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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
Right ventricular protection with coronary sinus retrograde cardioplegia
Clinical Anatomy, 1994
Fifteen consecutive patients having open heart surgery using retrograde cardioplegia were studied to demonstrate that important venous collateralization exists between the coronary sinus (CS) and its left ventricular branches and the right ventricle (RV). The venous collateralization makes possible RV myocardial protection during retrograde cardioplegia. Right ventricular venous drainage principally occurs via anterior cardiac veins, which drain into the right atrium, and thebesian veins, which drain into both the RV and the atrium, generally without connection to the CS. Retrograde cardioplegia used during open heart surgery should, therefore, give inadequate myocardial protection to the RV. Two RV temperature probes used as markers for RV perfusion were monitored continuously during cardiac arrest. Systemic temperature while on cardiopulmonary bypass was 2YC, and the retrograde perfusate solution temperature was 4°C. Coronary sinus pressure during the bypass procedure was maintained between 20 torr and 50 torr. Mean temperatures at the two probe sites were 16.1"C and 14.5"C. We conclude that a complex network of venous collaterals between the coronary sinus and left ventricle and the right ventricle allow excellent myocardial protection during 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 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.
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.
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.
Superiority of retrograde cardioplegia after acute coronary occlusion☆
The Annals of Thoracic Surgery, 1991
Because antegrade cardioplegia may limit the distribution of cardioplegia beyond a coronary occlusion, this study was undertaken to determine whether retrograde coronary sinus cardioplegia provides superior myocardial protection during revascularization of an acute coronary occlusion. In 20 adult pigs, the second and third diagonal branches were occluded with a snare for 1?h hours. Animals were then placed on cardiopulmonary bypass and underwent 30 minutes of ischemic arrest with multidose, potassium, crystalloid cardioplegia. In 10 animals, the cardioplegia was given antegrade through the aortic root, whereas in 10 others, it was given retrograde through the coronary sinus. After the arrest period, the coronary snares were released and all hearts were reperfused for 3 hours. Postischemic damage in the he presence of coronary occlusions can alter the
The Journal of Thoracic and Cardiovascular Surgery, 1995
This study documents the gross flow characteristics and capillary distribution of cardioplegic solution delivered retrogradely with the coronary sinus open versus closed. Methods: Five explanted human hearts from transplant recipients were used as experimental models. Hearts served as their own controls and received two doses of warm blood cardioplegic solution, each containing colored microspheres. The first dose was delivered through a retroperfusion catheter with the coronary sinus open and the second dose was delivered with the sinus occluded. Capillary flow was measured at twelve ventricular sites and gross flow was measured by examining coronary sinus regurgitation, thebesian vein drainage, and aortic eifluent (nutrient flow). Results: Coronary sinus ostial occlusion allowed for a significant decrease in total cardioplegic flow (1.74 + 0.40 ml/gm versus 1.06 +-0.32 ml/gm; p < 0.05) to occur while maintaining an identical intracoronary sinus pressure. Ostial occlusion also resulted in an increase in the ratio of nutrient flow/total cardioplegic flow from 32.3% ---15.1% to 61.3% -4-7.9% (p < 0.05). A statistically significant improvement in capillary flow was found at the midventricular level in the posterior intraventricular septum and posterolateral right ventricular free wall. This improvement was also documented for the intraventricular septum and right ventricle at the level of the apex. Conclusion: Coronary sinus occlusion during retrograde cardioplegia significantly improves cardioplegic delivery to the right ventricle and posterior intraventricular septum. Furthermore, the technique affords a significant improve. ment in nutrient cardioplegic flow while reducing the overall volume of cardioplegic solution administered. (J THORAC CARDIOVASC SURG 1995;109:941-7)