Is Warm Retrograde Blood Cardioplegia Better Than Cold for Myocardial Protection? (original) (raw)
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Long-term effects of cold cardioplegic myocardial protection in the rat
The Journal of Thoracic and Cardiovascular Surgery, 1984
Long-term effects of cold cardioplegic myocardial protection in the rat The long-term histologiceffects of the me of two cold cardioplegic solutiolti(St. Thomas' and saline) were studied and compared in a model of heterotopic cardiac tr'aItipiantation in rats of isogeneic strain. After cold cardioplegic arrest, hearts were stored for varyingtimes ("minimal," 30, or 90 minutes) in one of the solutionprior to tr'aItipiantation, giving a total of six groups (five animals in each group). Early assessment of myocardial injury 48 hours after tr'aItipiantationwas by the uptake of technetium99m pyrophosphate and by measurementof serum creatine kinase activity. Late assessment of myocardial injury at 3 months after tr'aItipiantationwas by quantitative histologic examination. The findings indicated that significant myocardialfibrosis occurred in hearts stored in both solutiOiti for the longest storage period (90 minutes) and that St. Thomas' cardioplegic formula conferred better myocardial protection after 90 minutes' storage than did cold saline, as judged by the degree of histologic injury at 3 months (p < 0.025). Significant correlation was found between long-term histologic changes at 3 months and the uptake of technetium 99m pyrophosphate (p < 0.001) and serum creatine kinase activity (p < 0.05) assessed at 48 hours. Uptake of technetium 99m pyrophosphate and increased serum creatine kinase activity was demoItitrated 48 hours after injury in animals having no detectable histologic injury at 3 months. These observatiOiti indicate that there may be technetium 99m pyrophosphateuptake and enzyme release from reversibly damaged myocardial cells.
European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery, 2016
Potassium-based depolarizing St Thomas' Hospital cardioplegic solution No 2 administered as intermittent, oxygenated blood is considered as a gold standard for myocardial protection during cardiac surgery. However, the alternative concept of polarizing arrest may have beneficial protective effects. We hypothesize that polarized arrest with esmolol/adenosine/magnesium (St Thomas' Hospital Polarizing cardioplegic solution) in cold, intermittent oxygenated blood offers comparable myocardial protection in a clinically relevant animal model. Twenty anaesthetized young pigs, 42 ± 2 (standard deviation) kg on standardized tepid cardiopulmonary bypass (CPB) were randomized (10 per group) to depolarizing or polarizing cardiac arrest for 60 min with cardioplegia administered in the aortic root every 20 min as freshly mixed cold, intermittent, oxygenated blood. Global and local baseline and postoperative cardiac function 60, 120 and 180 min after myocardial reperfusion was evaluated wi...
Oxygen requirements of the isolated rat heart during hypothermic cardioplegia
The Journal of Thoracic and Cardiovascular Surgery, 1988
Oxygen requirements of the isolated rat heart during hypothermic cardioplegia Effect of oxygenation on metabolic and functional recovery after five hours of arrest Previous studies from this laboratory demonstrated that the use of an oxygenated cardioplegic solution in the hypothermic arrested rat heart resulted in improved preservation of high-energy phosphate stores (adenosine triphosphate and creatine phosphate), mechanical recovery during reperfusion, and preservation of myocardial ultrastructure. In the current study the effect of cardioplegic solutions oxygenated with 30 %, 60 %, and 95 % oxygen was evaluated in the isolated rat heart with reference to the maintenance of adenosine triphosphate, creatine phosphate, oxygen consumption, functional recovery, and mitochondrial oxidative phosphorylation in vitro. Results indicate that the hearts receiving cardioplegic solutions supplemented with 95 % oxygen and 5 % carbon dioxide maintained adenosine triphosphate and creatine phosphate at control values for at least 5 hours. The oxygen consumption during elective cardiac arrest, mechanical performance during reperfusion, and in vitro mitochondrial oxygen uptake and phosphorylation rate were highest in the hearts receiving cardioplegic solutions supplemented with 95 % oxygen when compared to solutions with 30 % and 60 % oxygen. Addition of glucose and insulin to the cardioplegic solution (95 % oxygen) increased the adenosine triphosphate levels but failed to improve function after reperfusion. Although myocardial adenosine triphosphate and creatine phosphate were well preserved by the oxygenated cardioplegic solution, there was a discrepancy between the adenosine triphosphate levels at the end of the arrest period, which represents the potential for mechanical function, and the actual function of the hearts after 5 hours.
