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Retrograde cardioplegia in CABG: is it really useful? The microcirculation and a capillary unit model
Ilias A Kouerinis1, Christos G Manopoulos, George C Zografos
1Department of Cardiovascular and Thoracic Surgery, University of Thessaly-Larissa, Greece. ikouerinis@hotmail.com
Insights
Retrograde cardioplegia offers a unique alternative to antegrade methods in cardiac surgery, especially for coronary artery bypass grafts (CABGs). This review clarifies its role and compares it with antegrade perfusion for improved myocardial protection.
Area of Science:
- Cardiac Surgery
- Cardiovascular Perfusion
- Myocardial Protection
Background:
- Retrograde cardioplegia is utilized in cardiac surgery, often as an adjunct or alternative to antegrade methods.
- Its routine use in coronary artery bypass grafts (CABGs) is debated due to inconsistent study results.
- Existing research lacks detailed microcirculatory perfusion assessment, crucial for myocardial protection.
Purpose of the Study:
- To elucidate differences between antegrade and retrograde cardioplegia in CABGs.
- To emphasize the need for direct comparison of retrograde versus antegrade cardioplegia for safe outcomes.
- To clarify the role of Thebesian veins and venovenous connections in retroperfusion.
Main Methods:
- Review of existing literature on antegrade and retrograde cardioplegia.
- Analysis of anatomical differences between human and animal hearts impacting study bias.
- Utilizing a human capillary model to explain microcirculation during perfusion.
Main Results:
- Fundamental variations in study designs hinder direct comparison of antegrade and retrograde perfusion protocols.
- Most studies offer limited insight into microcirculatory perfusion, a key factor in myocardial protection.
- Anatomical differences between species can introduce significant bias in research findings.
Conclusions:
- Direct comparison of retrograde cardioplegia alone versus antegrade in CABGs is necessary for reproducible and safe results.
- Understanding the role of venous connections and species-specific anatomy is critical.
- A human capillary model provides a clearer explanation of microcirculatory events during different perfusion techniques.
Abstract:
Most surgeons, ourselves including, use retrograde cardioplegia in numerable operations in cardiac surgery. It is believed to be not only supplementary to antegrade, but also a unique alternative in special complicated cases. Regarding CABGs (coronary artery bypass grafts), many authors advocate its routine use together with antegrade, while others do not suggest it for standard practice. The existing disagreement on this special item is consequential to the different results among various protocols which have studied the effect of antegrade and retrograde perfusion. In these studies, fundamental variations in design, materials, and methods have resulted in an inability to compare results. Additionally, most of the published protocols studying cardioplegic arrest offer only a gross estimation of the microcirculatory perfusion, which is the basis of myocardial protection. Our present review is an attempt to elucidate the differences, explain the necessity of comparing retrograde cardioplegia alone with antegrade in CABGs for the reproduction of safe results, clarify the role of Thebesian veins and venovenous connections during retroperfusion, consider the critical anatomic differences between human hearts and those of animals which may result in serious study bias, and, finally, offer an explanation of what may really be going on in the microcirculation during antegrade and retrograde perfusion using a human capillary model.
