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Ak K, Dericioğlu O, Midi A, Kararmaz A, Er Z, Doğusan Z, Arsan S. Comparison of Bretschneider HTK and Blood Cardioplegia (4:1): A Prospective Randomized Study. Thorac Cardiovasc Surg 2024; 72:11-20. [PMID: 36638809 DOI: 10.1055/s-0042-1759710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND We compared the effect of intermittent blood and histidine-tryptophan-ketoglutarate (HTK) solution of Bretschneider on myocardial histopathology and perioperative outcome. METHODS Forty adult cardiac surgery patients were grouped into two (n = 20 for each): (1) Intermittent blood cardioplegia (IBC): had repeated cold 4:1 blood cardioplegia and (2) HTK: had a single dose of cold HTK for cardioprotection. Creatine kinase (CK)-MB, Troponin-I (cTn-I), pH, and lactate were studied in coronary sinus blood before and after aortic cross-clamping (AXC) and systemic blood at postoperative 6th, 24th, and 48th hours. Myocardial biopsy was performed before and after AXC for light microscopy. Vacuolation, inflammation, edema, and glycogen were graded semiquantitatively (from 0 to 3). The myocardial apoptotic index was evaluated via the terminal deoxynucleotidyl transferase dUTP nick end labeling. RESULTS There were no differences in perioperative clinical outcomes between the groups. The coronary sinus samples after AXC were more acidotic (7.15 ± 0.14 vs. 7.32 ± 0.07, p = 0.001) and revealed higher CK-MB (21.0 ± 12.81 vs. 12.60 ± 11.80, p = 0.008) in HTK compared with IBC. The HTK had significantly a higher amount of erythrocyte suspension intraoperatively compared with IBC (0.21 ± 0.53 vs. 1.68 ± 0.93 U, p = 0.001). Microscopically, myocardial edema was more pronounced in HTK compared with IBC after AXC (2.25 ± 0.91 vs. 1.50 ± 0.04, p = 0.013). While a significant increase in the apoptotic index was seen after AXC in both groups (p = 0.001), no difference was detected between the groups (p = 0.417). CONCLUSION IBC and HTK have a similar clinical outcome and protective effect, except for more pronounced myocardial edema and increased need for intraoperative transfusion with HTK.
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Affiliation(s)
- Koray Ak
- Department of Cardiovascular Surgery, Marmara University School of Medicine, Marmara Uninersitesi Hastanesi Mimar Sinan Cad. Fevzi Cakmak Mah. Ust Kaynarca Kalp ve Damar Cerrahisi Bolumu Pendik, Istanbul, Turkey
| | - Okan Dericioğlu
- Department of Cardiovascular Surgery, Marmara University School of Medicine, Istanbul, Turkey
| | - Ahmet Midi
- Department of Pathology, Bahcesehir University, School of Medicine, Istanbul, Turkey
| | - Alper Kararmaz
- Department of Anesthesiology and Reanimation, Marmara University School of Medicine, Istanbul, Turkey
| | - Zafer Er
- Department of Cardiovascular Surgery, Bozok University Faculty of Medicine Ringgold Standard Institution, Yozgat, Yozgat, Turkey
| | - Zeynep Doğusan
- Department of Pathology, Bone Marrow Transplantation Unite, Yeni Yüzyıl University School of Medicine, Istanbul, Turkey
| | - Sinan Arsan
- Department of Cardiovascular Surgery, Marmara University School of Medicine, Istanbul, Turkey
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Mukharyamov M, Schneider U, Kirov H, Caldonazo T, Doenst T. Myocardial protection in cardiac surgery-hindsight from the 2020s. Eur J Cardiothorac Surg 2023; 64:ezad424. [PMID: 38113432 DOI: 10.1093/ejcts/ezad424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 11/15/2023] [Accepted: 12/18/2023] [Indexed: 12/21/2023] Open
Abstract
Myocardial protection and specifically cardioplegia have been extensively investigated in the beginnings of cardiac surgery. After cardiopulmonary bypass had become routine, more and more cardiac operations were possible, requiring reliable and reproducible protection for times of blood flow interruptions to the most energy-demanding organ of the body. The concepts of hypothermia and cardioplegia evolved as tools to extend cardiac ischaemia tolerance to a degree considered safe for the required operation. A plethora of different solutions and delivery techniques were developed achieving remarkable outcomes with cross-clamp times of up to 120 min and more. With the beginning of the new millennium, interest in myocardial protection research declined and, as a consequence, conventional cardiac surgery is currently performed using myocardial protection strategies that have not changed in decades. However, the context, in which cardiac surgery is currently performed, has changed during this time. Patients are now older and suffer from more comorbidities and, thus, other organs move more and more into the centre of risk assessment. Yet, systemic effects of cardioplegic solutions have never been in the focus of attention. They say hindsight is always 20-20. We therefore review the biochemical principles of ischaemia, reperfusion and cardioplegic extension of ischaemia tolerance and address the concepts of myocardial protection with 'hindsight from the 2020s'. In light of rising patient risk profiles, minimizing surgical trauma and improving perioperative morbidity management becomes key today. For cardioplegia, this means accounting not only for cardiac, but also for systemic effects of cardioplegic solutions.
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Affiliation(s)
- Murat Mukharyamov
- Department of Cardiothoracic Surgery, Jena University Hospital, Friedrich Schiller University of Jena, Jena, Germany
| | - Ulrich Schneider
- Department of Cardiothoracic Surgery, Jena University Hospital, Friedrich Schiller University of Jena, Jena, Germany
| | - Hristo Kirov
- Department of Cardiothoracic Surgery, Jena University Hospital, Friedrich Schiller University of Jena, Jena, Germany
| | - Tulio Caldonazo
- Department of Cardiothoracic Surgery, Jena University Hospital, Friedrich Schiller University of Jena, Jena, Germany
| | - Torsten Doenst
- Department of Cardiothoracic Surgery, Jena University Hospital, Friedrich Schiller University of Jena, Jena, Germany
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3
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Rajagopal K. Commentary: Myocardial protection: Whatever you do, do it well. J Thorac Cardiovasc Surg 2023; 166:1468-1469. [PMID: 35219516 DOI: 10.1016/j.jtcvs.2022.01.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 01/25/2022] [Accepted: 01/26/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Keshava Rajagopal
- Department of Clinical Sciences, University of Houston College of Medicine, Houston, Tex; Houston Heart, HCA Houston Healthcare, Houston, Tex.
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Nowicki R, Berezowski M, Kulbacka J, Bieżuńska-Kusiak K, Jasiński M, Saczko J. Custodiol HTK versus Plegisol: in-vitro comparison with the use of immature (H9C2) and mature (HCM) cardiomyocytes cultures. BMC Cardiovasc Disord 2022; 22:108. [PMID: 35296256 PMCID: PMC8928626 DOI: 10.1186/s12872-022-02536-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 02/22/2022] [Indexed: 11/10/2022] Open
Abstract
Background Although cardioplegia is used since the ‘70s of the last century, debate on cardioprotection during cardio-surgical procedures is still actual. The selection of a particular method depends mainly on the preferences and experience of a specific center or even surgeon. Crystalloid cardioplegia is an aqueous ion solution similar to intracellular (Custodiol HTK) or extracellular (Plegisol) fluid. The potensional clinical advantages of relatively new idea of cardioplegia solution based on intracellular composition (Custodiol HTK) justifies futher research, but only a few used cultured cells in laboratory conditions. Methods In this study, the authors sought to compare Custodiol HTK with Plegisol cardioplegia solutions using an in-vitro model simulating cardioplegic arrest. The efficacy of myocardial protection during ischemia was investigated with susceptible indicators like the appearance of the deleterious effect of reactive oxygen species and oxidative stress markers. Immersed human cardiomyocytes and rat cardiomyoblasts H9C2 in cardioplegia for 4 h were examined for expression of oxidative stress markers (MnSOD, iNOS, HSP27), cardioplegic solutions cytotoxicity, and peroxidation damage of the cell’s lipids and proteins. All tests were performed after 0.5 h, 1 h, 2 h, and 4 h of incubation in identical physical and biological conditions, which is difficult to achieve in clinical trials. Results The lower cytotoxicity index performed on matured cells of human cardiomyocytes and highest dehydrogenase level showed after incubation with Custodiol HTK. This did not apply to tests on immature cells H9C2. Custodiol HTK induced significantly stronger iNOS expression. The decrease of HSP27 concentration has been instantaneous and maintained troughout the study only in both cultures incubated with Custodiol HTK. The other tests: lipid peroxidation, carbonyl groups concentration and MnSOD expression show no clear superiority evidence of used cardioplegic solutions. Conclusions Considering proceeded examinations on cultured cardiomyocytes, Custodiol HTK appears to be safer than Plegisol.
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Affiliation(s)
- Rafał Nowicki
- Clinical Department of Cardiac Surgery, Wroclaw Medical University, Wroclaw, Poland.
