Myocardial protection for the compromised ventricle during cardiac surgery: A comparative study (original) (raw)
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The Annals of Thoracic Surgery, 1970
he problem of myocardial preservation during cardiotomies is as old as open-heart surgery itself. At the advent of open-heart T surgery, various methods of cardioplegia were used to create a quiet operative field and at the same time to provide some degree of protection to the myocardium deprived of its blood supply [4-7, 16, 17, 19, 21, 23, 25, 26, 28, 31, 32, 34, 37, 511. The results of these operations were disappointing. A number of patients never got off the pump oxygenator, and the development of the ominous postoperative low-output syndrome was a rule rather than an exception. T h e causes of these unwanted results were undoubtedly complex: the operative technique was undeveloped, surgical experience scarce, valve prostheses inadequate, perfusion prolonged and unsatisfactory. Interestingly enough, in spite of the fact that these causes were well recognized, methods of myocardial protection-some of them undoubtedly unsatisfactory-received more than their share of the blame.
Comparison of two strategies for myocardial management during coronary artery operations
The Annals of Thoracic Surgery, 1994
Despite the current trend for using blood cardioplegia, ventricular fibrillation with intermittent ischemia is still used as a strategy to manage the myocardium with impressive results. These two methods of myocardial management were compared in 40 patients undergoing elective coronary artery operations using creatine kinase MB isoforms and troponin T assays. Each patient was randomized to have either cold blood cardioplegia (n = 20) or ventricular fibrillation with intermittent ischemia (n = 20) for myocardial management during the construction of distal anastomoses. Until recently, the comparison of different methods of myocardial management has been hindered by the lack of a specific and sensitive marker of myocardial damage. Analysis of creatine kinase MB isoforms (MB2, cardiac tissue form; MB1, plasma-modified form) and cardiac-specific troponin T (a structural protein) has been shown to improve the sensitivity for the detection of myocardial damage. There were no significant differences between the two I n deciding on an operative strategy for performing coronary operations, the surgeon should consider three factors in deciding on the best possible care of the patient. The primary objective is to graft all the appropriate coronary artery branches to technical perfection. The secondary objective is to ensure that the myocardium is not damaged, and the third is to avoid damaging other end organs in the process. The ideal circumstances for performing coronary anastomoses probably include a motionless, bloodless heart, high level optical magnification, and no time limit in which to perform the grafts. The ideal circumstances for the myocardium and the other end organs include physiologic pulsatile perfusion with arterial blood at 37°C, with no interruption of flow. Indeed the best management of the heart, brain, lungs, liver, and kidneys would be to avoid cardiopulmonary bypass altogether. Therefore, the choice of myocardial management strategy is one among a number of compromises that the surgeon has to make in achieving his or her three objectives, which are to perform an adequate operation while minimizing myocardial and other end organ damage. The balance to be struck between groups in age, sex ratio, extent of disease, or left ventricular function. Blood samples for analysis were collected before cross-clamp application and at time intervals up to 48 hours after. Median peak creatine kinase MB2 activity was found to be significantly higher in the blood cardioplegia group compared with ventricular fibrillation (26.5 U/L versus 19.5 U/L, respectively, p = 0.04). Although median peak troponin T concentration was higher in the blood cardioplegia group, the difference failed to reach significance (2.2 nglmL versus 1.6 nglmL, p = 0.15). The area under the time-activity curves (a reflection of total release) constructed for creatine kinase MB, MB2, and troponin T were not significantly different between the groups (p = 0.51,0.82, and 0.31, respectively). These results suggest that, for elective coronary artery operations, ventricular fibrillation is as effective a strategy to manage the myocardium as blood cardioplegia and it may even be superior.
