Antegrade Cardioplegia Delivery Research Articles

Is cardioplegia system pressure the optimal measure of coronary perfusion during antegrade cardioplegia delivery? A critical review of pressure measurements for optimal antegrade delivery.

Antegrade cardioplegia is routinely given during cardiac surgery. The delivery of antegrade cardioplegia from the cardiopulmonary bypass machine has many variables. Many perfusionists rely exclusively on cardioplegia system pressure to ensure safe antegrade delivery. Our group reviewed antegrade cardioplegia delivery in 50 patients undergoing coronary artery bypass graft. The data collected included the cardioplegia system pressure and the patient's direct aortic root pressure. The analysis of the data found weak correlation between the two pressures with a large mean difference and a wide standard deviation. The results suggest the direct measurement of aortic root pressure as guidance to antegrade cardioplegia instead of relying solely on cardioplegia system pressure.

Endoscopically assisted selective antegrade cardioplegia in minimally invasive aortic valve replacement for patients with aortic insufficiency

In minimally invasive aortic valve replacement via a right minithoracotomy for patients with significant aortic insufficiency, optimal cardioplegia delivery procedures remain controversial. This study aimed to describe and evaluate endoscopically assisted selective cardioplegia delivery in minimally invasive aortic valve replacement for aortic insufficiency. Between September 2015 and February 2022, 104 patients (mean age, 66.0±14.3 years) with moderate or greater aortic insufficiency underwent endoscopically assisted minimally invasive aortic valve replacement at our institutions. For myocardial protection, potassium chloride and landiolol were systemically administered before aortic crossclamping, and cold crystalloid cardioplegia was delivered selectively to the coronary arteries using step-by-step endoscopic procedures. The early clinical outcomes were also evaluated. Eighty-four patients (80.7%) had severe aortic insufficiency, and 13 patients (12.5%) had aortic stenosis and moderate or greater aortic insufficiency. A regular prosthesis was used in 97 cases (93.3%), and a sutureless prosthesis was used in 7 cases (6.7%). The mean operative, cardiopulmonary bypass, and aortic crossclamping times were 169.3±36.5, 102.4±25.4, and 72.5±21.8minutes, respectively. No patients underwent a conversion to full sternotomy or required mechanical circulatory support during or after surgery. No operative deaths or perioperative myocardial infarctions occurred. The median intensive care unit and hospital stays were 1 and 5 days, respectively. Endoscopically assisted selective antegrade cardioplegia delivery is safe and feasible for treating minimally invasive aortic valve replacement in patients with significant aortic insufficiency.

Endoaortic Balloon Occlusion in Totally Endoscopic and Percutaneous Robotic Cardiac Surgery.

Previous studies have shown that the endoaortic balloon occlusion (EABO) can provide satisfactory aortic cross-clamping with comparable surgical outcomes to thoracic aortic clamping in the setting of minimally invasive and robotic cardiac surgery. We described our approach to EABO use in totally endoscopic and percutaneous robotic mitral valve surgery. Preoperative computed tomography angiography is required to evaluate the quality and size of the ascending aorta, identify access sites for peripheral cannulation and endoaortic balloon insertion, and screen for other vascular anomalies. Continuous bilateral upper extremity arterial pressure and cranial near-infrared spectroscopy monitoring are essential to detect obstruction of the innominate artery due to distal balloon migration. Transesophageal echocardiography is needed for continuous monitoring of balloon positioning and antegrade cardioplegia delivery. Direct fluorescent visualization of the endoaortic balloon on the robotic camera allows for verification of balloon and efficient repositioning if needed. The surgeon should assess hemodynamic and imaging information simultaneously during the balloon inflation and delivery of antegrade cardioplegia. Aortic root pressure, systemic blood pressure, and balloon catheter tension affect the position of the inflated endoaortic balloon in the ascending aorta. The surgeon should eliminate all slack in the balloon catheter and lock it into position to prevent proximal balloon migration after the completion of antegrade cardioplegia. Using scrupulous preoperative imaging assessment and continuous intraoperative monitoring, the EABO can achieve adequate cardiac arrest in totally endoscopic robotic cardiac surgery, even in patients with previous sternotomy without compromise of surgical outcomes.