| | | | - Julita Kulbacka
- Department of Molecular and Cellular Biology, Faculty of Pharmacy, Wroclaw Medical University, Wroclaw, Poland
| | - Katarzyna Bieżuńska-Kusiak
- Department of Molecular and Cellular Biology, Faculty of Pharmacy, Wroclaw Medical University, Wroclaw, Poland
| | - Marek Jasiński
- Clinical Department of Cardiac Surgery, Wroclaw Medical University, Wroclaw, Poland.,Children's Memorial Pediatric Health Institute, Warsaw, Poland
| | - Jolanta Saczko
- Department of Molecular and Cellular Biology, Faculty of Pharmacy, Wroclaw Medical University, Wroclaw, Poland
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Wahba A, Milojevic M, Boer C, De Somer FMJJ, Gudbjartsson T, van den Goor J, Jones TJ, Lomivorotov V, Merkle F, Ranucci M, Kunst G, Puis L. 2019 EACTS/EACTA/EBCP guidelines on cardiopulmonary bypass in adult cardiac surgery. Eur J Cardiothorac Surg 2021; 57:210-251. [PMID: 31576396 DOI: 10.1093/ejcts/ezz267] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Affiliation(s)
- Alexander Wahba
- Department of Cardio-Thoracic Surgery, St Olav's University Hospital, Trondheim, Norway.,Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
| | - Milan Milojevic
- Department of Cardiovascular Anaesthesia and Intensive Care Unit, Dedinje Cardiovascular Institute, Belgrade, Serbia.,Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Christa Boer
- Department of Anaesthesiology, Amsterdam UMC, VU University, Amsterdam Cardiovascular Sciences, Amsterdam, Netherlands
| | | | - Tomas Gudbjartsson
- Department of Cardiothoracic Surgery, Faculty of Medicine, Landspitali University Hospital, University of Iceland, Reykjavik, Iceland
| | - Jenny van den Goor
- Department of Cardiothoracic Surgery, Academic Medical Centre of the University of Amsterdam, Amsterdam, Netherlands
| | - Timothy J Jones
- Department of Paediatric Cardiac Surgery, Birmingham Women's and Children's Hospital, Birmingham, UK
| | - Vladimir Lomivorotov
- Department of Anesthesiology and Intensive Care, E. Meshalkin National Medical Research Center, Novosibirsk State University, Novosibirsk, Russia
| | - Frank Merkle
- Academy for Perfusion, Deutsches Herzzentrum, Berlin, Germany
| | - Marco Ranucci
- Department of Cardiovascular Anaesthesia and Intensive Care Unit, IRCCS Policlinico San Donato, Milan, Italy
| | - Gudrun Kunst
- Department of Anaesthetics and Pain Medicine, King's College Hospital NHS Foundation Trust and School of Cardiovascular Medicine & Sciences, King's College London British Heart Foundation Centre of Excellence, London, UK
| | - Luc Puis
- Department of Perfusion, University Hospital Brussels, Jette, Belgium
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Pontailler M, David CH, Lacoste P, Guimbretière G, Marie B, Perigaud C, Mugniot A, Fellah I, Roussel JC, Senage T. Celsior ® crystalloid cardioplegia versus standard hyperkalemic normothermic blood cardioplegia: Analysis of myocardial protection in elective mitral valve repair. Perfusion 2021; 36:455-462. [PMID: 33530875 DOI: 10.1177/0267659121991760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION With the increase and refinement of video assisted mitral valve surgery, cristalloïd cardioplegia started regaining popularity. The aim of our study was to evaluate the effectiveness of Celsior®, a crystalloid cardioplegic solution, on myocardial protection in elective surgical mitral valve repair in comparison to blood based hyperkalemic cardioplegia. METHODS In this observational retrospective study, all consecutive elective isolated surgical mitral valve repair where Celsior® or normothermic hyperkalemic blood cardioplegia were used were included. Primary endpoint was any sign of myocardial protection failure (troponin levels, need for inotropic or mechanical support, rhythm disturbances, mortality). Secondary endpoint was Celsior® safety (allergic reactions, bleeding, organ toxicities). RESULTS From January 2009 to August 2016, 382 patients underwent elective isolated mitral valve repair in whom normothermic hyperkalemic blood cardioplegia (n = 181) or Celsior® (n = 201) were used. There were no statistically significant differences in baseline characteristics including Euroscore 2. Peak troponin (pg/ml) release and 30-days mortality were not statistically different. Need for cardioversion was significantly more frequent in the Celsior® group (47% vs 13%, p < 0.001). There was no statistical difference in post-operative atrial fibrillation, permanent pacemaker implantation, reoperation for bleeding, transfusion, acute kidney injury, haemoglobin at discharge or length of stay. No allergic reaction to Celsior® occurred. CONCLUSION Effective myocardial protection was achieved with the Celsior® cardioplegic solution with no unexpected toxicity. Celsior® may be an efficacious and safe cardioprotective strategy in mitral valve repair.
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Affiliation(s)
- Margaux Pontailler
- Department of Thoracic and Cardiovascular Surgery, Thorax Institute, Nantes Hospital University, Nantes, France
| | - Charles-Henri David
- Department of Thoracic and Cardiovascular Surgery, Thorax Institute, Nantes Hospital University, Nantes, France
| | - Philippe Lacoste
- Department of Thoracic and Cardiovascular Surgery, Thorax Institute, Nantes Hospital University, Nantes, France
| | - Guillaume Guimbretière
- Department of Thoracic and Cardiovascular Surgery, Thorax Institute, Nantes Hospital University, Nantes, France
| | - Basile Marie
- Department of Thoracic and Cardiovascular Surgery, Thorax Institute, Nantes Hospital University, Nantes, France
| | - Christian Perigaud
- Department of Thoracic and Cardiovascular Surgery, Thorax Institute, Nantes Hospital University, Nantes, France
| | - Antoine Mugniot
- Department of Thoracic and Cardiovascular Surgery, Thorax Institute, Nantes Hospital University, Nantes, France
| | - Imen Fellah
- Department of Thoracic and Cardiovascular Surgery, Thorax Institute, Nantes Hospital University, Nantes, France
| | - Jean-Christian Roussel
- Department of Thoracic and Cardiovascular Surgery, Thorax Institute, Nantes Hospital University, Nantes, France
| | - Thomas Senage
- Department of Thoracic and Cardiovascular Surgery, Thorax Institute, Nantes Hospital University, Nantes, France.,INSERM 1246, Methods in Patients-Centered Outcomes and Health Research - SPHERE, Nantes University, Nantes, France
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7
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El-Essawi A, Abdelhalim A, Groeger S, Breitenbach I, Brouwer R, Kück F, Harringer W. Predictors of postoperative atrial fibrillation persisting beyond hospital discharge after coronary artery bypass grafting. Perfusion 2020; 37:62-68. [PMID: 33342350 DOI: 10.1177/0267659120978647] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Minimal invasive extracorporeal circuits (MiECC) have been associated with a significant reduction in the incidence of postoperative atrial fibrillation (AF). Nevertheless, AF remains one of the most common complications following elective primary coronary artery bypass grafting (CABG). The aim of this study was to identify the predictors of AF persisting beyond the hospital stay in elective primary CABG patients. METHODS We conducted a retrospective analysis for the predictors of AF that persisted beyond discharge between all patients who received an elective isolated CABG in our institution between 2009 and 2014. Patients with a positive history for intermittent or persistent AF were excluded from the analysis. Almost all patients were discharged to a rehabilitation facility where they stayed for 3 to 4 weeks postoperatively. At rehab approximately 91% of them received Holter monitoring at least once prior to their discharge. RESULTS A total of 770 patients were included in the analysis of which 763 patients survived the in-hospital stay. The incidence of AF at hospital discharge was 4.2% (32/763) while that on Holter monitor at Rehab was 1.5% (10/685). Age and the type of extracorporeal circuit (ECC) utilized were the only significant predictors for both AF at discharge (p < 0.01 both) and on Holter monitor in rehab (p < 0.01 and 0.02, respectively). This was also confirmed on multivariate analysis. CONCLUSION Our findings show that the benefits of MiECC regarding the incidence of postoperative AF persist beyond hospital discharge. They may thus positively influence the outcomes of patients beyond the early postoperative period.
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Affiliation(s)
- Aschraf El-Essawi
- Department of Thoracic and Cardiovascular Surgery, Klinikum Braunschweig, Braunschweig, Germany.,Department of Throacic and Cardiovascular Surgery, University Medical Center Göttingen, Göttingen, Germany
| | - Ahmed Abdelhalim
- Department of Thoracic and Cardiovascular Surgery, Klinikum Braunschweig, Braunschweig, Germany
| | - Steffen Groeger
- Department of Thoracic and Cardiovascular Surgery, Klinikum Braunschweig, Braunschweig, Germany
| | - Ingo Breitenbach
- Department of Thoracic and Cardiovascular Surgery, Klinikum Braunschweig, Braunschweig, Germany
| | - Rene Brouwer
- Department of Thoracic and Cardiovascular Surgery, Klinikum Braunschweig, Braunschweig, Germany
| | - Fabian Kück
- Department of Medical Statistics, University Medical Center Göttingen, Göttingen, Germany
| | - Wolfgang Harringer
- Department of Thoracic and Cardiovascular Surgery, Klinikum Braunschweig, Braunschweig, Germany
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8
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Puis L, Milojevic M, Boer C, De Somer FMJJ, Gudbjartsson T, van den Goor J, Jones TJ, Lomivorotov V, Merkle F, Ranucci M, Kunst G, Wahba A. 2019 EACTS/EACTA/EBCP guidelines on cardiopulmonary bypass in adult cardiac surgery. Interact Cardiovasc Thorac Surg 2020; 30:161-202. [PMID: 31576402 PMCID: PMC10634377 DOI: 10.1093/icvts/ivz251] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Luc Puis
- Department of Perfusion, University Hospital Brussels, Jette, Belgium
| | - Milan Milojevic
- Department of Cardiovascular Anaesthesia and Intensive Care Unit, Dedinje Cardiovascular Institute, Belgrade, Serbia
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Christa Boer
- Department of Anaesthesiology, Amsterdam UMC, VU University, Amsterdam Cardiovascular Sciences, Amsterdam, Netherlands
| | | | - Tomas Gudbjartsson
- Department of Cardiothoracic Surgery, Faculty of Medicine, Landspitali University Hospital, University of Iceland, Reykjavik, Iceland
| | - Jenny van den Goor
- Department of Cardiothoracic Surgery, Academic Medical Centre of the University of Amsterdam, Amsterdam, Netherlands
| | - Timothy J Jones
- Department of Paediatric Cardiac Surgery, Birmingham Women’s and Children’s Hospital, Birmingham, UK
| | - Vladimir Lomivorotov
- Department of Anesthesiology and Intensive Care, E. Meshalkin National Medical Research Center, Novosibirsk State University, Novosibirsk, Russia
| | - Frank Merkle
- Academy for Perfusion, Deutsches Herzzentrum, Berlin, Germany
| | - Marco Ranucci
- Department of Cardiovascular Anaesthesia and Intensive Care Unit, IRCCS Policlinico San Donato, Milan, Italy
| | - Gudrun Kunst
- Department of Anaesthetics and Pain Medicine, King's College Hospital NHS Foundation Trust and School of Cardiovascular Medicine & Sciences, King's College London British Heart Foundation Centre of Excellence, London, UK
| | - Alexander Wahba
- Department of Cardio-Thoracic Surgery, St Olav s University Hospital, Trondheim, Norway
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
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9
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Kunst G, Milojevic M, Boer C, De Somer FM, Gudbjartsson T, van den Goor J, Jones TJ, Lomivorotov V, Merkle F, Ranucci M, Puis L, Wahba A, Alston P, Fitzgerald D, Nikolic A, Onorati F, Rasmussen BS, Svenmarker S. 2019 EACTS/EACTA/EBCP guidelines on cardiopulmonary bypass in adult cardiac surgery. Br J Anaesth 2019; 123:713-757. [DOI: 10.1016/j.bja.2019.09.012] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
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10
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El-Essawi A, Breitenbach I, Haupt B, Brouwer R, Morjan M, Harringer W. Aortic valve replacement with or without myocardial revascularization in octogenarians. Can minimally invasive extracorporeal circuits improve the outcome? Perfusion 2018; 34:217-224. [PMID: 30394847 DOI: 10.1177/0267659118811048] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE The positive impact of minimally invasive extracorporeal circuits (MiECC) on patient outcome is expected to be most evident in patients with limited physiologic reserves. Nevertheless, most studies have limited their use to low-risk patients undergoing myocardial revascularization. As such, there is little evidence to their benefit outside this patient population. We, therefore, set out to explore their potential benefit in octogenarians undergoing aortic valve replacement (AVR) with or without concomitant myocardial revascularization. METHODS Based on the type of the utilized ECC, we performed a retrospective propensity score-matched comparison among all octogenarians (n = 218) who received a primary AVR with or without concomitant coronary artery bypass grafting in our institution between 2003 and 2010. RESULTS A MiECC was utilized in 32% of the patients. The propensity score matching yielded 52 matched pairs. The 30-day postoperative mortality (2% vs. 10%; p=0.2), the incidence of low cardiac output (0% vs. 6%; p=0.2) and the Intensive Care Unit (ICU) stay (2.5 ± 2.6 vs. 3.8 ± 4.7 days; p=0.06) were all in favour of the MiECC group, but failed to reach statistical significance while the 90-day postoperative mortality did (2% vs. 16%; p=0.02). CONCLUSION MiECCs have a positive influence on the outcome of octogenarians undergoing AVR with or without concomitant coronary artery bypass grafting. Their use should, therefore, be extended beyond isolated coronary artery bypass graft (CABG) surgery.
