Right ventricular protection with coronary sinus retrograde cardioplegia (original) (raw)
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Anatomic and hemodynamic considerations influencing the efficiency of retrograde cardioplegia
The Annals of Thoracic Surgery, 2001
cardioplegia Anatomic and hemodynamic considerations influencing the efficiency of retrograde http://ats.ctsnetjournals.org/cgi/content/full/71/4/1389 on the World Wide Web at: The online version of this article, along with updated information and services, is located Print ISSN: 0003-4975; eISSN: 1552-6259. Southern Thoracic Surgical Association. One of the major issues raised by cardiac surgical procedures requiring cardiopulmonary bypass is the question of myocardial protection. The preferred route for the administration of cardioplegia is controversial. A number of studies show the beneficial effects of retrograde cardioplegia but some demonstrate only partial or poor myocardial protection. This paper reviews the anatomy and anatomic variations of the coronary sinus, the coronary sinus orifice and cardiac veins, and the major systemic venous drainage, all of which may affect the distribution of retrograde cardioplegia. (Ann Thorac Surg 2001;71:1389 -95) P ratt [1] suggested in 1898 that oxygenated blood could be supplied to an ischemic myocardium through the coronary venous system. In 1956, Lillehei and colleagues [2] used retrograde coronary sinus perfusion to protect the heart during an aortic valve operation. Since then, retrograde coronary sinus cardioplegia (RCP) has gained widespread use as a method of myocardial protection in a broad range of cardiac procedures. The advantages of RCP are (1) the provision of a relatively uniform distribution of cardioplegia even in the presence of severe coronary artery disease which can alter the distribution of antegrade cardioplegia [3, 4
Retrograde Coronary Sinus Perfusion for Myocardial Protection during Cardiopulmonary Bypass
Annals of Thoracic Surgery, 1978
The pathophysiology of retrograde coronary sinus perfusion was studied in a vented, nonworking heart in vitro. The fraction of nutritional blood flow, estimated with the trapping index of radioactive microspheres (15 k 5 p), is approximately one-fifth of total flow. The runoff is primarily through the thebesian system and venovenous channels, as is shown with Microfil injection studies. These results suggest that retrograde coronary sinus perfusion would be of marginal value in revascularizing a working heart but would be effective in protecting a hypothermic, nonworking myocardium.
cardioplegia Anatomic and hemodynamic considerations influencing the efficiency of retrograde
2008
One of the major issues raised by cardiac surgical procedures requiring cardiopulmonary bypass is the question of myocardial protection. The preferred route for the administration of cardioplegia is controversial. A number of studies show the beneficial effects of retrograde cardioplegia but some demonstrate only partial or poor myocardial protection. This paper reviews the anatomy and anatomic variations of the coronary sinus, the coronary sinus orifice and cardiac veins, and the major systemic venous drainage, all of which may affect the distribution of retrograde cardioplegia.
The Annals of Thoracic Surgery, 1988
The efficacy of retrograde coronary sinus cardioplegia (RCSC) administered through the right atrium compared with aortic root cardioplegia (ARC) has not been examined critically in patients undergoing coronary artery bypass grafting (CABG). Twenty patients having elective CABG were randomized prospectively to receive cold blood ARC (Group I, 10 patients) or cold blood RCSC (Group 11, 10 patients). Patient demographics were similar in both groups. Ventricular function was assessed preoperatively by radionuclide ventriculography and postoperatively by simultaneous hemodynamic and radionuclide ventriculographic studies with volume loading. There was no change in ejection fraction (EF) (preoperative versus postoperative value) in Group I (50 f 6% versus 53 f 6%) but in group 11, at similar peak systolic pressure and similar left ventricular end-diastolic volume index (LVEDVI), LVEF improved significantly (49 f 6% versus 60 f 12%, p < 0.05). Postoperative ventricular function (stroke work index versus EDVI) for the left ventricle and right ventricle were similar in both groups. Evaluation of postoperative LV systolic function (end-systolic blood pressure versus end-systolic volume index) and diastolic function (pulmonary capillary wedge pressure versus EDVI) were also similar in both groups.
