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The Effects of Cardioplegia on Coronary Pressure–Flow Velocity

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The Effects of Cardioplegia on Coronary Pressure–Flow Velocity European Journal of Cardio-thoracic Surgery 16 (1999) 324±330 www.elsevier.com/locate/ejcts The effects of cardioplegia on coronary pressure±¯ow velocity relationships during aortic valve replacement Xu Y. Jin, Derek G. Gibson, John R. Pepper* Downloaded from https://academic.oup.com/ejcts/article/16/3/324/479982 by guest on 29 September 2021 Departments of Cardiac Surgery and Cardiology, Royal Brompton Hospital, Sydney Street, London SW3 6NP, UK Received 21 December 1998; received in revised form 31 May 1999; accepted 7 June 1999 Abstract Objective: The acute physiological response of the coronary circulation to aortic valve replacement (AVR) has not been fully elucidated. This study aimed to characterize the changes in coronary perfusion pressure-¯ow velocity relationships, and to test whether this relationship is affected by cardioplegic method. Methods: Nineteen patients (mean age 67 ^ 12 (SD) years, 9 males) undergoing aortic valve replace- ment who received either cold blood cardioplegia (CBC, n 9) or warm blood cardioplegia (WBC, n 10), were prospectively studied before and 30 min after the operation, using transesophageal Doppler echocardiography combined with high ®delity left ventricular (LV) and aortic pressures. We thus determined: (1) Diastolic ¯ow velocities in proximal anterior descending coronary artery (LAD), and simultaneous aorta to LV pressure differences. (2) The slope (LAD proximal linear resistance) and pressure intercept (zero ¯ow pressure) of this relationship. (3) Overall LAD linear resistance as the ratio of mean diastolic ¯ow velocity to mean pressure difference between aorta and left ventricle. (4) LV myocardial stroke work. Results: Following operation, myocardial stroke work fell from 5.2 ^ 2.7 to 3.0 ^ 1.7, mJ cm23 (P 0:001), LAD mean diastolic ¯ow velocity increased from 47 ^ 19 to 74 ^ 21, cm s21 (P 0:0002). LAD overall linear resistance fell (0.75 ^ 0.24 vs. 1.26 ^ 0.26, mmHg cm21 s, P 0:001). LAD proximal linear resistance, however, remained unchanged (P 0:21), but the zero ¯ow pressure fell (18 ^ 12.6 vs. 27 ^ 12.2, mmHg above LV end diastolic pressure, P 0:013). With similar fall in myocardial work postoperatively, there was a greater fall in zero ¯ow pressure after WBC than CBC (48 ^ 28 vs. 19 ^ 13,% of pre-op, P 0:012), and a greater increase in ¯ow velocity time integral (127 ^ 81 vs. 53 ^ 59,%, P 0:039). Conclusion: Instantaneous diastolic LAD pressure-¯ow velocity relations in the early postoperative period can be explained more satisfactorily in terms of zero ¯ow pressure and proximal linear resistance than simple resistance alone. The fall in zero ¯ow pressure alone explains the increase in LAD ¯ow velocity immediately after aortic valve replacement. The extent of this fall is greater after warm rather than cold blood cardioplegia. q 1999 Elsevier Science B.V. All rights reserved. Keywords: Coronary pressure±¯ow velocity relationship; Aortic valve replacement; Cardioplegia; Doppler echocardiography 1. Introduction may play an important role in determining ¯ow and thus the acute response of coronary circulation during cardiac The acute response of the coronary circulation to cardio- surgery. pulmonary bypass has been extensively investigated [1±4]. In the clinical setting, ¯ow velocities in the proximal Coronary resistance, calculated as the simple ratio of perfu- coronary arteries can be reliably measured by transesopha- sion pressure to its ¯ow rate, has variably been found to rise geal echocardiography [8,9]. Changes in coronary ¯ow [2] or fall [3,4] immediately after cardiac surgery. These velocity pro®le several weeks after aortic valve replacement changes may be related to the diverse nature and extent of have been documented [10,11], but few studies have been coronary vascular injury by cardioplegia and reperfusion reported during the operation itself. We have previously [5]. The precise mechanisms underlying changes in coron- found that retrograde warm blood cardioplegia resulted in ary resistance remain incompletely understood. It is possible a less satisfactory protection of hypertrophic myocardium that the simple ratio of pressure to ¯ow may not adequately than cold blood cardioplegia [12]. However, it is not clear characterise coronary hemodynamics. Indeed, the existence whether the cardioplegia method also has an independent of a ®nite coronary zero ¯ow pressure [6,7], which is effect upon the coronary hemodynamic response. Taking assumed to be zero in the orthodox de®nition of resistance, advantage of the relative stability and accessibility of intra-operative conditions, we have combined measure- * Corresponding author. Tel./fax: 144-171-351-8530. ments