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Affiliation(s)
- Aschraf El-Essawi
- 1 Department of Thoracic and Cardiovascular Surgery, Klinikum Braunschweig, Braunschweig, Germany
| | - Ingo Breitenbach
- 1 Department of Thoracic and Cardiovascular Surgery, Klinikum Braunschweig, Braunschweig, Germany
| | - Benjamin Haupt
- 2 Academy of Perfusion, German Heart Centre Berlin, Berlin, Germany
| | - Rene Brouwer
- 1 Department of Thoracic and Cardiovascular Surgery, Klinikum Braunschweig, Braunschweig, Germany
| | - Mohammed Morjan
- 1 Department of Thoracic and Cardiovascular Surgery, Klinikum Braunschweig, Braunschweig, Germany
| | - Wolfgang Harringer
- 1 Department of Thoracic and Cardiovascular Surgery, Klinikum Braunschweig, Braunschweig, Germany
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11
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Ucak HA, Uncu H. Comparison of Del Nido and Intermittent Warm Blood Cardioplegia in Coronary Artery Bypass Grafting Surgery. Ann Thorac Cardiovasc Surg 2018; 25:39-45. [PMID: 30089762 PMCID: PMC6388299 DOI: 10.5761/atcs.oa.18-00087] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Purpose: In this study, we aim to investigate the efficacy and clinical results of using Del Nido solution (DNS) in coronary artery bypass grafting (CABG) surgery by comparing with intermittent warm blood cardioplegia (IWBC). Methods: Between March 2017 and February 2018, 297 adult patients who underwent primary isolated CABG surgery with cardiopulmonary bypass (CPB) were included in the study. We used DNS in 112 patients and IWBC was used in 185 patients. We compared both the clinical and the laboratory results. Results: Aortic cross-clamp time, CPB time, and peak glucose level are lower with DNS. But we did not observe any meaningful difference of clinical results between two methods including postoperative myocardial enzyme release. Conclusion: Del Nido cardioplegia was developed for immature heart and pediatric surgery. But in our opinion, it is a good and useful alternative to CABG surgery with similar results to IWBC.
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Affiliation(s)
- Haci Ali Ucak
- Department of Cardiovascular Surgery, University of Health Sciences Adana City Hospital, Adana, Turkey
| | - Hasan Uncu
- Department of Cardiovascular Surgery, University of Health Sciences Adana City Hospital, Adana, Turkey
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12
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López-Menéndez J, Miguelena J, Morales C, Callejo F, Silva J. Myocardial protection in on-pump coronary artery bypass grafting surgery: analysis of the effectiveness of the use of retrograde Celsior ®. Ther Adv Cardiovasc Dis 2018; 12:263-273. [PMID: 30081729 DOI: 10.1177/1753944718792428] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND We analyzed the adequacy of the myocardial protection achieved with a single dose of retrograde crystalloid Celsior®, compared with an accepted standard (microplegia), in on-pump coronary artery bypass grafting surgery (CABG). METHODS This was a retrospective comparative clinical study conducted in a single institution that included all the patients operated on who had elective isolated on-pump CABG, from March 2006 to June 2014. We evaluated maximum postoperative troponin T (TnT) as a marker of myocardial damage, adjusted for possible confounders using propensity score matching. We also analyzed markers of recovery of myocardial function, and the safety of the intravenous use of Celsior®. RESULTS During the study period, 261 patients were included, divided in two groups: (a) continuous retrograde blood-based microplegia (114 patients); (b) retrograde single-dose crystalloid Celsior® (147 patients). The propensity score adjusted maximum TnT was significantly lower in the Celsior group [average treatment effect = -0.55 ng/dl; 95% confidence interval (CI) -1.10 to -0.1 ng/dl; p = 0.048]. There were no differences in the postoperative use of intra-aortic balloon of counterpulsation or in the requirements of high-dose inotropic medications. In-hospital mortality was equivalent in both study groups ( p = 0.73); surgical re-exploration because of bleeding was equivalent ( p = 0.37). There were no differences in prolonged mechanical ventilation ( p = 0.65) and intensive care unit length of stay ( p = 0.87). CONCLUSION An isolated single dose of retrograde Celsior® may be an effective and safe myocardial protection strategy in on-pump CABG.
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Affiliation(s)
- José López-Menéndez
- Cardiac Surgery, Hospital Universitario Ramón y Cajal, Carretera de Colmenar Viejo, Km 9.7, Madrid 28034, Spain
| | - Javier Miguelena
- Cardiac Surgery, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Carlos Morales
- Cardiac Surgery, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Francisco Callejo
- Cardiac Surgery, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - Jacobo Silva
- Cardiac Surgery, Hospital Universitario Central de Asturias, Oviedo, Spain
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13
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Nardi P, Vacirca SR, Russo M, Colella DF, Bassano C, Scafuri A, Pellegrino A, Melino G, Ruvolo G. Cold crystalloid versus warm blood cardioplegia in patients undergoing aortic valve replacement. J Thorac Dis 2018; 10:1490-1499. [PMID: 29707299 DOI: 10.21037/jtd.2018.03.67] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Myocardial protection techniques during cardiac arrest have been extensively investigated in the clinical setting of coronary revascularization. Fewer studies have been carried out of patients affected by left ventricular hypertrophy, where the choice of type and temperature of cardioplegia remain controversial. We have retrospectively investigated myocardial injury and short-term outcome in patients undergoing aortic valve replacement plus or minus coronary artery bypass grafting with using cold crystalloid cardioplegia (CCC) or warm blood cardioplegia (WBC). Methods From January 2015 to October 2016, 191 consecutive patients underwent aortic valve replacement plus or minus coronary artery bypass grafting in normothermic cardiopulmonary bypass. Cardiac arrest was obtained with use of intermittent antegrade CCC group (n=32) or WBC group (n=159), according with the choice of the surgeon. Results As compared with WBC group, in CCC group creatine-kinase-MB (CK-MB), cardiac troponin I (cTnI), aspartate aminotransferase (AST) release, and their peak levels, were lower during each time points of evaluation, with the greater statistically significant difference at time 0 (P<0.05, for all comparisons). A time 0, CK-MB/CK ratio >10% was 5.9% in CCC group versus 7.8% in WBC group (P<0.0001). At time 0 CK-MB/CK ratio >10% in patients undergoing isolated aortic valve replacement was 6.0% in CCC group versus 8.0% in WBC group (P<0.01). No any difference was found in perioperative myocardial infarction (0% versus 3.8%), postoperative (PO) major complications (15.6% versus 16.4%), in-hospital mortality (3.1% versus 1.3%). Conclusions In aortic valve surgery a significant decrease of myocardial enzymes release is observed in favor of CCC, but this difference does not translate into different clinical outcome. However, this study suggests that in presence of cardiac surgical conditions associated with significant left ventricular hypertrophy, i.e., the aortic valve disease, a better myocardial protection can be achieved with the use of a cold rather than a warm cardioplegia. Therefore, CCC can be still safely used.
