J Thorac Cardiovasc Surg 1994;107:641-0642
© 1994 Mosby, Inc.
The balloon inflation technique to confirm good placement of the retroplegia cannula
L. Noyez, MD
Department of Thoracic and Cardiac Surgery
University Hospital Nijmegen St. Raboud
Nijmegen, The Netherlands
To the Editor:
Transatrial cannulation of the coronary sinus, circumventing the need for bicaval cannulation, snares, and atriotomy, is an important technical point leading to the widespread use of retrograde cardioplegia.
1 Several techniques for cannulation are described. 1, 2 Confirmation of the placement is obtained mainly by manual palpation of the catheter posteriorly in the atrioventricular groove. Other possibilities are the observation of black, pulsatile blood in the cannula and the registration of a coronary sinus waveform by means of a pressure line. 1 Black, pulsatile blood, however, can also come from the right ventricle and the coronary sinus waveform registration can be difficult in patients in hemodynamically unstable condition, and does not ensure that the balloon, preventing backflow of the cardioplegia in the right atrium, is well placed in the sinus. Confirmation by manual palpation is of course the best method, but during reoperations, in which the heart should be handled as little as possible to prevent atheroembolism, 3 it is virtually impossible to palpate the atrioventricular groove.
With the balloon inflation technique, the catheter is inserted in the right atrium as described by Gundry and colleagues, 1 and then gently pushed into the coronary sinus. When we suppose that the catheter is well placed, pressure is monitored and the balloon is inflated with 3 to 5 ml blood or saline solution. With good placement of the catheter, the balloon will obstruct the coronary sinus and there will be a rapid rise of the pressure. Deflation of the balloon is followed by a decline in coronary sinus pressure back to the basic value (Fig. 1). When the cannula is in the right ventricle, inflation of the balloon will not have any effect on the pressure. In patients in unstable condition or with extremely low pressure, recognizing the coronary sinus waveform is sometimes difficult. The increase in the pressure ensures good placement, however, not only of the tip of the catheter but also of the balloon. In reoperations, there is no need for dissection of the posterior side of the heart.
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Fig. 1. Coronary sinus pressure graph. Inflation of the balloon in the coronary sinus is followed by an increase of the coronary sinus pressure; deflation is followed by a decline back to the baseline. ECG, Electrocardiogram.
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This method can be used with the Gundry RCSP catheter (DLP, Inc., Grand Rapids, Mich.), which has a separate balloon inflation line, but also with the Buckberg cannula (Research Medical, Inc., Midvale, Utah), which has a self-inflating balloon. After withdrawal of the stylet, several milliliters of blood or saline solution is infused in the catheter; the catheter is so constructed that the balloon is inflated first (our registration is done with a Buckberg cannula). This balloon inflation technique provides an easy and usable method for confirmation of the good placement of the retrograde coronary sinus catheter.
References
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Gundry SR, Sequiera A, Razzouk AM, McLaughlin JS, Bailey LL. Facile retrograde cardioplegia: transatrial cannulation of the coronary sinus. Ann Thorac Surg 1990;50:882-7.[Abstract]
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Chitwood WR. Retrograde cardioplegia: current methods. Ann Thorac Surg 1992;53:352-5.[Abstract]
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Keon WJ, Heggtveit HA, Leduc J. Perioperative myocardial infarction caused by atheroembolism. J THORAC CARDIOVASC SURG 1982;84:849-55.[Abstract]
