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This video demonstrates an alternative approach to positioning the retrograde cardioplegia catheter during coronary artery bypass grafting for three-vessel coronary disease involving the left anterior descending artery (LAD), obtuse marginal artery one (OM1), and obtuse marginal artery two (OM2). The operation began in the standard fashion with endoscopic harvest of the left radial artery and left great saphenous vein, followed by pedicled left internal mammary artery (LIMA) harvest. After systemic heparinization and cannulation, antegrade and retrograde cardioplegia catheters were placed—antegrade in the proximal ascending aorta and retrograde through the right atrium. 
 
In this demonstration, the retrograde catheter was inserted superior-lateral to the right atrial appendage, remaining above the venous cannula. This trajectory allowed direct engagement of the coronary sinus. Once the catheter was positioned, the purse-string suture was secured, and retrograde cardioplegia was successfully delivered after confirmation of the expected pressure change. 
 
Positioning the retrograde catheter superior to the venous cannula prevented compression or distortion of the coronary sinus ostium by the venous drain. This prevented poor balloon seating, difficulty advancing the catheter, inadequate cardioplegia delivery, and potential coronary sinus injury. Overall, this technique provided more reliable access to the coronary sinus and helped ensure consistent myocardial protection. 

References

1. Avoidance of Coronary Sinus Injury During Retrograde Cardioplegia. Orihashi, Kazumasa et al.The Annals of Thoracic Surgery, Volume 102, Issue 6, e583 – e586.
2. Daggett, W. M., Randolph, J. D., Jacobs, M., O'Keefe, D. D., Geffin, G. A., Swinski, L. A., Boggs, B. R., & Austen, W. G. (1987). The Superiority of Cold Oxygenated Dilute Blood Cardioplegia. Annals of Thoracic Surgery, 43(4), 397-402. https://doi.org/10.1016/S0003-4975(10)62813-5
3. Derryberry S, Tribble C. In Through the Out Door: Tips and Tricks for Giving Retrograde Cardioplegia. Heart Surg Forum. 2018 Jul 26;21(4):E311-E317. doi: 10.1532/hsf.2063. PMID: 30084786.
4. Orihashi K., et al., “Avoidance of coronary sinus injury during retrograde cardioplegia,” The Annals of Thoracic Surgery, 2016; 101(4): 1426-1430

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