Transoesophageal Echocardiography Guidance of Antegrade Cardioplegia Delivery for Cardiac Surgery

Transoesophageal Echocardiography Guidance of Antegrade Cardioplegia Delivery for Cardiac Surgery

Transesophageal Echocardiography Guidance of Antegrade Cardioplegia Delivery for Cardiac Surgery.

The initial volume of antegrade cardioplegia used to induce asystole during aortic cross-clamp still is based on empiric methods and may be excessive, potentially leading to hyperkalemia, myocardial edema, and acute left ventricular distention from aortic regurgitation. The objectives were to determine whether the volume of cardioplegia required to induce asystole is proportional to left ventricular mass, and whether the degree of left ventricular distention is proportional to the severity of aortic regurgitation. Prospective observational study. Two tertiary university hospitals. Transesophageal echocardiography was used to estimate left ventricular mass (prolate ellipse revolution formula), quantify aortic regurgitation, and monitor for distention during initial antegrade cardioplegia delivery. The volume of cardioplegia required for asystole was recorded. Fifty-eight patients aged over 18 years scheduled for cardiac surgery requiring aortic cross-clamping. There was a weak correlation of left ventricular mass and antegrade cardioplegia volume required for asystole (r = 0.35, p = 0.047). The degree of left ventricular distention correlated moderately with the severity of aortic regurgitation (r = 0.55, p = 0.007) and was excessive and stopped early (aborted) in 24% of all patients, including 18% of 39 patients without aortic regurgitation. An aortic regurgitation vena contracta of 0.3 cm predicted aborted cardioplegia with modest accuracy (AUC 0.81, 0.66-0.99, p = 0.02, sensitivity 71%, specifity 81%). Estimated left ventricular mass is not a useful predictor of the initial volume of antegrade cardioplegia required to induce asystole. However transesophageal echocardiography can predict and monitor for left ventricular distention, which is common.

Alternative Method for Cardioplegia Delivery During Totally Endoscopic Robotic Intracardiac Surgery

The optimal technique for antegrade cardioplegia delivery during totally endoscopic robotic surgery is still evolving. Cardioplegia delivery with endovascular balloon clamping of the aorta is commonly used but this method has several disadvantages and may lead to serious complications. We describe a novel cardioplegia delivery procedure for totally endoscopic intracardiac surgeries such as atrial septal defect closure and mitral valve repair. The method uses a transthoracic aortic clamp and an antegrade cardioplegia cannula without the need for thoracotomy. The technique is safe and reliable, permits simple cardioplegic arrest, and prevents complications related to endovascular balloon clamping during robot-assisted intracardiac surgery.

Misplacement of Left Ventricular Vent as a Cause of Cardioplegia Failure During Routine Open-Heart Surgery

We report an unusual cause of failure of successful delivery of antegrade cardioplegia through the aortic root that was caused by the accidental passage of the left ventricular vent catheter across the aortic valve producing acute aortic regurgitation. This problem is best prevented.

Use of Axillary Cannulation for Simultaneous Endo-Occlusion and Antegrade Perfusion during Minimally Invasive Surgery

We aimed to develop an antegrade arterial perfusion method that would allow a single suture line on the heart. Using an 8-mm Dacron graft sewn to the right axillary artery, we performed antegrade arterial flow and simultaneous endo-occlusion, as well as the delivery of antegrade cardioplegia. Five patients underwent right axillary antegrade flow, with intention to use axillary endo-occlusion. There were no deaths, axillary artery injuries, or conversions to sternotomy. One patient who had a small (6 mm) axillary artery required femoral arterial balloon placement with axillary arterial flow. When using a 100-mm endoballoon, transesophageal echo alone is suitable for placement of the endoballoon. All patients are alive and doing well at least 1 year after surgery. The right axillary artery is a suitable conduit for simultaneous endo-occlusion, antegrade flow, and antegrade cardioplegia delivery during mitral valve surgery.

