MMCTS
(June 28, 2005). doi:10.1510/mmcts.2004.000695
Copyright © 2005 European Association for Cardio-thoracic Surgery
Procedure
Antegrade administration of cardioplegia
Michael P. Siegenthaler*
Department of Cardiovascular Surgery, University of Freiburg, Hugstetterstrasse 55, 79106 Freiburg, Germany
* Corresponding author: * Tel.: +49-761-270 6138; fax: +49-761-270 2788. E-mail: siegenth{at}ch11.ukl.uni-freiburg.de
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Summary
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Antegrade cardioplegia remains the single most widespread mode of cardioplegia administration to protect the myocardium for cardiac surgical procedures. It is often used in combination with retrograde cardioplegia. In this article, we describe our method of antegrade blood cardioplegia administration and discuss the advantages as well as the disadvantages of antegrade cardioplegia administration.
Key Words: Antegrade cardioplegia • Cardiopulmonary bypass • Myocardial protection • Operative technique
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Introduction
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Antegrade cardioplegia, i.e. the injection of a cardioplegic solution in the aortic root with a cross-clamped aorta, remains the single most common mode of cardioplegia administration to protect the myocardium for cardiac surgical procedures. A combination of antegrade with retrograde cardioplegia appears to give a better myocardial protection in high-risk patients [1,2,3]. In the following section, a description of the method of antegrade blood cardioplegia administration is given, and the advantages as well as the disadvantages are discussed with reference to the current literature.
Antegrade cardioplegia
Antegrade cardioplegia leads to a fast cardioplegic arrest of the heart. Its administration depends on a competent aortic valve and hence it should not be used in patients with aortic regurgitation. In the experimental setting, antegrade cardioplegia leads to better cooling of the right ventricle compared to retrograde cardioplegia administration alone [4]. In patients with coronary artery disease, cardioplegia maldistribution can occur with the use of antegrade cardioplegia alone, which is avoided when combined with retrograde cardioplegia administration [3]. In the absence of coronary artery disease, antegrade cardioplegia leads to an even distribution of cardioplegia. Even though there is no evidence of an additional benefit of retrograde cardioplegia in the absence of coronary stenosis, we find a combination with retrograde cardioplegia administration useful for complex procedures requiring a prolonged clamp time, as intermittent retrograde cardioplegia can be administered without interruption of the surgical procedure.
In patients with aortic valve insufficiency, antegrade cardioplegia can be administered directly into the coronary ostia. Direct administration of cardioplegia carries the potential danger of coronary artery dissection, selective introduction and perfusion only into the left anterior descending or circumflexa coronary artery in patients with a short left main coronary artery, and also carries the possiblity of late ostial coronary artery stenosis. This technique is discussed and described in detail in a separate article (see Doenst T. Selective antegrade administration of cardioplegia. Doi: 10.1510/mmcts.2004.000703).
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Surgical technique
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There are several antegrade cardioplegia catheters on the market. We use the catheter system shown in Photo 1. This catheter (MMCTSLink 52) has three lumen, one for the cardioplegia administration through which a metal introducer needle is placed, one for venting the aortic root after the administration of cardioplegia and a thin pressure monitor lumen.
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Photo 1 The antegrade cardioplegia catheter (MMCTSLink 52) is shown. On top is the lumen for venting of the aortic root after administration of cardioplegia. In the middle (arrow) is the cardioplegia lumen, through which a metal introducer needle is inserted. The tip of the metal needle can be seen through the protective plastic cap, which is removed prior to using the catheter.
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Video 1 shows the steps of inserting the cardioplegia catheter. An anchoring suture (Ethibond, 4-0, on a C1 – needle – MMCTSLink 24) is placed at the planned site of insertion of the cardioplegia catheter. For needle insertion, we usually choose either the highest point of the available ascending aorta in order to vent the aortic root after removal of the aortic cross clamp, or we choose a suitable area for a proximal coronary anastomosis. Removal of excess fatty tissue from the anterior surface of the ascending aorta and 1.5 tours of the pursestring suture is beneficial for subsequent bleeding control. After securing the suture with a tourniquet, the suture is placed around the small pedestal at the foot of the catheter and subsequently the needle with the catheter is inserted into the ascending aorta. To prevent local dissections and embolization, it is very important that the needle is not inserted into a calcified plaque. Then the metal introducer needle is removed and the catheter is secured with the tourniquet. The cardioplegia catheter is attached to the cardioplegia line. We attach the cardioplegia line over a 4 lumen, "octopus-like" catheter (model CDS004S – MMCTSLink 53 – ERM product catalog) to the cardioplegia catheter, as the 4 lumen allows several modes of cardioplegia administration. After connecting the pressure line and the octopus catheter, we deair the system using the cardioplegia catheter in a retrograde fashion. This maneuver is important as it confirms good placement of the catheter in the aortic lumen after all manipulation.
