Delivering Cardioplegia Beyond Totally Occluded Native Coronary Arteries Through the Saphenous Bypass Vein Graft: Is It Really a Protective Technique?

Öz

Introduction: Antegrade route may fail to provide homogenous cardioplegia distribution in patients with totally occluded coronary arteries. Cardioplegia via vein graft beyond occlusion is considered as an alternative approach to achieve better myocardial protection. In this study, we aimed to compare myocardial protection achieved with antegrade cardioplegia and antegrade plus vein graft cardioplegia in patients with totally occluded coronaries. Patients and Methods: Consecutive 14 patients with at least one totally occluded coronary artery were randomly divided into two groups. Antegrade cardioplegia was used in group 1, antegrade plus vein graft cardiplegia was used in group 2. Creatine kinase, creatine kinase MB, lactate and troponine I levels were measured for myocardial damage monitorization. Samples were collected from the arterial line and coronary sinus simultaneously; at the beginning of the operation before extracorporal circulation institution (1), after completion of the distal anastomosis, immediately after "hot shot" cardioplegia infusion and aortic unclamping (2) and after removal of the side clamp (3). Measurements were repeated at the 6th (4), 12th (5), 24th (6) and 48th (7) postoperative hours from the peripheral arterial line. Groups were compared statistically. Results: In this study, cardiac enzymes and transcoronary lactate gradient were found similar in each measurement. Conclusion: Antegrade cardioplegia may achieve adequate myocardial protection in patients with totally occluded coronary arteries. Antegrade plus vein graft cardioplegia does not seem to provide any advantage in this spesific patient group.

Anahtar Kelimeler

• Cardioplegia; saphenous vein; coronary artery bypass.

Tam Tıkalı Nativ Koroner Arterlerde Safen Ven Baypas Grefti Yoluyla Kardiyopleji Verilmesi: Gerçekten Koruyucu Bir Teknik mi?

Öz

Giriş: Antegrad yol, tam tıkalı koroner arter hastalarında homojen kardiyopleji dağılımı sağlamada yetersiz kalabilir. Bu hastalarda tıkalı segmentin distaline ven greftiyle kardiyopleji uygulamak alternatif bir yöntem olabilir. Bu çalışmada, antegrad kardiyopleji uygulanan hastalarla antegrad kardiyoplejiyle eş zamanlı ven grefti kardiyoplejisi uygulanan tam tıkalı koroner arter hastalarını miyokardiyal koruma açısından biyokimyasal parametrelerle karşılaştırdık. Hastalar ve Yöntem: En az bir koroner arteri tam tıkalı 14 hasta randomize olarak iki gruba ayrıldı. Grup 1'e antegrad kardiyopleji uygulanırken Grup 2'ye eş zamanlı antegrad ve ven grefti kardiyoplejisi uygulandı. Kreatin kinaz, kreatin kinaz MB, laktat, troponin I ölçüldü. Örnekler radial arter ve koroner sinüsten kardiyopulmoner baypastan önce (1), distal anastomozlar tamamlandıktan sonra (2), side klemp kaldırıldıktan sonra (3) arter ve koroner sinüsten, operasyon sonrası altıncı (4), 12. (5), 24. (6) ve 48. (7) saatlerde arterden alındı. Gruplar istatistiksel olarak kıyaslandı. Bulgular: Gruplar arasında kardiyak enzimler ve transkoroner laktat gradiyenti açısından fark bulunmadı. Sonuç: Antegrad kardiyopleji total tıkalı koroner arter varlığında yeterli miyokard koruması sağlayabilir. Antegrad ve ven greft kardiyoplejisi bu spesifik hasta grubunda bir avantaj sağlamamaktadır.

Anahtar Kelimeler

• Kardiyopleji, safen veni, koroner arter baypas.

Kaynakça

1. Soltesz EG, Laurence RG, De Grand AM, Cohn LH, Mihaljevic T, Frangioni JV. Image-guided quantification of cardioplegia delivery during cardiac surgery. Heart Surg Forum 2007;10:E381-6.
2. Aronson S, Lee B, Zaroff J, Wiencek J, Walker R, Fienstein S, et al. Myocardial distribution of cardioplegic solution after retrogra- de delivery in patients undergoing cardiac surgical procedures. J Thorac Cardiovasc Surg 1993;105:214-21.
3. Menasche P, Subayi JB, Veyssie L, le Dref O, Chevret S, Piwnika A. Efficacy of coronary sinus cardioplegia in patients with comple- te coronary artery occlusion. Ann Thorac Surg 1991;51:418-23.
4. Bhayana JN, Kalmbach T, Booth F, Mentzer R, Schimert G. Com- bined antegrade/retrograde cardioplegia for myocardial protecti- on: a clinical trial. J Thorac Cardiovasc Surg 1989;98:956-60.
5. Onem G, Sacar M, Baltalarli A, Ozcan AV, Gurses E, Sungurtekin H. Comparison of simultaneous antegrade/vein graft cardioplegia for myocardial protection. Adv in Therapy 2006;23:869-77.
6. Noyez L, van Son J, van der Werf T, Knappe J, Gimbrere J, van Asten N, et al. Retrograde versus antegrade delivery of cardioplegic solution in myocardial revascularization. A clinical trial in patients with three vessel coronary disease who underwent myocardial re- vascularization with extensive use of the internal mammary artery. J Thorac Cardiovasc Surg 1993;105:854-63.
7. Partington M, Acar C, Buckberg G, Julia P, Kofsky E, Bugyi H. Stu- dies of retrograde cardioplegia. I. Capillary blood flow distribution to myocardium supplied by open and occluded arteries. J Thorac Cardiovasc Surg 1989;97:605-12.
8. Allen BS, Winkelmann JW, Hanafy H, Hartz RS, Bolling KS, Ham J, et al. Retrograde cardioplegia does not adequately perfuse the right ventricle. J Thorac Cardiovasc Surg 1995;109:1116-24.

9. Winkelmann J, Aronson S, Young CJ, Fernandez A, Lee BK. Ret- rograde-delivered cardioplegia is not distributed equally to the right ventricular free wall and septum. J Cardiothorac Vasc Anesth 1995;9:135-9.
10. Fabiani JN, Deloche A, Swanson J, Carpentier A. Retrograde cardi- oplegia through the right atrium. Ann Thorac Surg 1986;41:101-2.
11. Carrier M, Gregorie J, Khalil A, Thai P, Latour JG, Pelletier LC. Myocardial distribution of retrograde cardioplegic solution asses- sed by myocardial thallium 201 uptake. J Thorac Cardiovasc Surg 1994;108:1115-8.
12. Hirata N, Sakai K, Ohtani M, Sakaki S, Ohnishi K. Assessment of myocardial distribution of retrograde and antegrade cardi- oplegic solution in the same patients. Eur J Cardiothorac Surg 1997;12:242-7.