Use Of Retrograde Cardioplegia Research Articles

Use of Retrograde Cardioplegia in Coronary Artery Bypass Graft Surgery

Background: Retrograde Cardioplegia is a widespread method for myocardial protection in coronary bypass surgery and to abroad range of open heart surgical procedures in addition to antigrade Cardioplegia,Objectives: Is to evaluate the use of retrograde cardioplegia and its advantages in coronary bypass surgery at Ibn Al-Nafees Teaching Hospital, Department of Cardiac Surgery,Patients and methods: This is a retrospective study that was conducted at Ibn Al-Nafees Teaching Hospital from the first of January to the first of October 2015, fifty patients with coronary artery dieses were admitted to the hospital and coronary artery bypass graft (CABG) surgery was done under cardiopulmonary bypass using retrograde cardioplegic canula through the coronary sinus from the right atrium in addition to antigrade cardioplegia from aortic root for myocardial protection during surgery on arrested heart using cold crystalloid cardioplegia.Results: The fifty patients who were studied were operated upon, the age of patients was ranged from 37-79 year with a mean age 0f 60 year and male to female ratio was 3:1. 25 patients (50%)had left main coronary artery lesion ,all underwent bypass surgery on cardiopulmonary bypass machine using retrograde cardioplegia in addition to antegrade. in 45 patient (90%) the heart picked up (beating) spontaneously without using D.C shock while in five patient (10%) internal D.C shock was required for beating the heart from the state of ventricular fibrillation .In all patients , coming off from heart lung machine was easy with a small dose of inotropics agents. Intra aortic balloon pump was used in one patient. Only one early death observed in this study due to post operative renal failure.Conclusion: Retrograde cardioplegia is a safe , widespread, and effective method for myocardial protection in addition to antegrade cardioplegia and this achieved longer time of protection during cardiac arrest . This method is very useful in patients with left main coronary artery disease.

الإستعمال العكسي لمادة الكارديوبليجيافي عمليات زرع الشرايين التاجية في القلب

الإستعمال العكسي لمادة الكارديوبليجيافي عمليات زرع الشرايين التاجية في القلب

Late-presenting aortopulmonary window: Illustration of an uncommon lesion.

Sir, Aortopulmonary window (APW) is an uncommon lesion resulting from abnormal septation of the truncus arteriosus into the aorta and the pulmonary artery (PA). In developing countries, late presentation of such a lesion is not unheard of, but is clearly rare.[1] We here describe a huge APW presenting in an adolescent and suggest that use of retrograde cardioplegia offers a simple technical consideration to facilitate an expeditious and safe surgical undertaking in the given scenario. A 12-year-old male was admitted in our unit with a long history of shortness of breath, recurrent respiratory tract infections, and increased sweating. Chest X-ray [Figure 1] showed pulmonary plethora, cardiomegaly, and dilated pulmonary arteries. His echocardiography revealed a large APW shunting predominantly left to right with pan diastolic flow reversal in the arch, dilated left ventricle and pulmonary arteries, and mild pulmonary regurgitation. His electrocardiogram (ECG) showed left ventricular volume overload with left ventricular forces besides presence of q wave in lead V6. In view of his history, ECG and chest X-ray finding coupled with predominant left to right shunting and flow reversal in the ECHO, the case was considered to be operable and a cardiac catheterization was avoided.Figure 1: Chest X-ray showing enlarged pulmonary vessels along with evidence of pulmonary overflowAt operation we encountered a massive APW involving almost the entire ascending aorta with hugely dilated branch pulmonary arteries [Figure 2]. The size of the window necessitated cannulation of the beginning of the arch of aorta. Conventional repair in this case would have mandated snaring his tense and dilated branch PA to deliver cardioplegia, a maneuver not without risk. Additionally, existing pulmonary regurgitation had the potential to cause failure of cardioplegia delivery. Therefore, we cross-clamped the aorta immediately after instituting the bypass to prevent flooding the pulmonary circuit and administered retrograde cardioplegia resulting in quick diastolic arrest. We proceeded onto repair by anterior sandwich method.[2] The cross-clamp time was 15 min and bypass duration was 17 min. Recovery was uneventful. Postoperative ECHO was unremarkable, but for moderately elevated PA pressure and mild PR. The patient has been discharged on antipulmonary hypertensive therapy.Figure 2: Intraoperative photograph of aortopulmonary windowAPW represents a malformation in the division of the aortopulmonary trunk during embryogenesis and is encountered uncommonly. The potential to cause irreversible pulmonary vascular disease mandates repair at diagnosis early in life.[3] Beginning with simple ligation by Gross,[4] various surgical methods have been described and the type of repair and cardioplegia delivery method often depend upon the surgeon's preference. Location of the fistulous communication at the aortic root mandates that antegrade cardioplegia can only be delivered by snaring the branch PA, which is a rather straightforward surgical maneuver in a routine case. We suggest, however, that in case of a delayed presentation resulting in enormous dilatation of pulmonary arteries and consequent pulmonary regurgitation, retrogarade cardioplegia greatly facilitates the surgical repair and should be considered.

