Research Article
Percutaneous Retrograde Cardioplegia in Minimal Access Aortic Valve Replacement Reduces Aortic Cross-Clamping Time Significantly
Scohy TV1*, van Kerckhoven G1, Bentala M2, Bramer S2, Laboutv JAM2 and Gerritse BM1
1Department of Anaesthesiology and Intensive Care, Amphia Hospital, Netherlands
2Department of Cardiothoracic Surgery, Amphia Hospital, Netherlands
*Corresponding author: Thierry V. Scohy, Department of Anaesthesiology and Intensive Care, Amphia Hospital, Breda, Netherlands
Published: 01 Dec, 2017
Cite this article as: Scohy TV, van Kerckhoven G, Bentala
M, Bramer S, Laboutv JAM, Gerritse
BM. Percutaneous Retrograde
Cardioplegia in Minimal Access Aortic
Valve Replacement Reduces Aortic
Cross-Clamping Time Significantly. Clin
Surg. 2017; 2: 1796.
Abstract
Introduction: One of the main obstacles of minimally invasive surgery for Aortic Valve Replacement
(M-AVR) is the increased Cardiopulmonary Bypass (CPB) and aortic cross-clamping time. We
Hypothesize that the use of a percutaneous coronary sinus catheterto deliver retrograde cardioplegia
may facilitate surgery and reduce CPB- and aortic cross-clamping time.
Methods: Data were collected prospectively at the Amphia Hospital, Breda, and the Netherlands
from May 2014 to May 2016 and were analysed retrospectively. A total of 40 M-AVR patients
were included. In all cases warm blood cardioplegia was used. The initial dose of cardioplegia was
administered antegradely through the aortic root in all 40 patients. In all patients cardioplegia was
repeated each 20 min. Patients with a percutaneous coronary sinus catheter received their following
doses of cardioplegia retrogradely, whereas patients without a coronary sinus catheter received
cardioplegia selectively through the coronary ostia.
Results: 23 patients received retrograde cardioplegia through a percutaneous coronary sinus
catheter versus 17 patients that received their cardioplegia solely antegradely. Mean aortic crossclamp
time was significantly shorter in the percutaneous coronary sinus catheter group (63 ± 11 vs.
55 ± 12, p=0.045).The mean CPB time was 8 minutes shorter in the percutaneous coronary sinus
catheter group, although this was not significant (82 min ± 14 vs. 74 min ± 14, p=0.075). Maximum
Troponin T did not differ significantly between the two groups (0.12 [0.08] vs. 0.13 [0.11], p=0.227).
Conclusion: Percutaneous retrograde cardioplegia administered through a coronary sinus
catheterin minimal invasive AVR reduces aortic cross-clamping time significantly.
Keywords: Retrograde cardioplegia; Minimally invasive surgery aortic valve replacement;
Percutaneous coronary sinus catheter
Introduction
Minimally invasive surgery for Aortic Valve Replacement (M-AVR) was introduced in 1996 and is now an acknowledged and established method of surgery. Compared to conventional sternotomy for aortic valve replacement (AVR), M-AVR diminishes postoperative ventilation time, reduces pain, hospital length of stay, time until return to full activity, and decreases use of blood products [1-10]. Although M-AVR has a mortality rate comparable to conventional AVR [1-8], one of the main obstacles of M-AVR is the increased Cardiopulmonary Bypass (CPB) and aortic cross-clamping time [9,10]. At the Amphia Hospital Breda, The Netherlands, intermittent 20:1 diluted warm blood cardioplegia solution, administered at a 20-minutes interval, is used since many years. Unfortunatelyrepeated ante grade warm blood cardioplegia delivery selectively through both coronary ostia can be time consuming. Labriola, et al. [11] published in 2016 that the use of necklines may facilitate surgery by reducing the number of lines to be inserted and removed by surgeons, and provide an unobstructed view of the surgical field [11]. Labriola et al. also showed that retrograde cardioplegia can be delivered through a percutaneous Coronary Sinus Catheter (CSC), guided by Transoesophageal Echography (TEE), via the right internal jugular vein (PR9 Catheter, Edwards Scientific, Salt Lake City, Utah USA), positioned in the coronary sinus [11]. To show possible benefits of this retrograde canula we analysed our M-AVR data retrospectively, focussing on CPB time and aortic cross-clamping time.