Objective: To evaluate the benefits of simultaneous aortic root and vein graft cold blood cardioplegia and continuous controlled warm blood perfusion through vein grafts during proximal aortocoronary anastomosis in conventional coronary artery bypass graft surgery in patients with multi-vessel coronary artery disease. Methods: The prospective randomised study was conducted at Chaudary Pervaiz Elahi Institute of Cardiology, Multan, Pakistan, from April 2013 to June 2014, and comprised patients of isolated conventional coronary artery bypass graft surgery. The patients were randomised into 2 groups; Group I had patients in whom multiperfusion set was used for cardioplegia and continuous warm blood perfusion through vein grafts during proximal ends anastomosis, and Group II had patients in whom routine aortic root antegrade cardioplegia was used with no warm blood perfusion during proximal anastomosis of vein grafts. Data was analysed using SPSS 20. Results: There were 434 patients in the study, with Group 1 having 215(49.5%) being the study group, and Group II having 219(50.5%)being the Control group. The groups showed no significant difference in the number of grafts, and aortic cross-clamp time (p>0.05 each). Total bypass time was significantly prolonged in the Control Group (p=0.001). Incidence of intra-operative arrhythmias, peri-operativemyocardial infarction, need for inotropic support and intra-aortic balloon counter-pulsation and operative mortality were significantly higher in the Control group (p<0.05 each). Conclusions: Simultaneous aortic root and vein graft cold blood cardioplegia and continuous controlled warm blood perfusion was beneficial for myocardial protection and early patient outcome.
Warm heart surgery and results of operation for recent myocardial infarction
Annals of Thoracic Surgery, 1991
Revascularization procedures after recent myocardial infarction are associated with higher mortality and morbidity compared with elective coronary artery bypass grafting. Traditional methods of myocardial protection impose a further ischemic insult on already compromised myocardium. Continuous cold blood cardioplegia may eliminate ischemia but may still leave the heart anaerobic. Theoretically, warm aerobic arrest addresses both of these issues and may become an attractive alternative to standard hypothermic ischemic arrest in this setting. In 115 nonrandomized patients undergoing coronary artery bypass grafting within 6 hours to 7 days of an acute myocardial infarction, myocardial protection was provided with continuous cold (4°C) or continuous he initial, yet on-going, goal of myocardial protective T techniques during cardiac operations has been to prolong safe operating time by minimizing ischemic damage to the heart. This goal ultimately becomes an attempt at maintaining the myocardial energy supply at a level greater than its demand during the time of operation. Cardioplegic preservation therefore strives to optimize the ratio of energy supply to consumption and the capacity of the heart to utilize oxygen and substrate, whether aerobic or anaerobic. This capacity will be determined by the temperature and composition of the perfusate, and the distribution, adequacy, and duration of the infusion.
Myocardial Protection in Cardiac Surgery
Revista brasileira de anestesiologia
Malbouisson LMS, Santos LM, Auler Jr JOC, Carmona MJC -Proteção Miocárdica em Cirurgia Cardíaca JUSTIFICATIVA E OBJETIVOS: A proteção miocárdica define o conjunto de estratégias que objetivam atenuar a intensidade da lesão de isquemia-reperfusão miocárdica durante a cirurgia cardíaca e suas conseqüências sobre a função miocárdica. Um melhor entendimento dos fenômenos fisiopatológicos relacionados à isquemia-reperfusão miocárdica e da cardioproteção promovida por determinados fármacos e técnicas anestésicas tem dado ao anestesiologista papel importante na proteção miocárdica durante o procedimento cirúrgico. O objetivo desta revisão foi abordar os mecanismos de lesão miocárdica e as modalidades de proteção miocárdica com enfoque para a técnica anestésica. CONTEÚDO: São abordados os mecanismos de lesão miocárdica durante os eventos de isquemia-reperfusão e suas conseqüências clínicas assim como às técnicas de proteção realizadas durante a cirurgia cardíaca. Ênfase especial é dada aos fármacos e técnicas anestésicas, como anestésicos halogenados, opióides e fármacos adjuvantes, pois estes têm mostrado efeitos cardioprotetores em cirurgia cardíaca. CONCLUSÕES: A associação de técnica anestésica adequada com agentes anestésicos cardioprotetores às técnicas habituais de proteção miocárdica realizadas pelo cirurgião pode contribuir para prevenção de disfunção miocárdica e promover melhor recuperação no período pós-operatório. SUMMARY Malbouisson LMS, Santos LM, Auler Jr JOC, Carmona MJC -Myocardial Protection in Cardiac Surgery
