Kappler Benjamin, Pabittel Dara R, van Tuijl Sjoerd, Stijnen Marco, de Mol Bas A J M, van der Wal Allard C
LifeTec Group B.V., Eindhoven, the Netherlands.
Department of Cardiothoracic Surgery, Amsterdam, Academic Medical Center, the Netherlands.
J Clin Transl Res. 2018 Jul 18;4(2):105-112. eCollection 2019 Jan 10.
The cardiac lymphatic system drains excess fluid from the cardiac interstitium. Any impairment or dysfunction of the lymph structures can result in the accumulation of interstitial fluid, and may lead to edema and eventually cardiac dysfunction. Lymph originates directly from the interstitium and carries real-time information about the metabolic state of cells in specific regions of the heart. The detailed anatomy of the epicardial lymphatic system in individuals is broadly unknown. Generally, the epicardial lymphatic system is not taken into consideration during heart surgery. This study investigates the feasibility of detailed mapping and cannulation of the porcine epicardial lymphatic system for use in preservation of explanted hearts and heart failure studies in pigs and humans.
The anatomy of the epicardial lymphatic systems of forty pig hearts was studied and documented. Using a 27 G needle, India ink was introduced directly into the epicardial lymphatic vessels in order to visualise them. Based on the anatomical findings thus obtained, two cannulation regions for the left and right principal trunks were identified. These regions were cannulated with a 26 G intravenous Venflon cannula-over-needle, and a Galeo Hydro Guide F014 wire was used to verify that the lumen was patent.
The main epicardial lymphatic collectors were found to follow the main coronary arteries. Most of the lymph vessels drained into the left ventricular trunk, which evacuates fluid from the left heart and also partially from the right heart. The right trunk was often found to drain into the left trunk anterior basally. Right heart drainage was highly variable compared to the left. In addition, the overall cannulation success rate of the selected cannulation sites was only 57%.
Mapping of the porcine epicardial lymphatic anatomy is feasible. The right ventricular drainage system had a higher degree of variability than the left, and the right cardiac lymph system was found to be partially cleared through the left lymphatic trunk. To improve cannulation success rate, we proposed two sites for cannulation based on these findings and the use of Venflon cannulas (26 G) for cannulation and lymph collection. This method might be helpful for future studies that focus on biochemical sample analysis and decompression.
Real-time biochemical assessment and decompression of lymph may contribute to the understanding of heart failure and eventually result in preventive measures. First its relevance should be established by additional research in both arrested and working porcine hearts. Imaging and mapping of the epicardial lymphatics may enable sampling and drainage and contribute to the prevention or treatment of heart failure. We envision that this approach may be considered in patients with a high risk of postoperative left and right heart failure during open-heart surgery.
心脏淋巴系统从心脏间质中引流多余的液体。淋巴结构的任何损伤或功能障碍都可能导致间质液积聚，并可能导致水肿，最终引发心脏功能障碍。淋巴直接起源于间质，并携带有关心脏特定区域细胞代谢状态的实时信息。个体的心外膜淋巴系统的详细解剖结构大致未知。一般来说，心脏手术中不会考虑心外膜淋巴系统。本研究探讨详细绘制猪心外膜淋巴系统图谱并进行插管的可行性，以用于保存离体心脏以及猪和人类的心力衰竭研究。
对40个猪心脏的心外膜淋巴系统的解剖结构进行了研究并记录。使用27G针头将印度墨水直接注入心外膜淋巴管以使其可视化。根据由此获得的解剖学发现，确定了左右主干的两个插管区域。用26G静脉留置针进行插管，并使用Galeo Hydro Guide F014导丝确认管腔通畅。
发现主要的心外膜淋巴收集器沿着主要冠状动脉走行。大多数淋巴管汇入左心室主干，该主干从左心以及部分从右心引流液体。右主干通常在基部前方汇入左主干。与左心相比，右心的引流情况差异很大。此外，所选插管部位的总体插管成功率仅为57%。
绘制猪心外膜淋巴解剖图谱是可行。右心室引流系统的变异性高于左心室，并且发现右心淋巴系统部分通过左淋巴主干清除。为提高插管成功率，我们基于这些发现提出了两个插管部位，并使用静脉留置针（26G）进行插管和淋巴收集。该方法可能有助于未来专注于生化样本分析和减压的研究。
对淋巴进行实时生化评估和减压可能有助于理解心力衰竭，并最终促成预防措施。首先，其相关性应通过对停跳和跳动的猪心脏进行更多研究来确定。心外膜淋巴管的成像和绘图可能有助于采样和引流，并有助于预防或治疗心力衰竭。我们设想，对于心脏直视手术期间术后发生左右心力衰竭风险较高的患者，可考虑采用这种方法。