Total aortic arch replacement with patent left internal thoracic artery graft after previous coronary artery bypass graft surgery

A 78-year-old man, who had previously undergone coronary artery bypass graft surgery, was admitted to our department for treatment of a distal aortic arch aneurysm. A total aortic arch replacement with a patent left internal thoracic artery (LITA) graft was successfully performed without cardiac ischemic or neurological complications. Use of retrograde cardioplegia with intermittent pressure-augmented retrograde cerebral perfusion without clamping and dissecting the LITA graft were effective in myocardial and cerebral protection.

Associated factors with survivals in patients undergoing orthotopic heart transplant using retrograde blood microcardioplegia

Several techniques and cardioplegic solutions have been used for heart preservation during transplant procedures. Unfortunately, there is a lack of ideal method for myocardial preservation in the clinical practice. The use of retrograde cardioplegia provides continuous infusion of cardioplegic solution during the graft implantation. This strategy may provide better initial recovery of the graft. The objective of this study is to describe the experience of a single center where all patients received the same solution for organ preservation and were subjected to continuous retrograde blood microcardioplegia during implantation of the graft and to evaluate factors associated to early and late mortality with this technique.This is a retrospective, observational and descriptive study of a single center.During the study period were performed 35 heart transplants. Fifteen (42.9%) patients were in cardiogenic shock. The probability of survival was 74.8±7.8%, 60.4±11.3% and 15.1±13.4% at 1 year, 5 years and 10 years of follow-up, respectively. The median survival time was 96.6 months.The use of myocardial protection with retrograde cardioplegic solution may reduce the risks associated morbidity due to cold ischemia time during the heart transplant, and we suggest that this benefit may be even greater in cases of cold ischemia time longer ensuring protection to the myocardium.

Images in Anesthesia: Anesthetic implications of persistent left superior vena cava

persistent left superior vena cava (PLSVC) has an incidence of 0.3% of the population.1 During normal embryologic development, the left brachiocephalic vein develops as a bridge between the left and right anterior cardinal veins. The caudal part of the right anterior cardinal vein becomes the normal superior vena cava (SVC) and the left anterior cardinal vein caudal to the left brachiocephalic vein normally collapses and degenerates. If this portion of the left anterior cardinal remains patent, it becomes a PLSVC which opens into the right atrium via the vein of Marshall and dilated coronary sinus (Figure 1). This can result in a bilateral SVC or the absence of a right SVC.2 Typically, PLSVCs are found by chest radiograph after left subclavian or jugular venous catheter insertion, especially with a pulmonary artery catheter (PAC). The catheter is seen along the left side of the mediastinum (Figure 2). Placement of a central venous catheter or PAC into a PLSVC might be mistaken for placement into other areas that overlie a PLSVC on a radiograph such as the subclavian or carotid artery, mediastinum, pleural space, or thoracic duct. Lastly, the use of retrograde cardioplegia in the coronary sinus during asystolic heart surgery may be ineffective.3

Reoperative coronary bypass surgery: Effect of patent grafts and retrograde cardioplegia

