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Reply to: Myocardial oxidative stress protection with sevoflurane versus propofol

Ballester, Mayte; Llorens, Julio; Martinez-Leon, Juan*

European Journal of Anaesthesiology: June 2012 - Volume 29 - Issue 6 - p 297–298
doi: 10.1097/EJA.0b013e3283527f6c

From the Department of Anaesthesiology and Critical Care, Hospital Clinico Universitario, Valencia, Spain (MB, JL) and Department of Cardiovascular Surgery, Consorcio Hospital General Universitario, Valencia, Spain (JML)

*Current affiliation: Consorcio Hospital General Universitario, Valencia, Spain.

Correspondence to Mayte Ballester, MD, PhD, Department of Anaesthesiology and Critical Care, Hospital Clinico Universitario, Avda, Blasco Ibañez, 17, 46010, Valencia, SpainTel: +34 65 682 1534; fax: +34 96 386 2644; e-mail:

Published online 3 April 2012


We thank Tandon and Pandey1 for their interest in our study.2 We would like to make the following comments regarding their concerns about specific surgical points.

First of all, we confirm we did not have any incidence of coronary sinus injury in any patient. Our group has a lot of experience, over many years, of retrograde myocardial protection with excellent results and no complications.3,4 In our study, we used a balloon retroplegia catheter for blood retrieval purposes only. We only inflated the balloon to obtain blood samples according to the study protocol at three different time points,2 reducing the possibility of complications that in most cases are due to overinflation. Moreover, we introduced the balloon catheter through a purse string in the lateral wall of the right atrium and, after each sample retrieval, we placed the tip of the cannula in the atrium cavity avoiding possible damage to the coronary sinus. When another sample was needed, we repositioned the catheter under finger control at the entry of the coronary sinus, as we usually do for myocardial protection purposes.

Finally, the use of coronary shunts for the conduct of the anastomosis is a controversial issue. Our group has much experience in off-pump coronary artery bypass graft (CABG) surgery, performing around 200 cases per year. The mean number of grafts per patient is 3.1 and we do not use shunts. We agree with Mack5 that the placement of a shunt can be cumbersome and may damage the native vessel endothelium,6 especially in the distal part of the coronary vessel, causing early occlusion or late stenosis. Lucchetti et al.7 reported that intracoronary shunts are beneficial during off-pump CABG in patients with an isolated left anterior descending coronary artery lesion. They advised the use of intracoronary shunts only in patients with unstable angina and left ventricular dysfunction. Hangler et al.8 reported that the insertion of intracoronary shunts during beating heart surgery leads to severe endothelial denudation in human coronary arteries, and therefore they recommend using intracoronary shunts selectively in patients with critical ischaemia or in patients with technical difficulties as a result of anatomical conditions. In our study, we had no patients with these characteristics and we did not observe any complication due to the absence of distal coronary perfusion during performance of the anastomosis.

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There are no conflicts of interest. None of the authors has received any financial support.

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1. Tandon M, Pandey CK. Myocardial oxidative stress protection with sevoflurane versus propofol. Eur J Anaesthesiol 2012; 29:296–297.
2. Ballester M, Llorens J, Garcia-de-la-Asuncion J, et al. Myocardial oxidative stress protection by sevoflurane vs. propofol: a randomised controlled study in patients undergoing off-pump coronary artery bypass graft surgery. Eur J Anaesthesiol 2011; 28:874–881.
3. Martinez-León J, Carbonell C, Ortega J. A new technical approach for retrograde administration of cardioplegic solutions. Thorac Cardiovasc Surgeon 1989; 37:372–373.
4. Martinez-León J, Carbonell C, Ortega J. Myocardial protection by retrograde cardioplegic perfusión in the presence of acute coronary artery obstruction. An experimental study. Scand J Thor Cardiovasc Surg 1992; 26:207–212.
5. Michael Mack. CABG interview. (2011). http:// [accessed 13 March 2012].
6. Stanbridge RDL, Hadjinikolaou LK. Technical adjuncts in beating heart surgery. Comparison of MIDCAB to off-pump sternotomy: a meta-analysis. Eur J Cardiothorac Surg 1999; 16 (suppl 2):S24–S33.
7. Lucchetti V, Capasso F, Caputo M, et al. Intracoronary shunt prevents left ventricular function impairment during beating heart coronary revascularization. Eur J Cardiothorac Surg 1999; 158:225–229.
8. Hangler HB, Pfaller K, Ruttmann E, et al. Effects of intracoronary shunts on coronary endothelial coating in the human beating heart. Ann Thorac Surgery 2004; 77:776–780.
© 2012 European Society of Anaesthesiology