MMCTS
(August 9, 2005). doi:10.1510/mmcts.2004.000703
Copyright © 2005 European Association for Cardio-thoracic Surgery
Procedure
Direct cannulation of the coronary ostia
Torsten Doenst*
Department of Cardiovascular Surgery, Albert-Ludwigs-University of Freiburg, Hugstetter Str. 55, 79106 Freiburg, Germany
* Corresponding author: * Tel.: +49-761-270 6196; fax: +49-761-270 6136. E-mail: doenst{at}ch11.ukl.uni-freiburg.de
 |
Summary
|
|---|
Direct cannulation of the coronary ostia is a technique used by many surgeons in aortic valve surgery, especially when the valve is incompetent. It is safe and feasible, but the small risk of it causing a potentially devastating ostial stenosis must be kept in mind.
Key Words: Coronary ostium • Valve surgery • Myocardial protection
|
Introduction
|
|---|
Direct cannulation of the coronary ostia is an option for delivery of cardioplegia (either blood or crystalloid) used by many surgeons to protect the heart when the aorta is opened. It is a requirement if the valve is incompetent and antegrade delivery is the route of choice. The principles of cardioplegia and its composition are the same as for antegrade delivery into the aortic root with a competent aortic valve (see ref. [1] for fundamentals of cardioplegia and its pathophysiological background).
|
Surgical technique
|
|---|
If antegrade delivery of cardiolplegia is the route of choice, direct cannulation is an option for patients in whom the aorta must be opened and the valve is competent, but it is absolutely necessary if the aortic valve is incompetent. The cannulae can be held at the entrance of the ostium (Video 1) or can be inserted further, which allows fixation of the cannulae for the duration of the case and easier repeat delivery of cardioplegia.
Click on image to view video |
Video 1 The video sequence demonstrates the delivery of blood cardioplegia through a 6-mm Polystan coronary perfusion cannula into one coronary button during a Bentall procedure. If the cannula is supposed to stay in place, a smaller size should be chosen and the cannula has to be advanced further into the coronary.
|
|
The fixation can be achieved by a 4/0 or5/0 suture that is stitched transmurally through the aorta approximately 1–2 cm above the ostia (if a Bentall procedure is performed the stitch should be placed in a section of the aorta that is later resected or excluded). The suture can either be tied (this is recommended if the cannula used is small and likely to be compressed by a tourniquet) or snared over a tourniquet. The delivery technique has several advantages and disadvantages. Direct cannulation allows the repeated antegrade delivery of blood cardioplegia during the procedure, and with correct placement of the catheters, it may help to expose the aortic valve. This snare suture around the tube just proximal to the coronary ostia may thus help with exposure in addition to fixing the cannula. The cannulae will also prevent debris from falling into the coronaries, for instance, during the decalcification of the annulus in a patient with a stenotic aortic valve. The biggest disadvantage of this technique is the incidence of coronary ostial stenoses in a small percentage of patients which is caused by intimal damage by the cannulas [2,3]. To keep this complication from happening, it is imperative to: (1) use soft cannulas (e.g. a Polystan cannula – MMCTSLink 66); (2) choose the correct cannula size; and (3) avoid forcing the tip into the coronary. Another disadvantage may be the incomplete delivery of cardioplegia in cases of severe coronary artery disease. This disadvantage is shared with all other forms of antegrade delivery.
Several companies provide cannulae for ostial cannulation. For adults, most commonly used sizes range between 4 and 6 mm. Cannulae can be straight (mainly used for the left coronary ostium) or bent (mainly used for the right coronary ostium). The average adult patients will be well served with a 6-mm straight cannula for the left and a 4 or 5-mm bent or straight cannula for the right coronary artery. For information on the DLP arteriotomy cannula and the coronary ostia perfusion cannula, see MMCTSLink 67, and pages 35–37 of the ERM catalog in MMCTSLink 53.
|
References
|
|---|
- Siegenthaler MP, Antegrade administration of cardioplegia. Multimed Man Cardiothorac Surg. doi:10.1510/mmcts.2004.000695.[Abstract/Free Full Text]
- Chavanon O, Carrier M, Cartier R, Hebert Y, Pellerin M, Perrault LP. Early reoperation for iatrogenic left main stenosis after aortic valve replacement: a perilous situation. Cardiovasc Surg 2002;10:256–263.[Medline]
- Menasche P, Kural S, Fauchet M, Lavergne A, Commin P, Bercot M, Touchot B, Georgiopoulos G, Piwnica A. Retrograde coronary sinus perfusion: a safe alternative for ensuring cardioplegic delivery in aortic valve surgery. Ann Thorac Surg 1982;34:647–658.[Abstract]
|
|
Top
Summary
Introduction