardiac surgeon, nothing less.

When I was 20-something, just holding

the retractor as a second assistant did not

make the goal seem nearer. Was it possi-

ble that the dream could go sour?

I had the opportunity to work as a sec-

ond assistant with some great surgeons,

and some not so fantastic. As Dr Kumar

says, it is a very impressionable part of

one’s life and can have a profound bear-

ing on one’s later career.

But alas, the days of the second as-

sistant are numbered. The European

Union’s working time directive
3

has

cursed the current and future genera-

tions of trainees with only 48 hours

of work per week. This has resulted

in severe manpower shortages in hos-

pitals across the United Kingdom,

and almost all our surgical procedures

are now done with a single assistant.

We have learned to adapt to this and

now do not find the need for second as-

sistants except for the most complex

cases. The loss, however, will be that

of the trainees who will miss out on

such a wonderful training opportunity.

And for those lucky enough to have

this chance, make the most of it. Look

at it as an opportunity that has knocked

on your door.and if you don’t answer
soon, it will go away forever.

Vipin Zamvar, MS
Royal Infirmary of Edinburgh

Edinburgh, UK

References
1. Kumar TK. The second assistant in cardiac surgery:

the challenges and answers. J Thorac Cardiovasc

Surg. 2009;137:1311-4.

2. Milton J. When I consider how my light is spent. In:

Ricks C, ed. The Oxford book of English verse. New

York: Oxford University Press USA; 1999. p.168.



Letters to the Editor
3. EUR-Lex [Internet]. Luxembourg: Publications Of-

fice of the European Union; c2009 [updated 2009

Nov 12; cited 2009 Oct 10]. Council Directive 93/

104/EC of 23 November 1993 concerning certain

aspects of the organization of working time; [about

1 screen]. Available from: http://eur-lex.europa.eu/

LexUriServ/LexUriServ.do?uri¼CELEX:31993L01
04:EN:HTML

doi:10.1016/j.jtcvs.2009.09.060
INTRA-ATRIAL REROUTING
BY THE POSTERIOR LEFT
ATRIAL WALL FLAP FOR
TOTAL ANOMALOUS
PULMONARY VENOUS
RETURN DRAINAGE INTO THE
CORONARY SINUS IN
NEONATES
To the Editor:

We read with great interest the new

procedure for total anomalous pulmo-

nary venous return (TAPVR) drainage

into the coronary sinus (CS), which

Yamagishi and colleagues
1

success-

fully performed for an infant weighing

5.5 kg. Briefly, the roof of the CS was

incised toward the left atrium (LA) to

create a flap from the posterior wall

of the LA (¼ the anterior wall of the
common chamber and the CS). The

flap thus created was then moved ante-

riorly to cover the entire atrial commu-

nication and the CS orifice. However,

we were unable to find any follow-up
FIGURE 1. A, Echocardiogram after surgery. Parast

common chamber. B, Another parasternal long-axis v

chamber. RV, Right ventricle; LV, left ventricle; Ao,

The Journal
reports on this procedure. We recently

successfully performed this procedure

for 2 neonatal cases and recognized

several important features associated

with this surgery.
CASE 1

A baby girl with a birth weight of

2.7 kg underwent this new procedure

for TAPVR drainage into the CS at 8

days of age. She was discharged on

postoperative day 22 without any

complications. Postoperative echocar-

diogram demonstrated a large commu-

nication between the LA and the

common chamber (Figure 1, A). An
abnormal continuous flow was de-

tected at the superior wall of the CS.

This flow was directed toward the

common chamber and appeared to be

a small coronary arterial flow (Fig-

ure 1, B). This abnormal flow disap-
peared 2 months after the operation.

One year after the operation, the

patient was doing well with no evi-

dence of arrhythmia.
CASE 2

The new procedure was also per-

formed on a 20-day-old baby girl

(birth weight, 3.0 kg) who had
ernal long-axis view during the diastolic phase showin

iew showing an abnormal continuous flow from the p

aorta; LA, left atrium; CC, common chamber.

of Thoracic and Cardiovascular Surge
TAPVR drainage into the CS. Because

the posterior wall flap of the LA was

not sufficiently large to cover the

entire atrial septal defect and CS ori-

fice, a fresh autologous pericardial

patch was applied to close the rest of

the atrial communication. At 1 year

and 7 months after the operation, she

is in good clinical status with no

arrhythmia.

The usual surgical treatment for

TAPVC to the CS is either the CS

cut-back procedure or the Van Praagh

technique.
2

The advantages of this

new procedure compared with these

previously performed procedures are

as follows:

1. Sufficiently wide communication

between the LA and the common

chamber can be obtained.

2. Neither prosthetic materials nor au-

tologous pericardium is required

for closing the atrial communica-

tion and the CS orifice.

However, the following cautionary

points should be noted:

1. During making the CS anterior wall

flap, the incision line may enter into

the pulmonary venous orifices.

2. Anastomosing the flap to the ante-

rior edge of the CS orifice may

damage the atrioventricular node.
g a large communication between the LA and the

osterior wall of the new LA toward the common

ry c Volume 139, Number 3 799

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	They also serve who only stand and wait
	References