Asian Cardiovasc Thorac Ann 2000;8:118-120
© 2000 Asia Publishing EXchange Pte Ltd
Coronary Sinus Injuries Following Retrograde Cardioplegia
Ahmed F Elwatidy, MD, FRCS
Prince Sultan Cardiac Center
Riyadh, Saudi Arabia
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For reprint information contact: Ahmed F Elwatidy, MD, FRCS Tel: 966 4 423 3988 Ext. 85423 Fax: 966 4 423 4756 email: afelwatidy{at}hotmail.com North West Armed Forces Hospital, P.O. Box 100, Tabuk, Saudi Arabia.
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Abstract
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A retrograde coronary sinus cardioplegia catheter was used for administration of retrograde cardioplegic solution in 620 of 942 coronary bypass procedures performed over a 3-year period. Coronary sinus injuries were encountered in 4 patients (0.65%).
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Introduction
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Delivery of cardioplegia through the coronary sinus has gained increasing popularity as a method of myocardial protection. Buckberg1 reported that more than 90% of cardiac surgeons in the United States are currently using the retrograde technique alone or complementary to the antegrade technique for myocardial protection. The advantages of retrograde cardioplegia have been well documented but there have been a few reports of complications caused by this technique.2–5 Although the incidence of such complications is not known precisely, there is accumulating evidence suggesting that the rate of coronary sinus (CS) rupture may be increasing.6,7 The incidence of CS rupture might also increase during the learning phase of the blind insertion technique for the retrograde cardioplegic cannula.
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Patients and Methods
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A retrograde CS cardioplegia catheter was used for administration of retrograde cardioplegic solution in 620 of 942 coronary bypass procedures performed over a 3-year period. CS injuries occurred in 4 patients (0.65%). There were 3 men and 1 woman, their ages were 45, 56, 59, 67 years. All 4 underwent elective coronary artery bypass surgery. A standard median sternotomy and pericardiotomy were performed and the aorta was cannulated. A two-stage venous cannula was inserted through a right atrial pursestring suture. Another pursestring suture was placed on the right atrial free wall 2 cm from the right atrioventricular groove (course of the right coronary artery) for insertion of the retrograde cannula before the institution of cardiopulmonary bypass. The blind insertion technique was used in all cases, whereby the heart is slightly retracted to the left side and cephalad, the right atrium is punctured, and the retrograde cannula with a self-inflatable balloon (JLP; JLP-Medtronic, Grand Rapids, MI, USA) is directed into the CS. In all 4 cases, retrograde cardioplegia was used to complement antegrade cardioplegia. Direct palpation or visualization of the cannula in the CS, as well as monitoring CS pressure, were used to confirm correct positioning of the cannula.
In these 4 cases, there was difficulty in introducing the cannula into the CS and forceful insertion was probably used. In 2 cases, a feeling that the CS had given way was noted during insertion of the cannula, massive venous bleeding was observed coming from the back of the heart, and the tip of the cannula was seen coming out from the coronary sinus. In the other 2 cases, hematomas of 2 x 3 cm2 and 4 x 5 cm2 were observed at the back of the heart around the coronary sinus, there was no bleeding, and the cannula was in the correct place in the CS. The retrograde CS cannula was withdrawn from the CS in each case and the retrograde route was abandoned. Cardiopulmonary bypass was instituted immediately with systemic hypothermia to 25°C, the aorta was crossclamped, and the initial dose of antegrade blood cardioplegia (1 L) was given to arrest the heart. The heart was vented from the aortic root, gently retracted cephalad, and the CS area was examined carefully. In the second 2 cases where intact subepicardial hematomas surrounded the CS, it was decided to leave them undisturbed. In the other 2 cases, the CS was torn. The first tear, measuring 1.5 cm in length, was successfully repaired with continuous 7/0 polypropylene suture after a little trimming of the coronary sinus edge. The second tear was larger (2.5 x 0.5 cm) and there was little of the CS edge to suture (complete laceration). It was decided to use a fresh autologous pericardial patch for the repair. A continuous 7/0 polypropylene suture was used to stitch a rhomboid pericardial patch to the CS edge on the left atrial side. The other edge of the pericardial patch was sewn to the epicardium close to the CS (ventricular side), so that the stitches were relatively superficial and in a direction parallel to the obtuse marginal arteries.
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Results
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The repair was successful in both cases and the operation continued in the usual fashion. After reversal of heparin, a second inspection of the CS confirmed good hemostasis. All 4 patients had an uneventful postoperative course and echo-Doppler studies on the 5th postoperative day were satisfactory. After one month, additional echo-Doppler studies were carried out and these demonstrated no abnormalities.
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Discussion
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Coronary sinus injury is a rare but potentially lethal complication of the retrograde cardioplegia technique. A small sinus in a frail patient may be stretched to the point of rupture during inflation of the balloon.2 The presence of a membrane closing the orifice of the CS can also lead to difficult introduction resulting in CS injury.6 In each of these 4 cases, a retrograde cannula with a self-inflatable balloon was used and forceful insertion due to a small sinus or abnormal valve might have resulted in the complications observed. Using a manually inflatable balloon, in spite of the fact that most surgeons follow the recommendations of the manufacturer, complications still happen. Some surgeons have recommended a careful way of inflating the balloon, which is accomplished by leaving the balloon completely deflated until the initiation of cardioplegia delivery.8 As the cardioplegia is delivered, balloon inflation is slowly and cautiously commenced while carefully watching the CS pressure readout on the monitor. As soon as the pressure begins to increase, indicating adequate obstruction of the backflow into the atrium, inflation of the balloon is stopped.
