- Retrograde cardioplegia is helpful in delivering protection that can't be administered reliably or conveniently in an antegrade fashion. - Severe coronary artery disease, with acute and chronic occlusions - Aortic insufficiency - As a baseline, or when the heart is lifted in such a way that it makes the aortic valve incompetent - When administration of antegrade cardioplegia is inconvenient as it requires you to stop what you are doing and put the heart in a position where antegrade can be given through the root or with hand-held ostial catheters. [^a] - Aortic valve (root is open) - Mitral valve (Heart is twisted around) - Prolonged case (Multiple components: Valve plus CABG, Valve plus Valve) - It is felt to be required in re-operative bypass grafting to flush out debris that may have been dislodged from old grafts - Pitfalls and limitations of Retrograde cardioplegia - A little extra time to insert - Coronary sinus injury - Not everybody has coronary sinus anatomy suitable for technique.[^b] - In order to reliably use the catheter and not have it dislodged with changes in heart position, it is usually positioned past the posterior great vein. Along with the nature of typical RV venous drainage, this means the RV is poorly protected with retrograde. - Topical slush should be strongly considered to further protect the right heart, particularly in the non-dominant right that can't be satisfyingly infused with a hand held catheter, and in the chronically occluded right.[^c] - In situations when it is required, and blind attempts to insert the retrograde catheter are unsuccessful, or when the right atrium is to be opened in the natural course of the procedure (tricuspid valve surgery, superior septal or trans-septal approach to mitral, biatrial maze, etc.), the opportunity exists for "Optimal Retrograde Cardioplegia". Create a pursestring with prolene immediately around the coronary sinus ostium, and insert the retrograde catheter without a stylet so that the balloon passes only just past the pursestring, then cinch the pursestring and secure the stylet to the grommet with silk. This allows the best possible protection of whatever myocardium drains into the sinus, and when necessary is an unobtrusive way of delivering continuous retrograde. - Our institutional preference is for a self-filling balloon, whose pressure therefore does not exceed that created distally to it by the infusion of cardioplegia, and is less likely to cause the 'burst' style of injury. - We also do not use the seperate monitoring line to track pressure, preferring to rely on direct back-pressure measurements from the circuit itself. The additional monitoring line clutters the field, and we will usually clip it and cut it when our inventory of our preferred catheter runs out, and we are forced to use a catheter that includes it. - All things considered, retrograde cardioplegia is only rarely required for routine CABG, but is used in almost every other kind of case requiring cardiac arrest. [^a]: Argument for Del Nido Cardioplegia [^b]: See [[2001 Anatomy of Coronary Sinus and Retrograde Cardioplegia copy.pdf]] [^c]: It bears repeating that ice slush should not be allowed to contact the left phrenic from within the pericardium.