Table 1
Materials and Methods
Study design, setting and patients
Data were prospectively collected at the Amphia Hospital, Breda,
and the Netherlands from May 2014 to May 2016 and analysed
retrospectively. A total of 40 M-AVR patients, diagnosed with severe
aortic stenos is, were included. Patients were 18 years or older and
were operated by either one of two experienced cardiothoracic
surgeons in M-AVR (MB and SB). In our institution, warm blood
cardioplegia is intermittently delivered, every 20 min, with the
purpose of inducing and maintaining cardioplegic arrest. The
cardioplegic solution is produced by mixing oxygenated blood with a
hyperkalemic solution in a 20:1 ratio.The initial dose of cardioplegia
was administered antegrade through the aortic root in all 40 patients.
In all patients cardioplegia was repeated after 20 min. Patients, with
a percutaneous coronary sinus catheter, received their following
doses of cardioplegia retrogradely. Patients without a percutaneous
coronary sinus catheter received their following doses antegradely
by selective canulation of the coronary ostia. Patients received either
a bio prosthetic or mechanical valve. The percutane coronary sinus
catheter (retrograde cardioplegia) was solely employed when one of
the two cardiothoracic anaesthesiologists, who are experienced in the
use of this device, were available (BG and TS). The standard cardiacanaesthesia
protocol was used in all patients. After induction with
midazolam, sufentanil and rocuronium, anaesthesia was maintained
with sevoflurane and remifentanil. As patients were not subjected to
investigational actions the medical ethics commission was notified,
but further approval of a medical ethics commission was not
necessary. Patient confidentiality was guaranteed according to the
Dutch law on personal data protection.
Operative technique
The operative technique of M-AVR has been extensively described
[12-14]. A vertical small 5 cm skin incision is made on the region of
the manubrium sterni joint. A partial J-sternotomy is performed with
a Hall® Saw. The J parts of the bone incision is performed with the unprotected blade of the Hall® Saw, from lateral to medial and from
the second or the third inter costal space, depending on the body
habitus of the patient. The pericardium is opened and the pericardium
edges are pulled out through the incision, and fixed to the skin. The
right femoral vein is used for vein cannulation. A Sorin double staged
vein cannula is placed through the femoral vein using the Seldinger
technique, positioned under TEE guidance. The arterial cannulation
is done centrally in the ascending aorta. An aortic root needle is
placed. Venting takes place through the aortic valve. The retrograde
cardioplegia coronary sinus catheter is placed percutaneously through
the right internal jugular vein guided by TEE guidance. All intended
percutane coronary sinus catheters are adequately positioned without
any negative side effects. The aorta is cross-clamped using a Cosgrove
flexible aortic cross-clamp. Cardioplegia delivery was considered
successful when dark blood appeared from both coronary ostia
administration.
Data collection
Data were retrospectively collected; baseline characteristics,
such as patient age and sex, pre-operative Hb and creatinine. Preoperative
comorbidity, such as left ventricular function, aortic
valve regurgitation and left ventricular hypertrophy. Collected
operative characteristics were CPB time and aortic cross-clamping
time. Postoperative outcome measures were maximum Troponin
T, postoperative myocardial infarction, postoperative potassium,
maximum creatinine and postoperative adverse events. Primary we
compared CPB time and aortic cross clamping time between the PR9
retrograde- and the anterograde cardioplegia group. Secondly, we
investigated whether the difference in clamping time led to difference
in myocardial damage, measured by maximum Troponin T and the
occurrence of myocardial infarction postoperatively.
Definition of adverse events
Death in relation to surgery was defined as any death occurring
during the same hospital admission as for the surgery. Renal disorders
were defined as an elevated creatinine, decreased urine output and
the necessity for Continuous Veno-Venous Hemofiltration (CVVH).
Postoperative myocardial infarction was defined as a changing ECG
with signs of ischemia and elevated troponin T. The category other
adverse events was used as a collection category.
Statistics
All data were analysed using SPSS Statistics Version 22 (IBM,
Armonk, NY, USA). Categorical variables are described as numbers
(percentages). Continuous variables were described as mean (±
standard deviation) if normally distributed, or median [inter quartile
range] if not normally distributed. Statistical analyses between
the two groups were made using the unpaired T test for numerical
variables and the Pearson Chi Square for categorical data. Statistical
significance was accepted as p< 0.05.