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Affiliation(s)
- Paolo Nardi
- Division of Cardiac Surgery, Faculty of Medicine and Surgery, Tor Vergata University, Rome, Italy
| | - Sara R Vacirca
- Division of Cardiac Surgery, Faculty of Medicine and Surgery, Tor Vergata University, Rome, Italy
| | - Marco Russo
- Division of Cardiac Surgery, Faculty of Medicine and Surgery, Tor Vergata University, Rome, Italy
| | - Dionisio F Colella
- Division of Anesthesiology, Faculty of Medicine and Surgery, Tor Vergata University, Rome, Italy
| | - Carlo Bassano
- Division of Cardiac Surgery, Faculty of Medicine and Surgery, Tor Vergata University, Rome, Italy
| | - Antonio Scafuri
- Division of Cardiac Surgery, Faculty of Medicine and Surgery, Tor Vergata University, Rome, Italy
| | - Antonio Pellegrino
- Division of Cardiac Surgery, Faculty of Medicine and Surgery, Tor Vergata University, Rome, Italy
| | - Gerry Melino
- Department of Experimental Medicine and Surgery, Faculty of Medicine and Surgery, Tor Vergata University, Rome, Italy
| | - Giovanni Ruvolo
- Division of Cardiac Surgery, Faculty of Medicine and Surgery, Tor Vergata University, Rome, Italy
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Siddiqi S, Blackstone EH, Bakaeen FG. Bretschneider and del Nido solutions: Are they safe for coronary artery bypass grafting? If so, how should we use them? J Card Surg 2018; 33:229-234. [DOI: 10.1111/jocs.13539] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Shirin Siddiqi
- Department of Thoracic and Cardiovascular Surgery; Cleveland Clinic Foundation; Cleveland Ohio
| | - Eugene H. Blackstone
- Department of Thoracic and Cardiovascular Surgery; Heart and Vascular Institute; Cleveland Ohio
- Department of Quantitative Health Sciences; Research Institute; Cleveland Ohio
| | - Faisal G. Bakaeen
- Department of Thoracic and Cardiovascular Surgery; Heart and Vascular Institute; Cleveland Ohio
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El-Essawi A, Breitenbach I, Haupt B, Brouwer R, Baraki H, Harringer W. Impact of minimally invasive extracorporeal circuits on octogenarians undergoing coronary artery bypass grafting. Have we been looking in the wrong direction? Eur J Cardiothorac Surg 2017; 52:1175-1181. [PMID: 28582490 DOI: 10.1093/ejcts/ezx156] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2017] [Accepted: 04/23/2017] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Minimally invasive extracorporeal circuits (MiECCs) aim at the preservation of physiologic reserves, the impact of which is expected to be most evident in patients in whom these are depleted. In this context, octogenarians present a subpopulation of specific interest. METHODS Based on the type of the utilized ECC, we performed a retrospective comparison between all octogenarians (n = 324) who received a primary coronary artery bypass in our institution from 2003 until 2010. RESULTS An MiECC was used in 52% of patients. Preoperative variables showed that the MiECC patients were older (83 ± 2 vs 82 ± 2 years; P = 0.001), had higher incidence of renal dysfunction (8% vs 3%; P = 0.04), moderately reduced left ventricular function (43 vs 33%; P = 0.07) and lower incidence of unstable angina (20% vs 28%; P = 0.06). To overcome these differences, a propensity score matching was performed and yielded 126 matched pairs of patients. The overall transfusion of packed red blood cells (2.3 ± 2.3 vs 3.4 ± 3.2 units per patint; P = <0.001), the rate of low cardiac output (0% vs 6%; P = 0.01) and the 30-day postoperative mortality (2.4% vs 9.5%; P = 0.02) were all in favour of the MiECC group in the matched patient population. CONCLUSIONS The MiECC concept has shown its benefits regarding both morbidity and mortality in this high-risk patient population. We believe that this beneficial effect finds its reason in a better preservation of physiologic reserves that are essential for a positive outcome in this patient group.
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Affiliation(s)
- Aschraf El-Essawi
- Department of Thoracic and Cardiovascular Surgery, Klinikum Braunschweig, Germany
| | - Ingo Breitenbach
- Department of Thoracic and Cardiovascular Surgery, Klinikum Braunschweig, Germany
| | - Benjamin Haupt
- Academy of Perfusion, German Heart Centre Berlin, Berlin, Germany
| | - Rene Brouwer
- Department of Thoracic and Cardiovascular Surgery, Klinikum Braunschweig, Germany
| | - Hassina Baraki
- Department of Cardiothoracic Surgery, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
| | - Wolfgang Harringer
- Department of Thoracic and Cardiovascular Surgery, Klinikum Braunschweig, Germany
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Mimic B, Ilic S, Vulicevic I, Milovanovic V, Tomic D, Mimic A, Stankovic S, Zecevic T, Davies B, Djordjevic M. Comparison of high glucose concentration blood and crystalloid cardioplegia in paediatric cardiac surgery: a randomized clinical trial. Interact Cardiovasc Thorac Surg 2016; 22:553-60. [PMID: 26831677 DOI: 10.1093/icvts/ivv391] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2015] [Accepted: 12/04/2015] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES This study investigates the effects of high glucose content on patients undergoing cold crystalloid versus cold blood cardioplegia in terms of early clinical results, functional myocardial recovery and ischaemia-reperfusion injury in patients undergoing repair of acyanotic cardiac lesions. METHODS Patients were randomly assigned to receive either crystalloid (n = 31) or blood cardioplegia (n = 31). Early clinical results were assessed. Changes in left ventricular fractional shortening, arterial blood lactate levels, central venous saturation, cardiac Troponin I release and blood glucose concentration were measured during the first 24 h after ischaemia. RESULTS There was no significant difference in clinical outcomes and postoperative complication rates between groups. The postoperative changes in left ventricular function, lactate levels, central venous saturation and Troponin I were not significantly different between groups. The use of crystalloid cardioplegia was associated with significant increases in serum glucose compared with blood cardioplegia. CONCLUSIONS A high glucose content blood cardioplegia does not show any advantage compared with crystalloid cardioplegia in terms of clinical outcomes, functional recovery and the degree of ischaemic injury in infants and children undergoing repair of acyanotic heart lesions. High glucose concentration of the cardioplegic solution might potentiate ischaemia-reperfusion injury and diminish the beneficial effects of blood cardioplegia.
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Affiliation(s)
- Branko Mimic
- Department of Cardiac Surgery, University Children's Hospital, Belgrade, Serbia Department of Cardiothoracic Surgery, Great Ormond Street Hospital, London, UK
| | - Slobodan Ilic
- Department of Cardiac Surgery, University Children's Hospital, Belgrade, Serbia School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Irena Vulicevic
- Department of Cardiac Surgery, University Children's Hospital, Belgrade, Serbia
| | | | - Danijela Tomic
- Department of Cardiac Surgery, University Children's Hospital, Belgrade, Serbia
| | - Ana Mimic
- Department of Anaesthesiology, Clinical Centre of Serbia, Belgrade, Serbia
| | - Sanja Stankovic
- Centre for Medical Biochemistry, Clinical Centre of Serbia, Belgrade, Serbia
| | - Tatjana Zecevic
- Department of Cardiac Surgery, University Children's Hospital, Belgrade, Serbia
| | - Ben Davies
- Department of Cardiothoracic Surgery, Great Ormond Street Hospital, London, UK
| | - Miroslav Djordjevic
- School of Medicine, University of Belgrade, Belgrade, Serbia Department of Urology, University Children's Hospital, Belgrade, Serbia
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Baikoussis NG, Papakonstantinou NA, Verra C, Kakouris G, Chounti M, Hountis P, Dedeilias P, Argiriou M. Mechanisms of oxidative stress and myocardial protection during open-heart surgery. Ann Card Anaesth 2015; 18:555-64. [PMID: 26440242 PMCID: PMC4881677 DOI: 10.4103/0971-9784.166465] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2015] [Accepted: 08/10/2015] [Indexed: 11/25/2022] Open
Abstract
Cold heart protection via cardioplegia administration, limits the amount of oxygen demand. Systemic normothermia with warm cardioplegia was introduced due to the abundance of detrimental effects of hypothermia. A temperature of 32-33°C in combination with tepid blood cardioplegia of the same temperature appears to be protective enough for both; heart and brain. Reduction of nitric oxide (NO) concentration is in part responsible for myocardial injury after the cardioplegic cardiac arrest. Restoration of NO balance with exogenous NO supplementation has been shown useful to prevent inflammation and apoptosis. In this article, we discuss the "deleterious" effects of the oxidative stress of the extracorporeal circulation and the up-to-date theories of "ideal'' myocardial protection.
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Affiliation(s)
- Nikolaos G. Baikoussis
- Department of Cardiovascular and Thoracic Surgery, “Evangelismos” General Hospital of Athens, Athens, Greece
| | | | - Chrysoula Verra
- Department of Medical Biopathology, Patras General Hospital, Patras, Greece
| | - Georgios Kakouris
- Department of Medical Biopathology, Patras General Hospital, Patras, Greece
| | - Maria Chounti
- Nursing School - Technological Institute of Patras, Patras, Greece
| | - Panagiotis Hountis
- Department of Thoracic and Cardiovascular Surgery, Athens Naval and Veterans Hospital, Athens, Greece
| | - Panagiotis Dedeilias
- Department of Cardiovascular and Thoracic Surgery, “Evangelismos” General Hospital of Athens, Athens, Greece
| | - Michalis Argiriou
- Department of Cardiovascular and Thoracic Surgery, “Evangelismos” General Hospital of Athens, Athens, Greece
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Cardioprotection: a review of current practice in global ischemia and future translational perspective. BIOMED RESEARCH INTERNATIONAL 2014; 2014:325725. [PMID: 25276778 PMCID: PMC4172998 DOI: 10.1155/2014/325725] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/19/2014] [Revised: 07/31/2014] [Accepted: 08/11/2014] [Indexed: 12/02/2022]
Abstract
The idea of protecting the heart from ischemic insult during heart surgery to allow elective cardiac arrest is as old as the idea of cardiac surgery itself. The current gold standard in clinical routine is a high potassium regimen added either to crystalloid or blood cardioplegic solutions inducing depolarized arrest. Ongoing patient demographic changes with increasingly older, comorbidly ill patients and increasing case complexity with increasingly structurally abnormal hearts as morphological correlate paired with evolutions in pediatric cardiac surgery allowing more complex procedures than ever before redefine requirements for cardioprotection.
Many, in part adversarial, regimens to protect the myocardium from ischemic insults have entered clinical routine; however, functional recovery of the heart is still often impaired due to perfusion injury. Myocardial reperfusion damage is a key determinant of postoperative organ functional recovery, morbidity, and mortality in adult and pediatric patients.
There is a discrepancy between what current protective strategies are capable of and what they are expected to do in a rapidly changing cardiac surgery community. An increased understanding of the molecular players of ischemia reperfusion injury offers potential seeds for new cardioprotective regimens and may further displace boundaries of what is technically feasible.
