Ann Thorac Surg 1997;63:539-541
© 1997 The Society of Thoracic Surgeons
Case Report
Rare Complication of Retrograde Cardioplegia: Inner Wall Perforation of the Right Atrium
Guo-Wei He, MD, PhD
Division of Cardiothoracic Surgery, Department of Surgery, University of Hong Kong, Grantham Hospital, Aberdeen, Hong Kong
Accepted for publication July 29, 1996.
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Abstract
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Retrograde cardioplegia has been widely applied with satisfactory results. This report presents a case in which the retrograde cannula was inserted into the coronary sinus by penetrating the inner wall of the right atrium rather than through the orifice of the coronary sinus. Surgeons should be cautious of this possibility, particularly in patients with a dilated right atrium in which the space between trabeculae is enlarged and the atrial tissue is friable. Under this situation, the tip of the cannula is easily caught in such a space and may penetrate the wall of the right atrium, which affects the delivery of cardioplegia.
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Introduction
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Retrograde cardioplegia infusion provides a few advantages in delivering cardioplegia during cardiac operations. First, it is superior to antegrade cardioplegia in the delivery of capillary flow to jeopardized myocardium and therefore may avoid the nonhomogeneous distribution of antegrade delivery [1, 2]. Second, it can be delivered continuously and therefore minimally affects operative procedures. Third, in operations requiring ascending aortotomy such as in aortic valve replacement, use of retrograde cardioplegia reduces the need for repetitive cardioplegic infusion directly through the coronary ostium [3] and therefore saves aortic cross-clamp time and reduces the possible damage to the coronary ostia. In addition, although not well established yet, it is possible that retrograde perfusion of cardioplegia may wash out any debris in the proximal coronary arteries, and this may reduce the incidence of coronary emboli, particularly in aortic valve replacement when the aortic valve is severely calcified. However, despite the fact that the insertion of the retrograde cannula is technically easy under most situations, it could be problematic. This report describes an unusual complication of insertion of a retrograde cardioplegia cannula, which perforated the inner wall adjacent to the coronary sinus and was inserted into the sinus directly through the perforated inner wall of the right atrium (RA).
A 67-year-old woman had a long-standing history of rheumatic heart disease and was diagnosed to have triple-valve disease. The mitral valve was insufficient and stenotic, as was the aortic valve. In addition, there was evidence of severe tricuspid insufficiency. Echocardiography showed that the area of the mitral orifice was 1.2 cm2 with severe regurgitation. The aortic valve was significantly stenotic with moderate regurgitation. The tricuspid annulus was significantly enlarged, and there was severe tricuspid regurgitation. On physical examination, there was evidence of high venous pressure and right heart failure (eg, hepatomegaly, ascites). Replacement of both the aortic and mitral valve as well as tricuspid annuloplasty were judged to be indicated.
The operation was performed with median sternotomy. The heart was significantly enlarged, with a largely dilated RA. The ascending aorta was dilated. The aorta was cannulated. The superior and inferior venae cavae were separately cannulated. A small pursestring was placed on the right atrium for the insertion of the retrograde cardioplegia cannula (Retroplegia; Research Medical Inc, Midvale, UT). There was a slight resistance felt on the tip of the cannula during the insertion. Ventricular arrhythmia and hypotension developed, and cardiopulmonary bypass was immediately instituted. On bypass the cannula was inserted and the tip was felt in the coronary sinus as usually it is. The cannula was connected to a cardioplegic set in the routine way.
Moderate hypothermia was applied. The aorta was opened and blood cardioplegia was directly infused into both the left and right coronary ostia. After the antegrade infusion, retrograde perfusion of blood cardioplegia was given. A slightly higher perfusion pressure was noticed. At the rate of 150 mL/min, the pressure was 40 mm Hg. Although this was in the "normal range" during the delivery, the rate was reduced to 120 mL/min to maintain the perfusion pressure less than 30 mm Hg, which is my usual practice. At this rate, the delivery of retrograde cardioplegia was as smooth as usual. The valve replacement followed the routine procedure. The mitral valve and the aortic valve were replaced by St. Jude Medical (St. Paul, MN) valve prostheses. The left atrium and the aorta was closed. During this period, retrograde cardioplegia was infused every 20 minutes without giving any more antegrade cardioplegia. Topical cooling was also applied. The heart remained electrically still for whole period of cross-clamping.
