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Francica A, Tonelli F, Rossetti C, Tropea I, Luciani GB, Faggian G, Dobson GP, Onorati F. Cardioplegia between Evolution and Revolution: From Depolarized to Polarized Cardiac Arrest in Adult Cardiac Surgery. J Clin Med 2021; 10:jcm10194485. [PMID: 34640503 PMCID: PMC8509840 DOI: 10.3390/jcm10194485] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Accepted: 09/28/2021] [Indexed: 12/12/2022] Open
Abstract
Despite current advances in perioperative care, intraoperative myocardial protection during cardiac surgery has not kept the same pace. High potassium cardioplegic solutions were introduced in the 1950s, and in the early 1960s they were soon recognized as harmful. Since that time, surgeons have minimized many of the adverse effects by lowering the temperature of the heart, lowering K+ concentration, reducing contact K+ time, changing the vehicle from a crystalloid solution to whole-blood, adding many pharmacological protectants and modifying reperfusion conditions. Despite these attempts, high potassium remains a suboptimalway to arrest the heart. We briefly review the historical advances and failures of finding alternatives to high potassium, the drawbacks of a prolonged depolarized membrane, altered Ca2+ intracellular circuits and heterogeneity in atrial-ventricular K+ repolarization during reanimation. Many of these untoward effects may be alleviated by a polarized membrane, and we will discuss the basic science and clinical experience from a number of institutions trialling different alternatives, and our institution with a non-depolarizing adenosine, lidocaine and magnesium (ALM) cardioplegia. The future of polarized arrest is an exciting one and may play an important role in treating the next generation of patients who are older, and sicker with multiple comorbidities and require more complex operations with prolonged cross-clamping times.
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Affiliation(s)
- Alessandra Francica
- Division of Cardiac Surgery, University of Verona Medical School, 37126 Verona, Italy; (F.T.); (C.R.); (I.T.); (G.B.L.); (G.F.); (F.O.)
- Correspondence: ; Tel.: +39-3356213738
| | - Filippo Tonelli
- Division of Cardiac Surgery, University of Verona Medical School, 37126 Verona, Italy; (F.T.); (C.R.); (I.T.); (G.B.L.); (G.F.); (F.O.)
| | - Cecilia Rossetti
- Division of Cardiac Surgery, University of Verona Medical School, 37126 Verona, Italy; (F.T.); (C.R.); (I.T.); (G.B.L.); (G.F.); (F.O.)
| | - Ilaria Tropea
- Division of Cardiac Surgery, University of Verona Medical School, 37126 Verona, Italy; (F.T.); (C.R.); (I.T.); (G.B.L.); (G.F.); (F.O.)
| | - Giovanni Battista Luciani
- Division of Cardiac Surgery, University of Verona Medical School, 37126 Verona, Italy; (F.T.); (C.R.); (I.T.); (G.B.L.); (G.F.); (F.O.)
| | - Giuseppe Faggian
- Division of Cardiac Surgery, University of Verona Medical School, 37126 Verona, Italy; (F.T.); (C.R.); (I.T.); (G.B.L.); (G.F.); (F.O.)
| | - Geoffrey Phillip Dobson
- Heart and Trauma Research Laboratory, College of Medicine and Dentistry, James Cook University, Townsville 4811, Australia;
| | - Francesco Onorati
- Division of Cardiac Surgery, University of Verona Medical School, 37126 Verona, Italy; (F.T.); (C.R.); (I.T.); (G.B.L.); (G.F.); (F.O.)
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Wang W, Wang T, Piao H, Li B, Wang Y, Li D, Zhu Z, Xu R, Liu K. Change in Functional Moderate Mitral Regurgitation after Aortic Valve Replacement. Braz J Cardiovasc Surg 2019; 34:659-666. [PMID: 31364827 PMCID: PMC6894038 DOI: 10.21470/1678-9741-2018-0331] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Objective To evaluate the changes of the mitral valve geometrics and the degrees of moderate mitral regurgitation (MR) in patients undergoing aortic valve replacement (AVR) for aortic stenosis (AS). Methods A retrospective analysis study of intraoperative transesophageal echocardiography (TEE) and postoperative transthoracic echocardiography (TTE) was performed in 49 patients diagnosed with pure AS combined with moderate MR, who underwent AVR from January 2013 to December 2017. TEE was used to evaluate the direct geometric changes of the mechanical effects on mitral annulus after AVR. TTE was used to evaluate the changes of MR after operation. All patients underwent TTE during the midterm follow-up. The mean follow-up time was 40.21 months. Results All of the 49 patients had moderate MR. Anterolateral-posteromedial diameter, anterior-posterior diameter, and mitral annular area were significantly reduced after AVR, while no significant changes were found in the intraoperative left ventricular loading conditions before and after AVR. The degree of mitral valve regurgitation, left ventricular size, left atrial size, left ventricular end-diastolic volume, and left ventricular to aortic pressure gradient were significantly reduced before discharge, and midterm follow-up showed good results. Conclusion This study supports the belief that aortic outflow tract obstruction and an actual mechanical compression of the anterior mitral annulus after AVR would cause reduction in MR. Ventricular remodeling would also cause reduction in MR with time going on. Patients with AS, especially young patients with moderate MR, were most likely to benefit from AVR in early time.
