Image-Guided Quantification of Cardioplegia Delivery during Cardiac Surgery
DOI:
https://doi.org/10.1532/HSF98.20071099Abstract
Background. Homogenous distribution of cardioplegia delivered to the myocardium has been identified as an important predictor of post-cardiopulmonary bypass ventricular recovery and function. Presently, a method to determine adequate distribution of cardioplegia in patients during cardiac surgery does not exist. The goal of this study was to evaluate the feasibility of quantifying cardioplegia delivery using a novel, noninvasive optical method. Such a system would permit instantaneous imaging of jeopardized myocardium and allow immediate, intraoperative corrective measures.
Methods. We have previously developed a portable, intraoperative near-infrared (NIR) fluorescence imaging system for use in large animal cardiac surgery that simultaneously displays color video and NIR fluorescent images of the surgical field. By introducing exogenous, NIR fluorophores, specific cardiac functions can be visualized in real-time.
Results. In a porcine cardiopulmonary bypass model, we demonstrate that the FDA-approved intravascular fluorophore indocyanine green (ICG) permits real-time assessment of cardioplegia delivery. ICG was injected into an aortic root and/or transatrial coronary sinus catheter during delivery of crystalloid cardioplegia solution. Segmental distribution was immediately noted at the time of injection. In a subset of animals, simulated coronary occlusions resulted in imaging defects consistent with poor cardioplegia delivery and jeopardized myocardium. Videodensitometric analysis was performed on-line to quantify distribution to the right ventricle and left ventricle.
Conclusions. We report the development of a novel, noninvasive, intraoperative technique that can easily and safely provide a visual assessment of cardioplegia delivery (antegrade and/or retrograde) and that offers the potential to quantify the relative segmental distribution during cardiac surgical procedures.
References
Aldea GS, Hou D, Fonger JD, Shemin RJ. 1994. Inhomogeneous and complementary antegrade and retrograde delivery of cardioplegic solution in the absence of coronary artery obstruction. J Thorac Cardiovasc Surg 107:499-504.nAronson S, Lee BK, Liddicoat JR, et al. 1991. Assessment of retrograde cardioplegia distribution using contrast echocardiography. Ann Thorac Surg 52:810-4.nBalacumaraswami L, Abu-Omar Y, Choudhary B, et al. 2005. A comparison of transit-time flowmetry and intraoperative fluorescence imaging for assessing coronary artery bypass graft patency. J Thorac Cardiovasc Surg 130:315-20.nDe Grand AM, Frangioni JV. 2003. An operational near-infrared fluorescence imaging system prototype for large animal surgery. Technol Cancer Res Treat 2:553-62.nDearani JA, Axford TC, Patel MA, et al. 2001. Role of myocardial temperature measurement in monitoring the adequacy of myocardial protection during cardiac surgery. Ann Thorac Surg 72:S2235-43; discussion S2243-4, S2267-2270.nGarski TR, Staller BJ, Hepner G, et al. 1978. Adverse reactions after administration of indocyanine green. JAMA 240:635.nHope-Ross M, Yannuzzi LA, Gragoudas ES, et al. 1994. Adverse reactions due to indocyanine green. Ophthalmology 101:529-33.nKhuri SF, Josa M, Marston W, et al. 1983. First report of intramyocardial pH in man. II. Assessment of adequacy of myocardial preservation. J Thorac Cardiovasc Surg 86:667-78.nKim S, Lim YT, Soltesz EG, et al. 2004. Near-infrared fluorescent type II quantum dots for sentinel lymph node mapping. Nat Biotechnol 22:93-7.nKumbhani DJ, Healey NA, Birjiniuk V, et al. 2004. Intraoperative regional myocardial acidosis predicts the need for inotropic support in cardiac surgery. Am J Surg 188:474-80.nMenasche P, Subayi JB, Veyssie L, et al. 1991. Efficacy of coronary sinus cardioplegia in patients with complete coronary artery occlusions. Ann Thorac Surg 151:418-23.nNakayama A, del Monte F, Hajjar RJ, Frangioni JV. 2002. Functional near-infrared fluorescence imaging for cardiac surgery and targeted gene therapy. Mol Imaging 1:365-77.nNtziachristos V, Bremer C, Weissleder R. 2003. Fluorescence imaging with near-infrared light: new technological advances that enable in vivo molecular imaging. Eur Radiol 13:195-208.nPartington MT, Acar C, Buckberg GD, Julia PL. 1989. Studies of retrograde cardioplegia. II. Advantages of antegrade/retrograde cardioplegia to optimize distribution in jeopardized myocardium. J Thorac Cardiovasc Surg 97:613-22.nSoltesz EG, Kim S, Laurence RG, et al. 2005. Intraoperative sentinel lymph node mapping of the lung using near-infrared fluorescent quantum dots. Ann Thorac Surg 79:269-77; discussion 269-77.nTakaba T, Inoue K. 2000. Past and present in myocardial protection. Ann Thorac Cardiovasc Surg 6:3-8.nTakahashi A, Chambers DJ, Braimbridge MV, Hearse DJ. 1988. Optimal myocardial protection during crystalloid cardioplegia. Interrelationship between volume and duration of infusion. J Thorac Cardiovasc Surg 96:730-40.nVogt PR, Bauer EP, Graves K. 2003. Novadaq Spy Intraoperative Imaging System—current status. Thorac Cardiovasc Surg 51:49-51.nWinkelmann J, Aronson S, Young CJ, et al. 1995. Retrograde-delivered cardioplegia is not distributed equally to the right ventricular free wall and septum. J Cardiothorac Vase Anesth 9:135-9.nZaroff J, Aronson S, Lee BK, et al. 1994. The relationship between immediate outcome after cardiac surgery, homogeneous cardioplegia delivery, and ejection fraction. Chest 106:38-45.n