Table 2
Table 3
Results
A total of 40 patients had elective M-AVR during the study period. Twenty-three patients received retrograde cardioplegia through a percutane coronary sinus catheter (Retrograde M-AVR group). The patient’s demographic characteristics are listed in Table 1. Operative characteristics are presented in Table 2. Mean aortic cross-clamping time was significantly shorter in the retrograde M-AVR group (63 min ± 11 vs. 55 min ± 12, p=0.045). The mean CPB time was slightly longer in the solely antegrade cardioplegia M-AVR group, but did not differ significantly (82 min ± 14 vs. 74 min ± 14, p=0.075). The main clinical outcomes of the groups are presented in Table 3. Maximum Troponin T did not differ between the two groups (0.12umol/L [0.08] vs. 0.13umol/L [0.11], p=0.227). There were two postoperative myocardial infarctions in the antegrade M-AVR group as opposed to zero in the retrograde M-AVR group. However, this difference was not statistically significant (p=0.091). One patient in the antegrade M-AVR group required a re-exploration due to excessive drain production, caused by leakage from the aortic seam.
Discussion
The present study shows that retrograde cardioplegia through a percutane coronary sinus catheter does reduce aortic crossclamping time significantly during M-AVR. We also see a tendency of shorter CPB times of mainly 8 min in the retrograde cardioplegia M-AVR group. This can be explained by the fact that administering retrograde cardioplegia through a percutane coronary sinus catheter, in a setting of M-AVR, facilitates delivery of cardioplegia, as the surgical procedure does not have to be stopped for administration of selective cardioplegia in both coronary ostia, which sometimes can be time-consuming and challenging in M-AVR. Adequate cardioplegia delivery must only be checked, by the appearance of dark fluid from both coronary ostia. As published by Labriola, et al. [11] the percutane coronary sinus catheter ensure effective retrograde cardioplegia of the heart and allow surgeon stop rate in an unobstructed surgical field [11]. On the other hand the anaesthesiologist will need some extra time to deploy the percutane coronary sinus catheter successfully [11]. Shehada et al. [10] published comparable aortic cross-clamp times (M-AVR 65.6 ± 18.4 min vs. conventional AVR 64.3 ± 19.8 min, P=0.25) in his propensity score analysis between M-AVR and conventional AVR (n=585 in both groups) [10], those aortic crossclamp times are comparable with our solely antegrade cardioplegia M-AVR (63 ± 11 min). On the other hand, Shehada, et al. [10] published much longer operation time compared to a full sternotomy because of limited exposure of the heart and much longer CPB times for M-AVR compared with conventional AVR (93.5 ± 25 vs. 88 ± 28 min, P< 0.001) [10]. Our CPB times (82 ± 14 min vs. 74 ± 15 min) are much shorter, which can partially be explained by a gain of experience over time. The main principle of myocardial protection in cardiac surgery is to preserve myocardial function by preventing ischemia with the use of cardioplegia. Therefore, in our institution, warm blood cardioplegia is intermittently delivered in the coronary arteries. We are well aware of the fact that myocardial protection is still a major issue in cardiac surgery, since inadequate protection increases the risk of postoperative cardiac dysfunction. We only saw a significant reduction of aortic cross-clamp time in this study. The sample size of this pilot study was generally not large enough to detect a significant difference of maximum Troponin T (0.12 umol/L [0.08] vs. 0.13 umol/L [0.11], p=0.227) between the groups, therefore 948 patients are needed. Minimal invasive AVR has several advantages such as shorter length of stay [1-3,5,6,8] shorter duration of ventilation [1,2,6,8], decreased time until return to full activity [2], improved cosmetics [4,8,10], decreased rate of postoperative renal failure [5] and less postoperative pain [8] compared with conventional AVR. A recent meta-analysis found no significant difference between AVR and MAVR for postoperative a trial fibrillation, myocardial infarctions, pneumonia, pneumothorax, sternal/wound infections or mortality rate [3]. Since our study shows a significant reduced aortic cross-clamp time with the use of a percutane coronary sinus catheter for retrograde cardioplegia, additional studies are required to determine whether the use of percutane coronary sinus catheter is associated with better outcomes in M-AVR.
