Table Of ContentThe Coronary Sinus
Printing of the proceedings of the
First International Symposium on
Myocardial Protection via the
Coronary Sinus held in Vienna,
February 27th-29th, 1984,
is supported in part by grants from
Abbott Laboratories and ~llJedl·tech.
Incorporated.
The Coronary Sinus
Proceedings of the
1st International Symposium on Myocardial
Protection via the Coronary Sinus
Edited by W. Mohl, E. Wolner, D. Glogar
With Contributions by M. Abbate, H. Abe, A. Aigner, C. S. Apstein, G. Arnold, W. G. Austen,
J. Batanero, G. Battaglia, R. Bauer, A. Benassi, A. Berdeaux, J. Berland, W. Bircks, W. H. Bleifeld,
A. Bodefeld, J.P. Bourdarias, M. J. Buckley, G. Bulkey, M. Bulves, L. Carli, A. Carpentier, A. Casale,
N. Casinello, R. C. J. Chiu, A. A. Ciuffo, W. D. Coats, E. Corday, A. Cribier, H. F. Cuenoud,
J. E. Dalen, M.A. D'Ambra, J. K. Drury, J. Fabian, J. N. Fabiani, J. C. Farcot, D.P. Faxon,
M. C. Fishbein, M. Fuentes, E. Gallasch, J. Garcia, I. Gielchinsky, J. F. Giudicelli, D. Glogar,
J. M. Gore, M. Goto, S. B. Gottsman, C. Groschopp, A. D. Guerci, S. R. Gundry, R. V. Haendchen,
S. Hag!, H. Halperin, C. W. Hamm, W. Heimisch, C. F. M. Heintzberger, G. Hellige, 0. Hiramatsu,
M. M. Hirsh, M. Hochberg, A. Hoeft, H. M. Hoffmeister, M. Hori, D. H. Hunneman, S.M. Hussain,
M. Inoue, A. K. Jacobs, A. Juhasz-Nagy, M. Kagiyama, F. Kaindl, F. Kajiya, M. Kaminski,
H. S. Karagueuzian, M.A. Kellett, T. Kenner, F. Kind!, W. Klepetko, G. S. Kobinia, K. Kodama,
W. J. Kolff, H. Korb, Y. Koretsune, U. Kreimeier, H.-L. Kronholz, B. Krug, K. Kucharsky,
W. Kupper, A. Lametschwandtner, P. J. LaRaia, I. Lengyel, B. Letac, D. Levantesi, M. J. Levesque,
A. Lomeo, M. von Ludinghausen, A. Lunkenheimer, P. P. Lunkenheimer, G. Luppi, W. J. Mandel,
P.R. Maroko, J. A. Martinez, M. Marzilli, G. Mattioli, G. Maurer, M. Mauser, S.M. McSweeney,
H. Mayr, S. Meerbaum, N. Mendler, J. Merker, M. Mishima, K. Mito, M.G. Modena, W. Mohl,
J. J. Moll, J. W. Moll, E. Moravcsik, A. Moritz, M. Moser, M. M. Muller, M. Naka, M. Nakai,
S. Nanto, R. M. Nerem, J. C. Norman, Y. Ogasawara, M. Ohta, A. Papiewski, L. Papp, V. Parsonnet,
L. Patane, T. Peter, M. B. Peterson, K. Podzuweit, U. Pott, C. J. Preusse, C. Punzengruber,
G. Raberger, R. Rabinovits, E. Ratajczyk-Pakalska, J. Reiland, D. Robles, A. J. Roberts, T. J. Ryan,
H. N. Sabbah, H. Schad, J. Schaper, W. Schaper, P. Schindler, G. Schopf, H. D. Schulte, J. Schuster,
J. Schutz, R. Seitelberger, K. Sloan, K. A. Spector, P. D. Stein, Z. Szabo, S. Tadaoka, J. Tarnai,
K. Taniura, W. Timischl, G. Tomonaga, M. Torres, M. Tschabitscher, K. Tsujioka, Y. Wada,
J. Wagiel, P. J. Walter, W. D. Watkins, B. H. Weiner, M. L. Weisfeldt, L. Wetstein, T. Wiesner,
M. Winkler,J. Winter, R. E. Winters, E. Wolner, H. G. Wolpers, S. Yamazaki, R. G. Zennaro,
M. C. Zwolinski
Springer-Verlag
Berlin Heidelberg GmbH
W. Mohl, M.D. E. Wolner, M.D. D. H. Glogar, M.D.
2nd Surgical Clinic 2nd Surgical Clinic Kardiologische
U niversity of Vienna University ofVienna U niversitătsklinik
Spitalgasse 23 Spitalgasse 23 Garnisongasse 13
1090 Vienna, Austria 1090 Vienna, Austria 1090 Vienna, Austria
CIP-Kurztitelaufnahme der Deutschen Bibliothek
The coronary sinus: proceedings of the Ist. Internat. Symposium on Myocardial Protection via the
Coronary Sinus / ed. by W. Moh1 ... With contributions by M. Abbate ...
