RETROGRADE CARDIOPLEGIA.pptx112233444455

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1. RETROGRADE CARDIOPLEGIA Presented by: MOHIT BANGAR ( 3 rd year ) Presented to: DR. UJJWAL K. CHOWDHARY

2. HISTORY OF RETROGRADE CARDIOPLEGIA EARLY DEVELOPMENTS: 1950s-1960s: cardioplegia emerged as a method to protect the heart during surgery. Early techniques primarily focused on antegrade delivery through the coronary arteries. 1970s: the concept of retrograde cardioplegia began to take shape. The rationale was to provide an alternative route for delivering cardioplegia, particularly in cases where coronary artery disease or aortic valve disease might impede effective antegrade delivery Dr. Gerald Buck berg and colleagues significantly advanced the technique. They demonstrated that retrograde cardioplegia could provide uniform myocardial protection, particularly in patients with coronary artery obstructions. 1980s-1990s: the technique gained widespread acceptance as surgeons recognized its benefits, especially in patients those undergoing repeat surgeries.

3. Retrograde delivery Retrograde cardioplegia is a technique used in cardiac surgery to deliver a cardioplegic solution. Allowing the solution to flow backward through the coronary veins to perfuse the myocardium. This method induce cardiac arrest and provides myocardial protection by delivery the solution in opposite direction of normal flow, ensuring uniform distribution and protection of heart muscles, especially in areas that may not be adequately reached by antegrade cardioplegia. Used for valve surgery when aorta is opened and antegrade isn’t possible. Blood travels into coronary sinus and comes out of the coronary ostia in aortic root.

4. TECHNIQUE USED.. The process involves placing a catheter in coronary sinus, through which the cardioplegic solution is infused. The solution then flows retrograde through coronary veins and into the myocardium. Coronary arteries myocardium Coronary veins Coronary sinus RETROGRADE ANTEGRADE

5. PRESSURE OF RETROGRADE Retrograde pressure: 25 – 40mmHg Keep coronary sinus pressures mid 30mmHg as low pressures may compromise cardioplegia distribution, while too high pressures may rupture the coronary sinus.

6. FLOW RATE OF RETROGRADE Flow rate: 150 – 200ml/min Conditions that influence the flow of cardioplegia delivery: LOW FLOW (below therapeutics dose): Overinflated balloon Too deep insertion of cannula into coronary sinus Rotation of heart 2. HIGH FLOW (above therapeutic dose) Inadequate cardioplegia distribution Leakage of blood around inadequately filled balloon Ruptured coronary sinus

7. TEMPERATURE The temperature of retrograde cardioplegia is typically maintained between 4-10 degree Celsius . this hypothermic solution helps to reduce the metabolic demands of heart muscle providing myocardial protection during surgery by slowing cellular activity and minimizing damage. cardioplegia temperature is controlled with a dual cooler/heater unit. The cooler portion of the unit is set at 4 C for cold cardioplegia delivery.

8. Advantages of retrograde Improved myocardial protection. Enhanced myocardial preservation. Better distribution of cardioplegia. Reduce oxygen demand. Flushing of air and debris. Provide continuous cardioplegia.

9. Pitfalls of retrograde Inadequate RV protection. Catheter placement can be difficult. Risk of coronary sinus injury. Inadequate perfusion. Potential for back pressure issues. May lead to coronary sinus rupture or backflow into systemic circulation.

10. indications Retrograde cardioplegia is indicated in several specific scenarios: Diffuse coronary artery disease (when there is widespread coronary artery disease that might impair the effectiveness of antegrade) Inadequate antegrade cardioplegia(if not possible due to poor coronary perfusion then retrograde serve as alternative) Complex cardiac anatomy ( during blockage or complex anatomy of coronary arteries) Reoperative surgery During urgent or emergency surgeries where rapid myocardial protection is needed.

11. How retrograde is better than antegrade cardioplegia Better Perfusion of Ischemic Areas: Retrograde cardioplegia is delivered via the coronary sinus into the coronary veins, which can provide better perfusion to areas of the myocardium that may be poorly perfused or blocked during antegrade delivery, particularly in cases of severe coronary artery disease. Effective in Aortic Insufficiency: In patients with aortic valve insufficiency, antegrade cardioplegia may not be effective because the solution can leak back into the left ventricle. Retrograde cardioplegia bypasses the aortic valve, making it more effective in such cases. Homogeneous Distribution: Retrograde delivery can provide a more homogeneous distribution of the cardioplegic solution, especially in the presence of coronary artery obstructions, ensuring better myocardial protection. Better Protection in Hypertrophied Hearts: Hypertrophied hearts, often seen in patients with chronic hypertension or aortic stenosis, may benefit more from retrograde cardioplegia as it ensures adequate delivery of the cardioplegic solution throughout the thickened myocardium. Reduced Risk of Embolization: Retrograde delivery reduces the risk of coronary artery embolization compared to antegrade delivery, where debris or air can be introduced into the coronary arteries.

12. Conti…. Clinical Scenarios Favoring Retrograde Cardioplegia Severe Coronary Artery Disease: When coronary obstructions are significant, retrograde cardioplegia can ensure adequate myocardial protection. Aortic Valve Insufficiency: As mentioned, retrograde delivery is more effective when the aortic valve is insufficient. Previous CABG (Coronary Artery Bypass Grafting): Patients with previous bypass grafts may benefit from retrograde cardioplegia to ensure all areas of the myocardium receive adequate protection. Hypertrophic Cardiomyopathy: The thickened myocardium in hypertrophic cardiomyopathy requires effective perfusion, which retrograde cardioplegia can provide. Emergency Situations: In certain urgent cases where rapid myocardial protection is needed, retrograde cardioplegia may be more quickly and effectively administered.

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