Ann Thorac Surg 1998;66:2085-2087
© 1998 The Society of Thoracic Surgeons
Case Reports
Percutaneous coronary sinus cannulation guided by transesophageal echocardiography
Igor M. Plotkin, MDa,
Charles D. Collard, MDa,
Sary F. Aranki, MDb,
Robert J. Rizzo, MDb,
Stanton K. Shernan, MDa
a Department of Anesthesia, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
b Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
Accepted for publication May 19, 1998.
Address reprint requests to Dr Plotkin, Department of Anesthesia, Brigham and Women’s Hospital, 75 Francis St, Boston, MA 02115
e-mail: (plotkin{at}zeus.bwh.harvard.edu)
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Abstract
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We investigated whether percutaneous cannulation of the coronary sinus could be accomplished without fluoroscopy using transesophageal echocardiography in patients undergoing minimally invasive cardiac operations. The coronary sinus was cannulated without significant complications using transesophageal echocardiography in 10 of 11 patients (mean, 10.5 minutes). Percutaneous cannulation of the coronary sinus can be accomplished in a safe and efficient manner using transesophageal echocardiography without the need for fluoroscopy.
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Introduction
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Since the first demonstration in 1982 of the effectiveness of retrograde cardioplegia in protecting the myocardium during cardiopulmonary bypass [1], the administration of retrograde cardioplegia alone or in conjunction with anterograde cardioplegia has become standard practice in many institutions. Recently, a novel endovascular port-access system (Heartport, Inc, Redwood City, CA) was introduced to enable cardiopulmonary bypass with cardioplegic arrest in patients undergoing minimally invasive coronary artery bypass grafting or mitral valve operations [2–4]. Anterograde and retrograde cardioplegia is delivered in this system through a transfemoral endoaortic occlusion catheter and a coronary sinus catheter (CSC), respectively. Because direct cannulation of the coronary sinus (CS) can be extremely difficult or even impossible due to limited surgical exposure, the CSC is usually inserted with fluoroscopic or angiographic guidance. We have found the routine use of fluoroscopy to be unwarranted, as atraumatic cannulation of the CS can be accomplished using transesophageal echocardiography (TEE) alone. Because TEE is used routinely to monitor the position of the endoaortic occlusion catheter [4, 5], cannulation of the CS without using fluoroscopy limits exposure of the patient and operating room personnel to unnecessary radiation and potentially decreases health care costs by reducing expenditures on accessory equipment and personnel. We describe our experience with percutaneous cannulation of the CS using TEE guidance in 11 patients undergoing minimally invasive cardiac operations.
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Methods
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After obtaining informed consent from 11 patients undergoing minimally invasive coronary artery bypass grafting or valvular operations, a multiplane TEE probe (Acuson, Mountain View, CA) was inserted under general anesthesia and the coronary sinus visualized (Fig 1). The right internal jugular vein was cannulated with an 11-F introducer and a 9-F preshaped triple-lumen CSC (Heartport, Inc, Redwood, CA) inserted through the introducer to a depth of 20 cm. The anticontamination sheath was extended over the catheter and the sterile set-up was disassembled, allowing the surgeons to begin preparing the patient. While visualizing the CS using TEE (Fig 1B), the anaesthesiologist directed the preshaped CSC across the right atrium toward the CS ostium and engaged it, with or without the help of the catheter guidewire (Fig 2A). The catheter was then inserted 3 to 4 cm into the CS and its position confirmed by TEE (Fig 2B) and by ventricularization of the CS waveform after balloon inflation.
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Fig 1. (A) Image of coronary sinus at 0° (transverse view). (CS = coronary sinus; LA = left atrium; RA = right atrium; RV = right ventricle; TV = tricuspid valve.) (B) Image of coronary sinus at 90° to 120° (bicaval view). (CS = coronary sinus; LA = left atrium; RA = right atrium; SVC = superior vena cava.)
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Fig 2. (A) Bicaval view of an engaged coronary sinus catheter. (CSC = coronary sinus catheter; LA = left atrium; SVC = superior vena cava.) (B) Transverse view of an engaged coronary sinus catheter with an inflated balloon. (CSB = coronary sinus balloon; LV = left ventricle; RA = right atrium; RV = right ventricle.)