Objective: To determine the effects of patent or diseased aorta-coronary bypass grafts and retrograde cardioplegia on mortality during reoperative coronary bypass surgery. Methods: We conducted a retrospective review of prospectively gathered data, supplemented by systematic chart review, of all patients (n = 744) undergoing reoperative coronary bypass surgery at our institution between 1990 and 1997. Independent predictors of survival were determined by stepwise logistic regression analysis. Results: At least one patent or stenosed graft to the left anterior descending artery was present in 50% of patients, to the circumflex territory in 27% of patients, and to the right coronary artery territory in 33% of patients. The previous left anterior descending graft was a saphenous vein in 82% and a left internal thoracic artery in 18% of patients. In-hospital mortality occurred in 42 (5.6%) patients. Patent or diseased grafts of any coronary artery territory did not significantly increase the risk of mortality. Retrograde cardioplegia use increased in more recent years, was more frequent in patients with stenosed grafts, and was associated with improved survival. Independent predictors of mortality were as follows (with odds ratios and 95% confidence intervals in parentheses): failure to use retrograde cardioplegia (odds ratio 2.81; 1.28-6.20), New York Heart Association class (odds ratio 2.69; 1.25-5.81), peripheral vascular disease (odds ratio 2.60; 1.25-5.41), and left ventricular grade (2.07; 1.31-3.27). Conclusions: In this series, patent or stenosed grafts were not associated with an increased risk of mortality during reoperative coronary bypass surgery, possibly because of increased use of retrograde cardioplegia in this patient group. We strongly recommend the routine use of retrograde cardioplegia during redo coronary bypass surgery. (J Thorac Cardiovasc Surg 2001;121:83-90)

Retrograde crystalloid cardioplegia preserves left ventricular systolic function better than antegrade cardioplegia in patients with occluded coronary arteries

Objective: To investigate retrograde and antegrade crystalloid cardioplegia in terms of cardiac cooling and postoperative cardiac function. Design: Prospective, randomized, and blinded. Setting: University hospital. Participants: Twenty male patients with triple-vessel disease and proximal occlusion of the circumflex or the left anterior descending coronary artery. Interventions: Left ventricular ejection fraction at rest and during exercise was evaluated by nuclear ventriculography the day before and 3 months after surgery. After induction of anesthesia and hourly for the first 5 postoperative hours, hemodynamic, echocardiographic, and electrocardiographic data were acquired. Myocardial temperature was measured with needle thermistors in 3 myocardial regions. Measurements and Main Results: Demographic and temperature data were analyzed by t-test. Hemodynamic and echocardiographic data were analyzed by analysis of variance. The groups were similar in baseline characteristics. Retrograde cardioplegia cooled the region distal to an occlusion better than antegrade cardioplegia (9.6°C ± 4.8°C v 21.8°C ± 5.9°C; p < 0.01). Hemodynamic, echocardiographic, and electrocardiographic data did not differ between the groups. Three months after surgery, the retrograde cardioplegia group showed a higher left ventricular ejection fraction at rest (58% ± 10% v 47% ± 10%; p < 0.02) and during exercise (58% ± 13% v 47% ± 10%; p ± < 0.05) compared with the antegrade cardioplegia group. Conclusions: Retrograde cardioplegia provides more homogenous myocardial cooling than antegrade cardioplegia in hearts with coronary artery occlusions. The use of retrograde cardioplegia seems to benefit long-term left ventricular function. Copyright © 2000 by W.B. Saunders Company

Can Retrograde Cardioplegia Alone Provide Adequate Protection for Cardiac Valve Surgery?

When aortic insufficiency is present, antegrade delivery of cardioplegia requires coronary cannulation. Use of retrograde cardioplegia simplifies administration. The efficacy of the retrograde route alone in ensuring adequate myocardial protection may be assessed by the clinical outcome. We used closed transatrial coronary sinus perfusion as the sole method of cardioplegia delivery in 100 patients who underwent valve operations, either isolated or combined with coronary (n=24), ascending aortic aneurysm (n=8), or other procedures. Eighty-one patients were in New York Heart Association (NYHA) Class III or IV; 23 had undergone previous heart operations; 23 were admitted from the coronary care unit (CCU); and 20 had left ventricular ejection fraction (LVEF) of < or = 40%. Operative mortality was 2%. An intra-aortic balloon pump was required in eight patients. On univariate analysis, perioperative use of inotropes (n=26) was related to age > or = 70 years (p=0.02), COPD (p=0.05), pulmonary hypertension (p=0.005), higher NYHA Class (p=0.0006), preoperative heart failure (p=0.006), lower LVEF (p=0.0003), urgency (p=0.00001), admission from the CCU (p=0.006), repeat operation (p=0.03), coronary artery disease (p=0.02), and longer ischemic (p=0.02) and bypass times (p=0.0003). On multivariate stepwise logistic regression analysis, use of inotropes was related to preoperative lower LVEF (p=0.02) and urgency of operation (p=0.0002). Perioperative complications included ventricular arrhythmia in six, heart block in one, renal dysfunction in nine, and stroke in two patients; no patient had myocardial infarction. Good clinical results can be obtained by using retrograde cardioplegia alone without prior doses of antegrade cardioplegia in all valve operations.

