Coronary sinus rupture with retrograde cardioplegia

Coronary sinus (CS) rupture occurring during retrograde cardioplegia (RCP) is a rare complication. Patients with left ventricular hypertrophy are at higher risk for injury to the CS. The patient was a 66-year-old female with hypertension, ischemic cardiomyopathy and dysrhythmias, who had evidence of an anterior wall myocardial infarction, congestive heart failure and angina. During coronary artery bypass surgery, antegrade cardioplegia was initially administered, but aortic insufficiency prevented adequate myocardial cooling. RCP was then administered and the heart cooled appropriately. After approximately 300 ml of blood cardioplegic solution had been given, the CS pressure suddenly dropped from 30 mmHg to zero. RCP administration was stopped, and the surgeon palpated a hematoma over the area of the CS, which later ruptured upon rotation of the heart. A primary repair could not be performed, so a pericardial patch was placed over the area of disruption, which appeared to provide adequate hemostasis. The patient was weaned from cardiopulmonary bypass (CPB), but began to bleed freely from the CS distal to the pericardial patch. The patient was placed back on CPB to allow further repair of the CS, but the tissues were thin and friable and the ventricle disassociated from the ventricular septum. The situation was deemed not salvageable and further attempts at repair were stopped. The perfusionist should monitor infusion pressures and the CS waveform during RCP delivery. Changes in the waveform may indicate cannula malposition, loss of balloon seal, or, more rarely, CS rupture; such changes should prompt immediate cessation of RCP delivery.