Ihnken K, Morita K, Buckberg G D, Aharon A, Laks H, Panos A L, Drinkwater D C, Chugh R, Del Rizzo D, Salerno T A
Division of Cardiothoracic Surgery, UCLA School of Medicine 90024-1741.
J Card Surg. 1994 Jan;9(1):15-25. doi: 10.1111/j.1540-8191.1994.tb00819.x.
Concern over myocardial damage from simultaneous arterial (antegrade) and coronary sinus (retrograde) perfusion has led to alternating between these delivery routes to maximize their individual benefits. Based upon predominant retrograde drainage via Thebesian veins, this study: (1) confirms experimentally the safety of simultaneous arterial and coronary sinus perfusion; and (2) reports initial clinical application of this combined strategy in 155 consecutive patients.
Five mini-pigs (25 to 30 kg) underwent 1 hour of aortic clamping with simultaneous aortic and coronary sinus perfusion at 200 mL/min with normal blood (37 degrees C) before and after 30 minutes of perfusion with either warm (37 degrees C) or cold (4 degrees C) blood cardioplegia. Coronary sinus pressure was always less than 30 mmHg. There was no right or left ventricular edema, lactate production, or lipid peroxidation as transmyocardial and myocardial conjugated dienes were unaltered, and postbypass recovered left ventricular end-systolic elastance (conductance catheter) and preload recruitable stroke work index 101% +/- 3% and 109% +/- 90%, respectively. CLINICAL: Simultaneous arterial/coronary sinus perfusion was used in 155 consecutive high risk patients (New York Heart Association Class III to IV) undergoing isolated coronary artery bypass grafting (CABG) (n = 109) and CABG+valve replacement/repair or aneurysm (n = 46). Included were 16 patients in cardiogenic shock and 24 undergoing reoperation. Mean aortic clamping time averaged 90 +/- 4 minutes (range 30 to 207), with 3.5 +/- 0.1 grafts per patient; all anastomoses were performed with the aorta clamped. Cold intermittent blood cardioplegia was used for distal anastomoses and valve implantation/repair in 123 patients, and warm continuous blood cardioplegia was used in 32 patients. Following a warm cardioplegic reperfusate, all patients received warm noncardioplegic blood perfusion simultaneously via grafts and coronary sinus. Coronary sinus pressure was always less than 40 mmHg. Of 18 patients requiring postoperative mechanical circulatory support (IABP), 16 had IABP placed preoperatively for cardiogenic shock. There were three postoperative myocardial infarctions (2%), and six patients died (3.9% mortality).
These experimental and clinical findings overcome perceived concerns about myocardial damage from simultaneous arterial and coronary sinus perfusion, and suggest this approach may add to the armamentarium of cardioprotective strategies.
由于担心同时进行动脉（顺行）和冠状静脉窦（逆行）灌注会导致心肌损伤，因此一直在这两种灌注途径之间交替使用，以最大限度地发挥它们各自的益处。基于经Thebesian静脉的主要逆行引流，本研究：（1）通过实验证实了同时进行动脉和冠状静脉窦灌注的安全性；（2）报告了这一联合策略在155例连续患者中的初步临床应用。
五只小型猪（25至30千克）在使用温血（37℃）或冷血（4℃）心脏停搏液灌注30分钟前后，接受1小时的主动脉钳夹，同时以200毫升/分钟的速度进行主动脉和冠状静脉窦灌注，灌注液为正常血液（37℃）。冠状静脉窦压力始终低于30毫米汞柱。未出现右心室或左心室水肿、乳酸生成或脂质过氧化，因为跨心肌和心肌共轭二烯未发生改变，体外循环后恢复的左心室收缩末期弹性（导管测量）和前负荷可增加的每搏功指数分别为101%±3%和109%±90%。临床：155例连续的高危患者（纽约心脏协会III至IV级）接受了单纯冠状动脉旁路移植术（CABG）（n = 109）以及CABG+瓣膜置换/修复或动脉瘤手术（n = 46），术中采用了同时进行动脉/冠状静脉窦灌注。其中包括16例心源性休克患者和24例再次手术患者。平均主动脉钳夹时间为平均（90±4）分钟（范围30至207分钟），每位患者平均植入3.5±0.1个移植物；所有吻合均在主动脉钳夹下进行。123例患者在远端吻合和瓣膜植入/修复时使用了冷间歇性血液心脏停搏液，32例患者使用了温连续性血液心脏停搏液。在使用温性心脏停搏再灌注液后，所有患者通过移植物和冠状静脉窦同时接受温性非心脏停搏血液灌注。冠状静脉窦压力始终低于40毫米汞柱。在18例需要术后机械循环支持（IABP）的患者中，16例术前因心源性休克放置了IABP。术后发生了3例心肌梗死（2%），6例患者死亡（死亡率3.9%）。
这些实验和临床研究结果消除了人们对同时进行动脉和冠状静脉窦灌注导致心肌损伤的担忧，并表明这种方法可能会增加心脏保护策略的手段。