Transesophageal echocardiographic evaluation of perioperative coronary sinus trauma

Retrograde cardioplegia is relatively safe, with a rate of coronary sinus rupture of 0.6%. With the advent of perioperative transesophageal echocardiography, it is now possible to detect and evaluate the extent of damage consequent to the use of retrograde cardioplegia and better formulate an intraoperative course of action. The evolution of these lesions can also be monitored by transesophageal echocardiography during the postoperative period.

Aortic Valve Operations Under Deep Hypothermic Circulatory Arrest for the Porcelain Aorta: “No-Touch” Technique

Background. Aortic valve replacement or repair becomes a high-risk procedure in patients in whom the ascending aorta cannot be clamped either because of extensive calcification and risk of cerebral embolus or because of extensive adhesions precluding safe dissection and clamping. Methods. We report the results of aortic valve replacement or repair with deep hypothermic circulatory arrest in 3 patients. Techniques to improve results include routine use of epiaortic and transesophageal echocardiography, avoidance of manipulation of the ascending aorta until the circulation is arrested, avoidance of antegrade cardioplegia, routine use of retrograde cardioplegia and retrograde cerebral perfusion, when feasible, and minimal aortotomy (just enough to excise and replace or repair the valve). Results. Operations were accomplished in approximately 1 hour each with minimal manipulation of the aorta, thus minimizing aortic trauma and subsequent risk of cerebral embolus. Each patient had an unremarkable recovery without neurologic complications. Conclusions. Aortic valve replacement or repair using the “no-touch” technique and deep hypothermic circulatory arrest is the preferred method when dealing with the porcelain or unclampable aorta.

Unusual pitfall of use of retrograde cardioplegia

The use of retrograde cardioplegia can lead to several complications, mainly related to injuries during the cannulation of the coronary sinus. We herein present a case report of injury to the right coronary artery related to kinking due to the pursestring on the right atrium.

A Critical Assessment of Neurological Risk During Warm Heart Surgery

A prospective randomized trial comparing retrograde warm blood cardioplegia with cold oxygenated crystalloid cardioplegia in coronary bypass patients at Emory University revealed an increased risk of adverse neurological events in the warm group (4.5% vs 1.4%, p < 0.005). Multivariant analysis found four variables to be independent predictors of adverse neurological outcome: congestive heart failure (p = 0.002); age (p = 0.002); aortic cross-clamp time (p = 0.02); and randomization to the warm group (p = 0.026). In Toronto, a prospective randomized trial compared antegrade warm blood cardioplegia with antegrade cold blood cardioplegia. Compared to the Emory trial, the Toronto series contained fewer female patients (16% vs 25%), fewer patients older than age 70 (16% vs 30%), and fewer redo operations (4% vs 14%). The other prominent differences between the Emory series and the Toronto series were: extensive use of retrograde cardioplegia in the Emory series; mild hypothermia in the warm group in the Toronto series; and elevated serum glucose in the warm group in the Emory series. The Toronto series showed no difference in adverse neurological events comparing cold versus warm cardioplegia groups. A comparison of these two series suggests that mild hypothermia in the Toronto series, elevated glucose in the Emory series, or the use of retrograde cardioplegia may be operative in the elevated incidence of adverse neurological events seen in the Emory series in addition to a relatively larger number of high-risk patients (female, elderly, and redo) in the Emory series.

Risk analysis of primary versus reoperative coronary artery bypass grafting

Reoperative coronary artery bypass grafting is being performed with increasing frequency, in part as a function of the increasing pool of patients who have undergone initial coronary artery bypass grafting and in part because of the natural progression of atherosclerosis. The great majority of patients require reoperation because of graft atherosclerosis or because of a combination of graft and native-vessel disease. Significant risk factors for reoperation include the lack of an internal mammary artery graft or incomplete revascularization at the time of the primary operation, age, and New York State Heart Association classification. Despite an increasing experience with reoperations, operative mortality remains high, approximately three to five times that of initial bypass operation. Similarly, reoperations are associated with increased morbidity, including increased rates of bleeding and low output states. Specific problems encountered at reoperation include graft atherosclerosis, progression of native-vessel disease, and a significant increase in perioperative bleeding. Bypass ischemic times tend to be longer. The use of retrograde cardioplegia and blood conservation programs may prove to be effective solutions for these problems. If perioperative results can be improved, it would appear that the longterm outlook for these patients is reasonably good.

