The Safety of Simultaneous Arterial and Coronary Sinus Perfusion: Experimental Background and Initial Clinical Results

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. Experimental: Five mini-pigs (25 to 30 kg) underwent 1 hour of aortic clamping with simultaneous aortic and coronary sinus perfusion at 200 mUmin with normal blood (37°C) before and after 30 minutes of perfusion with either warm (37°C) or cold (4°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 arteriaVcoronary 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 replacementlrepair 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 implantationhepair in 123 patients, and warm continuous blood cardioplegia was used in 32 patients. Following a warm cardioplegic reperfusate, all patients received warm non-cardioplegic 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). Conclusion: 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. (J Card Surg 1994;9:15–25)     

Idiopathic fibrosing pancreatitis in a 3-year-old girl: a case report and review of the literature

Idiopathic fibrosing pancreatitis is a rare condition that affects children and adolescents. It can be the cause of recurrent abdominal pain and obstructive jaundice. There are 46 cases reported in the literature, including the first case reported by Comfort et al (Comfort MW, Gambill EE, Baggenstoss AH. Chronic Relapsing Pancreatitis. Gastroenterology 1946;6:239-285) in 1946. We report the case of a 3-year-old girl who presented with abdominal pain and obstructive jaundice. We performed a magnetic resonance cholangiopancreatography study as part of the workup of obstructive jaundice. We will review the literature on pediatric idiopathic fibrosing pancreatitis and highlight the use of endoscopic retrograde choledocho-pancreatography and magnetic resonance cholangiopancreatography in the investigation of this disease.     

Echocardiographic indices of the middle-aged and elderly

Echocardiographic parameters were examined in people between 50 and 79 years of age. They were shown to change with advancing age, the seventh decade of life being in this respect significantly different from the preceding and the following decades. This period is associated with moderate enlargement of the left-ventricular cavity and a reduction in myocardial contractility. Strong correlation has been demonstrated with systolic parameters, which may be an evidence that adequate operation of the heart at this age is mostly supported through systolic reserve.