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Facile retrograde cardioplegia: transatrial cannulation of the coronary sinus
S R Gundry1, A Sequiera, A M Razzouk
1Department of Surgery, Loma Linda University Medical Center, California 92354.
Insights
A novel transatrial catheter enables coronary sinus (CS) cardioplegia, simplifying the procedure. This technique achieved effective myocardial cooling and reduced inotrope use, proving CS cardioplegia more facile than antegrade methods.
Area of Science:
- Cardiovascular Surgery
- Medical Devices
- Cardioplegia Delivery
Background:
- Coronary sinus (CS) cardioplegia offers benefits but is underutilized due to complex cannulation requirements.
- Existing methods necessitate bicaval cannulation, snares, and atriotomy, limiting widespread adoption.
- Antegrade cardioplegia is a common alternative, but CS delivery may offer advantages.
Purpose of the Study:
- To introduce and evaluate a novel catheter for simplified transatrial CS cardioplegia.
- To assess the efficacy and safety of this new technique in a large patient cohort.
- To compare the outcomes of transatrial CS cardioplegia with previous antegrade cardioplegia methods.
Main Methods:
- A new catheter with a flexible stylet for hockey-stick configuration was designed.
- Blind intubation of the CS was performed transatrially in 225 consecutive patients.
- Catheter position, myocardial temperatures, and clinical outcomes were monitored.
Main Results:
- Successful CS intubation was achieved in all patients.
- Myocardial temperatures reached 7-8°C across all walls after cardioplegia infusion.
- Reduced inotrope use (10% vs. 38%) and no instances of heart block or CS injury were observed.
- Atheromatous material was flushed retrogradely from grafts during revascularization.
Conclusions:
- Transatrial cannulation of the CS is feasible and simplified by the novel catheter design.
- This technique facilitates effective myocardial protection and reduces the need for inotropic support.
- Transatrial CS cardioplegia is a more facile and potentially advantageous alternative to antegrade cardioplegia.
Abstract:
The benefits of coronary sinus (CS) cardioplegia are well known, yet CS cardioplegia is not used widely owing to the need for bicaval cannulation, snares, and an atriotomy. We designed and used in 225 consecutive patients a catheter containing a flexible removable stylet that, when shaped into a hockey-stick configuration, enabled blind intubation of the CS through a small pursestring in the right atrium, guided easily into the CS using a finger on the atrioventricular groove at the inferior vena cava. The CS was intubated in all patients; a pressure-limited balloon at the catheter tip was inflated after cross-clamping. An integral distal pressure line measured CS pressure. Catheters were placed distally within the great cardiac vein beyond the posterior interventricular vein; the position did not alter cooling: right ventricular free wall, septum, and left ventricular free wall temperatures were 7 degrees +/- 2 degrees, 8 degrees +/- 2 degrees, and 7 degrees +/- 2 degrees C, respectively, after an initial 10 mL/kg of blood cardioplegia. Transatrial CS cardioplegia was used in 45 aortic valve replacements, 22 mitral valve replacements, 4 triple-valve replacements, 6 congenital lesions, and 148 coronary revascularizations, including 40 redo operations. Atheromatous material was routinely flushed retrogradely from cut old vein grafts during revascularization; 70 revascularizations (47%) were performed urgently for acute infarction or jeopardized myocardium. No heart block or CS injury occurred, and inotrope use dropped to 10% of patients (from 38% in the previous 256 patients with antegrade blood cardioplegia). We conclude that the CS can be cannulated transatrially and that CS cardioplegia is more facile than antegrade cardioplegia.(ABSTRACT TRUNCATED AT 250 WORDS)