1216 CORRESPONDENCE

ReplyTo the Editor:

The letters of Dr Berger and Dr Garibaldi concerning the article byFleisher and co-workers [1] point out the interest paid by surgeonsto the technical issues raised by iatrogenic injury of the coronarysinus and lead me to add two brief comments. I completely agreewith Dr Berger that it is safe to "tailor" the degree of ballooninflation to the individual patient's coronary sinus anatomy. It is amatter of daily experience that the volume of fluid required toachieve proper sealing of the coronary sinus varies in relation withthe size of the sinus as well as with the precise location of theballoon within the venous conduit. Furthermore, with the use ofcontinuous retrograde cardioplegia, whether cold or warm, this"optimal" inflation volume may vary even in the same patientduring the procedure. Thus, every surgeon has experienced thatretraction of the heart required for performing a distal obtusemarginal or posterior descending coronary artery anastomosiscauses, by itself, a rise in coronary sinus pressure if cardioplegia isbeing delivered retrogradely. It is therefore my practice to keepthe balloon completely deflated (or at most minimally inflated)during this stage of the procedure so that the distal pressure doesnot exceed, say, 50 mm Hg. As the heart subsequently is reposi­tioned in the pericardial cavity and the operation proceeds withanterior distal anastomoses or associated valve replacement, thepressure obviously goes down and the balloon then is (relinflateduntil a satisfactory driving pressure is reestablished. Conversely,although I also agree with most of Dr Garibaldi's statements, Icannot share his opinion that "a patch repair probably is condu­cive to further bleeding or to thrombosis of the coronary sinus."Doctor Fleisher's experience-and that (often unpublished) ofothers-clearly demonstrates that suture of a large pericardialpatch over the area of injury can be, in some instances, the onlylife-saving technique. I acknowledge, however, that anchoring ofthe patch may result in some impediment to the venous return,thereby causing an increase in coronary sinus pressure proximalto the obstruction and, consequently, persistent bleeding. Shouldthat occur, the decompression of the area under tension can beaccomplished successfully by the interposition of a prosthetic graftbetween the patch and the right atrium [2].

Philippe Menasche, MD, PhD

Department of Cardiovascular SurgeryHiJpital Lariboisiere2 Rue Ambroise Pare75475 Paris Cedex 10France

References1. Fleisher AG, Sarabu MR, Reed GE. Repair of coronary sinus

rupture secondary to retrograde cardioplegia. Ann Thorac Surg1994;57:476-8.

2. Weiss S]. Management of difficult coronary sinus rupture. AnnThorac Surg 1994;58:548-50.

Surgeons, Nonsurgeons, and Cardiac PacingTo the Editor:

The provocative study by Ferguson and associates [1] entitled"Should Surgeons Still be Implanting Pacemakers?" is commend­able but misdirected. I suggest that the correct title should havebeen "Should Nonsurgeons Implant Pacemakers?"

Ferguson and associates invoke the argument of a potentialreduction in cost to encourage physicians without primary surgicaltraining to implant permanent pacemakers, emphasizing the po-

© 1994 by The Society of Thoracic Surgeons

Ann Thorae Surg1994;58:1212-8

tential reduction in cost. They do not, however, address the skillsthat well-trained cardiologists and surgeons bring to the implan­tation facility. An evaluation of the skills, knowledge, and expe­rience listed below may help the reader to appreciate howspecialized and exquisite pacemaker implantation has become.

As a surgeon responsible for training residents and fellows,experience has taught me the limitations of the technical capabil­ities of house officers and most attending nonsurgeons in theoperating room. Some trainees fumble through knot-tying formonths; some never learn. (There are a few exceptions to thisunkindly generalization about surgical skills; a co-author of thearticle is one of them.) In the face of unusual situations such as theabsence of veins, scarring at the operative site, and anatomicvariations, the nonsurgeon often is lost. Some hardly can learnhow to expose the cephalic vein, an operative approach that hasgained new importance in light of the dangers of introducer­related complications; tension pneumothorax, hemothorax,wound hemorrhage, and lead-conductor crush fracture betweenthe first rib and the clavicle are just a few of these unfortunateevents. Nonsurgeons now are embarking on solo insertion ofimplanted cardioverter / defibrillators. Imagine the problems thatsoon will appear with the unbridled proliferation of this practice!

Outsiders tend to regard pacemaker implantation as a minorprocedure, one that can be learned easily by anyone. As anexample of this attitude, some pacemaker manufacturers for yearshave sent their nonsurgeon customers to a week's "training" inEurope, after which they return as "certified" pacemaker experts.Rumors have it that this disgraceful practice still exists. I stillreceive requests from nonsurgeons for permission to watch me doa case or two; the supposition is that they will thereby learn allthere is to know about pacing and they will then return home todo the work themselves.

Recommendations for appropriate training have not been lack­ing; several publications have enunciated them [2-7]. It is abun­dantly clear that the subspecialty of pacing is complex andrequires substantial preparation; it cannot be treated lightly.

The following list, although not comprehensive, illustrates thescope of these topics, which fall roughly into three categories:

I. Clinical assessment of the patient; selection of therapy anddevices1. Clinical characteristics that distinguish cardiac from non­

cardiac syncope; interpretation of ambulatory-monitoringreports and event recordings, exercise testing, electrophysi­ologic testing, tilt-table testing, carotid-sinus massage, Val­salva and Muller maneuvers; physical examination includ­ing cardiac auscultation and a search for other causes ofsyncope; knowledge of cardiac anatomy, including normaland congenital variations of the venous system, conductionsystem, cardiac blood supply, and the relationship of theheart to the surrounding tissues; cardiac effects of variousdrugs, electrolyte disturbances, hypoxia, and systemic andneurologic disease.

2. Selection and prescription of appropriate physiologic pac­ing modes.

II. Knowledge and skills related to pacemaker insertion1. Understanding of basic surgical principles including sterile

operating-room techniques, skin preparations, and drap­ing; indications and uses of various anesthetics and sopo­rifics; maintenance of airway patency; techniques of incis­ing, ligating, suturing, tissue handling, and hemostasis.

2. Identifying anatomic landmarks, methods of venous cut­down on a variety of access veins, familiarity with theintroducer technique, management of intraoperative prob­lems such as vascular lacerations, pneumothorax, massive

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