Click on image to view video |
Video 1 The antegrade cardioplegia catheter (MMCTSLink 52) has been inserted into the aortic root at the site of a planned proximal coronary anastomosis. It has been connected with an "octopus-like" catheter (MMCTSLink 53) to the cardioplegia line. Adequate placement of the antegrade catheter has been confirmed by retrograde flushing after connecting all lines. The catheter is secured in place with a tourniquet, which is shown on the right in the assistant's hand.
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After cardiopulmonary bypass is instituted, the cold cardioplegia line is flushed. The subsequent steps can be seen on Video 2. The blood pressure is lowered to approximately 50–60 mmHg just before clamping the aorta, the aorta is cross-clamped and administration of cold antegrade blood cardioplegia ensues. The perfusionist usually starts at a rate of 300 ml/min to ensure closure of the aortic valve and then reduces it immediately to the target flow rate of 200 ml/min. We aim for a perfusion pressure of 60–80 mmHg in the aortic root and slow the flow down if the pressure exceeds 80 mmHg. We use a 3/16 inch cardiolplegia line: with a pressure of 80 mmHg in the aortic root, the pressure at the pump does not exceed 150 mmHg. Within a few heart beats, the potassium leads to the typical EKG changes on the monitor strip with subsequent cardioplegic arrest. At the end of the procedure, the antegrade cardioplegia needle is removed and either a proximal coronary anastomosis is performed at that site or the suture is ligated after adequate venting. As one suture often does not secure the needle-hole sufficiently, we secure the site with a second suture.
Click on image to view video |
Video 2 The surgeon is placing the aortic cross clamp. Care is taken to avoid dislodgement of the antegrade cardioplegia catheter during this maneuver. The administration of cold antegrade blood cardioplegia begins immediately with clamping of the aorta.
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Results
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There is a controversy, if antegrade cardioplegia protects the right ventricle better than retrograde cardioplegia. In a dog model with temporary ligation of the left anterior descending coronary artery, antegrade cardioplegia administration led to a better cooling and preservation of right ventricular function than retrograde cardioplegia [4]. In clinical studies, a better protection of the right ventricle with antegrade cardioplegia is more difficult to demonstrate. One randomized study demonstrated a preserved postoperative right ventricular function with antegrade cardioplegia in coronary artery bypass patients without right coronary artery (RCA) stenosis as opposed to a decreased right ventricular function in the early postoperative phase with the use of retrograde cardioplegia alone [5]. In the same study, inadequate protection of the right ventricle was found in all patients with RCA stenosis, irregardless if only antegrade or retrograde cardioplegia was administered. Therefore, it appears advisable to use antegrade as well as retrograde cardioplegia to protect the right ventricle in the presence of RCA stenosis. In addition, another study demonstrated that right ventricular cooling appears to be more effective if both antegrade and retrograde cardioplegia are employed compared to antegrade cardioplegia administration alone [6].
The problem of maldistribution of the cardioplegia solution in patients with coronary artery disease with antegrade cardioplegia alone has been well documented, as antegrade cardioplegia administration appears to provide inferior cooling distal to severe coronary stenosis than retrograde administration [7,8].
In high-risk coronary patients, outcomes with antegrade cardioplegia alone appear to be inferior thana combination of ante- and retrograde cardioplegia administration [1,2]. However, in patients with preserved LV function, cardioplegia maldistribution appears to have less of a negative clinical impact, and some studies show little to no advantage of combining ante- and retrograde cardioplegia [9,10]. Even if in certain patient populations no difference in major clinical events result from the use of antegrade cardioplegia alone, the analysis of more subtle markers of myocardial damage, such as troponin I, demonstrates a better myocardial protection with the combination of antegrade and retrograde cardioplegia than with antegrade cardioplegia alone [11,12].