Study Limitations
The present study is based on a retrospective analysis of our prospectively collected database, and thus it reflects a single centre experience only, and carrying all the limits that a retrospective analysis design implies.
Conclusion
Retrograde cardioplegia administered through a percutane coronary sinus catheter in minimal invasive AVR reduces aortic cross-clamping time significantly.
References
- Tabata M, Umakanthan R, Cohn LH, Bolman RM 3rd, Shekar PS, Chen FY, et al. Early and late outcomes of 1000 minimally invasive aortic valve operations. Eur J Cardiothorac Surg. 2008;33(4):537-41.
- Brinkman WT, Hoffman W, Dewey TM, Culica D, Prince SL, Herbert MA, et al. Aortic valve replacement surgery: comparison of outcomes in matched sternotomy and PORT ACCESS groups. Ann Thorac Surg. 2010;90(1):131-5.
- Phan K, Xie A, Di Eusanio M, Yan TD. A meta-analysis of minimally invasive versus conventional sternotomy for aortic valve replacement. Ann ThoracSurg. 2014;98:1499-511.
- Malaisrie SC, Barnhart GR, Farivar RS, Mehall J, Hummel B, Rodriguez E, et al. Current era minimally invasive aortic valve replacement: techniques and practice. J ThoracCardiovasc Surg. 2014;147(1):6-14.
- Bowdish ME, Hui DS, Cleveland JD, Mack WJ, Sinha R, Ranjan R, et al. A comparison of aortic valve replacement via an anterior right minithoracotomy with standard sternotomy: a propensity score analysis of 492 patients. Eur J Cardiothorac Surg. 2016;49(2):456-6.
- Gilmanov D, Farneti PA, Ferrarini M, Santarelli F, Murzi M, Miceli A, et al. Full sternotomy versus right anterior minithoracotomy for isolated aortic valve replacement in octogenarians: a propensity-matched study. Interact CardiovascThorac Surg. 2015;20(6):732-41.
- Gilmanov D, Solinas M, Farneti PA, Cerillo AG, Kallushi E, Santarelli F, Glauber M. Minimally invasive aorticvalvereplacement: 12-yearsinglecenterexperience. Ann Cardiothorac Surg. 2015;4(2):160-9.
- Neely RC, Boskovski MT, Gosev I, Kaneko T, McGurk S, Leacche M, et al. Minimallyinvasiveaortic valvereplacementversusaortic valvereplacement through full sternotomy: the Brigham and Women's Hospital experience. Ann Cardiothorac Surg. 2015;4(1):38-48.
- Brown ML, McKellar SH, Sundt TM, Schaff HV. Ministernotomy versus conventional sternotomy for aortic valve replacement: a systematic review and meta-analysis. J Thorac Cardiovasc Surg. 2009;137(3):670-9.
- Shehada S-E, Öztürk Ö, Wottke M, Lange R. Propensity score analysis of outcomes following minimal access versus conventional aortic valve replacement. Eur J CardiothoracSurg. 2016;49:464-70.
- Labriola C, Paparella D, Labriola G, Dambruoso P, Cassese M, Speziale G. Reliability of Percutaneous Pulmonary Vent and Coronary Sinus Cardioplegia in the Setting of Minimally Invasive Aortic Valve Replacement: A Single-Center Experience. J CardiothoracVascAnesth. 2016;31(4):1203-9.
- von Segesser LK, Westaby S, Pomar J, Loisance D, Groscurth P, Turina M. Less invasive aortic valve surgery: rationale and technique. Eur J CardiothoracSurg. 1999;15(6):781-5.
- Cohn LH, Adams DH, Couper GS, Bichell DP, Rosborough DM, Sears SP, et al. Minimally invasive cardiac valve surgery improves patient satisfaction while reducing costs of cardiac valve replacement and repair. Ann Surg. 1997;226(4):421-6.
- Doll N, Borger MA, Hain J, Bucerius J, Walther T, Gummert JF, et al. Minimal access aortic valve replacement: effects on morbidity and resource utilization. Ann ThoracSurg. 2002;74(4):S1318-22.