Performance of pig heart after 30 or 120 minutes hypothermic arrest
Journal of Surgical Research, 1983
The effect of the duration of hypothermic (T = 1S'C) potassium cardioplegic arrest and &hernia on the heart was determined by measuring the response of the isolated in situ pig heart to 180 min of perfusion (n = 12) to provide appropriate control values for the study of 30 (n = 25) or 120 (n = 27) min of ischemia, followed by 60 min of reperfusion. In some of these animals, myocardial tissue samples were obtained for measurement of adenosine triphosphate (ATP) and creatine phosphate (CP), (6 in the perfusion group, 7 in the 30 min of ischemia and 60 min of reperfusion group and 15 in the I20 min of ischemia and 60 min of reperfusion group). In the remaining animals, measurements of either left ventricular performance (LVP), myocardial oxygen metabolism (MVOs) or plasma creatine kinase (CK) were obtained (6 in the prolonged perfusion group, 12 in the 120 min of &hernia and 60 min of reperfusion group, [6 LVP and MVO, and 6 CK] and 18 in the 30 min of &hernia and 60 min of reperfusion group [ 13 LVP, 17 MVO, and 6 CK]). During prolonged perfusion, left ventricular performance, expressed as developed pressure, AZ', fell from an initial value of 175 + 36 to 128 + 19 mm Hg at 30 min of perfusion, followed by a more gradual decline to a final value of 113 rt 8 mm Hg at 180 min of perfusion. These decreases were not significantly lower than the initial value. The percentage of myocardial extraction declined in a similar manner, but coronary blood flow was constant over this interval. The primary effect of 30 or 120 min of ischemia was to reduce left ventricular developed pressure, AP, during reperfusion to more than 70% of the corresponding value in the control group (these differences were statistically significant) which suggests that prolonging the period of &hernia did not cauSe further deterioration of cardiac performance. The plasma concentration of CK rose in the control group of hearts subjected to prolonged perfusion from an initial value of 35 + 6 to a final value of 59 k 8 IU/liter (P < 0.05). While plasma CK increased during reperfusion in both &hernia/ reperfusion groups, these values were not significantly higher from prearrest values. Thus hypothermic cardioplegic &hernia of this duration did not appear to result in tissue necrosis, but there was a significant reduction in left ventricular performance which was independent of the duration of &hernia between the limits of 30 and 120 min.
The Journal of Thoracic and Cardiovascular Surgery, 1982
Benefits of normothermic induction of blood cardioplegia in energy-depleted hearts, with maintenance of arrest by multidose cold blood cardioplegic infusions This study tests the hypothesis that warm induction of cardioplegia prior to prolonged maintenance by multidose infusions of cold blood cardioplegic solution would increase the tolerance of energy-depleted hearts to subsequent aortic clamping. Eighty percent* depletion of subendocardial adenosine triphosphate (ATP) was produced in 30 dogs by 45 minutes of normothermic ischemia. This was followed either by unmodified blood reperfusion or 2 additional hours of aortic clamping with multidose cold blood cardioplegia. We compared a brief (5 minute) period of 37°C cardioplegic induction to standard 4°C blood cardioplegic induction to determine if warm induction would enhance metabolic and functional recovery. Warm cardioplegic induction resulted in more oxygen consumption than cold induction (/6.9 versus 8./ eel /00 gm)*, and lower levels of glucose-6-phosphate (G6P), suggesting better aerobic metabolism (0.97 versus /.87 pM Igm wet weight). * Prompt repletion of creatine phosphate (CP) occurred with warm and cold cardioplegic induction, although ATP levels remained low. Hearts undergoing ischemia and unmodified reperfusion consumed insufficient oxygen to meet basal metabolic needs during reperfusion (7 cc/lOO gm below requirement)* and recovered only 33% ± 5%* of control left ventricular performance. Better function occurred with cold cardioplegic induction (63% ± 5%), * and almost complete recovery (85% ± 5%) occurred when warm induction of cardioplegia was used. We conclude that warm induction followed by prolonged cold multidose blood cardioplegic arrest enhances aerobic metabolism. results in normal left ventricular performance. and improves tolerance of aortic clamping in energy-depleted hearts.