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Affiliation(s)
- Weitie Wang
- Jilin University Second Hospital of Bethune Department of Cardiovascular Surgery Changchun Jilin People's Republic of China Department of Cardiovascular Surgery, Second Hospital of Bethune, Jilin University, Changchun, Jilin, People's Republic of China
| | - Tiance Wang
- Jilin University Second Hospital of Bethune Department of Cardiovascular Surgery Changchun Jilin People's Republic of China Department of Cardiovascular Surgery, Second Hospital of Bethune, Jilin University, Changchun, Jilin, People's Republic of China
| | - Hulin Piao
- Jilin University Second Hospital of Bethune Department of Cardiovascular Surgery Changchun Jilin People's Republic of China Department of Cardiovascular Surgery, Second Hospital of Bethune, Jilin University, Changchun, Jilin, People's Republic of China
| | - Bo Li
- Jilin University Second Hospital of Bethune Department of Cardiovascular Surgery Changchun Jilin People's Republic of China Department of Cardiovascular Surgery, Second Hospital of Bethune, Jilin University, Changchun, Jilin, People's Republic of China
| | - Yong Wang
- Jilin University Second Hospital of Bethune Department of Cardiovascular Surgery Changchun Jilin People's Republic of China Department of Cardiovascular Surgery, Second Hospital of Bethune, Jilin University, Changchun, Jilin, People's Republic of China
| | - Dan Li
- Jilin University Second Hospital of Bethune Department of Cardiovascular Surgery Changchun Jilin People's Republic of China Department of Cardiovascular Surgery, Second Hospital of Bethune, Jilin University, Changchun, Jilin, People's Republic of China
| | - Zhicheng Zhu
- Jilin University Second Hospital of Bethune Department of Cardiovascular Surgery Changchun Jilin People's Republic of China Department of Cardiovascular Surgery, Second Hospital of Bethune, Jilin University, Changchun, Jilin, People's Republic of China
| | - Rihao Xu
- Jilin University Second Hospital of Bethune Department of Cardiovascular Surgery Changchun Jilin People's Republic of China Department of Cardiovascular Surgery, Second Hospital of Bethune, Jilin University, Changchun, Jilin, People's Republic of China
| | - Kexiang Liu
- Jilin University Second Hospital of Bethune Department of Cardiovascular Surgery Changchun Jilin People's Republic of China Department of Cardiovascular Surgery, Second Hospital of Bethune, Jilin University, Changchun, Jilin, People's Republic of China
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Malhotra A, Wadhawa V, Ramani J, Garg P, Sharma P, Pandya H, Rodricks D, Tavar R. Normokalemic nondepolarizing long-acting blood cardioplegia. Asian Cardiovasc Thorac Ann 2017; 25:495-501. [PMID: 28975821 DOI: 10.1177/0218492317736448] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective Blood cardioplegia, the gold-standard cardioprotective strategy, requires frequent dosing, resulting in hyperkalemia-induced myocardial edema. The aim of our study was to compare the efficacy and safety of a long-acting blood-based cardioplegia with physiological potassium levels versus the well-established cold blood St. Thomas' Hospital no. 1 cardioplegia solution in multivalve surgeries. Methods One hundred patients undergoing simultaneous elective aortic and mitral valve replacement ± tricuspid valve repair were randomized in two groups. In group 1, adenosine 12 mg was given via the aortic root after crossclamping, followed by a single dose of long-acting solution at 14℃ (30 mLċkg-1); in group 2, an initial 30 mLċkg-1 of St. Thomas' cardioplegia at 14℃ was administered, followed by 15 mLċkg-1 every 20 min. Duration of cardiopulmonary bypass, inotropic score, arrhythmias, ventilation time, and the levels of interleukin-6, creatinine kinase-MB, and troponin I were compared. Results Mean cardiopulmonary bypass and crossclamp times were 134.04 ± 36.12 vs. 154.34 ± 34.26 ( p = 0.004) and 110.37 ± 24.80 vs. 132.48 ± 31.68 min ( p = 0.002), respectively, in the long-acting and St. Thomas' groups. Cardiac index, creatinine kinase-MB and troponin I levels were comparable. Interleukin-6 levels post-bypass were 61.72 ± 15.33 and 75.44 ± 31.78 pgċmL-1 ( p = 0.007) in the long-acting and St. Thomas' cardioplegia groups, respectively. Conclusions Single-dose long-acting cardioplegia gives a cardioprotective effect comparable to repeated doses of the well-established St. Thomas' Hospital no. 1 cold blood cardioplegia.
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Affiliation(s)
- Amber Malhotra
- 1 Department of Cardiovascular and Thoracic Surgery, UN Mehta Institute of Cardiology and Research Center, Civil Hospital, Ahmedabad, Gujarat, India
| | - Vivek Wadhawa
- 1 Department of Cardiovascular and Thoracic Surgery, UN Mehta Institute of Cardiology and Research Center, Civil Hospital, Ahmedabad, Gujarat, India
| | - Jaydip Ramani
- 1 Department of Cardiovascular and Thoracic Surgery, UN Mehta Institute of Cardiology and Research Center, Civil Hospital, Ahmedabad, Gujarat, India
| | - Pankaj Garg
- 1 Department of Cardiovascular and Thoracic Surgery, UN Mehta Institute of Cardiology and Research Center, Civil Hospital, Ahmedabad, Gujarat, India
| | - Pranav Sharma
- 1 Department of Cardiovascular and Thoracic Surgery, UN Mehta Institute of Cardiology and Research Center, Civil Hospital, Ahmedabad, Gujarat, India
| | - Himani Pandya
- 2 Department of Research, UN Mehta Institute of Cardiology and Research Center, Civil Hospital, Ahmedabad, Gujarat, India
| | - Dayesh Rodricks
- 3 Department of Perfusion Technology, UN Mehta Institute of Cardiology and Research Center, Civil Hospital, Ahmedabad, Gujarat, India
| | - Reema Tavar
- 4 Department of Cardiac Anesthesia, U N Mehta Institute of Cardiology and Research Center, Civil Hospital, Ahmedabad, Gujarat, India
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