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Ann Thorac Surg 2007;83:1206-1209
© 2007 The Society of Thoracic Surgeons
Department of Cardiac Surgery, Heart Center, University of Leipzig, Leipzig, Germany
Accepted for publication April 24, 2006.
* Address correspondence to Dr Battellini, University of Leipzig, Department of Cardiac Surgery, Heart Center Leipzig, Struempell Strasse 39, Leipzig, 04289 Germany (Email: battr{at}medizin.uni-leipzig.de).
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Abstract |
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Introduction |
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Three case reports have recently been described in which patients received AVR on the beating heart with open IMA grafts. Myocardial perfusion was maintained through the IMA, the native coronary system, the venous bypass grafts, and RCSP, respectively [3,6,7].
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Technique |
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Preoperatively all patients gave their written consent for the perioperative strategy and postoperatively for anonymous data publication.
The heart was exposed by redo sternotomy. Transesophageal echocardiography was used to monitor ventricular function during the whole procedure. Surgical dissection was limited for cannulation of the aorta, the right atrium (mostly bi-caval), venting of the ventricle through the right superior pulmonary vein, and localization of the proximal vein graft anastomoses. Dissection of the left internal mammary artery was avoided, and it supplied the heart throughout the whole procedure.
Systemic temperature was maintained at 34°C to avoid ventricular fibrillation. The quality of the aorta was assessed, and if it was calcified at the usual clamping site, a femoral or aortic arch cannulation was considered. A coronary sinus catheter was introduced through a right atrial pursestring incision and was positioned as near as possible to the coronary sinus ostium. The balloon was inflated and the catheter was connected to a cardiopulmonary bypass (CPB) perfusion line (Fig 1). A flow of 300 mL/min of oxygenated blood into the coronary sinus system was established by a separate pump head under pressure control (<80 mm Hg). After the aorta was clamped, a transverse aortotomy was performed and the valve was excised. The valve was replaced while the heart was beating. There was little or no backflow through the coronary ostia due to advanced vessel disease. If backflow from the left coronary ostium disturbed the view, a 4-French Fogarty balloon catheter (EMB 40, Edwards Lifescience) was used to block it. The electrocardiogram and transesophageal echocardiography monitoring allowed early detection of insufficient myocardial blood supply requiring RCA perfusion through the venous bypass or augmentation of the RCSP up to 400 mL/min if idioventricular rhythm, hypokinesia, or ST segment elevations were seen. Concomitant cardiac procedures were performed as required. The CO2 was used routinely. After the aortotomy was closed, the air was removed from the heart and the cross clamp was released. The patient could be rapidly weaned from cardiopulmonary bypass. Individual surgical strategies according to the patient’s findings are illustrated in Figure 1. The mean postoperative creatine kinase-MB fraction on postoperative days 1 and 2 was 78.5 ± 20.2 and 57.5 ± 16.3 U/L, respectively, revealing good perioperative myocardial protection. For further patient and operative details see Table 1.
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Comment |
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In our series we used both simultaneous antegrade and retrograde blood perfusion with different strategies optimized to the individual patient findings. Retrograde coronary sinus perfusion and antegrade, perfusion through the patent IMA were consistently used. The third route was through the patent venous grafts and depended on the level of aortic clamp in relation to the proximal anastomoses, and whether or not concomitant coronary bypass grafting was indicated. Blood perfusion could be established through a new venous graft (case 1), through patent venous grafts when cross clamping was below the proximal anastomoses (case 2), or by super selective bypass perfusion using a straight soft 6.0 mm coronary cannula balloon tip (case 3 and 4). We did not perform ostial perfusion because of advanced coronary artery disease of the proximal arteries, including left main occlusion which, however, would be a fourth option.
The optimal technique of simultaneous RCSP remains for discussion. Based on a resting coronary blood flow rate in humans of about 225 mL/min, we hypothesized that delivery of 300 mL/min would be adequate in these hypertrophied, but antegrade-retrograde perfused hearts allowing to keep the coronary sinus pressure below 80 mm Hg and avoid the risk of venous hemorrhage. In our experience, high RCSP flow or additional RCA perfusion in some way is needed to safely avoid ST segment elevations or idioventricular rhythm.
We did not find evidence of venous coronary congestion during simultaneous antegrade-retrograde perfusion in our patients. We believe (along with Salerno) that antegrade and retrograde pathway complements each other presenting the best myocardial protection strategy for these high-risk patients with hypertrophied myocardium, reduced left ventricular function, and advanced native coronary artery disease. However, in each case, weaning from cardiopulmonary bypass was uneventful with low-dose catecholamines suggesting adequate myocardial protection during the procedure, even with prolonged ischemic time in a double valve case.
In conclusion, AVR on the continuously antegrade-retrograde and retrograde perfused beating heart is a safe and effective technique to achieve adequate myocardial protection and to minimize the risk of patent IMA injury. To decide which strategy is the most beneficial for the individual patient we considered: (1) aortic calcification and level of potential aortic clamping, (2) quality of previous bypass grafts, (3) native coronary anatomy, and (4) required concomitant cardiac procedures. Continuous electrocardiogram and transesophageal echocardiography monitoring during the entire procedure are needed to allow early adaptation in the perfusion pattern.
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