After mitral and aortic valve replacement, the venae cavae were snared and the RA was opened. At this time, the retrograde cannula was found not in the orifice of the coronary sinus. It was located about 1.5 cm away from the orifice and penetrated through the inner wall of the RA between trabeculae (Fig 1
). Due to the significant dilatation of the RA, the space between the trabeculae was enlarged and the tip of the cannula entered the coronary sinus from this space by penetrating the inner wall of the RA (Fig 2). At the outside of the RA, opposite the inside of the RA where the cannula was inserted between the trabeculae, there was a hemotoma (1 x 1 cm). This was obviously due to the damage to the RA wall during insertion of the cannula. However, there was no perforation of the full thickness of the RA wall. The cannula was removed, and there was no need to repair the inner wall as it only communicated with the coronary sinus.
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Fig 1. . The tip of the retrograde cardioplegia catheter was toward a space between trabeculae rather than the orifice of the coronary sinus (CS). (TV = tricuspid valve.)
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Fig 2. . The catheter was placed in the coronary sinus (CS) from a space between trabeculae by partially penetrating the inner wall of the right atrium. (TV = tricuspid valve.)
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The tricuspid annuloplasty was performed with the De Vega method, and the size of the annulus after the repair was 31 mm as measured by a St. Jude sizer. No more cardioplegia was needed. The RA incision was closed. There was no problem weaning the patient off cardiopulmonary bypass.
On the first operative day, the patient had torsade de pointes arrhythmia that was successfully controlled by cardioversion and pacing. The subsequent course was uneventful. She was discharged on the 18th postoperative day. The prolonged stay in the hospital was for adjustment of the dose of warfarin.
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Comment
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Because of the advantages of retrograde cardioplegia delivery and its technical feasibility by using the new retrograde cardioplegia cannula (Research Medical, Inc), I have been routinely using retrograde cardioplegia delivery for coronary bypass grafting and aortic valve replacement. In my experience, rarely it is difficult to insert the cannula into the coronary sinus before or during cardiopulmonary bypass. However, the present report reveals a possibility that the cannula may not be correctly inserted into the coronary sinus, particularly in patients with a dilated RA in which the space between the trabeculae is enlarged and the RA tissue is more friable than usual. Under this situation, the tip of the cannula is easily caught in the space between trabeculae, goes through the inner wall of the RA, and enters the coronary sinus through the perforation. Although in the present case this did not cause great complications except that a visible hemotoma on the RA wall was noticed and that the trauma may have caused temporary arrhythmia during the insertion, such misplacement of the cannula may completely perforate the RA wall. In this case the partial penetration of the RA wall already formed a subepicardial hemotoma of the RA. In addition, such misplacement of the retrograde cannula may cause a higher pressure during the retrograde cardioplegia delivery, as described in this report.
The exact incidence of the misplacement seen in this report is unknown. It is possible that the incidence of such penetrating is higher than we are aware of. In fact, the misplacement was discovered in the present case only because the patient required a tricuspid annuloplasty and therefore opening of the RA was necessary. Should this happen in operations in which opening of the RA is unncessary, insertion of the retrograde cannula through the space between the trabeculae penetrating to the coronary sinus would not be detected.
This report suggests that to avoid possibly unsatisfactory cardioplegia delivery or perforation of the back wall of the RA, the surgeon should be aware of the possibility that the insertion of retrograde cardioplegia cannula may penetrate the inner wall of the RA, particularly when the atrium is significantly dilated.
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Acknowledgments
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I gratefully acknowledge the contribution of Mr Tun-Tak Ng at the Department of Surgery, University of Hong Kong, for drawing the figures.
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Footnotes
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Address reprint requests to Prof He, Division of Cardiothoracic Surgery, University of Hong Kong, The Grantham Hospital, 125 Wong Chuk Hang Rd, Aberdeen, Hong Kong (e-mail: gwhe{at}hkucc.hku.hk).
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References
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- Partington MY, Acar C, Buckberg GD, et al. Studies of retrograde cardioplegia: capillary blood flow distribution to myocardium supplied by open and occluded arteries. J Thorac Cardiovasc Surg 1989;97:605–12.[Abstract]
- Gundry SR, Kirsh MM. A comparison of retrograde cardioplegia versus antegrade cardioplegia in the presence of coronary artery obstruction. Ann Thorac Surg 1984;38:124–7.[Abstract/Free Full Text]
- Menasché P, Subayi J-B, Piwnica A. Retrograde coronary sinus cardioplegia for aortic valve operations: a clinical report of 500 patients. Ann Thorac Surg 1990;49:556–64.[Abstract/Free Full Text]
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Abstract
Introduction
