Selective Retrograde Venous Revascularization of the Myocardium when PCI or CABG Is Impossible: Investigation in a Porcine Model
AbstractWe investigated the possibility of nourishing the myocardium through selective retrograde coronary venous bypass grafting (CVBG) with an off-pump technique and evaluated various methods of monitoring the physiological effects of this procedure. In a porcine model, the left internal mammary artery (LIMA) was anastomosed to the left anterior descending coronary vein (LAD vein) in an off-pump procedure. The LAD vein was ligated proximal to the anastomosis. The LAD artery was ligated proximally. The physiological effects were monitored using microdialysis, tissue oxygen tension, blood flow in LIMA, blood samples, and hemodynamic and histological analyses. As controls, 5 pigs underwent surgery involving only LAD artery ligation without CVBG. CVBG with LAD ligation was performed in 16 pigs; 12 survived CVBG and were monitored for 2-2.5 hours while in sinus rhythm, a 75% salvage rate after an otherwise lethal LAD artery occlusion. Immediately after LAD artery ligation, the anterior wall of the left ventricle became cyanotic and hypokinetic. Over time it regained color and contractility as flow in the LIMA increased. Microdialysis showed a significant increase in lactate. Initially tissue oxygen tension decreased, but with time some recovery was seen. Cardiac troponin T was elevated. Histological analysis showed ischemic changes. In control pigs, microdialysis was performed for 1.5 hours up to LAD artery ligation, after which all pigs died in ventricular fibrillation arrest. No increase in lactate was observed. These results indicate that after LAD artery occlusion, CVBG can nourish the myocardium to a certain extent and prevent death in the majority of cases, although varying degrees of ischemia remain.
Almeda FQ, Parrillo JE, Klein LW. 2003. Alternative therapeutic strategies for patients with severe end-stage coronary artery disease not amenable to conventional revascularization. Catheter Cardiovasc Interv 60:57-66.nBeck CS. 1948. Revascularization of the heart. Ann Surg 128(4):854-64.nBhayana JN, Olsen DB, Byrne JP, Kolff WJ. 1974. Reversal of myocardial ischemia by arterialization of the coronary vein. J Thorac Cardiovasc Surg 67(l):125-32.nGardner RS, Magovern GJ, Park SB, Dixon CM. 1974. Arterialization of coronary veins in the treatment of myocardial ischemia. J Thorac Cardiovasc Surg 68(2): 273-82.nHochberg MS, Roberts WC, Morrow AG, Austen WG. 1979. Selective arterialization of the coronary venous system: encouraging long-term flow evaluation utilizing radioactive microspheres. J Thorac Cardiovasc Surg 77(1):1-12.nHochberg MS, Roberts AJ, Parsonnet V, Fisch D. 1986. Selective arterialization of coronary veins: clinical experience of 55 American heart surgeons. In: Mohl W, Faxon DP Wolner E, editors. Clinics of CSI. New York: Springer-Verlag; p. 195-201.nKulik A, Borger MA, Scully HE. 2004. Aortovenous bypass grafting to the posterior left ventricle in absence of an identifiable coronary artery. Ann Thorac Surg 78:313-4.nMantovani V, Kennergren C, Goiny M, et al. 2006. Microdialysis for myocardial metabolic surveillance: developing a clinical technique. Clin Physiol Funct Imaging 26:224-231.nMukherjee D, Bhatt DL, Roe MT, Patel V, Ellis SG. 1999. Direct myocardial revascularization and angiogenesis: how many patients might be eligible? Am J Cardiol 84:598-600.nPratt FH. 1898. The nutrition of the heart through the vessels of thebesius and the coronary veins. Am J Physiol 1:86-103.nSadaba JR, Nair UR. 2004. Selective arterialization of the coronary venous system. Ann Thorac Surg 78:1458-60.nWikström G, Ronquist G, Nilsson S, Maripu E, Waldenström A. 1995. Continuous monitoring of energy metabolites using microdialysis during myocardial ischaemia in the pig. Eur Heart J 16:339-47.n
How to Cite
Author Disclosure & Copyright Transfer Agreement
In order to publish the original work of another person(s), The Heart Surgery Forum® must receive an acknowledgment of the Author Agreement and Copyright Transfer Statement transferring to Forum Multimedia Publishing, L.L.C., a subsidiary of Carden Jennings Publishing Co., Ltd. the exclusive rights to print and distribute the author(s) work in all media forms. Failure to check Copyright Transfer agreement box below will delay publication of the manuscript.
