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A Simple Technique for Multigraft Cardioplegic Infusion during Coronary Artery Bypass
A Simple Technique for Multigraft Cardioplegic Infusion during Coronary Artery Bypass Gerald M. Lawrie, M.D. ABSTRACT The use of a Silastic four-armed cardioplegic infusion device during coronary artery bypass grafting, which has facilitated multidose cardioplegic infusion through the aorta and vein grafts, is described. The device also permits transaortic needle sump suction for decompression of the left ventricle. This device has been used effectively in more than 250 patients. The presence of severe coronary artery stenoses may lead to uneven myocardial distribution of cold cardioplegic solution administered into the ascending aorta. The additional infusion of cardioplegic solution through saphenous vein grafts attached distal to stenotic lesions provides a method of achieving more uniform myocardial perfusion. A simple technique has been devised for multigraft infusion employing a cardioplegic infusion device with four distal branches.*
Fig 1 . Cardioplegic infusion deziice consisting of a Silastic infusion line (right) and four branches (left). The branches can be selectively occluded as needed (see Fie?2) by the plastic clips.
Technique The device consists of a Silastic tube with a proximal female end that fits the male end of a standard intravenous tube (Fig 1).One of the distal limbs has a connector that will fit standard %-inch pump tubing, connecting it to the sump suction and reservoir. The other three limbs have standard, Luer-Lok female fittings designed to receive the small, metal, olive-tipped cannulas that are inserted into the proximal ends of the saphenous vein graft segments. The device is connected as shown in Figure 2, and all of the limbs are flushed. The patient is placed on cardiopulmonary bypass with a single two-stage right atrial venous drainage cannula and ascending aortic arterial return. By means of crystalloid prime cooled to 4°C before the onset of bypass, the patient is cooled rapidly to 28°C. After the onset of cardiopulmonary bypass, the ascending aorta is cross-clamped and the cardioplegia infusion needle already connected to the infusion device is inserted into the ascending aorta. About 600 to 800 ml of crystalloid cardioplegic solution is infused. The amount is determined by the size of the heart and the rapidity of cessation of electrical activity. Topical ice-cold saline is also used to achieve local hypothermia. After the initial dose of cardioplegic solution is infused, the main infusion line is clamped and the sump
From the Departmcnt of Surgery, Baylor College of Medicine, and The Methodist Hospital, Texas Medical Center, Houston, TX 77030.
Accepted for puhlication Aug 27, 1984. *W. Pilling and C o . , Fort Washington, PA.
483
suction line is opened (see Fig 2). The first distal anastomosis is completed, and the vein graft is connected to one of the two remaining limbs. The sump line is clamped, and the cardioplegic solution is infused into the ascending aorta and the vein graft (see Fig 2). A volume of 150 to 200 ml is usually reinfused. During this period the heart is again cooled topically with more icecold saline solution. Following this infusion, the main infusion line is clamped and the sump suction line is reopened. The second distal anastomosis is completed, and the same sequence is repeated to infuse cardioplegia into the second vein graft. Additional grafts are placed without reinfusion. The proximal anastomoses are performed during partial aortic occlusion with a beating heart, during rewarming on cardiopulmonary bypass.
Comment Experience with this device in more than 250 coronary artery bypass operations has demonstrated it to be a simple, convenient, and reliable method of achieving multigraft cardioplegic infusion and transaortic left ventricular decompression. The device is currently used only to perfuse two separate vein grafts and the ascending aorta. To date, this method has proven adequate because the first two grafts are placed to the coronary vessels supplying the left ventricle, which allows good perfusion of the major mass of the heart and the left ventricular subendocardium. If more grafts needed to be infused, however, one of the vein graft infusion limbs could be easily disconnected and reconnected to another distal graft.
484 The Annals of Thoracic Surgery Vol 39
u Ice bath
During Distal Anastomosis
Sump
Distal Aorca
NO 5 May 1985
Fig 1 . Cardioplegic infusion deziice consisting of a Silastic infusion line (right) and four branches (left). The branches can be selectively occluded as needed (see Fie?2) by the plastic clips.
Technique The device consists of a Silastic tube with a proximal female end that fits the male end of a standard intravenous tube (Fig 1).One of the distal limbs has a connector that will fit standard %-inch pump tubing, connecting it to the sump suction and reservoir. The other three limbs have standard, Luer-Lok female fittings designed to receive the small, metal, olive-tipped cannulas that are inserted into the proximal ends of the saphenous vein graft segments. The device is connected as shown in Figure 2, and all of the limbs are flushed. The patient is placed on cardiopulmonary bypass with a single two-stage right atrial venous drainage cannula and ascending aortic arterial return. By means of crystalloid prime cooled to 4°C before the onset of bypass, the patient is cooled rapidly to 28°C. After the onset of cardiopulmonary bypass, the ascending aorta is cross-clamped and the cardioplegia infusion needle already connected to the infusion device is inserted into the ascending aorta. About 600 to 800 ml of crystalloid cardioplegic solution is infused. The amount is determined by the size of the heart and the rapidity of cessation of electrical activity. Topical ice-cold saline is also used to achieve local hypothermia. After the initial dose of cardioplegic solution is infused, the main infusion line is clamped and the sump
From the Departmcnt of Surgery, Baylor College of Medicine, and The Methodist Hospital, Texas Medical Center, Houston, TX 77030.
Accepted for puhlication Aug 27, 1984. *W. Pilling and C o . , Fort Washington, PA.
483
suction line is opened (see Fig 2). The first distal anastomosis is completed, and the vein graft is connected to one of the two remaining limbs. The sump line is clamped, and the cardioplegic solution is infused into the ascending aorta and the vein graft (see Fig 2). A volume of 150 to 200 ml is usually reinfused. During this period the heart is again cooled topically with more icecold saline solution. Following this infusion, the main infusion line is clamped and the sump suction line is reopened. The second distal anastomosis is completed, and the same sequence is repeated to infuse cardioplegia into the second vein graft. Additional grafts are placed without reinfusion. The proximal anastomoses are performed during partial aortic occlusion with a beating heart, during rewarming on cardiopulmonary bypass.
Comment Experience with this device in more than 250 coronary artery bypass operations has demonstrated it to be a simple, convenient, and reliable method of achieving multigraft cardioplegic infusion and transaortic left ventricular decompression. The device is currently used only to perfuse two separate vein grafts and the ascending aorta. To date, this method has proven adequate because the first two grafts are placed to the coronary vessels supplying the left ventricle, which allows good perfusion of the major mass of the heart and the left ventricular subendocardium. If more grafts needed to be infused, however, one of the vein graft infusion limbs could be easily disconnected and reconnected to another distal graft.
484 The Annals of Thoracic Surgery Vol 39
u Ice bath
During Distal Anastomosis
Sump
Distal Aorca
NO 5 May 1985