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Simultaneous arterial and coronary sinus cardioplegic perfusion: an experimental and clinical study
K Ihnken1, K Morita, G D Buckberg
1Division of Cardiothoracic Surgery, UCLA School of Medicine.
Insights
Simultaneous antegrade and retrograde coronary sinus perfusion is safe and effective for myocardial protection during cardiac surgery. This combined approach enhances cardioplegic delivery, preventing edema and improving patient outcomes in high-risk individuals.
Area of Science:
- Cardiovascular Surgery
- Cardiothoracic Medicine
- Myocardial Protection Strategies
Background:
- Coronary flow inhomogeneity necessitates alternating antegrade and retrograde perfusion routes.
- Previous concerns over myocardial damage limited simultaneous antegrade and retrograde cardioplegic delivery.
- Thebesian veins predominantly facilitate retrograde drainage, suggesting potential for combined perfusion benefits.
Purpose of the Study:
- To test the safety of simultaneous aortic (antegrade) and coronary sinus (retrograde) perfusion during aortic clamping.
- To evaluate the initial clinical application of this combined myocardial protection strategy.
- To assess the efficacy of combined perfusion in high-risk cardiac surgery patients.
Main Methods:
- Five minipigs underwent 1 hour of aortic clamping with simultaneous antegrade and retrograde perfusion.
- Perfusion included periods with warm or cold blood cardioplegia (BCP).
- The combined strategy was applied to 174 high-risk patients undergoing cardiac surgery (CABG, valve replacement).
Main Results:
- No significant right or left ventricular edema was observed in experimental models.
- No lactate production indicated preserved myocardial metabolism during perfusion.
- Coronary sinus pressure remained below 40 mmHg in both experimental and clinical studies.
Conclusions:
- Simultaneous antegrade and retrograde coronary sinus perfusion is safe during aortic clamping.
- This combined strategy effectively protects the myocardium during cardiac surgery.
- The approach shows promise for high-risk patients, including those in cardiogenic shock or undergoing reoperation.
Unlabelled:
The existence of inhomogeneous distribution of coronary flow with antegrade or retrograde perfusion alone has led to alternating between these delivery routes to maximize their individual benefits. Concern over myocardial damage prevented the simultaneous application of antegrade and retrograde cardioplegic blood delivery. Based upon the predominance of retrograde drainage via Thebesian veins, and evidence that pressure-controlled intermittent coronary sinus occlusion during antegrade cardioplegic delivery enhances its distribution and protective properties, this study tests (a) the hypothesis that simultaneous aortic and coronary sinus perfusion is safe during aortic clamping, and (b) reports initial clinical application of this combined strategy in 174 patients. Five minipigs (25-30 kg) underwent 1 hr of aortic clamping with simultaneous aortic (antegrade) and coronary sinus (retrograde) perfusion at 200 ml/min with normal blood (37 degrees C) before and after 30 minutes of perfusion with either warm (37 degrees C) or cold (4 degrees C) blood cardioplegia (BCP). Furthermore, the combined strategy was used in 174 high-risk patients (NYHA class III-IV) at 3 university hospitals to perform myocardial protection during CABG or valve replacement, or a combination of both. Included were 16 patients in cardiogenic shock and 24 undergoing reoperation. In both the clinical and the experimental studies the coronary sinus pressure was always < 40 mmHg in beating or arrested hearts.
Experimental:
Compared to control values (81.4 +/- 0.4% tissue water content), no right-ventricular (80.8 +/- 0.8%) or left-ventricular (79.5 +/- 0.3%) edema developed, no lactate was produced (control: -1.0 +/- 0.5 mg/100 g/min, empty beating: -0.64 +/- 5, and BCP arrest: -8.6 +/- 6.6).(ABSTRACT TRUNCATED AT 250 WORDS)