The regional capillary distribution of retrograde blood cardioplegia in explanted human hearts
The Journal of Thoracic and Cardiovascular Surgery, 1995
Warm retrograde blood cardioplegia is frequently used for myocardial protection, despite experimental studies questioning the adequacy of capillary flow to the right ventricle and septum. The capillary distribution of retrograde blood cardioplegia in the human heart is unknown. Hearts from eight transplant recipients with the diagnosis of idiopathic or dilated cardiomyopathy were arrested in situ with cold blood cardioplegia and excised with the coronary sinus intact. Within 20 minutes of explantation, colored microspheres mixed in 37 ° C blood cardioplegia were administered through the coronary sinus at a pressure of 30 to 40 mm Hg for 2 minutes. Twelve transmural myocardial samples were taken horizontally at the level of midventricle and apex to determine regional capillary flow rates. When retrograde warm blood cardioplegia was administered at a rate of 0.42 -+ 0.06 ml/gm/min, the left ventricle, the septum, the posterior wall of the right ventricle, and the apex consistently received capillary flow rates in excess of their metabolic requirements. The capillary perfusion of anterior and lateral walls of the right ventricle was marginally adequate to sustain aerobic metabolism. In explanted human hearts, retrograde blood cardioplegia provides adequate capillary flow to the left ventricle, the septum, the posterior wall of the right ventricle, and the apex; however, capillary flow to the anterior and lateral walls of the right ventricle is marginal. This study delineates the tenuous balance between supply and demand for right ventricular protection with warm continuous retrograde blood cardioplegia. (J TrIORAC CAR-DIOVASC SURG 1995;109:935-40)
The Journal of Thoracic and Cardiovascular Surgery, 1996
Retroperfusion of the coronary sinus does not provide homogeneous distribution of cardioplegic solution. The goal of this study was to analyze the distribution of flow during retrograde cardioplegic infusion in cadaveric human hearts with two different techniques of coronary sinus cannulation: (1) internal occlusion of the coronary sinus by balloon inflation and (2) external occlusion by tightening the orifice of the coronary sinus around a simple catheter. To evaluate differences between the two techniques, angiographic and electron-beam computed tomographic studies were performed. Computed digital angiography was performed on 14 hearts. Angiographic patterns varied according to type of coronary sinus cannulation. With the balloon inflation technique, the marginal vein and the anterior descending vein were perfused first; the posterior descending vein was not perfused. This vein was opacified secondarily through a venovenous anastomosis located at the apex of the heart. Backward flow into the right atrium (steal phenomenon) was demonstrated. At completion of retroperfusion, the inferior part of the septum remained poorly opacified. Conversely, angiographic findings after external occlusion of the coronary sinus revealed simultaneous injection of all venous channels. The entire septum was well opacified at completion of retroperfusion. Electronbeam computed tomographic study was performed on eight hearts with the external occlusion technique and nine with the internal occlusion technique. The computed tomographic findings confirmed the results of digital angiography. The peak myocardial enhancement and the peak rising rate of myocardial enhancement within the interventricular septum were significantly more important (p < 0.0001) when the external coronary sinus occlusion mode was used than when the internal coronary sinus occlusion mode was used. In all hearts except one, the right ventricular wall was not opacified, regardless of the type of cannulation and the type of radiologic analysis. This study demonstrates the importance of coronary sinus cannulation technique in optimizing the protection of the interventricular septum with retrograde cardioplegic infusion. (J Thorac Cardiovasc Surg 1996;112:1046-53) R etrograde cardioplegic infusion through the coronary sinus (CS) is an increasingly popular technique for myocardial protection. 1-3 Recent studies have shown, however, that this technique does not From the Departments of Cardiovascular Surgery a and Radiology and INSERM, b H6pital Broussais, and the Anatomic Institute of Paris, UFR Biom6dicales des St-Phres, ° Paris, France.
European Journal of Cardio-Thoracic Surgery, 1997
Objective: Myocardial areas distal to complete coronary artery occlusion are poorly protected by antegrade cardioplegia. Hence, retrograde cardioplegia becomes an important adjunct in myocardial protection. An aim of the study was to compare both methods prospectively. Methods: 158 coronary artery bypass grafting (CABG) patients were randomly assigned to two groups according to myocardial protection technique: 89 patients to group 1-retrograde cold blood cardioplegia (RCBC); and 69 patients to group 2-antegrade cold blood cardioplegia (ACBC). Preoperative parameters were similar but cross-clamp time and volume of cardioplegia needed were higher in the retrograde group. The results were assessed on the basis of: (1) clinical outcome; (2) ECG and enzymatic parameters of ischemia; (3) assessment of early systolic function by means of cardiac output (CO), stroke work index (SWI), left ventricular stroke work index (LVSWI) and right ventricular stroke work index (RVSWI) taken before, and 1 and 5 h after coming off bypass; (4) late systolic and diastolic function by echo assessment of segmental contractility of 17 segments and indexes of peak transmitral flow (TMI) taken 7 days and 6 months after operation. Results: Ischemic events, inotropes and ventricular fibrillation on reperfusion were significantly more frequent in the antegrade group. Sinus rhythm at an early stage postoperatively was found more frequently in the retrograde group. All these parameters became comparable 24 h after operation. Early myocardial recovery was better in the retrograde group where intraoperative improvement in CO and SWI was significant. At the same time, SWI decreased significantly in the antegrade group. RVSWI changes were similar in both groups. There were no differences in mortality and perioperative MI. Late myocardial performance by segmental contractility and diastolic transmitral flow were similar in both groups. Conclusions: Retrograde continuous blood cardioplegia reduces ischemic injury and permits better early recovery of myocardial function. There is no difference, however, regarding long-term assessment of myocardial recovery.