Asian Cardiovasc Thorac Ann 2000;8:330-332
© 2000 Asia Publishing EXchange Pte Ltd
Early Myocardial Resuscitation Via Coronary Sinus Retroperfusion
Mustafa Güden, MD,
Belhhan Akpinar, MD,
Osman Bayindir, MD,1,
Ertan Sa
ba
, MD,
lhan Sanisolu, MD,
Cem’i Demirolu, MD,2
Department of Cardiovascular Surgery
1 Department of Anesthesiology
2 Department of Cardiology
Kadir Has University Medical Faculty
Florence Nightingale Hospital
Istanbul, Turkey
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For reprint information contact: Belhhan Akpinar, MD Tel : 90 212 224 4950 Fax: 90 212 224 4982 email: belh{at}turk.net Department of Cardiovascular Surgery, Florence Nightingale Hospital, Abide-I Hürriyet Caddesi, No. 290  ili, Istanbul 80220, Turkey.
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Abstract
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Between January 1996 and December 1998, 9 patients needed emergency surgical revascularization after percutaneous transluminal coronary angioplasty failure. The mean age of these 6 men and 3 women was 64 ± 4.2 years. Under anesthesia and partial cardiopulmonary bypass, a cardioplegia needle was inserted into the ascending aorta and a retrograde cardioplegia cannula was introduced transatrially into the coronary sinus. Coronary sinus retroperfusion was performed during graft harvesting for revascularization. There was 1 death (11.1%) from multiorgan failure in a patient who had required cardiopulmonary resuscitation preoperatively. There was evidence of new myocardial infarction in 2 patients (22.2%) and the other 7 made a good recovery.
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Introduction
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The incidence of perioperative myocardial infarction (MI) among patients with failed percutaneous transluminal coronary angioplasty (PTCA) undergoing emergency coronary artery bypass grafting has been reported to be as high as 30% to 50%.1 In many cases of failed PTCA, surgery is performed on an urgent basis to prevent or limit the extent of infarction. Patients arriving in the operating room after acute PTCA failure usually have an energy-depleted ischemic myocardium accompanied by serious hemodynamic problems. Different management strategies have to be developed for optimal management of these difficult patients. The benefit of coronary sinus retro-perfusion was evaluated in 9 cases of failed PTCA where emergency coronary revascularization was carried out.
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Patients and Methods
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Between January 1996 and December 1998, 2420 patients had isolated PTCA, of whom 9 (0.37%) needed emergency surgical revascularization after acute PTCA failure. The mean age of these 6 men and 3 women was 64 ± 4.2 years. Seven of the patients had acute changes in their electrocardiogram, 3 were hemodynamically unstable (hypotension, arrhythmia), and 1 arrived in the operating room undergoing cardiopulmonary resuscitation. After anesthetic induction, partial cardiopulmonary bypass (CPB) was instituted urgently. A cardioplegia needle was inserted into the ascending aorta and a retrograde cardioplegia cannula was introduced transatrially into the coronary sinus. The lines were connected and coronary sinus retroperfusion was started at a controlled mean pressure of 40 mm Hg (Figure 1
). Without active cooling, the perfusate temperature was allowed to drop to between 32°C and 34°C. While the empty beating heart was perfused both antegradely and retrogradely, the arterial and venous conduits were harvested. Mean perfusion time before cardioplegic arrest was 27 ± 11 minutes. Before crossclamping, a small arteriotomy was made in the left anterior descending coronary artery (LAD) at the planned anastomotic site, and dark blood was observed coming retrogradely through the incision in all cases.
In 3 patients who were hemodynamically more stable, transesophageal echocardiographic evaluations could be made. In 2 patients who had dissection of the LAD, significant improvement was observed in the anterior and apical wall motion immediately after retrograde perfusion. In a patient with dissection of the right coronary artery (RCA), no improvement in wall function was noted although hemodynamic stability could be maintained.
All patients received diltiazem perfusion starting at the induction of CPB at a rate of 1 mg•kg–1•min–1, which was continued in the postoperative period for 48 hours at rates of 0.1 to 0.5 mg•kg–1•min–1. Simultaneous antegraderetrograde tepid blood cardioplegia and a single-clamp technique were used in all cases. The heart was perfused for at least 30 minutes before weaning was attempted. All patients received atrial and ventricular pacemaker leads. A low-dose (0.01 to 0.03 µg•kg–1•min–1) epinephrine infusion was started 10 minutes before the weaning process and regulated according to the hemodynamics. The clinical and operative data are shown in Table 1.
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Results
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Seven patients could be weaned from CPB under epinephrine infusion (mean dosage, 0.07 ± 0.025 µg•kg–1•min–1). An intraaortic balloon pump was necessary to discontinue CPB in 2 cases; in 1 patient who had severe aortoiliac disease, the balloon pump was introduced through the ascending aorta, the sternum was left open, and only the subcutaneous tissue and skin were closed. This patient, who had came to the operating room undergoing cardiopulmonary resuscitation, died 72 hours after the operation due to multiorgan failure (mortality, 11.1%). Three patients needed antiarrhythmic therapy for control of ventricular arrhythmias. Recovery was otherwise uneventful. Major electrocardiogram changes together with high enzyme levels indicating a new MI, occurred in 2 patients (22.2 %), whereas 7 had no electro-cardiogram changes suggestive of a new MI.