Why coronary artery bypass surgery is still the optimal treatment strategy for left main stem disease: an evidence-based review with a Malaysian surgical perspective

Left main stem (LMS) coronary artery disease (CAD) remains an important risk factor for increased mortality and morbidity at all stages of diagnosis and treatment of coronary artery disease. Anatomically,...

Perfusion During Coronary and Mitral Valve Surgery Utilizing Minimally Invasive Port-Access Technology

Minimally invasive surgery has been used in the treatment of some cardiovascular diseases. Port-Access surgery is a new minimally invasive technique that utilizes cardiopulmonary bypass and a specialized catheter system that provides cardiopulmonary support and myocardial preservation. Extrathoracic cardiopulmonary support is established with femero-femoral bypass with kinetic assisted venous drainage. An endovascular catheter system allows for all the benefits of mechanical support as well as myocardial preservation. This catheter system includes an endoaortic balloon catheter which functions as an aortic cross clamp and antegrade cardioplegia delivery catheter, endopulmonary vent, and endocoronary sinus catheter used for administration of retrograde cardioplegia. An initial cohort of 20 patients was treated by the Port-Access surgical approach with cardiopulmonary bypass. Ten patients had coronary artery surgery and 10 patients had mitral valve surgery. The average bypass times were 94.4 min (coronary artery) and 152.8 min (mitral valve). The mean aortic occlusion times were 49.7 min (coronary artery) and 112.6 min (mitral valve). All patients were weaned from bypass. This initial patient series demonstrated that Port-Access surgery was feasible in selected patients.

Continuous versus intermittent cardioplegia in the presence of a coronary occlusion

Coronary artery occlusions can alter the distribution of cardioplegia and result in ischemic damage. This study was undertaken to determine whether continuous antegrade cardioplegia delivery would result in colder temperature and provide better washout of acid metabolites than is possible with intermittent antegrade cardioplegia when coronary occlusions are present. Twenty pigs were placed on cardiopulmonary bypass and underwent 2 hours of ischemic arrest with occlusion of the middle left anterior descending coronary artery followed by 1 hour of reperfusion without occlusion of that artery. Ten pigs received intermittent (every 20 minutes) antegrade potassium crystalloid cardioplegia (4 °C), and 10 others had the same solution given continuously (30 mL/min). Cardioplegia distribution was assessed by continuous monitoring of myocardial pH (Khuri pH probe) and temperature in the region beyond the occlusion of the left anterior descending coronary artery. Both cardioplegic techniques resulted in tissue acidosis (continuous group, 6.69 ± 0.08, versus intermittent group, 6.73 ± 0.07; not significant). Average temperature in the left anterior descending coronary artery during arrest was also similar in both groups (continuous group, 18.3 ° ± 0.5 °C, versus intermittent group, 18.2 ° ± 0.5 °C). Because of these metabolic changes, both cardioplegic techniques resulted in abnormal wall motion in the anteroseptal region using two-dimensional echocardiography, but the scores were not significantly different (continuous group, 1.5 ± 0.3, versus intermittent group, 1.6 ± 0.4; 4 = normal to 0 = dyskinesia). We conclude that continuous antegrade cardioplegia delivery fails to enhance the washout of acid metabolites or lower myocardial temperature in the presence of a coronary occlusion and results in no better myocardial protection than can be obtained with an intermittent cardioplegic technique.

A Method of Decreasing Anastomotic Leaks and Delivering Cardioplegia in Aortic Root Replacement

Ascending aortic root replacement is associated with a significant incidence of bleeding from composite graft to annulus anastomosis and from coronary to composite anastomosis. We describe a technique for composite graft to annulus and coronary to composite graft anastomoses with circular Teflon donuts. We also describe a method for delivery of antegrade cardioplegia that allows assessment of anastomoses prior to weaning from bypass.