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Discussion
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There is a large body of literature evaluating different modes of cardioplegia application, of which only few studies suffice evidence-based medicine criteria. Based on the currently available data, antegrade cardioplegia administration in combination with retrograde cardioplegia offers a safe form of myocardial protection, with both good protection to the right heart and good distribution of cardioplegic solution in the presence of coronary artery disease. Combined antegrade and retrograde cardioplegia administration appears to be a safe and practical approach for all but the most straightforward cardiac procedures.
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References
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- Flack JE3rd, Cook JR, May SJ, Lemeshow S, Engelman RM, Rousou JA, Deaton DW. Does cardioplegia type affect outcome and survival in patients with advanced left ventricular dysfunction? Results from the CABG Patch Trial. Circulation 2000;102:III84–III89.
- Loop FD, Higgins TL, Panda R, Pearce G, Estafanous FG. Myocardial protection during cardiac operations. Decreased morbidity and lower cost with blood cardioplegia and coronary sinus perfusion. J Thorac Cardiovasc Surg 1992;104:608–618.[Abstract]
- Buckberg GD, Update on current techniques of myocardial protection. Ann Thorac Surg 1995;60:805–814.[Abstract/Free Full Text]
- Partington MT, Acar C, Buckberg GD, Julia PL. Studies of retrograde cardioplegia. II. Advantages of antegrade/retrograde cardioplegia to optimize distribution in jeopardized myocardium. J Thorac Cardiovasc Surg 1989;97:613–622.[Abstract]
- Honkonen EL, Kaukinen L, Pehkonen EJ, Kaukinen S. Myocardial cooling and right ventricular function in patients with right coronary artery disease: antegrade vs. retrograde cardioplegia. Acta Anaesthesiol Scand 1997;41:287–296.[Medline]
- Jegaden O, Eker A, Montagna P, Ossette J, Vial C, Guidollet J, Mikaeloff PH. Antegrade/retrograde cardioplegia in arterial bypass grafting: metabolic randomized clinical trial. Ann Thorac Surg 1995;59:456–461.[Abstract/Free Full Text]
- Ehrenberg J, Intonti M, Owall A, Brodin LA, Ivert T, Lindblom D. Retrograde crystalloid cardioplegia preserves left ventricular systolic function better than antegrade cardioplegia in patients with occluded coronary arteries. J Cardiothorac Vasc Anesth 2000;14:383–387.[CrossRef][Medline]
- Noyez L, van Son JA, van der Werf T, Knape JT, Gimbrere J, van Asten WN, Lacquet LK, Flameng W. Retrograde versus antegrade delivery of cardioplegic solution in myocardial revascularization. A clinical trial in patients with three-vessel coronary artery disease who underwent myocardial revascularization with extensive use of the internal mammary artery. J Thorac Cardiovasc Surg 1993;105:854–863.[Abstract]
- Jasinski M, Kadziola Z, Bachowski R, Domaradzki W, Wenzel-Jasinska I, Piekarski M, Wos S. Comparison of retrograde versus antegrade cold blood cardioplegia: randomized trial in elective coronary artery bypass patients. Eur J Cardiothorac Surg 1997;12:620–626.[Abstract]
- Savunen T, Kuttila K, Rajalin A, Inberg M, Niinikoski J, Jalonen J, Perttila J, Valtonen M, Engblom E, Peltola O. Combined cardioplegia delivery offers no advantage over antegrade cardioplegia administration in coronary surgical patients with a preserved left ventricular function. Eur J Cardiothorac Surg 1994;8:640–644.[Abstract]
- Onorati F, De Feo M, Mastroroberto P, Cristodoro L, Pezzo F, Renzulli A, Cotrufo M. Determinants and prognosis of myocardial damage after coronary artery bypass grafting. Ann Thorac Surg 2005;79:837–845.[Abstract/Free Full Text]
- Onorati F, Renzulli A, De Feo M, Santarpino G, Gregorio R, Biondi A, Cerasuolo F, Cotrufo M. Does antegrade blood cardioplegia alone provide adequate myocardial protection in patients with left main stem disease? J Thorac Cardiovasc Surg 2003;126:1345–1351.[Abstract/Free Full Text]
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Summary
Introduction
