Retrograde Blood Research Articles

Interrupted Aortic Arch and Aortic Atresia With Circle of Willis-Dependent Coronary Perfusion

We present a case of type B interrupted aortic arch and aortic atresia. This combination is usually incompatible with life. However, the presence of an aberrant right subclavian artery and enough blood flow through the circle of Willis allowed perfusion of the coronary arteries through retrograde carotid and aortic blood flow. A two-ventricular repair was successfully undertaken.

Metabolismo miocárdico após cardioplegia sangüínea hipotérmica retrógrada contínua com indução anterógrada normotérmica

OBJECTIVE: To determinate the alterations suffering by myocardium in the hypothermic retrograde continuous blood cardioplegia with antegrade warm cardioplegic induction. METHOD: A metabolic analysis of hypothermic retrograde continuous blood cardioplegia with antegrade warm cardioplegic induction was performed in a prospective study of 15 patients scheduled for elective coronary artery bypass grafting. Arterial and coronary sinus blood samples were simultaneously taken: before establishing cardiopulmonary bypass, after anterograde warm cardioplegic induction, when the aortic clamp was removed and 10, 30 and 60 minutes after reperfusion to analyze the oxygen content and lactate concentration. Four transmural left ventricular biopsy samples were obtained: before aortic clamping, immediately after the initial cardioplegia bolus, immediately before aortic declamping and 30 minutes after reperfusion to analyze the levels of ATP, ADP, AMP and lactate in the myocardium. The CK-MB isoenzyme was analysed in venous blood samples. RESULTS: There were no mortalities in the group. Inotropic support was not necessary in any patients and no peri- or post-operative myocardial infarction was detected. There was a decrease in the arterial-venous extraction of oxygen and lactate in the heart during reperfusion, a partial recovery occurred at 60 minutes of reperfusion. The levels of ATP and the other nucleotides in the myocardium were maintained during aortic clamping, but these levels decreased during the first 30 minutes of reperfusion. The lactate accumulated in the heart muscle during aortic clamping with a decrease occurring during reperfusion. CONCLUSIONS: From a metabolic point of view the method could not avoid an anaerobic metabolism during cross-clamping and only after 60 minutes of reperfusion there was a satisfactory metabolic recovery. These alterations are probably a reflection of cellular ischemic injury that occurs during cross-clamping and they seem to be of transitory effect. A better myocardium protection was observed with the addiction of anterograde warm induction cardioplegia.

<![CDATA[Myocardial metabolism after hypothermic retrograde continuous blood cardioplegia with anterograde warm cardioplegic induction]]>

<![CDATA[Myocardial metabolism after hypothermic retrograde continuous blood cardioplegia with anterograde warm cardioplegic induction]]>

Preventing Renal Failure in Thoracoabdominal Aortic Aneurysm Repair

In our cumulative experience of 1004 thoracoabdominal and descending thoracic aortic aneurysm repairs, approximately 20% of patients have suffered from some form of postoperative renal dysfunction. Although slightly lower than rates in the era of cross-clamp-and-go, the contemporary incidence of renal failure and consequent morbidity and mortality remain significant. Between January 1991 and February 2003, we used and appraised many different forms of renal protection. After September 1992, we began to routinely use the adjuncts of distal aortic perfusion and cerebrospinal fluid drainage for all thoracoabdominal and descending thoracic aortic aneurysm repairs. The methods we examined for renal protection included aortic perfusion, followed by warm blood visceral perfusion, antegrade cold blood visceral perfusion, retrograde cold blood perfusion, and the perioperative use of a renal protective pharmacologic agent, fenoldopam. The results were not overly promising. We are currently testing a method of split perfusion in which the renal arteries receive cold lactated Ringer's solution while the visceral arteries are perfused with cold blood. The major predictors of postoperative renal dysfunction are preoperative renal function, cross-clamp time, and repair extending to the renal arteries. Distal aortic perfusion is protective, but only for aortic repair that does not directly involve the renal arteries. Evidence shows that patients with cold perfusion have superior survival and recovery rates, but none of the adjuncts clearly prevent acute renal failure. The current mortality rates associated with postoperative renal failure remain high, and the pursuit of the optimal method of renal protection is a top priority.