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de Jonge M, van Boxtel AG, Soliman Hamad MA, Mokhles MM, Bramer S, Osnabrugge RLJ, van Straten AHM, Berreklouw E. Intermittent warm blood versus cold crystalloid cardioplegia for myocardial protection: a propensity score-matched analysis of 12-year single-center experience. Perfusion 2014; 30:243-9. [DOI: 10.1177/0267659114540023] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objectives: This study analyzes the efficacy in myocardial protection of two types of cardioplegia solutions, namely, blood and crystalloid cardioplegia, both given intermittently in patients undergoing coronary artery bypass grafting (CABG). Methods: Adult patients undergoing primary isolated coronary artery bypass grafting between January 1998 and January 2011 with cardiopulmonary bypass, using either blood or crystalloid cardioplegia, were identified in our database. Propensity score matching was performed to create comparable patient groups. Multivariate logistic regression analysis was performed to identify independent risk factors for perioperative myocardial damage. The primary endpoint of the study was the maximum creatine kinase-MB (CK-MB) value within 5 days postoperatively with a cut-off point of 100 U/L. Early mortality and perioperative low cardiac output syndrome in both groups were compared. Results: The study included 7138 CABG patients: 3369 patients using crystalloid cardioplegia and 3769 using blood cardioplegia. After propensity score matching, 2585 patients per study group remained for the analysis. Wilcoxon signed-rank test revealed significantly higher CK-MB levels in patients operated with the use of blood cardioplegia. Multivariate regression analysis identified blood cardioplegia as an independent risk factor for elevated CK-MB levels. However, it was associated with lower aspartate aminotransferase (AST) levels. The type of cardioplegia had no influence on early mortality, postoperative low cardiac output syndrome or intensive care unit stay. Conclusions: Blood cardioplegia was identified as an independent risk factor for elevated levels of CK-MB after CABG, but was associated with lower AST levels. The authors conclude that the type of cardioplegia had no significant influence on clinical outcome.
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Affiliation(s)
- M de Jonge
- Department of Cardiothoracic Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | - AG van Boxtel
- Department of Cardiothoracic Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | - MA Soliman Hamad
- Department of Cardiothoracic Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | - MM Mokhles
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - S Bramer
- Department of Cardiothoracic Surgery, Amphia Hospital, Breda, The Netherlands
| | - RLJ Osnabrugge
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - AHM van Straten
- Department of Cardiothoracic Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | - E Berreklouw
- Department of Cardiothoracic Surgery, Catharina Hospital, Eindhoven, The Netherlands
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Lee CH, Ju MH, Kim JB, Chung CH, Jung SH, Choo SJ, Lee JW. Myocardial injury following aortic valve replacement for severe aortic stenosis: risk factor of postoperative myocardial injury and its impact on long-term outcomes. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2014; 47:233-9. [PMID: 25207220 PMCID: PMC4157473 DOI: 10.5090/kjtcs.2014.47.3.233] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/27/2013] [Revised: 10/17/2013] [Accepted: 10/29/2013] [Indexed: 11/16/2022]
Abstract
Background As hypertrophied myocardium predisposes the patient to decreased tolerance to ischemia and increased reperfusion injury, myocardial protection is of utmost importance in patients undergoing aortic valve replacement (AVR) for severe aortic valve stenosis (AS). Methods Consecutive 314 patients (mean age, 62.5±10.8 years; 143 females) with severe AS undergoing isolated AVR were included. Postoperative myocardial injury (PMI) was defined as 1) maximum postoperative creatinine kinase isoenzyme MB or troponin-I levels ≥10 times of reference, 2) postoperative low cardiac output syndrome or episodes of ventricular arrhythmia, or 3) left ventricular ejection fraction of less than 55% and decrease in left ventricle (LV) ejection fraction of more than 20% of the baseline value. Results There were 90 patients (28.7%) who developed PMI. There were five cases of early death (1.6%), all of whom had PMI. On multivariable analysis, the use of histidine-tryptophan-ketoglutarate (HTK) solution instead of blood cardioplegia (odds ratio [OR], 3.06; 95% confidence interval [CI], 1.63 to 5.77; p=0.001), greater LV mass (OR, 1.04; 95% CI, 1.01 to 1.07; p=0.007), and increased cardiac ischemic time (OR, 1.13; 95% CI, 1.05 to 1.22; p<0.001) were independent predictors for PMI. Patients who had PMI showed significantly inferior long-term survival than those without PMI (p=0.049). Conclusion PMI occurred in a considerable proportion of patients undergoing AVR for severe AS and was associated with poor long-term survival. HTK cardioplegia, higher LV mass, and longer cardiac ischemic duration were suggested as predictors of myocardial injury.
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Affiliation(s)
- Chee-Hoon Lee
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Korea
| | - Min Ho Ju
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Korea
| | - Joon Bum Kim
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Korea
| | - Cheol Hyun Chung
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Korea
| | - Sung Ho Jung
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Korea
| | - Suk Jung Choo
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Korea
| | - Jae Won Lee
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Korea
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Zeng J, He W, Qu Z, Tang Y, Zhou Q, Zhang B. Cold Blood Versus Crystalloid Cardioplegia for Myocardial Protection in Adult Cardiac Surgery: A Meta-analysis of Randomized Controlled Studies. J Cardiothorac Vasc Anesth 2014; 28:674-81. [DOI: 10.1053/j.jvca.2013.06.005] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2013] [Indexed: 11/11/2022]
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Günday M, Bingöl H. Is crystalloid cardioplegia a strong predictor of intra-operative hemodilution? J Cardiothorac Surg 2014; 9:23. [PMID: 24468006 PMCID: PMC3914725 DOI: 10.1186/1749-8090-9-23] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2013] [Accepted: 12/30/2013] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Complications due to hemodilution (hematocrit value less than 22%) after cardiopulmonary bypass inevitably resulted with significantly greater intensive care requirements, long hospital stays, more operative costs, and increased mortality rates. We tried to identify whether crystalloid cardioplegia is the strongest predictor of intraoperative hemodilution or not. MATERIALS AND METHODS One hundred patients were included into this randomized prospective study. Patients were divided into the two groups. Crystalloid cardioplegia were given to the odd-numbered patients (Group 1, n=50 patients) and blood cardioplegia were given to the even-numbered patients (Group 2, n=50 patients). St. Thomas-II solution was used in Group-1 and Calafiore cold blood cardioplegia was in Group-2. RESULTS Average intraoperative hematocrit value was 18.4% ± 2.3 in crystalloid group 24.2% ± 3.4 in blood cardioplegia group (p<0.001). The lowest hematocrit value was 15% and 20% in two groups respectively (p<0.001). In crystalloid group average intraoperative packed red blood cell (RBC) transfusion was 2.3 ± 0.41 units, 0.7 ± 0.6 units blood cardioplegia group (p=0.001). Average transfused RBC was 2.7 ± 0.8 units in crystalloid group, 0.9 ± 0.4 units blood cardioplegia group (p<0.001). Multivariate analyses confirmed age (p = 0.005, OR = 3.78), female gender (p = 0.003, OR = 2.91), longer cross-clamp time (>60 minutes) (p = 0.001, OD = 0.97), body surface area <1.6 m2 (p = 0.001, OR = 6.01) and crystalloid cardioplegia (p < 0.001, OR = 0.19) as predictor of intraoperative hemodilution. CONCLUSION Crystalloid cardioplegia, compared to blood cardioplegia not only causes much more intra-operative hemodilution but also increases the blood transfusion requirement. Hemodilution and increased transfusion increases the intensive care unit and hospital stay, in the early postoperative period.
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Affiliation(s)
| | - Hakan Bingöl
- Department of Cardiovascular Surgery, Ankara Çankaya Hospital, Aşağı Dikmen mah, 575 sok, Orankent konutları B blok No:12, OR-AN Çankaya, Ankara, Turkey.
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Zacharias M, Mugawar M, Herbison GP, Walker RJ, Hovhannisyan K, Sivalingam P, Conlon NP. Interventions for protecting renal function in the perioperative period. Cochrane Database Syst Rev 2013; 2013:CD003590. [PMID: 24027097 PMCID: PMC7154582 DOI: 10.1002/14651858.cd003590.pub4] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND Various methods have been used to try to protect kidney function in patients undergoing surgery. These most often include pharmacological interventions such as dopamine and its analogues, diuretics, calcium channel blockers, angiotensin-converting enzyme (ACE) inhibitors, N-acetyl cysteine (NAC), atrial natriuretic peptide (ANP), sodium bicarbonate, antioxidants and erythropoietin (EPO). OBJECTIVES This review is aimed at determining the effectiveness of various measures advocated to protect patients' kidneys during the perioperative period.We considered the following questions: (1) Are any specific measures known to protect kidney function during the perioperative period? (2) Of measures used to protect the kidneys during the perioperative period, does any one method appear to be more effective than the others? (3) Of measures used to protect the kidneys during the perioperative period,does any one method appear to be safer than the others? SEARCH METHODS In this updated review, we searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, Issue 2, 2012), MEDLINE (Ovid SP) (1966 to August 2012) and EMBASE (Ovid SP) (1988 to August 2012). We originally handsearched six journals (Anesthesia and Analgesia, Anesthesiology, Annals of Surgery, British Journal of Anaesthesia, Journal of Thoracic and Cardiovascular Surgery, and Journal of Vascular Surgery) (1985 to 2004). However, because these journals are properly indexed in MEDLINE, we decided to rely on electronic searches only without handsearching the journals from 2004 onwards. SELECTION CRITERIA We selected all randomized controlled trials in adults undergoing surgery for which a treatment measure was used for the purpose of providing renal protection during the perioperative period. DATA COLLECTION AND ANALYSIS We selected 72 studies for inclusion in this review. Two review authors extracted data from all selected studies and entered them into RevMan 5.1; then the data were appropriately analysed. We performed subgroup analyses for type of intervention, type of surgical procedure and pre-existing renal dysfunction. We undertook sensitivity analyses for studies with high and moderately good methodological quality. MAIN RESULTS The updated review included data from 72 studies, comprising a total of 4378 participants. Of these, 2291 received some form of treatment and 2087 acted as controls. The interventions consisted most often of different pharmaceutical agents, such as dopamine and its analogues, diuretics, calcium channel blockers, ACE inhibitors, NAC, ANP, sodium bicarbonate, antioxidants and EPO or selected hydration fluids. Some clinical heterogeneity and varying risk of bias were noted amongst the studies, although we were able to meaningfully interpret the data. Results showed significant heterogeneity and indicated that most interventions provided no benefit.Data on perioperative mortality were reported in 41 studies and data on acute renal injury in 44 studies (all interventions combined). Because of considerable clinical heterogeneity (different clinical scenarios, as well as considerable methodological variability amongst the studies), we did not perform a meta-analysis on the combined data.Subgroup analysis of major interventions and surgical procedures showed no significant influence of interventions on reported mortality and acute renal injury. For the subgroup of participants who had pre-existing renal damage, the risk of mortality from 10 trials (959 participants) was estimated as odds ratio (OR) 0.76, 95% confidence interval (CI) 0.38 to 1.52; the risk of acute renal injury (as reported in the trials) was estimated from 11 trials (979 participants) as OR 0.43, 95% CI 0.23 to 0.80. Subgroup analysis of studies that were rated as having low risk of bias revealed that 19 studies reported mortality numbers (1604 participants); OR was 1.01, 95% CI 0.54 to 1.90. Fifteen studies reported data on acute renal injury (criteria chosen by the individual studies; 1600 participants); OR was 1.03, 95% CI 0.54 to 1.97. AUTHORS' CONCLUSIONS No reliable evidence from the available literature suggests that interventions during surgery can protect the kidneys from damage. However, the criteria used to diagnose acute renal damage varied in many of the older studies selected for inclusion in this review, many of which suffered from poor methodological quality such as insufficient participant numbers and poor definitions of end points such as acute renal failure and acute renal injury. Recent methods of detecting renal damage such as the use of specific biomarkers and better defined criteria for identifying renal damage (RIFLE (risk, injury, failure, loss of kidney function and end-stage renal failure) or AKI (acute kidney injury)) may have to be explored further to determine any possible benefit derived from interventions used to protect the kidneys during the perioperative period.