ISBN 978-3-642-54129-2 ISBN 978-3-642-54127-8 (eBook)
DOI 10.1007/978-3-642-54127-8
NE: Mohl, Werner [Hrsg.]; Abbate, M. [Mitverf.]; International Symposium on Myocardial Protec
tion via the Coronary Sinus <01, 1984, Wien>
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Copyright © 1984 by Springer-Verlag Berlin Heidelberg
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Softcover reprint of the hardcover lst edition 1984
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Preface
The most common cause of death in the civilized countries remains coronary heart dis
ease, a multifactorial illness which might be best treatable by prophylactic means. In spite
of improvements in diagnosis, drug therapy, monitoring, and particularly surgery morbi
dity and mortality of our patients oblige us to look for new frontiers in understanding the
pathophysiology of the disease and for new approaches in the treatment of myocardial
dysfunction, the limiting factor in the activity of patients surviving an acute myocardial
infarction. Salvage of viable myocardium still seems to be the most important challenge
in the treatment of acute ischemia. Lysis therapy to reopen occluded coronary arteries
seems to be promising in a great number of patients. However, several experimental re
ports of reperfusion injury and clinical series with a considerable number of patients, who
do not benefit from this intervention, need alternatives to reassess myocardial structure
and function. The necessity to find solutions to this problem coincides with the develop
ment of an alternate access route to deprived coronary vasculature. Starting with the
ideas and results gathered in the last 60 years, Meerbaum and Corday in Los Angeles and
our group here in Vienna developed two different approaches to myocardial protection
via the coronary sinus. After completing experimental evaluation and preliminary human
trials it is now time to draw the attention of the scientific community, as well as the prac
tising cardiologist and cardiovascular surgeon, to interventions such as synchronized ret
roperfusion or pressure controlled intermittent coronary sinus occlusion and retrograde
cardioplegia delivery during open heart surgery. This volume will present the proceedings
of the I st International Symposium of Myocardial Protection via the Coronary Sinus
held in Vienna, February 27 till29, 1984. The motivation to call for this convention was
to bring this rapidly developing subject to experts of related areas to guarantee a multidis
ciplinary evaluation of new therapeutic interventions. Since our knowledge of the basics
of the coronary venous system has to be developed we included the experience of anato
mists, physiologists, and even bioengineers for a synthesis of the available background in
formation. It is the aim of this book to identify what is known about the coronary venous
system, what is controversial, what we think about interventions such as retroperfusion
or intermittent coronary sinus occlusion, and which areas merit further study. The clini
cal entity of Beck's procedure particularly intrigued me, and eventually led me back to
the animal laboratory and the development of pressure controlled intermittent coronary
sinus occlusion. Therefore this book is dedicated to those who find special interest in pro
posed ideas and fulfill speculations so that research interests with many nuances become
formidable tasks and finally add to the puzzle of understanding the pathophysiology of
the heart.
Vienna, May 15, 1984 W. Mohl
v
Contents
Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . V
Part A: Coronary Sinus: Fundamentals
Anatomy
Nomenclature: Venae cardiacae-cardiac veins
Liidinghausen M von, Ratajczyk-Pakalska E, Tschabitscher M, Maurer G,
Glogar D, Mohl W .........................· ............................... .