The Journal of Thoracic and Cardiovascular Surgery, 1996
We used metabolic, enzymatic, and functional end points to compare the protective properties of continuous warm and intermittent cold cardioplegic infusion in isolated, blood-perfused rat hearts. After excision, hearts (n = 12 per group) were preserved for 3 hours by one of the following cardioplegic procedures: (1) continuous infusion of warm (37 ° C) blood cardioplegic solution prepared by mixing Fremes' solution with rat arterial blood in a ratio of 1:4, (2) continuous infusion of warm (37 ° C) crystalloid cardioplegic solution prepared by mixing Fremes' solution with bicarbonate buffer solution in a ratio of 1:4, or (3) intermittent infusion of cold (20 ° C) St. Thomas' Hospital cardioplegic solution number 2 infused for 3 minutes every 30 minutes during a 3-hour period of ischemia. In the continuousinfusion cardioplegic groups, the solution was infused through the aorta at a flow rate of 0.8 m l . m i n -l . g m -1 heart. At the end of the 3-hour preservation period, myocardial sodium-potassium adenosine triphosphatase activity (an index of ion-exchange activity) was assessed in six hearts in each group. The remaining hearts in each group were then aerobically perfused at 37 ° C with arterial blood (from a support rat) for a further 50 minutes, during which time they were atrially paced at 320 beats/min. At the end of this period, left ventricular developed and end-diastolic pressures were assessed with an intraventricular balloon; the hearts were then freeze-clamped and taken for the measurement of tissue adenosine triphosphate and creatine phosphate content. Hearts (n = 6) aerobically perfused with blood for 50 minutes (no cardioplegic infusion) served as control preparations. At a balloon volume of 180 ptl, the mean final values for left ventricular developed pressure in the continuous warm blood, continuous warm crystalloid, and intermittent cold cardioplegic groups were 98 +-5 mm Hg (p < 0.05), 70 -5 mm Hg, and 78 -+ 5 mm Hg, respectively. This was compared with 122 -5 mm Hg in control hearts (p < 0.05 vs the rest). For left ventricular end-diastolic pressure, the corresponding values were 33 -+ 3 mm Hg, 32 -+ 6 mm Hg, and 14 -4 mm Hg (p < 0.05), respectively. The control value was 16 -3 mm Hg (p < 0.05 vs continuous warm blood and continuous warm crystalloid groups). Tissue content of adenosine triphosphate was similarly reduced to approximately 50% of control values in all groups, and creatine phosphate content fully recovered in all groups. Sodium-potassium adenosine triphosphatase activity was poorly preserved in continuous warm crystalloid-treated hearts (0.012 +-0.003 vs 0.030 -0.008/_tmol inorganic phosphate, mg -a . min -1 From the
Myocardial Protection during Cardiac Surgery: Warm Blood versus Crystalloid Cardioplegia
World Journal of Cardiovascular Diseases, 2014
Purpose: Prevention of myocardial injury is essential during cardiac surgery. Both crystalloid and blood cardioplegia are popular methods for myocardial protection. Most experimental studies have been in favor of blood cardioplegia. The objective of this study is to determine whether the use of warm blood cardioplegia (BCP) is superior to crystalloid cardioplegia (CCP) by means of myocardial injury markers and clinical outcome parameters. Materials and Methods: In a consecutive series of 293 patients, the first 150 received crystalloid cardioplegia, whereas the next 143 patients received blood cardioplegia. Postoperative myocardial injury was assessed by CTnI and CK-MB. Perioperative morbidity and mortality and clinical outcome parameters (need for inotropic support, ICU and hospital stay) were recorded. An unpaired student t-test was performed to analyse continuous postoperative variables relating to myocardial damage. The presence of possible confounders influencing the CTnI or CK-MB concentrations was tested using a student t-test for continuous variables, for categorical