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Affiliation(s)
- Mathew Zacharias
- Dunedin HospitalDepartment of Anaesthesia & Intensive CareGreat King StreetDunedinNew ZealandPrivate Bag 192
| | - Mohan Mugawar
- St Vincent's University HospitalDepartment of Anaesthesia and Intensive Care MedicineElm ParkDublinIreland4
| | - G Peter Herbison
- Dunedin School of Medicine, University of OtagoDepartment of Preventive & Social MedicinePO Box 913DunedinNew Zealand9054
| | - Robert J Walker
- University of OtagoDepartment of MedicineDunedin School of MedicinePO Box 913DunedinNew Zealand9015
| | - Karen Hovhannisyan
- RigshospitaletThe Cochrane Anaesthesia Review GroupBlegdamsvej 9,Afsnit 5211, rum 1204CopenhagenDenmark2100
| | - Pal Sivalingam
- Princess Alexandra HospitalDepartment of AnaesthesiaIpswich RoadWoolloongabbaBrisbaneAustralia4102
| | - Niamh P Conlon
- St Vincent's University HospitalDepartment of AnaesthesiaElm ParkDublinIreland4
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Giordano P, Scrascia G, D'Agostino D, Mastro F, Rotunno C, Conte M, Rociola R, Paparella D. Myocardial damage following cardiac surgery: comparison between single-dose Celsior cardioplegic solution and cold blood multi-dose cardioplegia. Perfusion 2013; 28:496-503. [PMID: 23670806 DOI: 10.1177/0267659113486827] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Myocardial protection during cardiac surgery can be accomplished by different cardioplegic solutions. The aim of this study was to assess myocardial damage after heart valve surgery performed with myocardial protection of a single dose of Celsior cardioplegia or with repeated cold blood cardioplegia. After the stratification of 139 valvular patients by means of matching according to cross-clamp and cardiopulmonary bypass time, 32 patients were retained for comparison (16 patients received Celsior and 16 patients received cold blood cardioplegia). Creatine kinase-MB (CK-MB) and cardiac troponin I (cTnI) release were evaluated until six days after the operation. Pre-operative characteristics were similar in both groups. In the Celsior group, CK-MB and cTnI values were significantly higher from the first up to the sixth post-operative day. Peak cTnI values were 19.4 ± 13.4 and 9.7 ± 7 ng/mL (p=0.01) in the Celsior and the Cold Blood group, respectively. Peak CK-MB values were 79.6 ± 58.8 and 45.9 ± 20.6 U/L (p=0.07) in the Celsior and the Cold Blood group, respectively. Cold blood cardioplegia reduces perioperative myocardial damage compared to the Celsior solution in elective cardiac valve operations.
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Affiliation(s)
- P Giordano
- Division of Cardiac Surgery, Department of Emergency and Organ Transplant, University of Bari "Aldo Moro", Bari, Italy
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Jakobsen Ø, Næsheim T, Aas KN, Sørlie D, Steensrud T. Adenosine instead of supranormal potassium in cardioplegia: it is safe, efficient, and reduces the incidence of postoperative atrial fibrillation. A randomized clinical trial. J Thorac Cardiovasc Surg 2012; 145:812-8. [PMID: 22964356 DOI: 10.1016/j.jtcvs.2012.07.058] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2011] [Revised: 07/08/2012] [Accepted: 07/26/2012] [Indexed: 10/27/2022]
Abstract
OBJECTIVE We aimed to evaluate the efficacy and safety of a cold crystalloid cardioplegic solution with adenosine (1.2 mmol/L) instead of supranormal potassium. METHODS Sixty low-risk patients scheduled for elective coronary artery bypass grafting (CABG) were randomized to receive standard cold crystalloid hyperkalemic cardioplegia (hyperkalemic group) or normokalemic cardioplegia in which supranormal potassium was replaced with 1.2 mmol/L adenosine (adenosine group). End points were postoperative release of troponin T and creatine kinase MB, hemodynamics measured by PiCCO arterial thermodilution catheters, perioperative release of markers of endothelial activation and injury, and clinical course. RESULTS The adenosine group had a significantly shorter time to arrest than did the hyperkalemic group (mean ± standard deviation, 11 ± 5 vs 44 ± 18 seconds; P < .001). Three hearts in the adenosine group were probably not adequately drained and received additional hyperkalemic cardioplegia to maintain satisfactory cardioplegic arrest. There were no differences between groups with respect to perioperative release of markers of endothelial activation or injury and no differences between groups in postoperative release of troponin T or creatine kinase MB. Postoperative hemodynamics including cardiac index were similar between groups. The incidence of postoperative atrial fibrillation was significantly lower in the adenosine group than in the hyperkalemic group (4 vs 15; P = .01). CONCLUSIONS Adenosine instead of hyperkalemia in cold crystalloid cardioplegia is safe, gives more rapid cardiac arrest, and affords similar cardioprotection and maintenance of hemodynamic parameters, together with a marked reduction in the incidence of postoperative atrial fibrillation.
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Affiliation(s)
- Øyvind Jakobsen
- Department of Cardiothoracic and Vascular Surgery, University Hospital of North Norway and Institute of Clinical Medicine, Faculty of Health Sciences, University of Tromsø, Tromsø, Norway.
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Sá MPBO, Rueda FG, Ferraz PE, Chalegre ST, Vasconcelos FP, Lima RC. Is there any difference between blood and crystalloid cardioplegia for myocardial protection during cardiac surgery? A meta-analysis of 5576 patients from 36 randomized trials. Perfusion 2012; 27:535-46. [DOI: 10.1177/0267659112453754] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective: To compare the efficacy of blood versus crystalloid cardioplegia for myocardial protection in patients undergoing cardiac surgery. Methods: MEDLINE, EMBASE, CENTRAL/CCTR, SciELO, LILACS, Google Scholar and reference lists of relevant articles were searched for clinical studies that reported in-hospital outcomes after blood or crystalloid cardioplegia for myocardial protection during cardiac surgery procedures from 1966 to 2011. The principal summary measures were risk ratio (RR) for blood compared to crystalloid cardioplegia with 95% Confidence Interval (CI) and P values (considered statistically significant when <0.05). The RRs were combined across studies using the DerSimonian-Laird random effects model and fixed effects model using the Mantel-Haenszel model - both models were weighted. The meta-analysis was completed using the software Comprehensive Meta-Analysis version 2 (Biostat Inc., Englewood, New Jersey). Results: Thirty-six studies (randomized trials) were identified and included a total of 5576 patients (2834 for blood and 2742 for crystalloid). There was no significant difference between the blood and crystalloid groups in the risk for death (risk ratio [RR] 0.951, 95% CI 0.598 to 1.514, P=0.828, for both effect models) or myocardial infarction (RR 0.795, 95% CI 0.547 to 1.118, P=0.164, for both effect models) or low cardiac output syndrome (RR 0.765, 95% CI 0.580 to 1.142, P=0.094, for the fixed effect model; RR 0.690, 95% CI 0.480 to 1.042, P=0.072, for the random effect model). It was observed that there was no publication bias or heterogeneity of effects about any outcome. Conclusion: We found evidence that argues against any superiority in terms of hard outcomes between blood or crystalloid cardioplegia for myocardial protection during cardiac surgery.