Brady and colleagues9 reported nonsurgical causes of CS rupture in 3 cases where delayed CS rupture required urgent sternotomy for control of cardiac tamponade. The 3 cases followed catheter-mediated electrical ablation of posterior accessory atrioventricular pathways. CS rupture correlated with the ratio of catheter diameter to CS diameter in these cases.
Menasché and colleagues3,5 described 3 different types of CS injury (Figure l
): hematoma of the atrioventricular groove, usually due to over pressurization (in our cases, it was caused by repeated and difficult attempts at insertion), which in the absence of overt rupture should be respected; punctate perforation of the CS wall secondary to traumatic stylus-guided catheter insertion, which can be repaired easily with a few 6/0 polypropylene stitches; extensive laceration of the CS, which is the most difficult problem and skilful repair is needed. In the first of the patients who had the CS repaired successfully using a continuous 7/0 polypropylene stitch, the tear was close to the second type described by Menasché, although even longer and wider. In the other case of laceration, the lesion was larger and needed autologous pericardial patch repair that was effective in achieving both repair and thorough hemostasis.
Certain important technical principles in repairing large CS lacerations were emphasized in previous reports.2,3,5 The first is adequate exposure of the damaged area to permit accurate placement of the sutures, which implies total decompression of the left ventricle (venting through the right superior pulmonary vein was recommended). Venting through an already placed aortic root vent in our patients was sufficient, however, the right superior pulmonary vein would have been more effective. The second is that any type of material can be used for repairing the ruptured CS, including autologous pericardium, autologous vein patch, and bovine pericardium.2,6,8 Autologous pericardium is especially attractive because of its numerous advantages: immediate availability; ease of handling, fashioning, and suturing; hemostatic effectiveness due to its thickness and lack of porosity; and absence of additional cost. Some surgeons believe that repairing the CS without a patch can lead to narrowing of the sinus, which invites more bleeding and later thrombosis of the CS.8 An autologous pericardial patch should result in a widely patent nonrestrictive flow in the CS in order to prevent thrombosis. Weiss7 used an 8-mm thin-walled Gore-Tex conduit between the right atrium and a pericardial patch used for repair of the CS, to allow an alternative route for CS return to the right atrium. The third point that should be emphasized is that the patch should be sewn far away from the site of injury by means of fine monofilament suture (6/0 or 7/0 polypropylene) in a running fashion. On the ventricular side of the sulcus, sutures should be placed superficially across the epicardium, care being taken not to injure the major branches of the left circumflex coronary artery. Topical application of biological glue along the suture line can be useful. Finally, attention paid to the repair, which can be time consuming, should not distract from being equally committed to the quality of myocardial preservation during this phase or from performance of the operation.
The best treatment for such rare and potentially lethal injuries is prevention. Careful insertion and cautious inflation of the balloon are essential. However, use of a retrograde cannula with a self-inflatable balloon may be safer. It could also be easier to cannulate the CS before the institution of cardiopulmonary bypass and before the insertion of the right atrial cannula.8 There is nothing in the way, the right atrium is distended, and the CS is full. Cannulating the CS after bypass is also safe and this could be done with the right atrium distended. In our experience, cannulating the CS after right atrial cannulation is easy and has the advantage of avoiding misinsertion into the inferior vena cava which is already occupied by the right atrial cannula. Direct observation of the retrograde cannula, palpation of the cannula in the CS, and pressure monitoring in the CS are important to confirm proper positioning of the cannula. When any difficulty is experienced during cannulation of the coronary sinus and repeated careful trials are attempted, avoiding the retrograde technique may be the right decision.
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References
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Buckberg GD. Update on current techniques of myocardial protection. Ann Thorac Surg 1995;60:805–14.[Abstract/Free Full Text]
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Fleisher AG, Sarabu MR, Reed GE. Repair of coronary sinus rupture secondary to retrograde cardioplegia. Ann Thorac Surg 1994;57:476–8.[Abstract]
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Menasché P, Subayi J-B, Piwnica A. Retrograde coronary sinus cardioplegia for aortic valve operations: a clinical report on 500 patients. Ann Thorac Surg 1990;49:556–64.[Abstract]
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Chitwood RW Jr. Myocardial protection by retrograde cardioplegia: coronary sinus and right atrial methods. In: Cardiac surgery: state of the art reviews. Philadelphia: Hanley and Belfus, 1988:197–217.
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Menasché P, Subayi J-B, Veyssié L, Le Dref O, Chevret S, Piwnica A. Efficacy of coronary sinus cardioplegia in patients with complete coronary artery occlusions. Ann Thorac Surg 1991;51:418–23.[Abstract]
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Seyedhossein A, Baumgartner H, Miksovsky A, Mohl W. Closure of ruptured coronary sinus by a pericardial patch. Ann Thorac Surg 1996;62:889–91.[Abstract/Free Full Text]
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Weiss SJ. Management of difficult coronary sinus rupture. Ann Thorac Surg 1994;58:548–50.[Abstract]
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Berger TJ, Garibaldi AA, Fleisher AG, Reed GE, Menasché P. Coronary sinus rupture [letter]. Ann Thorac Surg 1994;58:1214–6.
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Brady GH, Ivey TD, Coltorti F, Stewart RB, Johnson G, Greene HL. Developments, complications, and limitations of catheter-mediated electrical ablation of posterior accessory atrioventricular pathways. Am J Cardiol 1988; 61:309–16.[Medline]
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Abstract
Introduction
