Chapter category: Heart
Coronary Sinus Interventions During Surgical Treatment of Acute Myocardial
Coronary Sinus Intervention in Cardiac Surgery, Second Edition
Edited by: Werner MohlISBN: 1-58706-006-X
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Chapter authors:
Friedhelm Beyersdorf
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In many centers, coronary artery bypass grafting is currently considered during or soon after an acute myocardial infarction only after failed angioplasty. Emergency coronary artery bypass grafting (CABG) is associated with a higher mortality (6–12%) and an increased risk for developing perioperative myocardial infarction (21–71%) as compared to elective CABG.28,57,107 During recent years, new observations have been made on the pathophysiology of ischemic and remote myocardium15,16,22 that gave the impetus for the development for new operative strategies for patients with acute myocardial infarction and cardiogenic shock. These strategies include treatment of the ischemic myocardium during the initial reperfusion phase in order to reduce the damage that follows after reperfusion with normal blood at systemic pressure.6,17,22
This new concept of treating the ischemic tissue during the initial reperfusion phase is currently controversial. The attempt to control various components of the reperfusate and the conditions of reperfusion6,17,22 is based on the following observations: 1) The myocardial cell has an intact structure and function even after a prolonged period of ischemia (6 hours);14 2) immediate return of regional contractility after normal blood reperfusion in the beating working heart can not be achieved even after short ischemic periods;111 and 3) control of the initial reperfusion phase results in an immediate return of contractility after prolonged periods of acute coronary occlusion.6
These experimental studies on the beneficial effects of modifying the initial reperfusion phase have been confirmed by other groups, in terms of controlled reflow,44,87,96,105,117 controlled reperfusion temperature,74 reduced calcium reperfusion,77,90,100,104 addition of diltiazem,72 substrate enhancement,34,45,46 ventricular unloading,64 addition of oxygen free radical scavengers,32,42,79 electromechanical quiescence and initially reduced reperfusion pressure,31,40,59,58 and leukocyte depletion.25 Furthermore, confirmation of the superiority of our concept of controlling the conditions of reperfusion and the composition of the reperfusate is reported as well.26,66,110,112 The results of these experimental studies in the acute model are further supported by a recent report in a chronic dog model where it has been shown that after acute occlusion of the anterior descending coronary artery for 2 hours, controlled surgical reperfusion resulted in a significantly better systolic shortening and less myocardial necrosis immediately and after one week as compared to normal blood reperfusion or no reperfusion at all.26
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