Color Doppler Imaging of Retrobulbar Hemodynamics in a Patient with Glaucoma Duet Associated with Dural Carotid-cavernous Sinus Fistula

Although elevated intraocular pressure (IOP) resulting from increased episcleral venous pressure is common in patients with dural carotid-cavernous sinus fistulas (DCFs), neovascular glaucoma (NVG) is rare. A 42-year-old woman with ocular congestive symptoms, including high IOP in her right eye, was diagnosed with right DCF with carotid angiography. Although the symptoms resolved after gamma knife radiosurgery was performed to treat the DCF, central retinal vein occlusion (CRVO) occurred 5 weeks later. Color Doppler ultrasonography indicated the absence of blood flow in the superior ophthalmic vein. This was unlike the retrograde pulsatile blood flow observed with Doppler ultrasonography before the gamma knife radiosurgery. The subsequent development of NVG was treated with a combination of peripheral retinal cryotherapy and diode laser transscleral cyclophotocoagulation. This is the first reported case of CRVO and NVG as complications of DCF after an uneventful gamma knife radiosurgery in a relatively young woman free of systemic cardiovascular or hematologic disorders. Color Doppler ultrasonography delineates orbital hemodynamic changes and helps provide a guide to treat complications associated with DCF.

Comparison of the immediate post-operative outcome of two different myocardial protection strategies: antegrade–retrograde cold St Thomas blood cardioplegia versus intermittent cross-clamp fibrillation

The objective of this study was to compare the immediate post-operative outcome of two myocardial protection strategies. Data of consecutive elective first time coronary artery bypass grafting (CABG) were analysed: Group A (n=671, antegrade-retrograde cold St Thomas blood cardioplegia) and Group B (n=783, intermittent cross-clamp fibrillation). Age, angina class, myocardial infarction (MI), pre-operative rhythm, respiratory disease, smoking, diabetes mellitus (DM), hypertension (HT), renal function, cerebrovascular disease, body mass index (BMI) and Parsonnet score were comparable. Significant differences existed in gender (P=0.02), peripheral vascular disease (PVD) (P=0.04), heart failure class (P=0.0001), left ventricular (LV) function (P=0.01), disease severity (P=0.02), left main stem (LMS) (P=0.02) and preinduction intra-aortic balloon pump(IABP) (P=0.08). Group A had more grafts (P=0.008), longer bypass (P=0.0001) and cross-clamp time (P=0.0001). Post-operative inotrope, MI, arrhythmias, neurological, renal complications, multi-organ failure, sternal re-wiring, ventilation, length of stay and mortality were comparable. There was higher IABP usage and longer intensive therapy unit (ITU) stay (P=0.01) in Group B. Chronic obstructive airway disease (COAD), renal dysfunction, cross-clamp time, bypass time, post-operative inotrope or IABP and re-exploration predicted longer ITU stay. Intermittent cross-clamp fibrillation is a versatile and cost-effective method of myocardial protection, with the immediate post-operative outcome comparable to antegrade-retrograde cold St Thomas blood cardioplegia in elective first-time CABG.

Even a Root Canal Has its Advantages: Dental Syringe as a Mist Blower

In coronary artery surgery, especially during off-pump procedures and when continuous retrograde warm blood cardioplegia is used, a gentle but effective system is required to improve visualization without desiccating tissues. A simple, efficient, reusable, and very cost-effective device is described.

Salvage of Free Second Toe with Venous Thrombosis by Shunting Backflow of Second Dorsal Metatarsal Artery-A Case Report

A 26-year-old Thai man underwent free toe transfer for reconstruction of his left band after multi-digit amputation. Unfortunately we encountered a problem of disseminated venous thrombosis. We dissected the thrombotic veins and found that the venous network was occluded by thrombi. Surprisingly, there was a retrograde arterial blood flow in the second dorsal metatarsal artery which immediately relieved the congestion. We shunted the backflow of the SDMA (second dorsal metatarsal artery) with a vein graft and successfully salvaged the free toe.

Cardioplegia retrógrada atrial: estudo clínico

This study presents the results in a group of fifteen patients submitted to cardiac surgery, using continuous atrial retrograde warm blood cardioplegia for myocardial protection. Eleven patients were submitted to myocardial revascularization and four were submitted to valvular transplantation. There was no need for inotropic drugs or intraaortic balloon pump support during or after the procedure, and no myocardial infarction was detected in this group. When the heart was arrested, the cardioplegia line was switched to the atrial cannula. The aortic root was vented throughout the cross-clamp period, and retrograde perfusion was assured by noting the engorged exygenated cardiac veins as well as the return of dark blood through the vent in the aortic root. The patients presented good clinical and laboratory course. No right ventricular dysfunction was detected. Two patients were in atrial fibrillation before the surgery, one of them returned to this cardiac rhythm three days after the procedure.

