Myocardial Protection in Minimally Invasive Mitral Valve Surgery: Retrograde Cardioplegia Alone Using Endovascular
Jean-Sebastien Lebon1, Pierre Couture1, Melissa Colizza1
1Department of Anesthesiology, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada.
Insights
Retrograde cardioplegia alone offers comparable myocardial protection to combined antegrade and retrograde methods in minimally invasive mitral valve surgery (MIMS). However, it was insufficient to achieve asystole in nearly a quarter of patients, necessitating further investigation into optimal delivery techniques.
Area of Science:
- Cardiac Surgery
- Cardiology
- Minimally Invasive Procedures
Background:
- Minimally invasive mitral valve surgery (MIMS) requires effective myocardial protection.
- Traditional antegrade cardioplegia delivery may be challenging in MIMS.
- Retrograde cardioplegia offers an alternative delivery route via the coronary sinus.
Purpose of the Study:
- To compare the efficacy of retrograde cardioplegia alone versus combined antegrade and retrograde cardioplegia in MIMS.
- To evaluate myocardial protection, hemodynamic stability, and clinical outcomes.
Main Methods:
- Retrospective study comparing 97 MIMS patients receiving retrograde cardioplegia alone with 118 patients receiving antegrade and retrograde cardioplegia.
- Cardioplegia delivered via coronary sinus catheter (retrograde) or standard antegrade/retrograde methods.
- Outcomes assessed included myocardial infarction markers, cardiac function, and clinical endpoints.
Main Results:
- Retrograde cardioplegia alone achieved adequate delivery in 74.2% of patients; 23.7% required additional antegrade cardioplegia.
- No significant differences in myocardial infarction, arrhythmias, or cardiac enzyme levels were observed between groups.
- Retrograde cardioplegia alone was associated with significantly lower lactate levels and shorter hospital stays.
Conclusions:
- Retrograde cardioplegia alone provides comparable myocardial protection to combined antegrade and retrograde cardioplegia in MIMS.
- Its sole use may not achieve complete asystole in all patients.
- Further research is needed to optimize retrograde cardioplegia delivery in MIMS.
Objective:
To compare myocardial protection with retrograde cardioplegia alone with antegrade and retrograde cardioplegia in minimally invasive mitral valve surgery (MIMS).
Design:
Retrospective study.
Setting:
Tertiary care university hospital.
Participants:
The authors studied 97 MIMS patients using retrograde cardioplegia alone and 118 MIMS patients using antegrade and retrograde cardioplegia.
Interventions:
The data from patients admitted for MIMS using retrograde cardioplegia (MIMS retro) between 2009 to 2012 were compared with the data from patients undergoing MIMS with antegrade and retrograde cardioplegia (MIMS ante-retro) between 2006 and 2010 (control group). Cardioplegia in the MIMS retro group was delivered solely through an endovascular coronary sinus (CS) catheter positioned under echographic and fluoroscopic guidance. Antegrade and retrograde cardioplegia was used in the MIMS ante-retro group. Data regarding myocardial infarction (MI; creatine kinase Mb, troponin T, electrocardiogram), myocardial function, and hemodynamic stability were collected for comparison.
Measurements And Main Results:
Adequate cardioplegia administration (CS pressure >30 mmHg and asystole) was attained in 74.2% of the patients with retrograde cardioplegia alone. In 23.7% of the patients, the addition of an antegrade cardioplegia was necessary. No difference was observed in the incidence of MI (0 MIMS retro v 1 for MIMS ante-retro, p = 0.3623), difficult separation from cardiopulmonary bypass, and postoperative malignant arrhythmia. No difference was found for maximal creatine kinase Mb (39.1 [28.0-49.1] v 37.9 [28.6-50.9]; p = 0.8299) and for maximal troponin T levels (0.39 [0.27-0.70] v 0.47 [0.32-0.79]; p = 0.1231) for MIMS retro and MIMS ante-retro, respectively. However, lactate levels in the MIMS retro group were significantly lower than in the MIMS ante-retro group (2.1 [1.4-3.05] v 2.4 [1.8-3.3], respectively; p = 0.0453). No difference was observed in duration of intensive care unit stay and death. MIMS retro patients had a shorter hospital stay (7.0 [6.0-8.0] v 8.0 [7.0-9.0] days; p = 0.0003).
Conclusion:
Retrograde cardioplegia administration alone provided comparable myocardial protection to antegrade and retrograde cardioplegia during MIMS, but was not sufficient to achieve asystole in one-fifth of patients.
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