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J Thorac Cardiovasc Surg 1995;109:1116-1126
© 1995 Mosby, Inc.

CARDIOPULMONARY BYPASS, MYOCARDIAL MANAGEMENT, AND SUPPORT TECHNIQUES

Retrograde cardioplegia does not adequately perfuse the right ventricle

Chicago, Ill.

From the Divisions of Cardiac Surgery, and Cardiology, The Universityof Illinois, Chicago, Ill.

Address for reprints: Bradley S. Allen, MD, University of Illinois,Cardiothoracic Surgery Department, 840 S. Wood Street, 518-H (M/C 958), Chicago,IL 60612.

Abstract

Surgeons often rely primarily on retrograde cardioplegiafor myocardial protection, because it provides adequate left ventricular perfusioneven in the presence of coronary artery disease. Clinically, however, adequateright ventricular perfusion by retrograde delivery has not been demonstrated.Using intraoperative transesophageal echocardiography, we examined retrogradedelivery of cardioplegic solutions by contrast echocardiography, which directlyassesses myocardial perfusion. In 15 patients (seven having coronary bypassand eight having valve operations), 4 ml of sonicated Isovue medium was injectedretrograde via a coronary sinus catheter. Myocardial perfusion was assessedquantitatively by visual inspection and background-subtracted videodensitometricanalysis. In five patients undergoing aortic valve replacement, right andleft coronary ostial drainage was estimated during retrograde infusion. Beforethe aortic crossclamp was removed, myocardial oxygen extraction was calculatedin all 15 patients by first delivering warm blood cardioplegic solution for2 minutes in a retrograde fashion and then taking samples from the cardioplegialine and aortic root. This determined the oxygen extraction ratio across themyocardium at the end of retrograde delivery. Warm blood cardioplegic solutionwas next given antegrade, and 15 seconds later samples were taken from thecardioplegia line and a right ventricular (acute marginal) vein to determinethe oxygen extraction ratio across the right ventricle. As assessed by contrastechocardiography, retrograde infusion resulted in almost four times more perfusionto the left ventricular free wall and septum than to the right ventricularfree wall (74 ± 2 versus 69 ± 2 versus 20 ± 2, p < 0.05). In those five patientswith an aortotomy the right ostial drainage was less than 5 ml/min whereasleft ostial drainage was estimated at 80 ml/min during retrograde administration.Oxygen extraction across the myocardium supplied by retrograde infusion waslow after 2 minutes. Conversely, when antegrade cardioplegia was started,right ventricular oxygen extraction rose fourfold (42% ± 5% versus11% ± 1%, p < 0.05), demonstrating that retrograde cardioplegiahad not adequately perfused the right ventricular myocardium. Conclusions: 1. Retrograde cardioplegia provides poor right ventricularmyocardial perfusion as assessed by contrast echocardiography and coronaryostial drainage. 2. This poor perfusion is inadequate to meet myocardial demandsas demonstrated by the high right ventricular oxygen extraction after a prolongedretrograde infusion. 3. Therefore surgeons must not rely solely on retrogradecardioplegia for right ventricular myocardial protection. This concept isespecially important if continuous warm blood cardioplegia is used, becausemyocardial requirements are then higher. (J T HORAC CARDIOVASC SURG 1995;109:1116-26)

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