Anatomy of the Coronary Arteries and Veins
Liidinghausen M von . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Anatomy of Coronary Veins
Tschabitscher M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
The Microcirculatory Vascular Bed of the Dog's Heart. A Scanning Electron
Microscopy Study of Vascular Corrosion Casts
Lametschwandtner A, Mohl W . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Automated Image Analysis for Measurement of Area of the Smallest Cardiac Veins
in Ventricular Myocardium
Ratajczyk-Pakalska E, Wagiel J, Kaminski M, KolffWJ . . . . . . . . . . . . . . . . . . . . . . . . . 33
Anatomical Basis for the Coronary Venous Outflow
Ratajczyk-Pakalska E, KolffWJ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
The Vascularization Pattern in the Ventricular Wall in Different Species During
Development
Heintz berger ChFM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 7
Functional Anatomy of the Coronary Sinusoids
Lunkenheimer A, Merker J, Lunkenheimer PP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
Dynamics of the Coronary Circulation
Wave Reflection and Pressure Flow Relations in the Coronary Circulation
Kenner T, Moser M, Mohl W . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
Fluid Dynamics in Proximal and Distal Coronary Artery Measured by Laser
Doppler Velocimeter
Kajiya F, Tsujioka K, Tomonaga G, Ogasawara Y, Tadaoka S, Goto M, Wada Y,
Kagiyama M, Mito K . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
Dynamic Characteristics of Diastolic Pressure - Flow Relation in the Canine
Coronary Artery
Tomonaga G, Tsujioka K, Ogasawara Y, Nakai M, Mito K, Hiramatsu 0, Kajiya F 79
VI
Coronary Fluid Dynamics
Nerem RM, Levesque MJ, Rabinovitz R, Wiesner T . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86
Determinants of Cardiac Pump Efficiency. Comparison of a Theoretical Model with
Experimental Data of Normo-and Hypothermic Dogs
Hoeft A, Korb H, Wolpers HG, Hellige G . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92
Origin of Phasic Coronary Venous Flow and the Capacitance of Intramyocardial
Coronary Vein
Tsujioka K, Tornonaga G, Ogasawara Y, Nakai M, Tadaoka S, Goto M, Kajiya F .. 100
Determination of Myocardial Blood Flow with Transcoronary Dye Dilution
Hoeft A, Korb H, Wolpers HG, Hellige G . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106
lntramyocardial Pressure Dynamics
Diastolic Distribution oflntramural Pressure in the Canine Left Ventricle
Marzilli M, Sabbah HN, Levantesi D, Stein PD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113
Is lntramyocardial Pressure Measurable?
Kreirneier U . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118
Cardiodynamics Governed by Intramyocardial Hydraulics
Lunkenheirner A, Lunkenheirner PP, Kronholz HL, Schutz J . . . . . . . . . . . . . . . . . . . . 125
Pathophysiology of Ischemia and Reperfusion
Purine Metabolism of the Heart
Muller MM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134
Sustained Anaerobic Metabolism After Recanalization of Coronary Artery in Acute
Myocardial Infarction
Nanto S, Kodama K, Naka M, Taniura K, Tarnai J, Koretsune Y, Hori M, Inoue M . 142
Failure of Postischemic ATP Repletion by Adenosine to Improve Regional
Myocardial Function
Hoffmeister HM, Mauser M, Schaper W . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148
Metabolic Changes of Glucose, Lactate and Free Fatty Acids During Ischemia and
Subsequent Reperfusion
Korb H, Hoeft A, Hunnernan DH, Wolpers HG, Hellige G . . . . . . . . . . . . . . . . . . . . . . . 153
Oxygen-Debt and -Repayment in the Early Phase of Myocardial Ischemia
Korb H, Hoeft A, Wolpers HG, Hellige G . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160
Penetration of Coronary Venous Injections into Ischemic Myocardium
Maurer G, Punzengruber C, Haendchen RV, Torres MAR, Meerbaurn S, Corday E . 16 7
The Evaluation of Collateral Function by Contrast Medium-Induced Hyperemia
Koretsune Y, Hori M, Inoue M, Kodama K, Nanto S, Mishirna M, Abe H . . . . . . . . . 176
Quantitative Assessment of Collateral Flow in Patients with Ischemic Heart Disease
Kupper W, Harnrn CW, Bleifeld WH......................................... 182
VII
Left Main Coronary Artery Stenosis: Evaluation by Coronary Sinus Blood Flow,
Lactate Metabolism and Holter Monitoring
Hamm CW, Kupper W, Bleifeld W . . . .. .. . . . . . . . . . .. .. . . . .. .. .. . . . . . . . . . .. .. . 188
Myocardial Protection, Complex Laboratory Examinations and their Computerized
Evaluation
