“Directed” Cardioplegia: A New Approach in Myocardial Protection in Left Main Coronary Artery Disease (original) (raw)
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The treatment of acute myocardial infarction due to the occlusion of the left main coronary disease
Cardiology journal, 2011
Acute myocardial infarction (AMI) due to the occlusion of the left main coronary artery (LMCA) is a rare but serious condition in the era of percutaneus coronary intervention (PCI). Even more rare is AMI involved with both LMCA and its branches like trifurcartion or bifurcation: this is challenging for interventional cardiologists, because it involves the extension of the myocardium complicated by cardiogenic shock and its technical difficulties. Trifurcating coronary artery disease is a complex atherosclerotic process involving the origin of one or more of three side branches arising from a left main coronary vessel or trunk, with or without the involvement of LMCA itself. There is no classification or standardized methodology to treat LMCA disease in elective percutaneous intervention procedures. Furthermore, acute myocardial infarction presenting with left main coronary artery trifurcation lesion seems to be more troublesome, especially in young patients. Few series of PCI on sig...
Kosuyolu Kalp Dergisi, 2012
Introduction: Antegrade route may fail to provide homogenous cardioplegia distribution in patients with totally occluded coronary arteries. Cardioplegia via vein graft beyond occlusion is considered as an alternative approach to achieve better myocardial protection. In this study, we aimed to compare myocardial protection achieved with antegrade cardioplegia and antegrade plus vein graft cardioplegia in patients with totally occluded coronaries. Patients and Methods: Consecutive 14 patients with at least one totally occluded coronary artery were randomly divided into two groups. Antegrade cardioplegia was used in group 1, antegrade plus vein graft cardiplegia was used in group 2. Creatine kinase, creatine kinase MB, lactate and troponine I levels were measured for myocardial damage monitorization. Samples were collected from the arterial line and coronary sinus simultaneously; at the beginning of the operation before extracorporal circulation institution (1), after completion of the distal anastomosis, immediately after "hot shot" cardioplegia infusion and aortic unclamping (2) and after removal of the side clamp (3). Measurements were repeated at the 6 th (4), 12 th (5), 24 th (6) and 48 th (7) postoperative hours from the peripheral arterial line. Groups were compared statistically. Results: In this study, cardiac enzymes and transcoronary lactate gradient were found similar in each measurement. Conclusion: Antegrade cardioplegia may achieve adequate myocardial protection in patients with totally occluded coronary arteries. Antegrade plus vein graft cardioplegia does not seem to provide any advantage in this spesific patient group.
2009
3 Abstract: There is still a debate about the cardioplegia administration method in patients with left main coronary disease. This prospective randomized study compared clinical, echocardiographic, markers of myocardial damage, morbidity and mortality in 103 consecutive patients with left main coronary artery disease treated with 2 different ways of giving the cardioplegic solutions. Patients were allocated into 2 groups according to the route of cardioplegia administration: combined antegrade- retrograde in 52 patients (group A) and antegrade alone in 51 patients (group B). The biochemical markers for myocardial damage showed statistically higher values in patients who underwent antegrade cardioplegia alone (group B) (P< 0.05), however, its levels never fulfilled the criteria of perioperative myocardial infarction. Postoperative recovery of left ventricular ejection fraction and wall motion score index did not differ significantly between the 2 groups.It was concluded that The c...
Efficacy of coronary sinus cardioplegia in patients with complete coronary artery occlusions
The Annals of Thoracic Surgery, 1991
Myocardial areas distal to complete coronary artery occlusions are poorly protected by antegrade cardioplegia. We assessed the effects of coronary sinus cardioplegia in 30 patients undergoing bypass operations and at high risk of cardioplegic maldistribution because of the following anatomical patterns of coronary artery disease: critical (250%) stenosis of the left main trunk with total occlusion of the right coronary artery (16 patients) or critical (270%) stenosis of the right coronary artery with total occlusion of the left anterior descending (11 patients) or circumflex artery (3 patients). After induction of arrest through the aorta, coronary sinus cardioplegia was given intermittently during the cross-clamp period at a flow rate of 100 mWmin. Intraoperatively, occluded arteries were consistently found to be filled with the retrogradely infused solution. One patient died early omplete occlusion of a coronary artery represents a C challenge for adequate delivery of cold cardioplegia and hence for adequate preservation of the myocardial area subserved by the occluded vessel [l-31. In the past years, retrograde administration of cardioplegic solution through the coronary sinus has emerged as an attractive alternative to the various strategies of antegrade cardioplegic delivery [l, 41 because the coronary venous system represents an extensive and unobstructed network that is expected to behave as a very effective conduit for delivering core cooling and cardioplegic additives throughout the thickness of the myocardium. Stimulated by our favorable experience with the use of coronary sinus cardioplegia in valve operations [5] as well as by the consistent experimental demonstration that retrograde coronary sinus cardioplegia affords better protection to myocardial areas distal to coronary artery occlusions than do antegrade methods [6, 71, we undertook this observational study to assess the effects of the coronary sinus approach in a subset of patients undergoing coronary artery bypass grafting (CABG) and selected on the basis of a highly predictable risk of cardioplegic maldistribution because of multivessel disease involving at least the complete occlusion of a major coronary artery.