of coronary artery ¯ow velocity with simultaneous E-mail address: [email protected] (J.R. Pepper) 1010-7940/99/$ - see front matter q 1999 Elsevier Science B.V. All rights reserved. PII: S1010-7940(99)00216-X X.Y. Jin et al. / European Journal of Cardio-thoracic Surgery 16 (1999) 324±330 325 Brompton Hospital. Written informed consent was obtained from all participants. There was no early mortality, morbid- ity, or side effects due to this study. Patients were studied under general anesthesia, main- tained with fentanyl (20 to 50 mgkg21), pancuronium oxide (0.1 mg kg21). A Swan-Ganz thermodilution balloon tip catheter was positioned with its tip in the pulmonary artery after induction of anesthesia and used for hemody- namic measurements. Cardiopulmonary bypass was routi- nely established using membrane oxygenator and roller pump, with hemodilution (hematocrit value 20-25%), and systemic hypothermia (288C nasopharyngeal temperature, when using cold blood cardioplegia, 9 patients), or with Downloaded from https://academic.oup.com/ejcts/article/16/3/324/479982 by guest on 29 September 2021 normothermia (378C), in 10 patients in whom continuous retrograde warm blood cardioplegia was given by a rando- mised approach which has been reported previously in detail [12]. 2.2. Protocols 2.2.1. Measurement of coronary blood ¯ow velocity A 5 MHz biplane transesophageal echocardiographic transducer (HP 21362C) interfaced with a Hewlett Packard 77025A Sonos 500 or 1500 Ultrasound System was posi- Fig. 1. Simultaneous recordings of electrocardiogram, ¯ow velocity of left tioned after induction of anesthesia. From the transesopha- anterior descending coronary artery, and high ®delity pressures in left geal horizontal view at aortic valve level, the proximal left ventricle and aortic root from a representative patient, with paper speed anterior descending coronary artery (LAD) was located on 21 of 100 mm s . (A) Before cardiopulmonary bypass; (B) immediately after the two dimensional colour ¯ow image. LAD blood ¯ow aortic valve replacement. Note that there was a signi®cant increase in velocity was recorded by 5 MHz pulsed Doppler with the coronary ¯ow velocity after the operation, particularly in mid and late diastole. sample volume (1 mm) placed at its proximal one third, i.e. 2±3 cm distal to the bifurcation of anterior descending and perfusion pressure and myocardial stroke work, derived circum¯ex arteries [8,9]. Records were made at a paper from aortic and left ventricular (LV) micromanometers speed 100 mm s21 with simultaneous electrocardiogram, and simultaneous LV echocardiogram. This approach LV pressure and aortic root pressure, before the onset of enabled us to incorporate the waterfall approach in assessing cardiopulmonary bypass in a stable hemodynamic state, the acute effects of aortic valve replacement on the coronary and repeated 30 min after the cardiopulmonary bypass had pressure-¯ow velocity relationship, and the possible in¯u- been weaned off, with the chest still open (Fig. 1). ence of cardioplegic methods. 2.2.2. Measurement of ascending aortic and LV pressures 2. Methods Once the pericardium had been opened, a 4 F catheter tip pressure transducer (Gaeltec CTC/4F/USCI, Gaeltec Ltd, 2.1. Subjects Isle of Skye, UK) was introduced into the left ventricle with its tip located in the mid-portion of the cavity via the We studied 19 patients undergoing elective isolated aortic roof of the left atrium and across the mitral valve [12,14]. valve replacement for predominant valvular aortic stenosis Another similar 4 F catheter was introduced directly into the (16 patients) or regurgitation (3 patients), with a mean age ascending aorta with its tip at coronary ostial level as 67 ^ 12 (mean ^ SD) years; 9 patients were male. LV mass con®rmed on the echo image. Both signal outputs were index was 195 ^ 45g m22 measured by M-mode echocar- ®ltered with an upper cutoff frequency of 1 kHz, pre-ampli- diography using standard criteria [13]. Patients with clini- ®ed (Gaeltec S7b, Gaeltec Ltd), and transferred to two cally signi®cant coronary artery disease ( . 50% of stenosis auxiliary lines of the echocardiograph. The pressure trans- in diameter) at prior coronary angiography, or in whom ducer tipped catheters were calibrated electrically before the echocardiographic recordings were inadequate for analysis initial measurement at the same zero level. Zero pressure were not included. This study is a part of a clinical research was taken as atmospheric. The pulmonary artery wedge project approved by the Ethics Committee of the Royal pressure was used to identify the LV end-diastolic pressure. 326 X.Y. Jin et al. / European Journal of Cardio-thoracic Surgery 16 (1999) 324±330 city were determined by digitising the simultaneous M- modes of the left ventricle to derive cavity dimension and anterior wall thickness
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