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Discussion
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The strategies available for myocardial protection have allowed surgeons to operate safely in elective coronary operations. However, a modified procedure may become necessary in patients with acute evolving MI who are transferred from the catheterization laboratory with an occluded coronary artery. Buckberg has championed the importance of initiating cardiac arrest with "resuscitation" or "induction" warm blood cardioplegia with amino acid enhancement directed at replenishing myocytes depleted of high-energy phosphates.2 In metabolically depleted and injured myocardium, such an approach significantly improves subsequent postoperative myocardial function by perioperative preservation of high-energy phosphates.2
Animal studies have shown that retrograde venous perfusion during pressure-controlled intermittent coronary sinus occlusion was effective in salvaging ischemic myocardium.3 These findings led to the suggestion that retroperfusion via the coronary sinus might be useful as a temporary means of preserving the viability of acutely ischemic myocardium in patients awaiting angioplasty or revascularization. Retroperfusion has commonly been used for circulatory support during PTCA procedures.4 However, its use during cardiac surgery has been limited to that of a valuable route for delivery of cardioplegic solutions. We believe there are several advantages of this method. Firstly, transatrial catheterization of the coronary sinus can be achieved within minutes, thus enabling the acutely ischemic myocardium to be perfused within a very short period of time. Since this is a controlled perfusion in an empty beating heart at 32°C to 34°C, the chance of reperfusion injury is expected to be low. Secondly, performance of a technically precise and expedient operation and use of arterial grafts are the prime determinants of both short- and long-term results in coronary surgery. Usually, in urgent situations such as PTCA failure, venous grafts are preferred to reduce the ischemic time during the pre-arrest period, but this can jeopardize long-term results. Coronary sinus retroperfusion enables arterial graft harvesting that is especially important in younger patients. It could be argued that this can also be carried out when the heart is arrested, but the ischemic period will inevitably be increased. Thirdly, ischemic time is reduced because the aorta is crossclamped only after the grafts are ready and since the single-clamp technique is used, reperfusion can start immediately after removal of the crossclamp.
The main goal during the pre-arrest period should be to maximize oxygen supply and reduce demand. This can be achieved by optimizing cardiopulmonary dynamics, rapid anesthetic induction and institution of partial CPB, and early reperfusion of the ischemic area.5 Although some of our patients had multiple-vessel disease, the acute injury was in the anterior myocardium due to LAD occlusion in 7 of the 9 cases. Experimental and clinical studies have shown that capillary flow during retrograde cardioplegia is four times greater in the left ventricle than in the right.5 The idea that coronary-sinus-delivered solutions predominantly perfuse the left ventricle has been well established in animal models. In human models, it was shown that 29% of retrograde capillary cardioplegia flow occurred in the left ventricle and only 4% in the right. This study indicated that approximately four-times more capillary flow occurred in the left ventricle than in the right. During retrograde perfusion, a crude assessment of the quality of perfusion could be made by observing the epicardium of the heart. Although delivering cardio-plegia solutions both antegradely and retrogradely in a simultaneous manner may cause myocardial edema, experimental clinical studies have proven that this is not the case. Unlike coronary arteries, the veins have rich venovenous anastomoses and cardioplegic drainage occurs through the thebesian veins directly into the body of the ventricles, explaining why simultaneous antegrade-retrograde cardioplegia can be delivered safely.5 The epicardial vein from the LAD area was full in all cases, while the vein from the posterior descending artery area was full in only 32% of cases. In addition, before cardioplegic arrest, a small arteriotomy was made on the LAD at the planned anastomotic site and dark blood was observed coming retrogradely through the incision, which inferred the efficiency of the system. During retrograde coronary perfusion in aortic valve surgery, we have nearly always observed dark blood coming from the left coronary ostium, while this was not the case for the right coronary ostium. Thus, it can be hypothesized that coronary sinus retroperfusion may not be as effective for acute occlusions of the right coronary artery. During our experience, transesophageal echocardiography during the procedure revealed improvement in wall function of the injured areas after retrograde coronary sinus perfusion in 2 patients with LAD lesions. No significant improvement was observed in 1 patient with a RCA lesion even though hemodynamic stability could be maintained. In view of the literature reports and these observations, the efficacy of the system for the RCA lesions needs to be further clarified. Coronary sinus retroperfusion, as an adjunct to antegrade perfusion in an empty beating heart at tepid temperatures, may serve as a useful modality for the application of treatment aimed at preserving the function and viability of ischemic tissue. Another possible application for coronary sinus retroperfusion might be during off-pump coronary surgery but further studies are needed to justify such an application.
Our limited experience suggests that controlled coronary sinus retroperfusion in energy-depleted hearts not only enables the surgeon to undertake arterial graft harvesting in emergency situations, which is important for the long-term outcome but also has a favorable effect on the early outcome in this high-risk group of patients. We believe that this system shows promise and is thus worthy of future study.
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References
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Buckberg GD, Marelli D. Myocardial protection. In: Kaiser LR, Kron LI, Spray TL, editors. Mastery of cardiothoracic surgery. 1st ed. Boston: Lippincott-Raven, 1998:287–306.
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Geary GG, Smith G, Suehiro GT, Zeman C, Siu B, McNamara JJ. Quantitative assessment of infarct size reduction by coronary venous retroperfusion in baboons. Am J Cardiol 1982;50:1424–30.[Medline]
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Costantini C, Sampaolesi A, Serra CM, Pacheco G, Neuburger J, Conci E, et al. Coronary venous retroperfusion support during high-risk coronary angioplasty in patients with acute ischemic syndromes. Circulation 1989;80: 116–25.
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Gates RN, Laks H. Retrograde cardioplegia. In: Karp RB, Laks H, Wechsler SA, editors. Advances in cardiac surgery. St. Louis: Mosby, 1998:115–35.
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Abstract
Introduction