Vojnosanitetski pregled, 2012
Introduction. The optimal revascularization strategy for unprotected left main coronary disease (ULMCD) is the subject of ongoing debate and patients with ULMCD still represent a challenge for interventionalist, especially in the setting of an acute coronary syndome (ACS). Case report. We presented two cases of percutaneous treatment of ULMCD in the settings of ACS (ST Segment Myocardial Infarction and Non ST Segment Myocardial Infarction - STEMI and NSTEMI) in a catheterization laboratory without back-up of cardiosurgical department. Both patients were hemodynamically unstable with clinical signs of cardiogenic shock. Coronary angiography revealed left main thromobosis and using intra-aortic balloon pump as hemodynamic support primary angioplasty procedures were performed. Immediately after the procedures the patients hemodynamically improved and remained stable till discharge from hospital. Conclusion. Percutaneous coronary intervention (PCI) has become the most common strategy of...
Percutaneous coronary intervention to treat unprotected left main: Common (un-answered) challenges
Kardiologia Polska
Percutaneous coronary intervention (PCI) with drug-eluting stent (DES) implantation is a widely adopted strategy to obtain myocardial revascularization in patients with unprotected left main (LM) disease. Although thoroughly investigated across scientific literature, LM PCI offers patient-specific technical options and poses many operative challenges that cannot be fully addressed by the published studies. Therefore, we have summarized and discussed in this review possible options related to PCI in LM patients. First, functional and imaging assessment for LM is still evolving and requires increased dedication to identify patients requiring revascularization and to enhance the results in the case of PCI performance. Second, specific coronary atherosclerosis patterns of LM involvement (like an isolated ostial disease of one of its bifurcation branches, extensive disease jeopardizing both branches, etc.) pose specific challenges for DES implantation so that careful selection of technical options (stepwise provisional single stent, upfront 2-stent strategy, when and how apply "kissing ballooning") is required. Third, despite improvement of techniques, PCI-related ischemia might not be tolerated by some patients with LM disease so mechanical circulatory support devices may come into play.
Heart and Vessels, 2010
Background: Refinements in percutaneous coronary intervention (PCI), including the use of intravascular ultrasound (IVUS) and fractional flow reserve (FFR), have allowed the treatment of complex lesions with good results. As a result, the percutaneous approach for left main coronary artery (LM) lesions has spread, including centers with a lower volume of PCI procedures. Our objective was to report the early and late outcomes of PCI in unprotected LM lesions. Methods: Consecutive patients treated at two different hospitals from August 2009 to July 2013 were included. The indication for the percutaneous approach was based on the clinical assessment and the calculation of Syntax score, EuroScore and on the patient's wishes. Results: Twenty-eight patients with mean age of 69.2 ± 10.1 years were treated, 39% were diabetic and 39% had acute coronary syndromes. Half of the patients had EuroScore ≥ 6; the Syntax score was 26.0 ± 8.4 and 82% had LM bifurcation lesions. Interventions were guided by IVUS and/or FFR in 71.4% of the patients, 93% were treated with drug-eluting stents, and the 1-stent technique was used in most occasions. Angiographic success was achieved in 100% of the cases. At the 19.2 ± 13.7 month follow-up, the rate of major adverse cardiac events was 21.4% in the follow-up longer than 4 years, cardiac death 14.2%, non-fatal myocardial infarction 3.5% and target-lesion revascularization 3.5%. Conclusions: PCI in unprotected LM lesions, guided by IVUS and/or FFR whenever possible, is safe and effective in the short and long-term, in the experience of a hospital with a moderate number of PCI procedures.
Pakistan Armed Forces Medical Journal, 2021
Objective: To compare the early outcome of Coronary Artery Bypass Graft surgery using a combination of antegrade and retrograde cardipoplegia with that utilizing antegrade cardioplegia alone in triple vessel coronary artery disease. Study Design: Comparative cross-sectional study. Place and Duration of Study: Department of Adult Cardiac Surgery of Armed Forces Institute of Cardiology and National Institute of Heart Diseases, Rawalpindi, from Sep 2013 to Apr 2019. Methodology: A total of 160 patients with triple vessel coronary artery disease who underwent CABG surgery for 90% or greater stenos is in at least one major vessel in each of the three territories, namely the left anterior descending, the circumflex and the right coronary artery were investigated retrospectively. These were divided into 2 equal groups on the basis of the technique of administration of cardioplegia: in group-1 only ante grade blood cardioplegia was administered for myocardial protection and group-2 was give...