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Affiliation(s)
- MPBO Sá
- Division of Cardiovascular Surgery of Pronto Socorro Cardiològico de Pernambuco – PROCAPE, Recife – Brazil
- University of Pernambuco – UPE, Recife – Brazil
- Nucleus of Postgraduate and Research in Health Sciences, Faculty of Medical Sciences and Biological Sciences Instituite – FCM/ICB, Recife – Brazil
| | - FG Rueda
- Division of Cardiovascular Surgery of Pronto Socorro Cardiològico de Pernambuco – PROCAPE, Recife – Brazil
- University of Pernambuco – UPE, Recife – Brazil
- Nucleus of Postgraduate and Research in Health Sciences, Faculty of Medical Sciences and Biological Sciences Instituite – FCM/ICB, Recife – Brazil
| | - PE Ferraz
- Division of Cardiovascular Surgery of Pronto Socorro Cardiològico de Pernambuco – PROCAPE, Recife – Brazil
- University of Pernambuco – UPE, Recife – Brazil
- Nucleus of Postgraduate and Research in Health Sciences, Faculty of Medical Sciences and Biological Sciences Instituite – FCM/ICB, Recife – Brazil
| | - ST Chalegre
- Division of Cardiovascular Surgery of Pronto Socorro Cardiològico de Pernambuco – PROCAPE, Recife – Brazil
- University of Pernambuco – UPE, Recife – Brazil
- Nucleus of Postgraduate and Research in Health Sciences, Faculty of Medical Sciences and Biological Sciences Instituite – FCM/ICB, Recife – Brazil
| | - FP Vasconcelos
- Division of Cardiovascular Surgery of Pronto Socorro Cardiològico de Pernambuco – PROCAPE, Recife – Brazil
- University of Pernambuco – UPE, Recife – Brazil
| | - RC Lima
- Division of Cardiovascular Surgery of Pronto Socorro Cardiològico de Pernambuco – PROCAPE, Recife – Brazil
- University of Pernambuco – UPE, Recife – Brazil
- Nucleus of Postgraduate and Research in Health Sciences, Faculty of Medical Sciences and Biological Sciences Instituite – FCM/ICB, Recife – Brazil
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Demmy TL, Molina JE, Ward HB, Gorton ME, Kouchoukos NT, Schmaltz RA, Shennib H. Custodiol versus Plegisol: A phase 3 multicentre myocardial protection study. Int J Angiol 2012; 17:149-53. [PMID: 22477420 DOI: 10.1055/s-0031-1278300] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
Abstract
BACKGROUND While considered simple and effective, crystalloid antegrade cardioplegia solutions have had few prospective multicentre comparison trials. METHODS A commercial intracellular-type histidine-tryptophan-ketoglutarate (HTK) cardioplegia solution (Custodiol HTK; Köhler Chemie GmbH, Germany) designed for 4 h of protection after a single administration was compared with a standard extracellular multidose product (Plegisol [PL]; Hospira Inc, USA) in an open-label, randomized, prospective seven-institution trial. A total of 136 isolated coronary bypass patients were randomly assigned into two groups and stratified by ejection fraction into categories of 40% or greater (n=118) and 20% to 39% (n=18). RESULTS The mean age of the study cohort was 62 years, of which 94% were men. Seventy per cent of patients had Canadian Cardiovascular Society class III angina and 75% had three-vessel disease anatomy. Cross-clamp times were nearly identical for patients in both cardioplegia groups; however, defibrillation was needed less often for patients who were treated with HTK (64% versus 91%, P<0.01). Hospital and intensive care unit stays, creatine kinase isoenzyme MB curves, cardiac outputs, inotrope levels, and deaths or serious adverse events (PL=13, HTK=14) were very similar between groups. Logistic regression showed that myocardial infarction or possible treatment-related adverse events were associated with high cardiac troponin I (cTn-I) levels 6 h after the procedure (P=0.001), and HTK treatment (OR 3.5, P=0.01). The primary study end point (6 h post-ischemia cTn-I) favoured PL (16.7±13.2 μg/L versus 20.3±13.5 μg/L, P=0.01). Patients who underwent circumflex grafting had higher cTn-I levels with HTK (P<0.001) and 48% required reinfusions due to cardiac warming. Longer intervals between doses correlated with high cTn-I levels (P=0.02). HTK provided prolonged protection with low cTn-I release (10 μg/L or less), although this occurred less frequently than with PL (17 versus 27 patients, P=0.06). CONCLUSIONS HTK caused more structural protein release and adverse events than PL, even when reinfusion was implemented.
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Affiliation(s)
- Todd L Demmy
- University of Missouri Cardiothoracic Surgery, Columbia, Missouri, USA
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Ried M, Kobuch R, Rupprecht L, Keyser A, Hilker M, Schmid C, Diez C. Reduced 30-day mortality in men after elective coronary artery bypass surgery with minimized extracorporeal circulation-a propensity score analysis. BMC Cardiovasc Disord 2012; 12:17. [PMID: 22424497 PMCID: PMC3323468 DOI: 10.1186/1471-2261-12-17] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2011] [Accepted: 03/16/2012] [Indexed: 11/30/2022] Open
Abstract
Background Impact of minimized extracorporeal circulation (MECC) for coronary surgery on mortality remains controversial and gender significantly influence outcome. Methods We analyzed 3,139 male patients undergoing elective coronary surgery between 01/2004 and 05/2009. Using propensity score matching after binary logistic regression, 1,005 patients (from 1,119 patients) undergoing surgery with MECC could be matched with 1,005 patients (from 2,020 patients) undergoing surgery with conventional extracorporeal circulation (CECC). Primary outcome was 30-day mortality. Results Unadjusted 30-day mortality was 2.7% in patients with CECC and 0.8% in those with MECC (mean difference -1.9%; p < 0.001). The adjusted mean difference (average treatment effect of the treated) after matching was -1.5% (95% confidence interval (CI) -2.6 to -0.4; p = 0.006). Postoperative hospital stay was shorter in patients operated with minimized systems (adjusted mean difference -0.8 days; 95% CI -1.46 to -0.09; p = 0.03) and incidence of postoperative neurocognitive dysfunction was also lower (adjusted mean difference -1.3%; 95% CI -2.2 to -0.4; p = 0.001). Chest tube drainage (adjusted mean difference +22 mL; 95% CI -47 to 91; p = 0.5) and risk for acute kidney injury, kidney injury and failure according to RIFLE criteria (adjusted mean difference -1.0%; 95% CI -2.5 to 0.6; p = 0.24) proved to be insignificant between both groups. Apart from reduced 30-day mortality, however, average treatment effects for intensive care unit stay, postoperative hospital stay, chest tube drainage and kidney injury did not significantly differ. Conclusion Using propensity score analysis, we observed an association between MECC and reduced 30-day mortality in men, but our results call for further analysis.
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Affiliation(s)
- Michael Ried
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, Franz-Josef-Strauß-Allee 11, Regensburg 93053, Germany.
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The estimation of oxidative stress markers and apoptosis in right atrium auricles cardiomyocytes of patients undergoing surgical heart revascularisation with the use of warm blood cardioplegia. Folia Histochem Cytobiol 2010; 48:202-7. [PMID: 20675275 DOI: 10.2478/v10042-010-0012-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Oxidative stress markers and apoptosis were estimated during elective surgical heart revascularization. Eight patients with good ejection fraction underwent coronary artery bypass grafting (CABG) with the use of warm blood cardioplegia. Two right atrium auricle biopsy specimens were collected before and after the operation. Specimens underwent immunocytochemical analysis of mitochondrial manganese superoxide dismutase (MnSOD) expression and apoptosis estimation by the TUNEL method. Ultrastructure analysis under electron microscope was made. Satisfactory results of the operation were obtained. After CABG the MnSOD expression increase in sections of auricles was observed through the increase of stain intensity and the percentage of cells with positive stain (from 30 to 80%). The apoptotic cells percentage remained at approximately the same level. Under the electron microscope insignificant pathological changes were observed. On this basis one may assume that in the case of cardiosurgical procedures with short aorta cross-clamping time and low operation risk level the application of cardioplegia sufficiently prevents reactive oxygen forms (ROF) cytotoxic activity although it does not inhibit the expression of oxidative stress (OS) markers. In our opinion the method of examining right atrium sections is safe and provides results comparable with other publications. It may also be a voice in the discussion on new methods of heart protection during cardiac surgery procedures.
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Cold blood cardioplegia reduces the increase in cardiac enzyme levels compared with cold crystalloid cardioplegia in patients undergoing aortic valve replacement for isolated aortic stenosis. J Thorac Cardiovasc Surg 2009; 139:874-80. [PMID: 19660338 DOI: 10.1016/j.jtcvs.2009.05.036] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2009] [Revised: 04/26/2009] [Accepted: 05/31/2009] [Indexed: 02/08/2023]
Abstract
OBJECTIVES Cardiac arrest during cardiac surgery is most commonly induced by cold blood or cold crystalloid cardioplegia. The results from clinical studies are divergent regarding which of the 2 solutions provides better myocardial protection. This might be explained by several factors. Both heterogeneity in disease for the included patients and the fact that most studies are retrospective in design and that patients with coronary artery disease with different degrees of myocardial ischemia are included might explain these findings. To circumvent these potentially confounding factors, we included in a prospective randomized study only patients undergoing aortic valve replacement for aortic stenosis without other significant cardiac disease. Patients were randomized to antegrade cold crystalloid or cold blood cardioplegia. METHODS Eighty patients with aortic stenosis undergoing aortic valve replacement without significant coronary artery stenosis or other significant concomitant heart valve disease were included in the study. They were randomized to either antegrade cold blood or cold crystalloid cardioplegic solution delivered through the coronary ostia every 20 minutes throughout the period of aortic crossclamping. Maximum postoperative creatine kinase isoenzyme MB and troponin-T levels, well-established markers of myocardial damage, were compared between the 2 groups. RESULTS Both maximum postoperative creatine kinase isoenzyme MB and troponin-T levels were significantly higher by approximately 100% in the cohort of patients receiving crystalloid compared with blood cardioplegia. Only in the group of patients receiving cold crystalloid cardioplegia was there a positive correlation between cardiac enzyme levels and crossclamp time. CONCLUSION Antegrade cold blood cardioplegia provides better myocardial protection than cold crystalloid cardioplegia in patients undergoing aortic valve replacement.
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Colangelo N, Moriggia S, Kieser T, De Simone F, Vescovo A, Palumbo L, Denti P, Guidotti A, Blasio A, Maisano F, Alfieri O. A cardioplegia circuit with versatility: the 'ReVerse' system. How to do it. Perfusion 2009; 23:205-7. [PMID: 19181751 DOI: 10.1177/0267659108101498] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Various methods of cardioplegia administration have been used in cardiac surgery: crystalloid, blood and mixed crystalloid/blood. Each of these types of cardioplegia administration typically needs a different circuit. This may correspond to an increase in cost and the time needed to change the circuit if required. When various modifications are performed on the circuit, this also increases the risk of contamination. In order to simplify the management of differing cardioplegia circuits, we devised one circuit for all solutions in all situations by adding one modification. The ReVerse cardioplegia circuit system is a description of a two-pump cardioplegia circuit which is adaptable to either blood or crystalloid cardioplegia. The change from one mode to another requires a manoeuvre of two clamps, allowing the blood solution to travel through shunt tubing into the apposite pumphead. In our experience the versatility of this circuit is a fast, safe method to administrate all types of cardioplegia solution, saving the space taken up by storing multiple circuits.
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Affiliation(s)
- N Colangelo
- Department of Cardiac Surgery and Cardiovascular Perfusion, San Raffaele Vita e Salute University Hospital, Milan, Italy.
