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Simultaneous antegrade and retrograde reperfusion after cardioplegic arrest for coronary artery bypass
A J Carpenter1, D M Follette, B Sheppard
1Wilford Hall Medical Center, Lackland Air Force Base, Texas, USA.
Insights
Simultaneous antegrade and retrograde warm blood reperfusion during coronary artery bypass surgery did not harm the heart. This method may lead to faster myocardial recovery but does not improve long-term outcomes.
Area of Science:
- Cardiovascular Surgery
- Cardiac Anesthesia
- Myocardial Protection
Background:
- Retrograde coronary sinus reperfusion allows myocardial revascularization under a single cross-clamp.
- Concerns exist regarding perfusate maldistribution or capillary overpressurization with combined antegrade/retrograde reperfusion.
Purpose of the Study:
- To compare postcardioplegic myocardial recovery in patients receiving retrograde-only versus simultaneous antegrade/retrograde reperfusion.
Main Methods:
- Prospective, randomized trial of 24 patients undergoing elective coronary artery bypass (CAB).
- Comparison of retrograde-only reperfusion (n=12) versus simultaneous antegrade/retrograde reperfusion (n=12) using warm blood from cardiopulmonary bypass (CPB).
- Assessment of myocardial recovery time, cardioversion, inotropic support, and hemodynamic parameters.
Main Results:
- No significant differences in age, ventricular function, grafts, CPB time, cardioversion, inotropic need, or postoperative hemodynamics.
- Significantly reduced myocardial recovery time in the simultaneous antegrade/retrograde reperfusion group (2.6+/-2.1 min vs 13.9+/-7.0 min).
Conclusions:
- Simultaneous antegrade and retrograde warm blood reperfusion is safe for the myocardium.
- Faster myocardial recovery may be due to a shorter warm ischemia time but does not improve postoperative performance.
Abstract:
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 postcardioplegic myocardial recovery among patients receiving retrograde reperfusion only and patients receiving simultaneous antegrade/retrograde 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 cardiopulmonary bypass (CPB) circuit. Twelve received retrograde reperfusion only, and 12 received simultaneous antegrade/retrograde 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 antegrade/retrograde 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.