Asian Cardiovasc Thorac Ann 2000;8:290-291
© 2000 Asia Publishing EXchange Pte Ltd
Retrograde Coronary Sinus Perfusion for Severe Left Main Stenosis
Lokeswara Rao Sajja, MCh,
Afroz Farooqi, MCh,
Ramesh Babu Yarlagadda, MD,1,
Mastan Saheb Shaik, MD,1,
Ramesh Babu Pothineni, DM,2
Division of Cardiothoracic Surgery
1
Division of Cardiac Anaesthesiology
2
Division of Cardiology
Citi Cardiac Research Centre
Vijayawada, India
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For reprint information contact: Afroz Farooqi, MCh Tel: 91 891 72 7272 Fax: 91 891 56 0858 Heart & Kidney Centre, Apollo Hospitals, Waltair Main Road, Visakhapatnam, Andhra Pradesh 530002, India.
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Abstract
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Between April 1996 through March 1999, 15 patients with severe (> 60%) left main coronary artery stenosis became hemodynamically unstable on induction of anesthesia, in spite of optimal pharmacological management. Retrograde coronary sinus perfusion was instituted soon after the median sternotomy to improve hemodynamics until the establishment of cardiopulmonary bypass after harvesting internal mammary artery and saphenous vein grafts.
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Introduction
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Management of patients with coronary artery disease has focussed on subgroups defined by angiographic characteristics. The first subgroup with significantly improved survival when managed surgically and followed up for 2 to 3 years was that of patients with left main coronary artery (LMCA) disease.
1
,
2
Significant LMCA stenosis is a definite indication for surgical revascularization and 10% to 15% of patients undergoing coronary artery bypass grafting have significant LMCA stenosis. Patients with a tight LMCA stenosis pose the problem of hemodynamic instability on induction of anesthesia, which may preclude safe internal mammary artery harvest. Retrograde coronary sinus perfusion in such cases may improve hemodynamics until the institution of cardio-pulmonary bypass (CPB).
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Technique
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After induction of anesthesia, a 7F femoral arterial sheath is placed in the left femoral artery. Soon after sternotomy, the patient is heparinized (1 mg•kg
–1
) and a 15F retrograde coronary sinus cannula with a manually inflating balloon is inserted using the closed transatrial technique. The femoral arterial sheath is connected to the coronary sinus perfusion cannula through a pressure line with a 3-way stopcock. Coronary sinus perfusion is started by opening the 3-way stopcock to the sinus, and the balloon of the retroperfusion cannula is inflated with 1.5 mL of normal saline. A schematic representation of the retroperfusion is shown in
Figure
1
. Coronary sinus pressure is monitored throughout.
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Figure 1.
Retroperfusion of the coronary sinus with blood derived from a cannula placed in the left femoral artery.
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Discussion
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This technique was employed from April 1996 through March 1999 in 15 patients with severe LMCA stenosis (> 60% narrowing) who became hemodynamically unstable on induction of anesthesia, in spite of optimal pharmacological management. The coronary sinus was cannulated easily in all patients. There was no arrhythmia or further drop in systemic pressure during cannulation. There was no coronary sinus injury. Hemodynamic para-meters are shown in
Table
1
. In those who had ischemic changes, the electrocardiogram reverted to normal after initiation of retrograde coronary sinus perfusion.
The standard practice is to institute CPB immediately after sternotomy in patients with hemodynamic instability on induction of anesthesia, and then harvest the conduits for coronary artery bypass grafting. However, harvesting internal mammary artery in a fully heparinized patient is cumbersome, and prolonged CPB time has adverse effects. Patients receiving an internal mammary artery graft to the left anterior descending coronary artery enjoy increased longevity and freedom from ischemic cardiac events, compared to those receiving only vein grafts.
3
Therefore, an internal mammary artery graft should be employed when technically possible. Stabilizing hemodynamics before institution of CPB allows adequate time to harvest arterial conduits meticulously. Animals studies have shown that retrograde myocardial perfusion via the coronary sinus immediately after occlusion of a coronary artery minimized infarct extension.
4
In these 15 patients, retrograde coronary sinus perfusion improved hemodynamics significantly, as evidenced by the rise in mean systemic arterial pressure, the decrease in pulmonary artery diastolic pressure, and improvement in the left ventricular ejection fraction (analyzed by Student's paired
t
test). It was presumed that retrograde coronary perfusion in these critically ill patients would buy time to harvest arterial conduits that have superior patency rates to vein grafts. However, further evaluation by a randomized study is required to fully assess the benefits of retrograde coronary sinus perfusion prior to the institution of CPB in patients with critical left main stenosis and unstable hemodynamics.
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References
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Takaro T, Hultgren HN, Lipton MJ, Detre KM. The VA cooperative randomized study of surgery for coronary arterial occlusive disease II. Subgroup with significant left main lesions. Circulation
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Takaro T, Peduzzi P, Detre KM, Hultgren HN, Murphy ML, van der Bel-Kahn J, et al. Survival in subgroups of patients with left main coronary artery disease. Veterans Administration Cooperative Study of Surgery for Coronary Arterial Occlusive Disease. Circulation
1982; 66
:14
–22.[Abstract/Free Full Text]
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Loop FD, Lytle BW, Cosgrove DM, Stewart RW, Goormastic M, Williams GW, et al, Influence of the internal-mammary-artery graft on 10-year survival and other cardiac events. N Engl J Med
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Horneffer PJ, Gott VL, Gardner TJ. Retrograde coronary sinus perfusion prevents infarct extension during intraoperative global ischemic arrest. Ann Thorac Surg 1986;42:139
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Abstract
Introduction
