J Thorac Cardiovasc Surg 2005;129:476-477
© 2005 The American Association for Thoracic Surgery
Clinical efficacy of retrograde coronary sinus perfusion in off-pump surgery
Harinder Singh Bedi, MCh, Executive Director and Chairman, Cardiac Sciences
Sigma New Life Heart Institute, 562, Phase 1, Mohali—160055, Punjab, India
To the Editor:
I read with great interest the article by Castella and Buckberg1on retrograde coronary sinus perfusion in off-pump surgery. My colleagues and I have been constantly stimulated by the pioneering work of Dr Buckberg on myocardial preservation. It is indeed very gratifying and encouraging to know that the technique we2 have been using regularly since September 1997 to perform off-pump coronary artery bypass grafting (OPCABG) with no ischemia during periods of construction of the distal anastomosis has been proven by the very elegant work of Castella and Buckberg1 to be effective in reducing systolic and diastolic dysfunction during periods of coronary occlusion. In our technique, after midsternotomy a retrograde coronary sinus catheter is inserted and connected to an antegrade cannula in the ascending aorta.2 Perfusion is now allowed through this route from the aorta to the coronary sinus, onward through the capillaries to the myocardium, and out through the arterioles at the site of ischemia. There is ample proof that ischemia is relieved as evidenced by the following facts: (1) reversion of electrocardiographic changes of ischemia, (2) vigorous backbleeding of dark blood on temporary release of the distal snare after arteriotomy, and (3) a good oxygen extraction ratio across the myocardium calculated by sampling blood from the antegrade cannula and from the arteriotomy.3
We have now gone one step further and use the method of active retroperfusion, using the driving pressure and oxygen of the aortic blood to perfuse areas of pre-existing acute ischemia. In grossly unstable patients with critical left anterior descending or left main stenosis, we have observed that retrograde coronary sinus perfusion reverses electrocardiographic changes, reduces pulmonary artery pressures, immediately improves cardiac contractility, and improves cardiac output (unpublished data). This gives time to harvest appropriate conduits, to perform any concomitant extracardiac procedure, and avoids "crashing" on cardiopulmonary bypass. One 75-year-old patient with vascular disease and cardiogenic shock was on preoperative intra-aortic balloon counterpulsation and preoperative ventilation, with associated critical bilateral extracranial symptomatic internal carotid artery disease. Retrograde coronary sinus perfusion allowed stabilization of the cardiac status and gave time to perform a carotid endarterectomy (Figure 1) followed by an OPCABG, with a good outcome.4
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Figure 1. Technique of retrograde perfusion during combined carotid endarterectomy and coronary artery bypass grafting. A, Antegrade cardioplegia cannula; R, retrograde coronary sinus cannula; S, stenosed coronary artery; CEA, carotid endarterectomy in progress; P, pressure monitoring line.
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My technique is a combination of pressure-controlled intermittent coronary sinus occlusion and arterial retroperfusion of the coronary sinus. Possibly a better method physiologically may well be a combination of synchronized retroperfusion and pressure-controlled intermittent coronary sinus occlusion. There is a great potential for developing catheters that could be inflated in the coronary sinus 6 times per minute,5 but while that happens I would recommend my simple technique of retrograde perfusion as a useful tool in the armamentarium of the cardiac surgeon for elective OPCABG as also for the acutely ischemic patient, in whom one gains some time and possibly avoids the institution of cardiopulmonary bypass. I would wholeheartedly agree with Lazar5 that a backward technique can still achieve forward progress.
References
- Castella M, Buckberg GD. Reduction of systolic and diastolic dysfunction by retrograde coronary sinus perfusion during off-pump coronary surgery. J Thorac Cardiovasc Surg. 2004;127:1018-1025.[Abstract/Free Full Text]
- Bedi HS, Suri A, Kalkat MS, Sengar BS, Mahajan V, Chawla R, et al. Global myocardial revascularization without cardiopulmonary bypass using innovative techniques for myocardial stabilization and perfusion. Ann Thorac Surg. 2000;69:156-164.[Abstract/Free Full Text]
- Bedi HS. Beating heart coronary artery bypass with continuous perfusion through the coronary sinus. In: Salerno TA, Ricci M, editors. Myocardial protection. New York: Blackwell Publishing; 2004. pp. 152-159.
- Bedi HS, Singh RP, Kalra GS. Retrograde coronary sinus perfusion for management of coexistent critical unstable carotid and coronary artery disease. Ind Heart J. 2002;54:717-719.[Medline]
- Lazar HL. Coronary sinus retroperfusion: can forward progress still be achieved by using a backward technique?. J Thorac Cardiovasc Surg. 2004;127:1549-1552.[Free Full Text]
