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Balloon occlusion of the aortic valve for antegrade continuous warm blood cardioplegia
Ann Thorac Surg 1995;59:1622-8
phy on the 36th postoperative day. The patient is now doing well.
Takaaki Sugita, MD Ryuzabro Yasuda, MD Tatsuo Magara, MD Tadao Nishikawa, MD Kazuhiko Katsuyama, MD Takehisa Nojima, MD Atsushi Katsura, MD Department qfl Cardiovascular SurgeN Shiga Seijinbyo Hospital Moriyama and Second Department of Surge~, Shiga University q[ Medical Science Seta, Ohtsu Shiga 520-21 Japan References 1. Midulla PS, Dapunt bE, Sadeghi AM, Quintana CS, Griepp RB. Aortic dissection involving a double aortic arch with a right descending aorta. Ann Thorac Surg 1994;58:874-5. 2. Sugita T, Yasuda R, Magara T, et al. Surgical therapy of a ruptured aortic aneurysm involving a Shuford type-3 rightsided aortic arch. J Jpn Assoc Thorac Surg 1990;38:122-5. 3. Shuford WH, Sybers RG, Gordon IJ, et al. Circumflex retroesophageal right aortic arch simulating mediastinal tumor of dissecting aneurysm. AJR 1986;146:491-6.
Balloon Occlusion of the A o r t i c V a l v e f o r Antegrade Continuous Warm Blood Cardioplegia To the Editor: It appears that continuous warm blood cardioplegia has become the method of choice for many cardiac surgeons. That modality of myocardial preservation has been reported to provide prominent myocardial protection by excluding ischemic time, side effects of hypothermia, and reperfusion injury I1]. However, in the presence of mild aortic valve incompetence not requiring surgical intervention associated with severe mitral or coronary disease, antegrade delivery of continuous warm blood cardioplegia is not feasible because sufficient coronary, perfusion cannot be secured because of cardioplegia leakage into the left ventricular cavity. Moreover, in mitral valve operations, even in the absence of aortic valve incompetence, it can be induced easily intraoperatively by retraction of the intraatrial septum for good exposure of the mitral valve. These potentially lethal conditions with warm blood cardioplegia leave us uncomfortable with our ability to provide adequate antegrade coronary artery flows and perhaps are the impetus for many surgeons initially to explore retrograde warm blood cardioplegia. Balloon occlusion of the aortic orifice for the antegrade administration of hypothermic cardioplegia in the presence of aortic regurgitation was first reported by Robicsek [2]. Recently we applied this technique for antegrade delivery of continuous warm blood cardioplegia and obtained gratifying results. Following Robicsek's maneuver, the balloon catheter is inserted retrograde through the aortic wall and the aortic valve into the left ventricular cavity, inflated, and pulled against the aortic orifice to occlude it. From a technical standpoint, it is imperative that the balloon be placed properly in the subaortic position. From our experience, it is likely that the balloon may be caught in the subvalvular apparatus of the mitral valve. To avoid this problem, proper placement of the inflated balloon should be © 1995 by The Society of Thoracic Surgeons
CORRESPONDENCE
1627
checked by palpation from the outside of the left ventricular wall. While the cardioplegic solution is infused continuously through the aortic root into the coronary arteries, the catheter is secured to the aortic wall with a tourniquet so that the balloon is not dislodged through the various manipulations of the operative procedure. To ascertain adequate cardioplegia infusion, we continuously monitor both the aortic root pressure a n d the coronary sinus oxygen saturation [3]. It is of note that this technique is also effective to avoid possible air embolism of the coronary arteries w h e n the cardiac beats are resumed with the left atrium open, as can occur incidentally during continuous warm blood cardioplegia infusion. Therefore, we do not remove the balloon catheter even after aortic unclamping until the cardiac beats are resumed a n d air is evacuated from the left atrial and ventricular cavities. Although there have been many good clinical results with retrograde warm blood cardioplegia which has burgeoning popularity, myocardial protection of the right ventricle using this method is still controversial [4]. That modality of cardioplegia delivery also remains technically challenging because of the possible coronary sinus rupture 15] and dislodgement of the perfusion cannula [6]. The above-mentioned technique for antegrade cardioplegia delivery using the balloon catheter to occlude the aortic orifice serves to remind us that the physiologic route of coronary perfusion with continuous warm blood cardioplegia, particularly in mitral valve operations, should not be forgotten or discarded.
