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How to determine the correct placement of the retrograde cardioplegia catheter

Unità Operativa di Cardiochirurgia, Istituto Clinico Humanitas, Via Manzoni, Rozzano, Italy

^* Corresponding author. Via Giovannino de Grassi 17, Milano 20123, Italy. Tel.: +39-2-82244555; fax: +39-2-82244691
eric.manasse{at}humanitas.it

Received February 13, 2002; received in revised form May 30, 2002; accepted June 3, 2002

	Abstract

Top Abstract Appendix A Acknowledgements

 
Besides the surgeon's experience, there is no objective method to detect whether the retrograde cannula is inserted correctly before injecting the cardioplegia and measuring the coronary sinus pressure after the aorta cross-clamp. Repositioning of the retrograde cannula once extracorporeally is not always an easy maneuver and may include the risk of venous air suction. Manual detection of the cannula's position may jeopardize the stability of an ischemic heart (Ann Thorac Surg 50(6) (1990) 882; J Cardiothorac Vasc Anesth 5(6) (1991) 646; Ann Thorac Surg 52(4) (1991) 879). Determining the retrograde cannula position avoiding unnecessary prolongation of the ischemia would allow a better protection of the heart. To our knowledge such a method has not yet been published.

Key Words: Correct placement; Retrograde cardioplegia; Catheter

In our practice we use either an antegrade or retrograde cardioplegia catheter (RCC) which is used whenever aortic incompetence is present and routinely in coronary and aortic surgery. From time to time this is the only available way to arrest and protect the heart if selective coronary cardioplegia is to be avoided. The inflow cannulas are positioned respectively in the ascending aorta and coronary sinus before starting extracorporeal circulation (ECC). To deliver cardioplegia we use a simple Y catheter coming from the ECC pump: one branch goes to the ascending aorta and the other one goes to the coronary sinus (Fig. 1). Once they are inserted and before clamping the ascending aorta, we use a simple and reliable test to verify the correct position of the retrograde cannula. We first measure the coronary sinus pressure with both catheters occluded (Fig. 2). Then we interconnect them by opening each line and clamping the main from the ECC. Obviously the arterial pressure exceeds the venous pressure and the arterial blood runs from the ascending aorta into the coronary sinus thus mimicking the RCC injection without arresting the heart. If the RCC is correctly inserted the coronary sinus pressure increases immediately to 20–30 mmHg; on the contrary it does not change at all if malpositioned. Since no tilting of the heart is needed, unstable hearts may also benefit from this simple technique because arrhythmias or pressure drops are avoided. This simple maneuver allows the surgeon to verify the retrograde cannula position before clamping the aorta and without using the RCC or manipulating the heart.

View larger version (22K): [in this window] [in a new window]   Fig. 1 Y cardioplegia catheter: the arrows show the physiological blood flow from the ascending aorta into the coronary sinus.

View larger version (27K): [in this window] [in a new window]   Fig. 2 (A) Basal condition; blue, coronary sinus pressure; red, systemic arterial blood pressure; green, ECG. (B) Operating field. (C) Opened Y cardioplegia catheter (note the isolated coronary sinus pressure increase).

	Appendix A

Top Abstract Appendix A Acknowledgements

Date: 07-Aug-2002 12:06

Message: The authors propose a simple, easy to reproduce and reliable method to verify the correct positioning of the retrograde cardioplegia cannula in coronary sinus. In fact the correct positioning is vital in order to provide adequate administration of cardioplegia, and therefore adequate myocardial protection, and either external visual inspection as well as finger palpation are not reliable in order to verify the position of the retrograde cannula. As the authors described, even the control of the pressure during cardioplegia administration, when limited to the value of the pressure recorded in the retrograde cannula, is not absolutely correlated with the adequate position of the cannula.

An additional method to verify the correct positioning, routinely utilized in our practice, is to verify the adequate introduction of the retrograde cannula in the coronary sinus by transoesophageal echocardiography. Of course the two methods are not mutually exclusive, and the combination of the two might further enhance the safety of the utilization of the combined antegrade and retrograde administration of blood cardioplegia, indispensable in the armamentarium of the modern cardiac surgeon, particularly when dealing with complex procedures, like Ross operation or other complex aortic root procedures.

Author: Dr. Verdi DiSesa, Chief, Cardiac Surgery, The Chester County Hospital, 701 East Marshall Street, West Chester, PA 19380, USA

Date: 09-Aug-2002 18:33

Message: The authors have proposed a clever method for verifying correct placement of the retrograde cardiplegia cannula in the coronary sinus. Their technique requires placement of the cannula prior to initiation of cardiopulmonary bypass. They imply that no manipulation of the heart is needed and may be an advantage of their technique.

However, they have not specified how they introduce and manipulate the cannula in the the coronary sinus. Is this portion of the procedure done blindly or is digital palpation at the right atrial-inferior vena caval junction employed? The former risks injury to the atrium, vena cava, or coronary sinus, and the latter may cause hemodynamic perturbation in unstable patients not already on bypass.

An alternative method is to insert the retrograde cannula after initiation of cardiopulmonary bypass but without complete emptying of the heart. Hemodynamic instability and entrainment of air are avoided, even if gentle palpation to locate the position of the cannula is employed. A test injection, or even the authors’ technique of creating an aorta to coronary sinus fistula, can still be accomplished to verify correct positioning prior to clamping the aorta and arresting the heart.

	Acknowledgements

Top Abstract Appendix A Acknowledgements

 
We wish to express our gratitude to Mrs Benedetta Nefri for the drawing.

PII: S1569929302000051

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted 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 Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Manasse, E. Articles by Gallotti, R. Search for Related Content PubMed PubMed Citation Articles by Manasse, E. Articles by Gallotti, R. Related Collections Cardiac - other Myocardial protection