Recent Developments in Myocardial Protection: Retrograde Cardioplegia

In recent years there has been increasing use of coronary sinus perfusion to deliver cardioplegic solutions during open-heart surgery. This has been aided by advances in coronary sinus catheter design and by easier methods of cannula insertion. Coronary sinus perfusion has been used with both intermittent crystalloid and blood cardioplegia and has recently evolved to include retrograde continuous normothermic blood cardioplegia. Coronary sinus perfusion has several advantages including safety, ease of use (with a single cannula placed out of the operative field), usefulness in patients with significant aortic regurgitation, redo coronary artery bypass graft surgery, and acute myocardial infarction. However, there are continuing concerns about the distribution of retrograde perfusion, preservation of right ventricular function, dislodgment of the coronary sinus catheter (and resulting ischemia during surgery), and damage to the coronary sinus.

Study on the usefulness of retrograde continuous warm blood cardioplegia in coronary artery bypass graft

Study on the usefulness of retrograde continuous warm blood cardioplegia in coronary artery bypass graft

Scleral and Conjunctival Hemorrhages Arising from a Gunshot Wound of the Chest: A Case Report

A young man committed suicide in the back seat of an automobile, witnessed by two law enforcement officers sitting in the front seat who had attempted to dissuade him from killing himself over an eight hour period. Death was caused by a contact gunshot wound of the anterior chest, which entered the midsternum and disrupted the anterior right atrium and ventricle of the heart, without involvement of either left ventricle or atrium. At the autopsy, bilateral fresh, confluent scleral and conjunctival sulcus hemorrhages were discovered, with no other evidence of facial or intracranial trauma. These hemorrhages are postulated to have arisen from a sudden pressure wave ascending through the superior vena cava, in a manner similar to the ocular findings associated with the retrograde venous blood flow that occurs during severe thoracic compression. These hemorrhages should not be mistaken for evidence that a decedent was beaten or otherwise involved in an assault episode.

Continuous retrograde blood cardioplegia

We present a technique of myocardial protection using retrograde cold blood cardioplegia. This safe and simple method allows excellent continuous and homogeneous cooling of the heart during the ischemic period in all types of open heart operations.

Importance of retrograde coronary flow in the prediction of experimental myocardial infarct size.

The relationship between myocardial infarct size (measured by a histochemical stain) and coronary collateral blood flow (measured via retrograde flow and by use of radioactive microspheres) was studied in anesthetized dogs with high, moderate and low retrograde flows undergoing a 2-hour occlusion and 30-min reperfusion of the left anterior descending coronary artery. The results demonstrate that experimental myocardial infarct size is closely related to native coronary collateral blood flow, and the large variability in collateral perfusion amongst dogs is a source of variability in the mass of myocardium undergoing irreversible damage following acute coronary occlusion. Results also demonstrate that the variability in experimental infarct size can be reduced and ultimate infarct size predicted prior to irreversible tissue injury by initial measurement of retrograde coronary blood flow.

Simultaneous Antegrade and Retrograde Reperfusion After Cardioplegic Arrest for Coronary Artery Bypass

Retrograde coronary sinus reperfusion with warm blood during proximal anastomoses permits completion of myocardial revascularization under a single cross-clamp application. Reperfusion with both antegrade (via arterial and vein grafts) and retrograde (via coronary sinus catheter) warm blood has raised concerns about maldistribution of perfusate or overpressurization of capillary beds. This prospective, randomized design compares post-cardioplegic myocardial recovery among patients receiving retrograde reperfusion only and patients receiving simultaneous antegradelretrograde reperfusion. Twenty-four patients were selected among all presenting as outpatients for elective coronary artery bypass (CAB). Each patient underwent CAB with cardioplegic arrest and single cross-clamp technique. During proximal anastomoses the heart was reperfused with warm blood from the cardiopul-monary bypass (CPB) circuit. Twelve received retrograde reperfusion only, and 12 received simultaneous antegradelretrograde reperfusion via an internal mammary artery (IMA) graft, all vein grafts, and the coronary sinus catheter. Vein graft perfusion was interrupted in each vein as the proximal anastomosis was performed. Myocardial recovery time (interval from initiating reperfusion until electrical and mechanical activity), cardioversion incidence, requirement for inotropic support, and Swan-Ganz hemodynamic parameters measured immediately 6 and 24 hours postoperatively were compared between groups. There were no differences between groups in age, ventricular function, number of grafts, or CPB time. Also, there were no differences in cardioversion, inotropic need, or postoperative hemodynamic performance. Myocardial recovery time was reduced in patients receiving simultaneous antegradehetrograde reperfusion (13·9 ± 7·0 vs 2·6 ± 2·1 minutes). Simultaneous reperfusion of warm blood antegrade and retrograde is not deleterious to the myocardium. More rapid recovery of myocardial function may represent a shorter period of warm ischemia but does not appear to translate to improved postoperative myocardial performance.

