Eur J Cardiothorac Surg 2000;17:193-194
© 2000 Elsevier Science NL
Retrograde perfusion of oxygenated blood during off pump revascularization to avoid ischemia
Harinder Singh Bedi,
Maninder Singh Kalkat
Department of Cardiac Surgery, Tagore Heart Care and Research Centre, Mahavir Marg, 339 Guru Teg Bahadur Nagar, Jalandhar, Punjab 144 003, India
Corresponding author. Tel.: +91-181-274-867; fax: +91-181-204-123
e-mail: bedi{at}jla.vsnl.net.in
We read with interest the report by Svedjeholm et al. [1]. The authors are to be complemented on their successful method of emergency retroperfusion for treatment of acute myocardial ischemia during early stages of surgery.
We have been using a similar method for avoiding ischemia during off pump CABG when the coronary artery is snared. After heparinization an antegrade cannula is placed in the ascending aorta and a retrograde cannula via the coronary sinus using standard techniques. The two are connected after de-airing by a multiport (Fig. 1). Oxygenated arterial blood from the ascending aorta is now allowed to perfuse the coronary sinus with continuous monitoring of coronary sinus pressure. The coronary sinus pressure almost never goes above 40 mmHg (Fig. 2), probably as the auto inflating balloon allows some degree of ‘leak’.
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Fig. 1. Operative photograph showing the antegrade cannula in the ascending aorta connected to the retrograde coronary sinus cannula in the coronary sinus. Continuous monitoring of coronary sinus pressure is done via the pressure line (P). Ante, antegrade cannula; Retro, retrograde cannula; RA, right atrium.
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Fig. 2. Freeze frame of monitor showing the tracing of the coronary sinus pressure (labelled RV) with the coronary sinus perfusion on (straight arrow) and with perfusion turned off (bent arrow). With perfusion on the coronary sinus pressure is well below a mean of 40 mmHg (scale of pressure tracing tracing is at 40 mmHg).
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We have used this technique along with other methods for off pump multivessel (all three territories) revascularization in 100 patients along with postoperative angiographic results [2]. The method allows unhurried anastomosis as there were never any signs of ischemia (except in three patients while performing anastomosis to a large RCA).
Proof of perfusion is shown by:
- In some cases (especially for LAD) there are ECG changes of ischemia on snaring the artery which revert to normal as soon as retrograde perfusion is commenced.
- On temporary release of the distal snare after the coronary arteriotomy a vigorous backbleeding of dark blood is seen in some cases.
Our method is a combination of pressure controlled intermittent coronary sinus occlusion (PICSO) and arterial retroperfusion of the coronary sinus, both of which are supported by previous experimental and clinical data [3,4].
References
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Svedjeholm R., Hakanson E., Forsman M. Treatment of acute myocardial ischemia during early stages of surgery by an easily applicable method for emergency retroperfusion. Eur J Cardio-thorac Surg 1999;15:551-552.
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Bedi H.S., Suri A., Kalkat M.S., Sengar B.S., Mahajan V., Chawla R., Sharma V.P. Multivessel global myocardial revascularization without cardiopulmonary bypass using innovative new techniques for myocardial stabilization and perfusion. Ann Thorac Surg 2000;69:156-164.[Abstract/Free Full Text]
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Mohl W., Menasche P., Snyder H.E., Roberts A.J. Current status of coronary sinus interventions. In: Karp R.B., Laks H., Wechesler A.S., eds. Advances in cardiac surgery, vol. 2. St Louis, MO: Mosby Year Book, 1990:31-62.
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Gundry S.R. Modification of myocardial ischemia in normal and hypertrophied hearts utilizing diastolic retroperfusion of the coronary sinus. J Thorac Cardiovasc Surg 1982;83:659-669.[Abstract]
Received September 22, 1999;
accepted December 21, 1999.
