Myocardial protection: a forgotten modality

European Journal of Cardio-Thoracic Surgery ◽

10.1093/ejcts/ezz215 ◽

2019 ◽

Author(s):

Bradley S Allen

Keyword(s):

Cardiac Surgery ◽

Myocardial Protection ◽

Myocardial Damage ◽

Current Method ◽

Enzyme Release ◽

Complete Protection ◽

Cardiac Enzymes ◽

Bloodless Field ◽

Optimal Protection ◽

The Ideal

SummaryThe goals of a cardiac surgical procedure are both technical excellence and complete protection of cardiac function. Cardioplegia is used almost universally to protect the heart and provide a quiet bloodless field for surgical accuracy. Yet, despite the importance of myocardial protection in cardiac surgery, manuscripts or dedicated sessions at major meetings on this subject have become relatively rare, as though contemporary techniques now make them unnecessary. Nevertheless, septal dysfunction and haemodynamic support (inotropes, intra-aortic balloon pump, assist devices) are common in postoperative patients, indicating that myocardial damage following cardiac surgery is still prevalent with current cardioplegic techniques and solutions. This article first describes why cardiac enzymes and septal function are the ideal markers for determining the adequacy of myocardial protection. It also describes the underappreciated consequences of postoperative cardiac enzyme release or septal dysfunction (which currently occurs in 40–80% of patients) from inadequate protection, and how they directly correlate with early and especially late mortality. Finally, it reviews the various myocardial protection techniques available to provide a detailed understanding of the cardioplegic methods that can be utilized to protect the heart. This will allow surgeons to critically assess their current method of protection and, if needed, make necessary changes to provide their patients with optimal protection.

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Myocardial protection during minimally invasive cardiac surgery through right mini-thoracotomy

Perfusion ◽

10.1177/0267659116679249 ◽

2016 ◽

Vol 32 (3) ◽

pp. 245-252 ◽

Cited By ~ 5

Author(s):

Micaela De Palo ◽

Pietro Guida ◽

Florinda Mastro ◽

Daniela Nanna ◽

Teresa A.P. Quagliara ◽

...

Keyword(s):

Cardiac Surgery ◽

Minimally Invasive ◽

Myocardial Protection ◽

Troponin I ◽

Minimally Invasive Cardiac Surgery ◽

Enzyme Release ◽

Time Duration ◽

Creatine Kinase Mb ◽

Cold Blood ◽

Mini Thoracotomy

Background: Myocardial damage is an independent predictor of adverse outcome following cardiac surgery and myocardial protection is one of the key factors to achieve successful outcomes. Cardioplegia with Custodiol is currently the most used cardioplegia during minimally invasive cardiac surgery (MICS). Different randomized controlled trials compared blood and Custodiol cardioplegia in the context of traditional cardiac surgery. No data are available for MICS. Aim: The aim of this study was to compare the efficacy of cold blood versus Custodiol cardioplegia during MICS. Method: We retrospectively evaluated 90 patients undergoing MICS through a right mini-thoracotomy in a three-year period. Myocardial protection was performed using cold blood (44 patients, CBC group) or Custodiol (46 patients, Custodiol group) cardioplegia, based on surgeon preference and complexity of surgery. Results: The primary outcomes were post-operative cardiac troponin I (cTnI) and creatine kinase MB (CKMB) serum release and the incidence of Low Cardiac Output Syndrome (LCOS). Aortic cross-clamp and cardiopulmonary bypass times were higher in the Custodiol group. No difference was observed in myocardial injury enzyme release (peak cTnI value was 18±46 ng/ml in CBC and 21±37 ng/ml in Custodiol; p=0.245). No differences were observed for mortality, LCOS, atrial or ventricular arrhythmias onset, transfusions, mechanical ventilation time duration, intensive care unit and total hospital stay. Conclusions: Custodiol and cold blood cardioplegic solutions seem to assure similar myocardial protection in patients undergoing cardiac surgery through a right mini-thoracotomy approach.