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Zacharias M, Conlon NP, Herbison GP, Sivalingam P, Walker RJ, Hovhannisyan K. Interventions for protecting renal function in the perioperative period. Cochrane Database Syst Rev 2008:CD003590. [PMID: 18843647 DOI: 10.1002/14651858.cd003590.pub3] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND A number of methods have been used to try to protect kidney function in patients undergoing surgery. These include the administration of dopamine and its analogues, diuretics, calcium channel blockers, angiotensin converting enzyme inhibitors and hydration fluids. OBJECTIVES For this review, we selected randomized controlled trials which employed different methods to protect renal function during the perioperative period. In examining these trials, we looked at outcomes that included renal failure and mortality as well as changes in renal function tests, such as urine output, creatinine clearance, free water clearance, fractional excretion of sodium and renal plasma flow. SEARCH STRATEGY We searched the Cochrane Central register of Controlled Trials (CENTRAL) (The Cochrane Library 2007, Issue 2), MEDLINE (1966 to June, 2007), and EMBASE (1988 to June, 2007); and handsearched six journals (Anesthesia and Analgesia, Anesthesiology, Annals of Surgery, British Journal of Anaesthesia, Journal of Thoracic and Cardiovascular Surgery, and Journal of Vascular Surgery). SELECTION CRITERIA We selected all randomized controlled trials in adults undergoing surgery where a treatment measure was used for the purpose of renal protection in the perioperative period. DATA COLLECTION AND ANALYSIS We selected 53 studies for inclusion in this review. As well as data analysis from all the studies, we performed subgroup analysis for type of intervention, type of surgical procedure, and pre-existing renal dysfunction. We undertook sensitivity analysis on studies with high and moderately good methodological quality. MAIN RESULTS The review included data from 53 studies, comprising a total of 2327 participants. Of these, 1293 received some form of treatment and 1034 acted as controls. The interventions mostly consisted of different pharmaceutical agents, such as dopamine and its analogues, diuretics, calcium channel blockers, ACE inhibitors, or selected hydration fluids. The results indicated that certain interventions showed minimal benefits. All the results suffered from significant heterogeneity. Hence we cannot draw conclusions about the effectiveness of these interventions in protecting patients' kidneys during surgery. AUTHORS' CONCLUSIONS There is no reliable evidence from the available literature to suggest that interventions during surgery can protect the kidneys from damage. There is a need for more studies with high methodological quality. One particular area for further study may be patients with pre-existing renal dysfunction undergoing surgery.
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Affiliation(s)
- Mathew Zacharias
- Department of Anaesthesia & Intensive Care, Dunedin Hospital, Great King Street, Dunedin, Otago, New Zealand, Private Bag 192.
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Chen Y, Almeida AA, Goldstein J, Shardey GC, Pick AW, Moshinsky R, Kejriwal NK, Lowe C, Jolley D, Smith JA. URGENT AND EMERGENCY CORONARY ARTERY BYPASS GRAFTING FOR ACUTE CORONARY SYNDROMES. ANZ J Surg 2006; 76:769-73. [PMID: 16922894 DOI: 10.1111/j.1445-2197.2006.03864.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Urgent and emergency coronary artery bypass grafting may be associated with significant mortality and morbidity. We report our recent experience with this group of patients. METHODS A retrospective analysis of 441 patients undergoing urgent and emergency surgery over a 3-year period was carried out. Multivariate analysis was used to identify subgroups of patients who were most at risk of death. RESULTS The 30-day mortality was 3.3 and 16.3% in the urgent and emergency groups, respectively. Urgent surgery was associated with significantly shorter duration of ventilation (16 h vs 69 h) and stay at the intensive care unit (31 h vs 102 h). The incidence of pneumonia, pulmonary embolism, renal failure and neurological events were also less in the urgent group. The preoperative use of the intra-aortic balloon pump was low (0.8% in the urgent group and 4.8% in the emergency group). Multivariate analysis showed that patients over 70 years of age (odds ratio 3.2, 95% confidence interval 1.1-9.5) with left main stenosis (odds ratio 4.4, 95% confidence interval 1.5-12.4) complicated by cardiogenic shock (odds ratio 17.8, 95% confidence interval 5.2-61.1) were at highest risk of death. Patients transferred directly to theatre from cardiac catheter laboratory following failed percutaneous interventions were found to be most at risk. Mortality in this group was 29%, with 50% patients being in shock and 36% having left main stenosis. CONCLUSION Satisfactory results have been obtained in urgent coronary artery bypass grafting, but acute coronary syndromes complicated by cardiogenic shock remain a high-risk group. Further studies are needed to define the optimal operative management in this group of patients.
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Affiliation(s)
- Yi Chen
- Cardiothoracic Surgery Unit, Monah Medical Centre, Clayton, Victoria, Australia
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Guru V, Omura J, Alghamdi AA, Weisel R, Fremes SE. Is blood superior to crystalloid cardioplegia? A meta-analysis of randomized clinical trials. Circulation 2006; 114:I331-8. [PMID: 16820596 DOI: 10.1161/circulationaha.105.001644] [Citation(s) in RCA: 83] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Many small, randomized, controlled trials have evaluated the effectiveness of blood as compared with crystalloid cardioplegia for myocardial protection during cardiac surgery. Blood cardioplegia provides a closer approximation to normal physiology, which may translate into measurable clinical benefits. This meta-analysis describes the effectiveness of blood cardioplegia in lowering adverse postoperative outcomes. METHODS AND RESULTS MEDLINE, EMBASE, and the Cochrane registry of controlled trials were searched for clinical trials. The search was restricted to peer-reviewed English language publications of randomized controlled trials that primarily compared blood and crystalloid cardioplegia in adult patients. Each trial was blindly assessed and abstracted by 2 reviewers. The primary outcomes were: low output syndrome (LOS), myocardial infarction (MI), and death. Surrogate outcomes included postoperative creatinine kinase MB (CKMB) increase. Random effects summary odds ratio (OR) for binary outcomes, and weighted mean difference for continuous outcomes were calculated. A total of 34 trials were included. The majority of trials were conducted in patients undergoing elective CABG surgery (n=18). The incidence of LOS was decreased significantly with blood cardioplegia (OR, 0.54; 95% confidence interval [CI], 0.34 to 0.84; P=0.006; 879 patients, 10 trials). The incidence of MI and death were similar between treatment groups (MI: OR, 0.78; 95% CI, 0.54 to 1.13; 4316 patients, 23 trials) (death: OR, 0.80; 95% CI, 0.46 to 1.40; 4022 patients, 17 trials). CKMB release after surgery at 24 hours was reduced with blood cardioplegia (5.9 U/L; 95% CI, 1.6 to 10.2; P=0.007; 821 patients, 7 trials). CONCLUSIONS Blood cardioplegia provides superior myocardial protection as compared with crystalloid cardioplegia, including lower rates of LOS, and early CKMB increase, whereas the incidence of myocardial infarction and death are similar.
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Affiliation(s)
- Veena Guru
- Division of Cardiovascular Surgery, Sunnybrook and Women's College Health Sciences Centre, 2075 Bayview Avenue, H-410, Toronto, Ontario M4N 3M5 Canada.
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Abstract
Cold crystalloid cardioplegia is clinically used since the mid-1960s. It is currently applied in adult and pediatric cardiac surgery patients and remains the preferred method of myocardial protection for many cardiac surgeons. This chapter gives a brief overview about the technical aspects of cold crystalloid cardioplegia application in the operating room.
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Affiliation(s)
- Hans J Geissler
- Department of Cardiothoracic Surgery, University of Cologne, Joseph-Stelzmann-Str. 9, 50924 Cologne, Germany
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Gaze DC, Collinson PO. Cardiac troponins as biomarkers of drug- and toxin-induced cardiac toxicity and cardioprotection. Expert Opin Drug Metab Toxicol 2005; 1:715-25. [PMID: 16863435 DOI: 10.1517/17425255.1.4.715] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Cardiac troponin T and I (cTnT, cTnI) are sensitive biochemical markers of myocardial cell necrosis and have been adopted as the gold standard tests for acute myocardial infarction. Subtle elevations in cTn above the detection limits of the currently available commercial assays confers poor prognosis. These markers are superior to classical enzyme markers of necrosis due to their cardiospecificity. The diagnosis of drug-induced cardiac toxicity using the classical enzymes is problematic due to the high elevations of these markers in skeletal muscle necrosis. cTnT and cTnI are now being adopted as sensitive biomarkers of drug-induced cardiac toxicity.
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Affiliation(s)
- David C Gaze
- St George's Hospital, Chemical Pathology, Blackshaw Road, Tooting, London SW17 0QT, UK.
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Amark K, Berggren H, Björk K, Ekroth A, Ekroth R, Nilsson K, Sunnegårdh J. Blood Cardioplegia Provides Superior Protection in Infant Cardiac Surgery. Ann Thorac Surg 2005; 80:989-94. [PMID: 16122471 DOI: 10.1016/j.athoracsur.2005.03.095] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2005] [Revised: 03/18/2005] [Accepted: 03/23/2005] [Indexed: 10/25/2022]
Abstract
BACKGROUND We hypothesized that blood cardioplegia preserves myocardial metabolism and function more effectively than St Thomas' crystalloid cardioplegia in infant cardiac surgery. METHODS Thirty infants with atrioventricular septal defects were randomly allocated to either blood or crystalloid intermittent cold (4 degrees C) cardioplegia. Arterial and coronary sinus blood was analyzed for lactate and oxygen. Cardiac output (thermodilution) and left ventricular function (echocardiography) were evaluated. RESULTS The lactate concentration in coronary sinus blood early after bypass was significantly higher after crystalloid cardioplegia than after blood cardioplegia (2.1 +/- 0.3 vs 1.3 +/- 0.1 mmol/L, p = 0.006), with a significant myocardial release of lactate after crystalloid but not after blood cardioplegia. Oxygen extraction (arterial-coronary sinus O2 content) was higher early after crystalloid cardioplegia (3.02 +/- 0.13 vs 2.35 +/- 0.22 mmol/L, p = 0.01), possibly reflecting a difference in oxygen debt. The cardiac index was higher after blood cardioplegia (4.9 +/- 0.3 vs 4.0 +/- 0.3 L/min(-1)/m(-2), p = 0.04) and echocardiographic grading of left ventricular function was better (4.1 +/- 0.17 vs 3.5 +/- 0.22 arbitrary units, p = 0.046). CONCLUSIONS This study indicates that blood cardioplegia preserves myocardial metabolism and function more effectively than crystalloid cardioplegia in infant cardiac surgery. The clinical significance of this finding is uncertain, but the more than 20% increase in cardiac index in the critical phase during weaning from bypass may be advantageous.
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Affiliation(s)
- Kerstin Amark
- Department of Pediatric Cardiology and Pediatric Anesthesia and Intensive Care, The Queen Silvia Children's Hospital, Göteborg, Sweden.
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