A current form follows:
The author(s) hereby transfer(s), assign(s), or otherwise convey(s) all copyright ownership of the manuscript submitted to Forum Multimedia Publishing, LLC (Publisher). The copyright transfer covers the exclusive rights to reproduce and distribute the article and the material contained therein throughout the world in all languages and in all media of expression now known or later developed, including but not limited to reprints, photographic reproduction, microfilm, electronic data processing (including programming, storage, and transmission to other electronic data record(s), or any other reproductions of similar nature), and translations.
However, Publisher grants back to the author(s) the following:
- The right to make and distribute copies of all or part of this work for use of the author(s) in teaching;
- The right to use, after publication in The Heart Surgery Forum, all or part of the material from this work in a book by the author(s), or in a collection of work by the author(s);
- The royalty-free right to make copies of this work for internal distribution within the institution/company that employs the author(s) subject to the provisions below for a work-made-for-hire;
- The right to use figures and tables from this work, and up to 250 words of text, for any purpose;
- The right to make oral presentations of material from this work.
Publisher reserves the right to grant or refuse permission to third parties to republish all or part of the article or translations thereof. To republish, such third parties must obtain written permission from the Publisher. (This is in accordance with the Copyright Statute, United States Code, Title 17. Exception: If all authors were bona fide officers or employees of the U.S. Government at the time the paper was prepared, the work is a “work of the US Government” (prepared by an officer or employee of the US Government as part of official duties), and therefore is not subject to US copyright; such exception should be indicated on signature lines. If this work was prepared under US Government contract or grant, the US Government may reproduce, royalty-free, all or portions of this work and may authorize others to do so, for official US Government purposes only, if the US Government contract or grant so requires.
I have participated in the conception and design of this work and in the writing of the manuscript and take public responsibility for it. Neither this manuscript nor one with substantially similar content under my authorship has been published, has been submitted for publication elsewhere, or will be submitted for publication elsewhere while under consideration by The Heart Surgery Forum, except as described in an attachment. I have reviewed this manuscript (original version) and approve its submission. If I am listed above as corresponding author, I will provide all authors with information regarding this manuscript and will obtain their approval before submitting any revision. I attest to the validity, accuracy, and legitimacy of the content of the manuscript and understand that Publisher assumes no responsibility for the validity, accuracy, and legitimacy of its content. I warrant that this manuscript is original with me and that I have full power to make this Agreement. I warrant that it contains no matter that is libelous or otherwise unlawful or that invades individual privacy or infringes any copyright or other proprietary right. I agree to indemnify and hold Publisher harmless of and from any claim made against Publisher that relates to or arises out of the publication of the manuscript and agree that this indemnification shall include payment of all costs and expenses relating to the defense of any such claim, including all reasonable attorney’s fees.
I warrant that I have no financial interest in the drugs, devices, or procedures described in the manuscript (except as disclosed in the attached statement).
I state that the institutional Human Subjects Committee and/or the Ethics Committee approved the clinical protocol reported in this manuscript for the use of experimental techniques, drugs, or devices in human subjects and appropriate informed consent documents were utilized.
Furthermore, I state that any and all animals used for experimental purposes received humane care in USDA registered facilities in compliance with the “Principles of Laboratory Animal Care” formulated by the National Society for Medical Research and the “Guide for the Care and Use of Laboratory Animals” prepared by the Institute of Laboratory Animal Resources and published by the National Institutes of Health (NIH Publication No. 85-23, revised 1985).