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Clampless cardioplegia: an alternative to conventional cardioplegia administration

Perfusion ◽

10.1177/0267659118817711 ◽

2018 ◽

Vol 34 (5) ◽

pp. 413-416

Author(s):

Sean Clingan ◽

James Reagor

Keyword(s):

Cardiac Surgery ◽

Operating Room ◽

Myocardial Protection ◽

Case Reports ◽

Functional Change ◽

Ascending Aorta ◽

Operative Complications ◽

Bloodless Field

Myocardial protection is of the utmost importance during cardiac surgery. At times, there are patients who present to the operating room who make the typical use of cardioplegia difficult or impossible. For these patients, a separate protocol and process must be in place. “Clampless cardioplegia” is an option when the ascending aorta cannot be cross-clamped, but the surgeon needs a bloodless field with a quiescent heart. This study reports on the process of developing a policy and protocol for utilizing clampless or systemic cardioplegia. Four case reports of patients who received clampless or systemic cardioplegia and their peri-operative courses are described. These four patients showed no cardiac functional change by post-operative echocardiogram and no peri-operative complications are reported.

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Safety of Custodiol cardioplegia: a cohort study in patients undergoing cardiac surgery with elongated aortic cross-clamp time

Perfusion ◽

10.1177/0267659119897239 ◽

2020 ◽

Vol 35 (7) ◽

pp. 591-597 ◽

Cited By ~ 1

Author(s):

Maarten de Haan ◽

Albert van Straten ◽

Ed Overdevest ◽

Michel de Jong ◽

Mohamed Soliman-Hamad

Keyword(s):

Creatine Kinase ◽

Cardiac Surgery ◽

Myocardial Protection ◽

Artery Bypass ◽

Myocardial Damage ◽

Mitral Valve Surgery ◽

Valve Surgery ◽

Bypass Grafting ◽

Aortic Cross Clamp Time ◽

Aortic Cross Clamp

Background/Objectives: The increasing complexity of patients undergoing cardiac surgery requires extended myocardial ischaemic periods. Cardiac surgeons demand a cardioplegic solution with prolonged myocardial protection. Therefore, we introduced Custodiol in our centre in 2011. The aim of this study was to investigate the safety and efficacy of Custodiol compared with the standard method of cardioplegia. Methods: Between 2011 and 2016, 188 adult patients who underwent mitral valve surgery combined with coronary artery bypass grafting were included in this retrospective study. In 113 patients, Custodiol cardioplegia was used to achieve cardiac arrest, while St. Thomas Hospital solution was used in 75 patients. The primary endpoint of the study was the degree myocardial damage which was estimated by the measurement of creatine kinase-myocardial band on the first postoperative day. A linear regression analysis was performed to compare the aortic cross-clamp time with the postoperative myocardial damage in both groups. Results: The extracorporeal circulation time and aortic cross-clamp were significantly longer in the Custodiol group than in the St. Thomas group: 125.6 ± 32.5 minutes versus 93.1 ± 27.7 minutes (p < 0.001), respectively. However, there was no significant difference between the two groups regarding the postoperative levels of creatine kinase-myocardial band (96 (70-140) U/L vs. 86 (69-120) U/L, respectively; p = 0.321). There was no significant differences between the two groups regarding the 30-day mortality (6.1% vs. 5.5%, respectively; p = 1.000) or 120-day mortality (9.6% vs. 11.0%, respectively; p = 0.806). Conclusion: Our findings demonstrate that Custodiol is a safe method of myocardial protection for patients who underwent mitral valve surgery with coronary artery bypass grafting in our hospital. Further investigations extended to more cardiac surgery populations are needed to confirm clinical benefits of Custodiol cardioplegia.

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2006 to 2019 Story; percutaneously implantable aortic valve prototypes

Journal of Cardiothoracic Surgery ◽

10.1186/s13019-021-01597-6 ◽

2021 ◽

Vol 16 (1) ◽

Author(s):

Constantinos Zervides ◽

Ornella Nohra ◽

Gabriel Hunduma ◽

Neil Wild Thomas ◽

Ramy Samia

Keyword(s):

Cardiac Surgery ◽

Aortic Valve ◽

Minimal Risk ◽

Synthetic Material ◽

Specific Criterion ◽

Online Databases ◽

The Ideal

Abstract Aims A review was conducted on the composition, advantages and limitations of available aortic valve prototypes to create an ideal valve for percutaneous implantation. Patients Patients with multiple comorbidities who cannot withstand the risks of open cardiac surgery. Methodology The search was performed using online databases and textbooks. Articles were excluded based on specific criterion. Results Ten prototypes created between 2006 and 2019 were found and reviewed. The prototypes had a set of advantages and limitations with their characteristics coinciding at times. Conclusions The ideal percutaneously implantable aortic valve should have minimum coaptation height, zero folds in the leaflets, minimum valve height, minimum leaflet flexion and three leaflets. It can be composed of biological or synthetic material, as long as it provides minimal risk of thrombosis. However, more studies are needed to ensure other ideal parameters.

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