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Ann Thorac Surg 2003;76:1337-1338
© 2003 The Society of Thoracic Surgeons

Correspondence

Continuous retrograde cardioplegia simplifies aortic valve replacement in the presence of a patent internal mammary artery

Yaron Bar-El, MD, Arkady Kophit, MD, Oved Cohen, MD, Victor Kertzman, MD

Department of Cardiac Surgery, Rambam Medical Center, PO Box 9602, Haifa 31096, Israel

e-mail: y_bar_el{at}rambam.health.gov.il

To the Editor:

We read with great attention and interest two reports [1, 2] in The Annals describing surgical techniques for aortic valve replacement in patients with previous coronary artery bypass grafting and a functioning internal mammary artery (IMA) graft. Both articles emphasize the benefits of avoiding dissection and manipulation of the IMA but differ on the method of myocardial protection, a problematic issue because of continuous perfusion of the heart by the unclamped IMA. Myocardial protection in the series of Byrne and associates [1] was achieved mainly by antegrade with or without retrograde perfusion of crystalloid cardioplegia at 4°C, supplemented with moderate to deep systemic hypothermia (median temperature, 20°C). Savitt and colleagues [2], on the other hand, have advocated the use of continuous antegrade oxygenated blood perfusion and mild systemic hypothermia of 32°C.

We also favor a minimal dissection approach in such cases. However, for myocardial protection, we use continuous retrograde perfusion of tepid, undiluted hyperkalemic blood cardioplegia, a slight modification of the minicardioplegia technique originally described by Menasche and colleagues [3]. Cardioplegic solution is administered directly from the oxygenator without any cooling or warming and therefore has the same temperature as the systemic perfusate — 30°C to 32°C. The main feature of this technique is that the heart is continuously perfused during the whole aortic cross-clamp period and is not ischemic [4]. The functioning IMA enhances myocardial protection by perfusing the anterior wall of the heart, while cardiac quiescence is easily maintained by the retrograde hyperkalemic cardioplegia.

This strategy of myocardial protection does not require deep hypothermia, thus making the operations shorter and simpler, and avoidance of coronary ostia perfusion catheters can greatly facilitate the surgical procedure. If backflow from the left main coronary artery ostium obscures the operative field, cardioplegia delivery can be halted for up to 5 minutes, systemic flow can be reduced temporarily, or the ostium can be temporarily occluded with a small sponge.

As our threshold for aortic valve replacement at primary coronary artery bypass grafting is low, our series of such replacements after previous revascularization comprises only 5 patients. There were no deaths, and morbidity was minimal. However, we have used this technique of myocardial protection routinely since 1994 in all patients and have found it to be safe and effective in complicated, lengthy operations requiring long periods of aortic cross-clamping [5].

References

  1. Byrne J.G., Karavas A.N., Filsoufi F., et al. Aortic valve surgery after previous coronary artery bypass grafting with functioning internal mammary artery grafts. Ann Thorac Surg 2002;73:779-784.[Abstract/Free Full Text]
  2. Savitt M.A., Singh T., Agrawal S., Choudhary A., Chaugle H., Ahmed A. A simple technique for aortic valve replacement in patients with a patent left internal mammary artery bypass graft. Ann Thorac Surg 2002;74:1269-1270.[Abstract/Free Full Text]
  3. Menasché P., Touchot B., Pradier F., Bloch G., Piwnica A. Simplified method for delivering normothermic blood cardioplegia. Ann Thorac Surg 1993;55:177-178.[Abstract]
  4. Menasché P., Peynet J., Touchot B., et al. Normothermic cardioplegia: is aortic cross-clamping still synonymous with myocardial ischemia?. Ann Thorac Surg 1992;54:472-478.[Abstract]
  5. Bar-El Y., Adler Z., Kophit A., et al. Myocardial protection in operations requiring more than 2 h of aortic cross-clamping. Eur J Cardiothorac Surg 1999;15:271-275.[Abstract/Free Full Text]




This Article
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Yaron Bar-El
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