HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Massimo Massetti Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Massetti, M. Articles by Khayat, A. Search for Related Content PubMed PubMed Citation Articles by Massetti, M. Articles by Khayat, A.

J Thorac Cardiovasc Surg 1998;115:264
© 1998 Mosby, Inc.

LETTERS TO THE EDITOR

Enhanced air removal from coronary circulation during cardiac operations

To the Editor:

I congratulate Sandhu and associates ¹ for their experimental study on coronary air embolism published in the May 1997 issue of the Journal. My interest in the paper is twofold: First, it focused the importance of coronary air embolism during cardiac procedures; second, it clearly demonstrated that retrograde coronary perfusion is the most effective technique to treat this complication.

Air trapping within the heart chambers and coronary circulation remains a serious threat to the success of an otherwise correct cardiac operation. The complication is especially regrettable because it is iatrogenic. Although a careful air removal maneuver allows gross air bubbles to be evacuated from heart chambers, the coronary circulation remains the most difficult district to clear of air before release of the aortic clamp. ² The effectiveness of retrograde perfusion through the coronary sinus in deairing the coronary circulation had not been clearly demonstrated until this work by Sandhu and his associates.

For many years we have routinely performed a technique to deair the heart that applies the concept of retrograde coronary perfusion. This technique is simple, rapid in execution, and requires neither special equipment nor selective coronary sinus cannulation. The deairing procedures are performed with the aorta crossclamped. The routine removal of air from the heart follows the course of the blood flow, beginning with the right side of heart and ending with the aorta.

1. After the caval tapes have been released, the right-sided chambers are gently filled (8 to 10 mm Hg). The first maneuver consists in the retrograde purging of the pulmonary artery tree and right ventricle through the opening in the right atrial appendage. A vigorous shake, together with a massage of the heart, makes the valves incompetent and permits the evacuation of air bubbles in a retrograde fashion. After the cavities on the right side have been purged satisfactorily, the right atrial appendage is closed, the main pulmonary artery clamped, and the filling pressure of the right atrium is gently increased to 15 to 20 mm Hg.

2. The second step purges the left-sided chambers. While the lungs are intermittently ventilated, the left side is cleared of air trough the bore (left open after the removal of the vent) in the right superior pulmonary vein and through an aortotomy connected to a gentle suction. With the patient in a deep Trendelenburg position, inversion of left atrial appendage, followed by sequential maneuvers of elevating and lowering the left ventricular apex, allows the bubbles to be pushed away and minimizes the tendency of air to be trapped in the left ventricle.

3. After the heart chambers have been purged satisfactorily, the final step is to enhance the residual air removal from the coronary system. With a filling pressure in the right atrium maintained at 15 to 20 mm Hg and the main pulmonary artery clamped (manually, with a vascular clamp or by a tape), manual compression (lasting 2 or 3 seconds) of the right cavities of the heart is performed. This adjunctive measure is repeated several times, and during the maneuver the right atrial pressure rises 60 to 80 mm Hg, producing in this fashion a retrograde purge of the coronary system through the coronary sinus and thebesian veins. The air bubbles trapped in the coronary system are easily pushed toward the aorta and cleared away. After the purge is completed, the clamp on the pulmonary artery is released to allow decompression of the cavities of the right side of the heart. Finally the right superior vein bore is closed under fluid, with the heart beating. The ascending aortic air-evacuation line will be closed later, after discontinuation of cardiopulmonary bypass.

The risk of air being trapped in the coronary circulation remains a major concern and is a difficult problem to overcome. The best way to enhance air removal from the coronary district seems to be a retrograde purge by way of the coronary sinus, as demonstrated by the work of Sandhu and colleagues. According to the technique of delivering cardioplegic solution through the right atrium described by Fabiani and colleagues, ³ the high pressure in the right atrium provides retrograde perfusion and purges not only by way of coronary sinus, but also via the thebesian veins and possible venous variants. The right chambers are unimpaired by the distentions, and any capillary or venular damage has been noted on biopsy specimens. This technique of air removal after cardiac operations has been used in more than 1000 patients in our department, and no complications related to the technique have been noted. The work of Sandhu and associates demonstrates clearly, in an experimental model, the effectiveness of retrograde coronary perfusion to deair the coronary circulation. Our technique is a simple clinical application of that concept.

Thoracic and Cardiovascular Surgery DepartmentUniversity Hospital Caen, Caen, France References

1. Sandhu AA, Spotnitz HM, Dickstein ML, Rose EA, Michler RE. Retrograde cardioplegia preserves myocardial function after induced coronary air embolism. J Thorac Cardiovasc Surg 1997;113:917-22.[Abstract/Free Full Text]
   
2. Oka Y, Inoue T, Hong Y, Sisto DA, Strom JA, Frater RWM. Retained intracardiac air. J Thorac Cardiovasc Surg 1986;91:329-38.[Abstract]
   
3. Fabiani JN, Deloche A, Swanson J, Carpentier A. Retrograde cardioplegia through the right atrium. Ann Thorac Surg 1986;41:101-2.[Abstract]
   

This article has been cited by other articles:

				N. Chaudhuri and M. S. J. Hickey Reply Ann. Thorac. Surg., November 1, 2000; 70(5): 1761 - 1761. [Full Text] [PDF]

				M. Massetti, P. Bruno, G. Babatasi, E. Neri, and A. Khayat Coronary air embolism after cardiopulmonary bypass: letter 2 Ann. Thorac. Surg., November 1, 2000; 70(5): 1760 - 1761. [Full Text] [PDF]

				N. Chaudhuri and M. St.J. Hickey A simple method of treating coronary air embolism after cardiopulmonary bypass Ann. Thorac. Surg., November 1, 1999; 68(5): 1867 - 1868. [Abstract] [Full Text] [PDF]

This Article Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Massimo Massetti Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Massetti, M. Articles by Khayat, A. Search for Related Content PubMed PubMed Citation Articles by Massetti, M. Articles by Khayat, A.