Ann Thorac Surg 2003;76:1317-1318
© 2003 The Society of Thoracic Surgeons
How to do it
Warning hint of a hidden early left main stem bifurcation during antegrade cardioplegia
Armin W. Erasmi, MDa,
Martin Misfeld, MDa,
Hans-H. Sievers, MDa*
a Clinic of Cardiac Surgery, University Clinic of Luebeck, Luebeck, Germany
Accepted for publication February 21, 2003.
* Address reprint requests to Dr Sievers, Clinic of Cardiac Surgery, University Clinic of Luebeck, Ratzeburger Allee 160, 23538 Luebeck, Germany
e-mail: herzchir{at}medinf.mu-luebeck.de
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Abstract
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The short left main trunk with early bifurcation is a common variation of the left coronary anatomy and is easily overlooked during antegrade selective cardioplegia resulting in the risk of single branch perfusion. We describe an obvious characteristic sign to detect this pitfall during blood cardioplegia.
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Introduction
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| Dr Sievers discloses that he has a financial relationship with Stockert Instrumente GmbH.
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Different methods for myocardial protection are used nowadays, ranging from cold fibrillation to antegrade or retrograde cardioplegia. Except cold fibrillation, all other methods have some principles in common (ie, achieving asystole, hypothermia, and in case of blood cardioplegia, oxygen delivery), and all three of these principles require sufficient perfusion of the coronary system. Inadequate perfusion will result in impaired myocardial protection or even infarction. If selective antegrade cardioplegia is applied, variable morphologic features of coronary ostial variations and especially early bifurcation of a short left main stem must be notified for proper intubation. Because the common surgical view most often does not allow sufficient insight into the left coronary ostium, early branching may be easily overlooked. We report a characteristic sign that may be helpful to detect this possible pitfall.
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Technique
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During antegrade blood cardioplegia of the left coronary artery attention must be given to any desaturated retrograde blood flow that may occur in the area of the left coronary ostium. If this happens, insufficient application of cardioplegia is likely being caused by selective intubation of just one of the left coronary branches. If this sign is found, careful inspection of the left coronary ostium must be performed to visualize the two ostia and to ensure adequate delivery of blood cardioplegia into both of them.
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Comment
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The left main trunk usually measures a number of centimeters in length but may also present with two coronary ostia side by side in 1% of all patients [1, 2]. The short left main trunk is not a coronary artery anomaly [3, 4] but a frequent variation of the left coronary artery morphology. This morphologic feature is associated with other physiologic variations such as the left dominant coronary system [5] and congenital bicuspid valve [6].
Preoperative angiography may indicate the presence and length of the left main trunk. However, coronary angiography is not always performed in emergency situations such as the acute type A aortic dissections or in younger patients with aortic valve disease.
An antegrade delivered cardioplegic solution will reappear as deoxygenated dark-red colored blood in the coronary sinus, the Thebesian system, and through the collateral vessels in the other coronary arteries. Selective intubation of the left main trunk leads to backflow of desaturated blood from the right coronary ostium in most patients. However, in case of early bifurcation of the left coronary artery, the tip of the cannula may extend beyond the bifurcation resulting in accidental and unrecognized exclusive perfusion of the left anterior descending or circumflex artery. However, in these patients the desaturated blood returns retrogradely from the nonperfused branch out of the ostium of the left main stem around the cardioplegia cannula (Fig 1).
In our experience this is undoubtedly a sign for selective intubation of only one branch of the left main trunk, requiring careful inspection of the left coronary ostium in search for other branches. By doing a careful inspection the early branching can be discovered (Fig 2),
and appropriate selective antegrade cardioplegia can be achieved by intubating both the branches consecutively. To overcome these problems, retrograde cardioplegia may be appropriate.
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Fig 1. Backflow of desaturated dark-red blood from in the left coronary ostium (between small arrows) around the cardioplegia cannula delivering oxygenated blood cardioplegia (big arrows) into one of the left main stem branches.
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Fig 2. Initially hidden and overlooked early bifurcation of the left main trunk becomes visible after extensive exploration of the left coronary ostium. The big arrow indicates the circumflex and the small arrow the left anterior descendent coronary artery.
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If the surgeon chooses to perfuse the coronaries by antegrade selective blood cardioplegia, he has to be aware of this morphologic feature [1]. The risk for intubation of only one of the two left main coronary artery vessels is well known as a pitfall during delivery of cardioplegia. However, a report about the backflow of desaturated blood from the left coronary ostium as a very helpful warning to be alert of an overlooked, nonperfused early branch of a short left main trunk was not found in the literature.
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References
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- Myocardial management during cardiac surgery with cardiopulmonary bypass. In: Kirklin JW, Barratt-Boyes BG, eds. Cardiac Surgery. New York: Churchill Livingstone Inc, 1993:129–66
- Hutchins G.M., Nazarian I.H., Bulkley B.H. Association of left dominant coronary arterial system with congenital bicuspid aortic valve. Am J Cardiol 1978;42:57.[Medline]
- Ogden J.A. Congenital anomalies of the coronary arteries. Am J Cardiol 1969;70:474-479.
- Dodge-Khatami A., Mavroudis C., Backer C.L. Congenital heart surgery nomenclature and database project: anomalies of the coronary arteries. Ann Thorac Surg 2000;69(Suppl 4):S270-297.[Abstract/Free Full Text]
- Krozon I., Deutsch P., Glassmann E. Length of the left main coronary artery: its relation to the pattern of coronary arterial distribution. Am J Cardiol 1974;34:787.[Medline]
- Murphy E.S., Rosch J., Rahimtoola S.H. Frequency and significance of coronary arterial dominance in isolated aortic stenosis. Am J Cardiol 1977;39:505.[Medline]
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Abstract
Introduction