Takeshi Miyairi, MD Hirotaka Inaba, MD Keih~ Tanaka, MD Akira Mizuno, MD Department of Cardiac Surge~ Asahi General Hospital 1-1326 Asahi-shi Chiba 289-25, Japan References 1. Lichtenstein SV, Ashe KA, El-Dalati H, Cusimano RJ, Panos A, Slutsky AS. Warm heart surgery. J Thorac Cardiovasc Surg 1991;101:269 -74. 2. Robicsek F. Administration of hypothermic cardioplegia in the presence of aortic regurgitation. Ann Thorac Surg 1985; 39:192-3. 3. Miyairi T, Miwa T, Takayama T, Ka K, Itoh K. Continuous monitoring of coronary sinus oxygen saturation during warm heart surgery. J Thorac Cardiovasc Surg 1994;108:795-6. 4. Caldarone CA, Krukenkamp IB, Misare BD, Levitsky SA. Perfusion deficit with retrograde warm blood cardioplegia. Ann Thorac Surg 1994;57:403-6. 5. Fleisher AG, Sarabu MR, Reed GE. Repair of coronary sinus rupture secondary to retrograde cardioplegia. Ann Thorac Surg 1994;57:476-8. 6. Salerno TA, Christakis GT, Abel J, et al. Technique and pitfalls of retrograde continuous warm blood cardioplegia. Ann Thorac Surg 1991;51:1023-5.
Reply To the Editor: 1 am very pleased that Miyairi and associates found my method of instituting antegrade cardioplegia in the presence of aortic regurgitation useful. Naturally, the technique is identical whether the cardioplegia is warm or cold. 1 also would like to call attention to a potential danger of the technique: The insertion of the balloon catheter in the left 0003-4975195/59.50
phy on the 36th postoperative day. The patient is now doing well.
Takaaki Sugita, MD Ryuzabro Yasuda, MD Tatsuo Magara, MD Tadao Nishikawa, MD Kazuhiko Katsuyama, MD Takehisa Nojima, MD Atsushi Katsura, MD Department qfl Cardiovascular SurgeN Shiga Seijinbyo Hospital Moriyama and Second Department of Surge~, Shiga University q[ Medical Science Seta, Ohtsu Shiga 520-21 Japan References 1. Midulla PS, Dapunt bE, Sadeghi AM, Quintana CS, Griepp RB. Aortic dissection involving a double aortic arch with a right descending aorta. Ann Thorac Surg 1994;58:874-5. 2. Sugita T, Yasuda R, Magara T, et al. Surgical therapy of a ruptured aortic aneurysm involving a Shuford type-3 rightsided aortic arch. J Jpn Assoc Thorac Surg 1990;38:122-5. 3. Shuford WH, Sybers RG, Gordon IJ, et al. Circumflex retroesophageal right aortic arch simulating mediastinal tumor of dissecting aneurysm. AJR 1986;146:491-6.