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Results
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Coronary sinus cannulation times and complications are given in Table 1. Insertion of the CSC was accomplished successfully in 10 of 11 patients with TEE guidance only. We were unable to insert the CSC in 1 patient despite several attempts, including the use of fluoroscopic guidance. Mean CS cannulation time was 10.5 minutes after placement of the introducer. No significant patient morbidity was observed in this series. Two patients with a preoperative history of atrial fibrillation had transient episodes of atrial fibrillation during insertion of the CSC, one of whom required cardioversion. Additionally, the CSC was dislodged briefly from the CS in one patient after surgical manipulation, but it was easily repositioned.
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Comment
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The performance of minimally invasive cardiac operations using cardiopulmonary bypass has necessitated the evolution of cardioplegic delivery because access to the ascending aorta and radial artery is often limited. We found that percutaneous cannulation of the CS for the administration of retrograde cardioplegia can be accomplished without fluoroscopy using TEE alone. Furthermore, percutaneous cannulation of the CS can be performed in less than 10 minutes, without significant complications or interference with surgical progress.
Cannulation of the CS might be associated with several complications. In our series, atrial fibrillation during CS cannulation was noted in two patients with a history of atrial fibrillation. In another patient, the CSC was dislodged from the CS during surgical manipulation. Finally, we were unable to percutaneously cannulate the CS under TEE guidance in one patient. Difficulty in percutaneous cannulation of the CS might be related to an inability to adequately visualize the CS by TEE, the presence of an acute angle between the superior vena cava and the CS, or interference from a thebesian valve overlying the CS ostium (Fig 3). Other potential complications of this technique include the possibility of right atrial or CS puncture leading to significant hemorrhage in a setting of limited surgical access.
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Fig 3. Bicaval view of the thebesian valve. (CS = coronary sinus; LA = left atrium; RA = right atrium; TV = thebesian valve.)
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Percutaneous cannulation of the CS using TEE guidance might also be useful in non-port-access cardiac surgical procedures. We have placed percutaneous CSCs using TEE guidance in patients undergoing minimally invasive aortic valve replacement via parasternal incisions and in patients undergoing reoperations. In all of these cases, direct transatrial cannulation of the CS would have been extremely difficult because of limited surgical exposure. Similarly, these catheters were positioned in an average time of 10.5 minutes without complication. Recently, an intraluminal, semirigid, rotating stent (Heartport, Inc, Redwood, CA) was incorporated to help steer the catheter into the CS ostium. Such improvements in CSC technology should facilitate the ease of percutaneous CS cannulation.
In summary, the routine use of fluoroscopy for percutaneous CS cannulation is unwarranted, as atraumatic cannulation of the CS can be accomplished using TEE while monitoring the CS pressure waveform. With continuing improvements in catheter technology and operator experience, percutaneous cannulation of the CS for administration of retrograde cardioplegia during minimally invasive cardiac operations can be accomplished safely and efficiently using TEE.
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Footnotes
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Drs Shernan, Aranki, and Rizzo received compensation from Heartport, Inc, to teach individuals how to use port-access technology. There were no funding sources specifically designated to support this study.
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References
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Menasché P., Kural S., Fauchet M., et al. Retrograde coronary sinus perfusion: a safe alternative for ensuring cardioplegic delivery in aortic valve surgery. Ann Thorac Surg 1982;34:647-658.[Abstract]
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Stevens J.H., Burdon T.A., Siegel L.C., et al. Port-access coronary artery bypass with cardioplegic arrest: acute and chronic canine studies. Ann Thorac Surg 1996;62:435-440.[Abstract/Free Full Text]
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Stevens J.H., Burdon T.A., Peters W.S., et al. Port-access coronary artery bypass grafting: a proposed surgical method. J Thorac Cardiovasc Surg 1996;111:567-573.[Abstract/Free Full Text]
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Schwartz D.S., Ribakove G.H., Grossi E.A., et al. Minimally invasive cardiopulmonary bypass with cardioplegic arrest: a closed chest technique with equivalent myocardial protection. J Thorac Cardiovasc Surg 1996;111:556-566.[Abstract/Free Full Text]
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Siegel L.C., St Goar F.G., Stevens J.H., et al. Monitoring considerations for port-access cardiac surgery. Circulation 1997;96:562-568.[Abstract/Free Full Text]
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Abstract
Introduction
