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Efficacy of coronary sinus cardioplegia in patients with complete coronary artery occlusions
P Menasché1, J B Subayi, L Veyssié
1Department of Cardiovascular Surgery, Hôpital Lariboisière, Paris, France.
Insights
Coronary sinus cardioplegia effectively protects heart muscle in patients with blocked arteries during bypass surgery. This method ensures adequate cardioplegia delivery to jeopardized myocardial areas, improving outcomes.
Area of Science:
- Cardiovascular Surgery
- Cardiac Anesthesia
- Myocardial Protection
Background:
- Antegrade cardioplegia is often insufficient for myocardial areas distal to occluded coronary arteries.
- Patients with complex coronary artery disease patterns face high risk of cardioplegic maldistribution.
- Effective myocardial protection is critical during coronary artery bypass grafting (CABG).
Purpose of the Study:
- To assess the efficacy of coronary sinus cardioplegia in patients at high risk of cardioplegic maldistribution.
- To evaluate myocardial protection in areas supplied by occluded coronary arteries during CABG.
- To determine if coronary sinus cardioplegia improves outcomes in high-risk surgical patients.
Main Methods:
- Coronary sinus cardioplegia was administered to 30 high-risk CABG patients with specific coronary artery disease patterns.
- The retrograde infusion was given intermittently during aortic cross-clamping at 100 mL/min.
- Intraoperative findings confirmed filling of occluded arteries with the cardioplegia solution.
Main Results:
- Occluded coronary arteries were consistently perfused with the retrogradely infused solution.
- Limited intraoperative ischemic damage was inferred from postoperative outcomes.
- No pathological evidence of inadequate myocardial protection was found at autopsy.
- Postoperative stroke volume indices remained stable compared to pre-bypass levels.
Conclusions:
- Coronary sinus cardioplegia appears effective in delivering cardioplegia to myocardial regions supplied by occluded arteries.
- This retrograde approach offers a viable strategy for myocardial protection in high-risk CABG patients.
- The findings suggest improved preservation of jeopardized myocardium, potentially reducing ischemic injury.
Abstract:
Myocardial areas distal to complete coronary artery occlusions are poorly protected by antegrade cardioplegia. We assessed the effects of coronary sinus cardioplegia in 30 patients undergoing bypass operations and at high risk of cardioplegic maldistribution because of the following anatomical patterns of coronary artery disease: critical (greater than or equal to 50%) stenosis of the left main trunk with total occlusion of the right coronary artery (16 patients) or critical (greater than or equal to 70%) stenosis of the right coronary artery with total occlusion of the left anterior descending (11 patients) or circumflex artery (3 patients). After induction of arrest through the aorta, coronary sinus cardioplegia was given intermittently during the cross-clamp period at a flow rate of 100 mL/min. Intraoperatively, occluded arteries were consistently found to be filled with the retrogradely infused solution. One patient died early postoperatively of low cardiac output and a second patient died later during his hospital stay, presumably of an arrhythmia. At autopsy, none of them had pathological evidence of inadequate myocardial protection. One patient sustained a myocardial infarction and 3 others required inotropes for more than 24 hours postoperatively. Postoperative values for right and left stroke volume indices were not significantly different from prebypass levels. Overall, these results are consistent with the occurrence of limited intraoperative ischemic damage and, by inference, suggest the efficacy of the coronary sinus route in preserving myocardial areas supplied by completely occluded coronary arteries and, hence, in jeopardy of inadequate cardioplegia delivery.