Balloon Occlusion of the A o r t i c V a l v e f o r Antegrade Continuous Warm Blood Cardioplegia To the Editor: It appears that continuous warm blood cardioplegia has become the method of choice for many cardiac surgeons. That modality of myocardial preservation has been reported to provide prominent myocardial protection by excluding ischemic time, side effects of hypothermia, and reperfusion injury I1]. However, in the presence of mild aortic valve incompetence not requiring surgical intervention associated with severe mitral or coronary disease, antegrade delivery of continuous warm blood cardioplegia is not feasible because sufficient coronary, perfusion cannot be secured because of cardioplegia leakage into the left ventricular cavity. Moreover, in mitral valve operations, even in the absence of aortic valve incompetence, it can be induced easily intraoperatively by retraction of the intraatrial septum for good exposure of the mitral valve. These potentially lethal conditions with warm blood cardioplegia leave us uncomfortable with our ability to provide adequate antegrade coronary artery flows and perhaps are the impetus for many surgeons initially to explore retrograde warm blood cardioplegia. Balloon occlusion of the aortic orifice for the antegrade administration of hypothermic cardioplegia in the presence of aortic regurgitation was first reported by Robicsek [2]. Recently we applied this technique for antegrade delivery of continuous warm blood cardioplegia and obtained gratifying results. Following Robicsek's maneuver, the balloon catheter is inserted retrograde through the aortic wall and the aortic valve into the left ventricular cavity, inflated, and pulled against the aortic orifice to occlude it. From a technical standpoint, it is imperative that the balloon be placed properly in the subaortic position. From our experience, it is likely that the balloon may be caught in the subvalvular apparatus of the mitral valve. To avoid this problem, proper placement of the inflated balloon should be © 1995 by The Society of Thoracic Surgeons
CORRESPONDENCE
1627
checked by palpation from the outside of the left ventricular wall. While the cardioplegic solution is infused continuously through the aortic root into the coronary arteries, the catheter is secured to the aortic wall with a tourniquet so that the balloon is not dislodged through the various manipulations of the operative procedure. To ascertain adequate cardioplegia infusion, we continuously monitor both the aortic root pressure a n d the coronary sinus oxygen saturation [3]. It is of note that this technique is also effective to avoid possible air embolism of the coronary arteries w h e n the cardiac beats are resumed with the left atrium open, as can occur incidentally during continuous warm blood cardioplegia infusion. Therefore, we do not remove the balloon catheter even after aortic unclamping until the cardiac beats are resumed a n d air is evacuated from the left atrial and ventricular cavities. Although there have been many good clinical results with retrograde warm blood cardioplegia which has burgeoning popularity, myocardial protection of the right ventricle using this method is still controversial [4]. That modality of cardioplegia delivery also remains technically challenging because of the possible coronary sinus rupture 15] and dislodgement of the perfusion cannula [6]. The above-mentioned technique for antegrade cardioplegia delivery using the balloon catheter to occlude the aortic orifice serves to remind us that the physiologic route of coronary perfusion with continuous warm blood cardioplegia, particularly in mitral valve operations, should not be forgotten or discarded.
Takeshi Miyairi, MD Hirotaka Inaba, MD Keih~ Tanaka, MD Akira Mizuno, MD Department of Cardiac Surge~ Asahi General Hospital 1-1326 Asahi-shi Chiba 289-25, Japan References 1. Lichtenstein SV, Ashe KA, El-Dalati H, Cusimano RJ, Panos A, Slutsky AS. Warm heart surgery. J Thorac Cardiovasc Surg 1991;101:269 -74. 2. Robicsek F. Administration of hypothermic cardioplegia in the presence of aortic regurgitation. Ann Thorac Surg 1985; 39:192-3. 3. Miyairi T, Miwa T, Takayama T, Ka K, Itoh K. Continuous monitoring of coronary sinus oxygen saturation during warm heart surgery. J Thorac Cardiovasc Surg 1994;108:795-6. 4. Caldarone CA, Krukenkamp IB, Misare BD, Levitsky SA. Perfusion deficit with retrograde warm blood cardioplegia. Ann Thorac Surg 1994;57:403-6. 5. Fleisher AG, Sarabu MR, Reed GE. Repair of coronary sinus rupture secondary to retrograde cardioplegia. Ann Thorac Surg 1994;57:476-8. 6. Salerno TA, Christakis GT, Abel J, et al. Technique and pitfalls of retrograde continuous warm blood cardioplegia. Ann Thorac Surg 1991;51:1023-5.
Reply To the Editor: 1 am very pleased that Miyairi and associates found my method of instituting antegrade cardioplegia in the presence of aortic regurgitation useful. Naturally, the technique is identical whether the cardioplegia is warm or cold. 1 also would like to call attention to a potential danger of the technique: The insertion of the balloon catheter in the left 0003-4975195/59.50