Evaluation of 7,000+ patients with two different routes of cardioplegia

BACKGROUND: This study examined the efficacy and safety of retrograde cardioplegia in comparison with an antegrade/retrograde approach. METHODS: Between January 1, 1991, and December 31, 1995, 7,032 coronary artery bypass procedures, alone or in combination with valve replacement/repair, were performed using either retrograde cardioplegia (R) or an antegrade/retrograde (AR) approach. There were 4,224 patients in the R group and 2,808 in the AR group. These included elective, urgent, emergent/salvage, first operative, and redo cases. RESULTS: All preoperative, intraoperative, and postoperative variables listed in The Society of Thoracic Surgeons National Cardiac Surgery Database were used to compare the two groups using univariate analysis. The pump time was longer in the AR group, with fewer grafts per patient. The R group had higher predicted risk (3.2% versus 3.0%; p = 0.04), more postoperative atrial fibrillation (34% versus 31%; p = 0.006), and longer postoperative length of stay (8.8 versus 8.0 days; p < 0.001). Using The Society of Thoracic Surgeons National Cardiac Surgery Database predicted risk group model, a subgroup of 221 coronary artery bypass grafting patients in the retrograde (s-R) and 132 coronary artery bypass grafting patients in the antegrade/retrograde (s-AR) group fell into a greater incidence of predicted mortality group (> or = 10%). The s-R subgroup had more patients in New York Heart Association functional class IV. Univariate analysis revealed higher postoperative atrial fibrillation (51% versus 41%; p = 0.05) and longer postoperative length of stay (12.8 versus 10.8 days; p = 0.03) in the s-R subgroup versus the s-AR subgroup. CONCLUSIONS: The results appear to favor neither approach. Preoperatively, both retrograde groups (R and s-R) had higher preoperative predicted risk, but operative mortality or complications were not significantly increased when compared with the AR and s-AR groups. Retrograde cardioplegia alone was shown to be effective in the R and s-R groups, but atrial fibrillation developed in more patients, which could have contributed to longer length of stay in these groups. Antegrade/retrograde cardioplegia offers good immediate outcome but the delivery method can be cumbersome and confusing during the adjustments of flow clamps for antegrade/retrograde delivery and may contribute to prolonged pump times. From this retrospective, nonrandomized review, it appears that retrograde cardioplegia alone provides as good myocardial protection and safety as an antegrade/retrograde approach in either the low-risk or high-risk patient.