Myocardial protection in operations requiring more than 2 h of aortic cross-clamping
European Journal of Cardio-Thoracic Surgery, 1999
Objective: Long periods of aortic cross-clamping time during cardiac surgery are associated with high rates of morbidity and mortality because of damage to the myocardium. Recently, we have used a method of myocardial protection based on the principles of hyperkalemic cardioplegic arrest. We use antegrade administration of warm, undiluted blood followed by continuous retrograde infusion of tepid, undiluted blood supplemented with potassium and magnesium. In this study, we have retrospectively reviewed our experience with this method of cardioprotection in operations requiring more than 2 h of cross-clamp time. Methods: We retrospectively reviewed the medical records of 1280 patients who underwent myocardial revascularization, valve repair or replacement, or a combination of both operations between January 1, 1994 and December 31, 1997. Patients were divided into two groups: the short cross-clamp group (SXC) (n = 1144) had cross-clamp times Ͻ120 min (mean, 78 ± 20 min; range, 35-119 min) and the long cross-clamp group (LXC) (n = 136) had cross-clamp times Ͼ 120 min (mean, 154 ± 31 min; range, 120-277 min). We compared preoperative, operative, and postoperative variables between the two groups. Results: Significantly more patients in the long cross-clamp group (43.4%) underwent the combined operation than in the short cross-clamp group (2.3%), and the rate of reoperation was significantly higher in the long cross-clamp group (12%) than in the short cross-clamp group (5%). Despite these differences in operative complexity, we found no difference in hospital mortality rates between the two groups. The only significant postoperative differences were that the long cross-clamp group had a greater need for inotropic agents (43 vs. 29%), higher serum levels of creatine kinase (880 ± 583 vs. 613 ± 418) and CK-MB (10.9 ± 6.4 vs. 5.9 ± 5.2), and a longer hospital stay (9.6 vs. 6.1 days). Conclusion: Long, complex operations requiring more than 2 h of cross-clamping can be performed safely with our method of cardioprotection based on continuous retrograde infusion of tepid, hyperkalemic, undiluted blood.
Annals of Thoracic and Cardiovascular Surgery
Purpose: In this study, we aimed to assess myocardial protection and ischemia-reperfusion injury in patients undergoing open heart surgery with isothermic blood cardioplegia (IBC) or hypothermic blood cardioplegia (HBC). Materials and Methods: A total of 48 patients who underwent isolated coronary artery bypass grafting or isolated mitral valve surgery between March 2017 and October 2017 were evaluated as randomized prospective study. Study groups (HBC: Group 1, IBC: Group 2) were compared in terms of interleukin 6 (IL-6), IL-8, IL-10, and complement factor 3a (C3a) levels, metabolic parameters, creatine kinase-muscle/brain (CK-MB) and high-sensitivity Troponin I (hsTn-I), and clinical outcomes. Results: Comparison of the markers of ischemia-reperfusion injury showed significantly higher levels of the proinflammatory cytokine IL-6 in the early postoperative period as well as IL-8, in Group 2 (p <0.001), whereas the anti-inflammatory cytokine IL-10 was significantly higher during the X1 time period (p = 0.11) in Group 2, and subsequently it was higher in Group 1. Using myocardial temperature probes, the target myocardial temperatures were measured in the patients undergoing open heart surgery with different routes of cardioplegia, and significant differences were noted (p = 0.000). Conclusion: HBC for open heart surgery is associated with less myocardial injury and intraoperative and postoperative morbidity, indicating superior myocardial protection versus IBC.
Arquivos Brasileiros de Cardiologia, 2001
Methods -In the control group (18 patients), surgery was performed with systemic hypothermia at 32ºC and intermittent crossclamping of the aorta. Extracorporeal circulation was used. In the preconditioning group (17 patients), 2 crossclampings of the aorta lasting 3min each were added prior to the intermittent crossclamping of the conventional technique with an interval of 2min of reperfusion between them. Blood samples for analyses of pH, pCO 2 , pO 2 , sodium, potassium, calcium, and magnesium were obtained from the coronary sinus at the beginning of extracorporeal circulation (time 1), at the end of the first anastomosis (time 2), and at the end of extracorporeal circulation (time 3).