Optimal delivery of cardioplegic solution for “redo” operations

Increasing experience suggests that retrograde cardioplegia offers several benefits during cardiac reoperations. However, the need for dissection to allow caval snares for open coronary sinus intubation or to palpate the atrioventricular groove for transatrial coronary sinus intubation may disturb diseased vein grafts or require more dissection than necessary. Although antegrade-retrograde techniques can be used, antegrade cardioplegia risks atheromatous embolization from old vein grafts. To optimize delivery of cardioplegic solution, we designed and used "no touch" transatrial intubation of the coronary sinus for retrograde delivery of cardioplegic solution in 63 consecutive patients aged 20 to 87 years (mean 68 years) undergoing 36 redo coronary bypass operations, 7 combined redo coronary bypass/valve replacements, 6 redo aortic valve repairs/replacements, 6 redo mitral valve repairs/replacements, 4 redo double valve repairs/replacements, 2 redo triple valve repairs/replacements, and 2 redo composite aortic valve and arch replacements. "No touch" coronary sinus cannulation was achieved by minimally dissecting the aorta and high right atrium enough for two purse-string sutures. No attempt was made to dissect the junction of the inferior vena cava and atrioventricular groove if old vein grafts were present. The distal pressure line of the Gundry DLP RCSP retrograde cardioplegia cannula (DPL, Inc., Grand Rapids, Mich.) was connected to a transducer, flushed, and then introduced into the right atrium. The pressure tracing thus obtained was observed while the catheter was advanced, using its curved stylet, "blindly" without touching the heart, through the right atrium into the coronary sinus until a coronary sinus waveform was obtained (similar to floating a thermodilution catheter). The catheter's distal balloon was then inflated to occlude the coronary sinus momentarily. A rise in sinus pressure confirmed placement. If pressure did not rise, the cannula was usually in the right ventricle and was repositioned. All coronary sinuses were successfully intubated blindly. Bypass was then instituted, the aorta crossclamped, and the proximal aorta vented. Old vein grafts were cut at the aorta before retrograde cardioplegia was begun; atheromatous material was routinely flushed retrogradely from vein grafts. Only after arrest were hearts dissected as needed. Antegrade cardioplegia was not used. There were two (3%) deaths, both from hospital-acquired pneumonia, no perioperative myocardial infarctions, and no episodes of heart block. Inotropic agents were used in six of 63 patients (10%). We conclude that "no touch" transatrial retrograde cardioplegia offers optimal, simplified myocardial protection for cardiac reoperations, permits arrest of the heart before cardiac manipulations, and expands the use of retrograde cardioplegia by obviating cardiac dissection.

Recent advances in myocardial protection using antegrade/retrograde blood cardioplegia.

This presentation details techniques of delivery of antegrade/retrograde blood cardioplegia to ensure its distribution to prevent ischemic during aortic clamping, and describes methods of using warm blood cardioplegia to resuscitate the heart when used to induce cardioplegia and reperfusion damage when given just before aortic unclamping. A technique of rapid transatrial cannulation of the coronary sinus is described to permit safe, rapid, and simple use of retrograde cardioplegia and avoid right heart isolation. Theoretic objectives of these operative techniques are discussed, together with presentation of the specific methods of achieving the aforementioned goals of using blood cardioplegia for resuscitation, prevention, and avoidance of ischemic and reperfusion damage. The preliminary clinical experience with antegrade/retrograde cardioplegia is summarized, and these results have led to adoption of these techniques of blood cardioplegia as the preferred method of myocardial protection in all adult operations and in many pediatric cardiac procedures.

Antegrade/Retrograde Blood Cardioplegia to Ensure Cardioplegic Distribution: Operative Techniques and Objectives

This article details techniques of delivery of antegrade/retrograde blood cardioplegia to ensure its distribution to prevent ischemic damage during aortic clamping, and describes methods of using warm blood cardioplegia to "resuscitate" the heart when used to induce cardioplegia and "avoid reperfusion damage" when given just before aortic unclamping. A technique of rapid transatrial cannulation of the coronary sinus is described to permit safe, rapid, and simple use of retrograde cardioplegia and avoid right heart isolation. Theoretic objectives of these operative techniques are discussed, together with presentation of the specific methods of achieving the aforementioned goals of using blood cardioplegia for resuscitation, prevention, and avoidance of ischemic and reperfusion damage. The preliminary clinical experience with antegrade/retrograde cardioplegia is summarized, and these results have led to adoption of these techniques of blood cardioplegia as the preferred method of myocardial protection in all adult operations and in many pediatric cardiac procedures.