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J Thorac Cardiovasc Surg 2008;136:236-237
© 2008 The American Association for Thoracic Surgery

Letter to the Editor

Reply to the Editor:

University Hospital Olomouc, Olomouc, Czech Republic

I greatly appreciate the comments of our French colleagues on our article describing an alternative approach to chest drainage using Redon drains. The main concern they raised was that the high suction used in our system could cause suction lesions on the heart or coronary grafts. They have experienced one case of bypass necrosis resulting from the high suction, but no such complication occurred in our cohort of 4297 patients. I have occasionally observed suction lesions on the heart or even the grafts during reoperations for bleeding when removing a drain that was in direct contact with them, but such lesions always appeared harmless and never led to any problems. In my opinion, the case of bypass necrosis described by Al-Attar, Raffoul, and Nataf was due to the coincidence of direct contact of the drain with a deficient wall of the venous graft.

Their interesting but certainly isolated case report of graft necrosis does not convince me to abandon our technique. I have also seen some isolated complications when using standard 32F chest tubes over the years, including graft thrombosis caused by tube compression or even fatal hemorrhagic shock caused by bleeding from the intercostal vessel in the posterior chest wall that was eroded by the chest tube. However, there is no surgical procedure that carries no risks.

When using our technique, care should be taken to avoid direct contact of the Redon drains with the grafts, and this can be achieved by positioning the drains as described in our article: on the bottom of the opened pericardial cavity and leaning against the pericardium rather than lying on the surface of the heart. The only situation in which the drains may be in close contact with the myocardium is when the pericardium is closed, which we routinely avoid when any grafts are put on the coronary arteries.

It should also be remembered that the applied suction is –816 cm H₂O only at the beginning of the drainage, with this decreasing as the reservoir fills with blood.

I should like to clarify that I have a different experience regarding the pain caused by the removal of Redon drains. Even though I remove them after disconnecting them from the reservoir (some surgeons do not disconnect them), the maneuver is no less painful than removing 32F chest tubes.

It is possible to use fewer drains in the pericardial cavity, and some of the surgeons at my institution prefer to insert only two or three of them. However, in my opinion the previously proposed scheme of four drains covering all regions around the heart is optimal.

I have recently changed the position of the left pleural drain, inserting it through the back wall of the pericardium rather than through its lateral wall, as described in our article. This is done so as to avoid the possibility of phrenic nerve injury. It is mandatory during this maneuver not only to lift the pericardium but also to deflate the lungs, especially during off-pump surgery, to avoid cautery lung injury.

The optimal negative pressure for our drainage is still unclear, but –20 cm H₂O seems too low for drains with an inner diameter of 2 mm. However, the main drawback of the French drainage system is the substantial additional cost caused by the use of a Pleur-evac unit (Teleflex Inc, Research Triangle Park, NC). The cost difference between using five Redon drains with reservoirs (as we do) and using three 32F chest tubes plus a Atrium Oasis 3600 (Atrium Medical Corp., NH, USA) reservoir is around $140 (US) per patient.

In summary, I would encourage our French colleagues and other surgeons to reconsider their drainage systems in favor of the one presented in our article.

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Gwozdziewicz, M. Search for Related Content PubMed Articles by Gwozdziewicz, M. Related Collections Mediastinum Pleura Chest wall