Hemodynamic Effects of Positive Pressure Ventilation

In order to investigate the effect of positive pressure ventilation on vena cava blood flow, intraoperative manometric measurements were made in three patients with blunt abdominal trauma. These patients had intra-abdominal hemorrhage but no injury to the vena cava. The vena cava pressure increased with stepwise increases in the inspiratory pressure of the ventilator. The implications of this for the management of injuries to the inferior vena cava are: control of blood loss from caval wounds requires blockage of retrograde and antegrade caval blood flow; temporary cessation can stop retrograde caval flow from the right atrium and allow identification and repair of the caval defect; and retrograde caval blood flow can be used to flush out air bubbles and blood clots.

Effects of coronary and extravascular pressure on intramyocardial and epicardial blood velocity.

In open-chest anesthetized dogs we measured phasic coronary blood velocity in an epicardial artery (left anterior descending), a small epicardial artery (within 0.5 cm before penetration into the myocardium), and an intramyocardial artery (septal) during changes in perfusion pressure and extravascular pressure. Circumflex artery diameter was also measured during pressure changes to directly assess vascular compliance. At low and normal arterial pressures (less than 125/86 mmHg) and during aortic insufficiency, the phasic character of blood flow velocity in the large epicardial arteries was markedly different from that in the small epicardial and septal arteries: there was retrograde systolic blood flow velocity in the septal artery and small epicardial artery, whereas antegrade blood flow velocity persisted in the left anterior descending artery. At pressures greater than 150/106 mmHg, the differences in the phasic character of blood flow velocity in the left anterior descending artery from that in the septal artery and small epicardial artery were small and decreased as aortic pressure increased. At pressures greater than 125 mmHg, the cross-sectional area change per millimeter of mercury was approximately three times less than at pressures between 30 and 75 mmHg, indicating decreased coronary compliance at the higher pressures. Increasing extravascular pressure in the septum (right ventricular hypertension) greatly increased retrograde systolic blood flow velocity in the septal artery (P less than 0.05). However, right ventricular bypass (0 right ventricular pressure) did not alter the phasic nature of blood flow velocity in the septal artery. From these results we confirmed that epicardial capacitance is inversely related to distending pressures.(ABSTRACT TRUNCATED AT 250 WORDS)

Spontaneous reversal of portal blood flow demonstrated by percutaneous transhepatic catheterization: Report of two cases

Two patients are described in whom percutaneous transhepatic catheterization of the portal vein for a hemodynamic study demonstrated a continuous reversed blood flow in the portal vein, entering into a large collateral. The measurements made of blood pressure in the superior mesenteric, splenic, and left gastric veins, and of ammonia, immunoreactive insulin, and C-peptide in blood taken from these and peripheral veins all indicated reversed portal vein blood flow. The evidence for retrograde portal vein blood flow was obtained in only 2 of 203 patients with cirrhosis in whom portal hemodynamics were studied by the same procedure. Thus, spontaneous reversal of portal vein blood flow does occur, but very rarely.

An extracorporeal shunt for the measurement of coronary flow in the closed-chest dog.

An extracorporeal shunt circuit interposed between the left carotid artery and the left coronary ostium employs an electromagnetic flowmeter to measure coronary blood flow in the closed-chest anesthetized dog. Flow may be measured with the animal's arterial pressure as the driving force; introduction of a roller pump, or a roller pump and a negative feedback pressure controller allows for constant flow or constant pressure modes. During occlusion of the circuit or cessation of pump flow, retrograde coronary blood flow can be collected for measurement. The construction of the circuit is relatively simple and inexpensive, using common laboratory materials and a commercially available electromagnetic flowmeter and probe.

Effects of fendilin hydrochloride (sensit) on systemic and coronary hemodynamics and on retrograde coronary blood flow in dogs.

Fendilin hydrochloride was tested in 9 normal anesthetized dogs and in 7 anesthetized dogs with acute coronary artery occlusion. The compound (1 mg/kg i.v.) caused a slight short lasting increase in coronary blood flow together with an increase in cardiac metabolic rate for oxygen of similar magnitude. There was no measurable effect on collateral conductance. No noteworthy effects on systemic hemodynamics were observed.