title: Mechanisms of incomplete cardioplegia distribution during coronary artery surgery. An intraoperative transesophageal contrast echocardiography study.
abstract: BACKGROUND
  Cardioplegia is used to protect the myocardium from ischemic injury during open-heart surgery. However, the delivery of cardioplegic solutions may be impaired by anatomic and/or functional conditions, such as the development of transient aortic regurgitation during antegrade administration of cardioplegia or shunting through a foramen ovale during retrograde administration. In this study, the authors used a new method of cardioplegia administration, based on intraoperative contrast echocardiography, to detect on-line causes of inadequate cardioplegia delivery.
  
  
  METHODS
  Forty patients with coronary artery disease and a competent aortic valve, who were treated consecutively, were enrolled in this study. Patients were monitored intraoperatively by transesophageal contrast echocardiography during cardioplegia delivery. Antegrade cardioplegia was administered into the aortic root following aortic occlusion in all patients. Twenty-two patients also received retrograde cardioplegia, administered through the right atrium. The echo-contrast agent consisted of a stable suspension of 5% human albumin microbubbles with a concentration of 4 x 10(8) microbubbles/ml and a diameter of 4 +/- 1 mu.
  
  
  RESULTS
  Antegrade cardioplegia was not associated with aortic regurgitation in 23 of 40 (58%) patients. Seven patients (17%) had only mild aortic regurgitation, four patients (10%) had moderate regurgitation, and six (15%) had severe aortic regurgitation. The percent of myocardial opacification was 76.0 +/- 10.5 in the 23 patients who did not have aortic regurgitation, 76.0 +/- 17.0 in the 7 patients who had mild regurgitation, 52.5 +/- 18.1 in the 4 patients who had moderate regurgitation, and 48.5 +/- 18.3 in 6 patients who had severe aortic regurgitation (Kruskal-Wallis stat, 12.9; P < 0.005). Retrograde cardioplegia was not associated with right-to-left shunt in 11 of 22 patients (50%). In seven patients (32%), there was only a mild passage of contrast material to the left atrium. In the remaining four patients (18%), there was a moderate (one patient) to severe (three patients) right-to-left shunt at the level of the fossa ovalis.
  
  
  CONCLUSIONS
  This study shows that incomplete myocardial distribution of cardioplegia, secondary to transient aortic valve incompetence or shunting through the foramen ovale, is not uncommon in patients undergoing coronary surgery.
authors.affiliation: Department of Cardiac Surgery, La Sapienza University of Rome, Italy.
authors.forename: P
authors.initials: P
authors.lastname: Voci
authors.forename: F
authors.initials: F
authors.lastname: Bilotta
authors.forename: Q
authors.initials: Q
authors.lastname: Caretta
authors.forename: F
authors.initials: F
authors.lastname: Chiarotti
authors.forename: C
authors.initials: C
authors.lastname: Mercanti
authors.forename: B
authors.initials: B
authors.lastname: Marino
mesh_terms: D002314:Cardioplegic Solutions / Q000008:administration & dosage*; D001026:Coronary Artery Bypass; D003327:Coronary Disease / Q000601:surgery*; D017548:Echocardiography, Transesophageal; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D016343:Monitoring, Intraoperative
chemical_list: D002314:Cardioplegic Solutions