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Ann Thorac Surg 2003;76:973
© 2003 The Society of Thoracic Surgeons

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Correspondence

Beating heart valvular surgery

^a Division of Cardiothoracic Surgery, University of Miami, 1611 NW 12th Avenue,East Tower 3072 (R-114),Miami, FL 33136, USA

e-mail: tsalerno{at}med.miami.edu

To the Editor:

The article by Matsumoto and associates [1] dealing with beating valvular surgery using retrograde perfusion compared with continuous retrograde warm blood cardioplegia caught our attention. The idea of continuous normothermic perfusion of the heart is not new. In 1956, Blanco showed that retrograde coronary sinus infusion of oxygenated blood at 50 mL/min was able to sustain a beating heart for 7 minutes in canine experiments [2]. Later, Gott and Lillehei were the first to combine continuous coronary perfusion with chemical asystole [3]. In 1991, we reported the use of simultaneous continuous antegrade and retrograde warm blood cardioplegia [4] as a means of improving myocardial protection. Deslauriers’ group [5], using MRI spectroscopy, has recently demonstrated that simultaneous delivery of cardioplegia provides near ideal myocardial protection.

Over the last 8 years, we have been routinely performing valve procedures on an empty beating heart using simultaneous antegrade and retrograde perfusion with oxygenated blood. Coronary sinus perfusion pressures and resistance in the perfusion circuit are monitored to keep them at 55 to 60 and 280 mg Hg, respectively. Using these criteria, we are able to generate flows in excess of 250 mL/min. When coronary bypass is also performed, the distal anastomoses are constructed first using the off-pump technique. The vein grafts are then used for antegrade perfusion of blood in addition to antegrade native coronary perfusion. When operating on the aortic valve, we directly cannulate the coronary ostia for continuous warm blood perfusion. Although unproven, we believe that this technique allows for less myocardial edema due to cardiac contraction and minimizes the risk of ischemia-reperfusion.

We believe that whether alternate or simultaneous, combining antegrade and retrograde routes of administration provides the best available myocardial protection, irrespective of the choice of perfusate (blood cardioplegia, oxygenated warm blood, etc). As opposed to the strategy pursued by Dr Matsumoto and colleagues, we favor simultaneous antegrade/retrograde delivery of normothermic blood during beating heart valvular or combined valvular and coronary artery surgery.

References

1. Matsumoto Y., Watanabe G., Endo M., et al. Efficacy and safety of on-pump beating heart surgery for valvular disease. Ann Thorac Surg 2002;74:678-683.[Abstract/Free Full Text]
2. Blanco G., Adam A., Fernandez A. A direct experimental approach to the aortic valve. II: Acute reperfusion of the coronary sinus. J Thorac Cardiovasc Surg 1956;32:171-176.
3. Gott V.L., Gonzales J.L., Paneth M., Varco R.L., Sellers R.D., Lillehei C.W. Cardiac retroperfusion with induced asystole for open surgery upon the aortic valve or coronary arteries. Proc Soc Exp Biol Med 1957;94:689-692.
4. Salerno T.A., Houck J.P., Barrozo C.A., et al. Retrograde continuous warm blood cardioplegia: a new concept in myocardial protection. Ann Thorac Surg 1991;51:245-247.[Abstract]
5. Tiang G., Xiang B., Dai G., et al. The effects of retrograde cardioplegia technique on myocardial perfusion and energy metabolism: a magnetic resonance imaging and localized phosphorous 31 spectroscopy study in isolated pig hearts. J Thorac Cardiovasc Surg 2000;120:544-551.[Abstract/Free Full Text]

This article has been cited by other articles:

				J. Wang, H. Liu, T. A. Salerno, B. Tomanek, R. Summers, R. Deslauriers, R. C. Arora, and G. Tian Alternate antegrade/retrograde perfusion: an effective technique to preserve hypertrophied hearts during valvular surgery Eur. J. Cardiothorac. Surg., January 1, 2009; 35(1): 69 - 76. [Abstract] [Full Text] [PDF]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Saqib Masroor Hassan Tehrani Tomas A. Salerno Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Masroor, S. Articles by Salerno, T. A. Search for Related Content PubMed PubMed Citation Articles by Masroor, S. Articles by Salerno, T. A. Related Collections Valve disease