variables ANOVA was used. A final longitudinal model was created for CTnI and CK-MB. CTnI was analyzed by a mixed model with random intercept and slope. For all tests performed, statistical significance was 5%. Results: Both groups were well matched with respect to preoperative variables. No significant difference could be found in maximum postoperative levels of CTnI 8.8 ± 18.4 µg/l in BCP vs 9.6 ± 16.5 µg/l in CCP, p = 0.6455) or CK-MB (19.2 ± 31.0 µg/l in BCP vs 26.4 ± 41.5 µg/l in CCP, p = 0.1209). Nor was there any significant difference in other postoperative variables. Testing treatment effect over time proved only significant influence of the surgical intervention type on CTnI levels in time (p < 0.001). Conclusion: This study could not show significantly higher myocardial injury in the group of patients re-* These authors contributed equally to the paper. # Corresponding author. H. De Bruyn et al.
International Heart Journal, 2005
The aims of this study were to evaluate myocardial metabolic activity during tepid blood cardioplegic infusion in the arrested heart in comparision with cold blood cardioplegia and to assess the early clinical outcomes of these patients. Thirty patients undergoing first elective coronary artery bypass grafting surgery were included and randomized to two groups (T for tepid and C for cold), 15 patients in each. Myocardial protection was similar in both groups except for the reinfusion of blood cardioplegia, which was 6°C in group C and 28°C in group T (same temperature as the body perfusion). The route of cardioplegic reinfusion was antegrade during the first reinfusion and retrograde during the second reinfusion. In order to assess myocardial metabolic activity, myocardial oxygen consumption (MVO 2), myocardial glucose uptake, and myocardial lactate and acid production were all calculated. Arterial and coronary venous blood samples were obtained from the aortic root cannula and coronary sinus. During cardioplegic reinfusions in the ischemic period, the calculated values of myocardial oxygen extraction, oxygen consumption, and glucose uptake were higher in group T than in group C (P < 0.05). This difference was observed during both antegrade and retrograde delivery of cardioplegic solution. Myocardial lactate production was greater in group C than in group T during cardioplegic reinfusion, both antegradely and retrogradely (P < 0.05). In all patients, cardiopulmonary bypass was terminated in the first attempt. The clinical outcome was similar in both groups. The results of this study indicate that globally ischemic myocardium is able to utilize more oxygen and glucose during cardioplegic reinfusions at a tepid temperature in comparison to cold. In addition, the data showed evidence of less myocardial injury and better left ventricular function throughout the critical period of recovery from global ischemia for the heart protected by tepid cardioplegia.
Transplantation Proceedings, 2002
W E HAVE DEVELOPED a cardioplegic solution in our laboratory, the centre de Résonance Magnétique Biologique et Médicale (CRMBM) solution, which has been reported to be more effective than the three most widely used solutions, the University of Wisconsin (UW), St Thomas, and Broussais solutions. This solution has been designed to limit endothelial dysfunction due to ischemiareperfusion injuries, namely a low K ϩ content 2 and the addition of L-arginine. The recently introduced Celsior solution (Celsior, Pasteur-Mérieux, Lyon, France) 4 has been observed in experimental and clinical studies to provide protection for donor hearts for a long ischemic time. In the present study, we compared the function, energy metabolism, and intracellular pH (pHi) after rat hearts had been submitted to 8 hours of cold ischemia in CRMBM solution versus Celsior solution and then undergone reperfusion. Biochemical analyses were also performed in coronary effluents and freeze-clamped hearts to assess membrane damage.