Lengyel I, Szabo Z . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 194
Acute Myocardial Ischemic Reduction with Ibuprofen in the Isolated Perfused
Rabbit Heart
Wetstein L . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 202
Effect of Dipyridamole on Coronary Flow; A Thermodilution Study of the Coronary
Reserve
Berland J, Cribier A, Letac B .. .. .. . . . . . . . .. .. .. .. .. .. . .. . . . .. .. .. .. . . . . . . . . . 212
Coronary Blood Flow Modifications After Administration of Captopril
Mattioli G, Zennaro G, Benassi A, Modena MG, Luppi G . . . . . . . . . . . . . . . . . . . . . . . 221
Cold Pressor Test, Incremental Cardiac Pacing, Coronary Hemodynamics and
Coronary Sinus Blood Rheology in Patients with Angina Pectoris and Normal
Coronary Angiogram
Fabian J, Bulvas M . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 227
Pathophysiology of Venous and Lymph Obstruction
Hemodynamic Pattern of Cardiodepression Elicitable from Reflexogenic Areas in
Left Coronary Venous System of the Dog
Juhasz-Nagy A, SzabO Z . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 231
Present Knowledge of the Effects of Experimental Cardiac Lymphatic Obstruction
Schad H .................................................................. 239
Part B: Myocardial Protection via the Coronary Sinus
Delivery of Cardioplegic Solution
An Overview of Myocardial Protection in Open-heart Surgery
Roberts AJ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 7
Cardiac Prostacyclin Metabolism During Canine Cardiopulmonary Bypass
Kobinia GS, LaRaia PJ, D'Ambra MA, Peterson MB, Watkins WD, Buckley MJ,
Austen WG . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 259
Thermographic Evaluation of Retrograde Cardioplegia: Experimental and Clinical
Studies
Moravcsik E, Papp L, Lengyel I, SzabO Z . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 266
Myocardial Compliance Following Retrograde Versus Antegrade Cardioplegia in the
Presence of Coronary Artery Obstmction
Gundry SR, Kirsh MM ..................................................... 270
VIII
Cold Cardioplegia via Retrograde Coronary Sinus Infusion for Myocardial
Protection
Chiu RCJ................................................................. 275
Metabolic and Ultrastructural Changes in the Ischemic Human Myocardium due to
Additional Perfusion of the Coronary Sinus with "Bretschneider Cardioplegic
Solution"
Walter PJ, Kindl F, Podzuweit K, Schaper J . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 284
Myocardial Equilibration Aspects of Ante-and Retrograde Crystalloid Cardioplegic
Perfusion
Preusse CJ, Winter J, Krug B, Schulte HD, Arnold G, Bircks W ................. 291
Coronary Venous Blood Parameters During Postischemic Reperfusion After Mitral
Valve Replacement
Schulte HD, Preusse CJ, Bodefeld A, Groschopp C, Pott U ..................... 297
Myocardial Protection via the Coronary Sinus in Cardiac Surgery: Comparative
Evaluation of Two Techniques
Fabiani JN, Reiland J, Carpentier A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 305
Myocardial Protection: Antegrade versus Retrograde Cardioplegia, a Clinical
Trial on 145 Patients
Lomeo A, Battaglia G, Carli L, Patane L, Abbate M . . . . . . . . . . . . . . . . . . . . . . . . . . . 312
Cardioplegia via the Coronary Sinus. Our Experience in 331 Cases
Fuentes M, Batanero J, Robles D, Martinez JA, Garcia J, Casinello N............ 316
Retroperfusion Modalities
The Beck Era: A Springboard for Renewed Research of Coronary Venous
Retroperfusion Aimed at Treatment of Myocardial Ischemia
Meerbaum S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 320
a) Selective Arterialization of Coronary Veins
Arterialization of the Left Anterior Descending Coronary Vein in Dogs:
Successful Long-Term Flow Evaluation
Hochberg MS, Gielchinsky I, Parsonnet V, Hussain SM, Norman JC . . . . . . . . . . . . . 328
Selective Arterialization of the Coronary Venous System Under Low Pressure
Moll JJ, Moll JW, Zwolinski MC, Kucharski K, Papiewski A, Maroko PR . . . . . . . . 336
b) Synchronized Retroperfusion
Fundamental Consideration of Synchronized Coronary Venous Retroperfusion:
an Alternate Vascular Channel for Protection of Jeopardized Ischemic Myocardium
Corday E, Meerbaum S, Drury JK . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 343
Synchronized Coronary Venous Retroperfusion: A Safe and Effective Treatment of
Acute Myocardial Ischemia
Drury JK, Yamazaki S, Meerbaum S, Fishbein M, Corday E . . . . . . . . . . . . . . . . . . . . 347
IX
