Francis Robicsek, MD, PhD

Department of Thoracic and Cardiovascular SurgeryCarolinas Heart InstituteCarolinas Medical Center1001 Blythe Blvd, Suite 300Charlotte, NC 28203e-mail: tjohn@sanger-clinic.com

References

1. Bauer M, Pasic M, Meyer R, et al. Morphometric analysis ofaortic media in patients with bicuspid and tricuspid aorticvalve. Ann Thorac Surg 2002;74:58–62.

2. Robicsek F. The post-stenotic dilatation of great vessels. ActaMorphol Acad Sci Hung 1954;4(Suppl1):41.

3. Robicsek F. The post-stenotic dilatation of great vessels. ActaMed Scand 1955;106:481–5.

4. Holman E. The obscure physiology of post-stenotic dilatation:its relation to the development of aneurysms. J Thorac Surg1954;28:109–33.

ReplyTo the Editor:

We thank Dr Robicsek for his comments on our report [1]describing the differences in morphologic analysis of the aorticmedia between patients with bicuspid and tricuspid aorticvalves. The two main findings of our morphometric study werethat the elastic membranes in patients with a bicuspid aorticvalve are thinner than those in patients with a tricuspid aorticvalve and that the distances between the elastic lamellae in-crease in both groups with enlarging diameter of the ascendingaorta.

As we wrote in this study, its results cannot resolve thequestion of whether the thinner elastic membranes in patientswith a bicuspid aortic valve are caused by altered hemodynam-ics or by a common developmental defect of the aortic valveand the wall of the ascending aorta. Whether the aortic wallalterations in patients with a bicuspid aortic valve are causedby a congenital defect of the aortic media or are due to theabnormal stress on the aortic wall caused by the malformedvalve has long been a matter of discussion. Therefore, wesuggested that further hemodynamic studies in combinationwith ultrastructural analysis of the elastic lamellae of theaortic media and other constituents of the aortic wall arenecessary.

We fully agree with Dr Robicsek that an examination of theaortic wall of newborns with a bicuspid aortic valve could alsohelp solve this problem.

Matthias Bauer, MDMiralem Pasic, MD, PhDRoland Hetzer, MD, PhD

Department of Cardiothoracic and Vascular SurgeryDeutsches Herzzentrum BerlinAugustenburger Platz 1Berlin 13353, Germanye-mail: mbauer@dhzb.de

Reference

1. Bauer M, Pasic M, Meyer R, et al. Morphometric analysis ofaortic media in patients with bicuspid and tricuspid aorticvalve. Ann Thorac Surg 2002;74:58–62.

Bridge Over Troubled Water: Bridging a GapTo the Editor:

I read with interest the editorial by Dr Suma [1], and wassurprised to see that the inventors of the “gold standard” arterialconduit bridge were not even quoted. In 1967, Vasili Kolesov [2]described an anastomosis between the internal mammary artery(IMA) and the left anterior descending artery. The operation wascarried out without extracorporeal bypass, and no coronarogra-phy was done previously. Kolesov was surely a great pioneer,but for many reasons, which are only now understandable,coronary surgery did not benefit from his genius and there wasno major breakthrough at that time from the Soviet Union. Infact, beating-heart surgery through thoracotomy, the Kolesovprocedure, only reappeared 15 years later.

Conversely, regular coronary surgery using the IMA as aconduit and carried out under total cardiopulmonary bypass(nowadays, the most frequent major procedure realizedthroughout the world on a daily basis) is the very procedureinvented by G. E. Green. In February 1968 [3], he was the first touse this artery to successfully bypass a stenosed left anteriordescending artery under total bypass after preoperative coro-nary angiography. Aware of the poor long-term results ofvenous bypasses in peripheral arterial surgery, and havingexperience in handling vessels of 1 mm in diameter, Green hadworked on the idea of this operation for at least 5 years beforebeing in a position to attempt it and to make it a safe, reliable,and reproducible procedure.

Technical difficulties were reduced by cardiac standstill, fullventricular decompression on total cardiopulmonary bypass,and use of high optical magnification (�8). Although immedi-ately adopted by some surgeons throughout the world, thistechnique remained marginal for a few years, especially in thenation where most coronary surgery operations was done.Nobody is a prophet in his own country!

Indifferent to the saphenous vogue of the 1970s, but influ-enced by his own good results, Green started to use bilateralmammaries as early as 1972. Consequently, he wrote severalpapers with the view of increasing use of the IMA. It must beconceded that the Cleveland Clinic was one of the first big teamsto switch from the saphenous vein to use of the mammaryartery, as for decades, they had been carrying out manyVineberg procedures. The very large series published by theCleveland Clinic team in 1986 helped popularize use of the IMA,as emphasized by Suma in his editorial, but at that time, Greenwas already routinely using both mammary arteries with se-quential anastomosis. Three years earlier, he had repeatedlyurged his colleagues to develop wider use of the IMA [4].

For more than 30 years, most of the procedures involving theIMA have been carried out using the technique first describedby Green. This needed to be clarified to bridge a gap . . . overtroubled water!

Henri J. Poulain, MD

Hopital Sud80054 AmiensCedex 1, Francee-mail: poulain.henri@chu-amiens.fr

338 CORRESPONDENCE Ann Thorac Surg2003;76:337–42

© 2003 by The Society of Thoracic Surgeons 0003-4975/03/$30.00Published by Elsevier Inc

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