Aortic Valve Plasty during Correction of Combined Mitral-Aortic Valve Diseases

The aim. To study the experience of valve-preserving operations on the aortic valve combined with plasty of the left atrium in patients with atriomegaly (the first clinical experience). Materials and methods. The study included 1890 patients with combined mitral-aortic valve diseases (CMAVD) who were undergoing surgical treatment at the National Amosov Institute of Cardiovascular Surgery of the National Academy of Medical Sciences of Ukraine in the period from 01/01/2006 to 01/01/2020. Of these, 156 (8.3%) underwent reconstructive intervention on the aortic valve during mitral valve replacement (MVR). Valve sparing procedures performed: - aortic valvotomy (93 patients); - aortic valvotomy + debridgment (30 patients); - aortic valvotomy + leaflet plication (4 patients); - removal of vegetation from the aortic valve (7 patients); - applying a patch of autopericardium on a leaflet (7 patients); - carpentier aortic valve annuloplication (2 patients); - aortic valve debridgment (12 patients); - aortic valve decalcification + Morrow operation (1 patient). All operations were performed under conditions of cardiopulmonary bypass (CPB) and moderate hypothermia (28-32 °C). Myocardial protection was carried out mainly by means of ante-retrograde pharmaco-cold cardioplegia with Custodiol solution in combination with external cooling of the heart. The time of aortic clamping was 82.4 ± 12.1 minutes, and the time of CPB was 117.5 ± 21.5 minutes. In 689 (78.4%) operated patients, blood loss was within 450 ml. In 29 (18.6%) patients, donor blood components were not used at the hospital stage. Conclusions. On the basis of the clinical experience gained, it seems appropriate to recommend reconstructive interventions on aortic valve with moderate changes in it in order to avoid traumatic two-valve prosthetics in the correction of combined mitral-aortic defects and to improve the survival rates and stability of good results.

Antegrade Intermittent Cold Cardioplegia in Comparison to Antegrade Intermittent Warm Cardioplegia in Heart Valve Surgery

Background: The cardioplegic arrest is essential for motionless and bloodless heart valve surgery. The objective of this work was to compare antegrade cold versus warm blood cardioplegia during valve surgery. Methods: This randomized controlled study included 100 patients who had mitral valve surgery. Patients were randomly assigned into two groups; the warm cardioplegic group (n= 50) and the cold cardioplegic group (n= 50). Study endpoints were creatine kinase myocardial band, lactate dehydrogenase, and troponin levels. Results: There was no significant difference in age and sex between groups (p= 0.51 and 0.56, respectively). Cardiopulmonary bypass was significantly longer in the cold group (85.66 ± 22.9 vs. 72.34 ± 25.09 minutes; P= 0.01); however, there was no difference in ischemic time (p= 0.32). The number of DC shocks given for each patient is less in the warm group with a median of 1.5 (range 1-3 times), while in the cold group, the median was 2 (range 2-4 times); p= 0.02. The amount of blood loss was significantly lower among the warm group (645.4 ± 464.93 ml vs. 404 ± 252.7 P< 0.01). warm group had significantly lower postoperative CK (532.78 ± 249.08 vs. 638.14 ± 344.01 IU/L; P< 0.01), CK-MB (78.64 ± 34.58 vs. 103.18 ± 82.11; P< 0.0.01), LDH level (805.3 ± 322.71 vs. 1060.88 ± 500.94 mg/dl; P< 0.01) and (0.4148 ± 0.226 vs. 0.6404 ± 0.411 ng/ml; P< 0.01). Conclusion: Antegrade warm blood cardioplegia may provide better myocardial protection during valve surgery compared to the cold cardioplegia. A larger study is recommended.

Using Next-generation RNA Sequencing to Examine Ischemic Changes Induced by Cold Blood Cardioplegia on the Human Left Ventricular Myocardium Transcriptome

Background: The exact mechanisms that underlie the pathological processes of myocardial ischemia in humans are unclear. Cardiopulmonary bypass with cardioplegic arrest allows the authors to examine the whole transcriptional profile of human left ventricular myocardium at baseline and after exposure to cold cardioplegia-induced ischemia as a human ischemia model. Methods: The authors obtained biopsies from 45 patients undergoing aortic valve replacement surgery at baseline and after an average of 79 min of cold cardioplegic arrest. Samples were RNA sequenced and analyzed with the Partek® Genomics Suite (Partek Inc., St. Louis, MO) for differential expression. Ingenuity Pathway Analysis (Ingenuity Systems, Redwood City, CA) and Biobase ExPlain (Biobase GmbH, Wolfenbuettel, Germany) systems were used for functional and pathway analyses. Results: Of the 4,098 genes with a mean expression value greater than 5, 90% were down-regulated and 9.1% were up-regulated. Of those, 1,241 were significantly differentially expressed. Gene ontology analysis revealed significant down-regulation in immune inflammatory response and complement activation categories and highly consistent was the down-regulation of intelectin 1, proteoglycan, and secretory leukocyte peptidase inhibitor. Up-regulated genes of interest were FBJ murine osteosarcoma viral oncogene homolog and the hemoglobin genes hemoglobin α1 (HBA1) and hemoglobin β. In addition, analysis of transcription factor–binding sites revealed interesting targets in factors regulating reactive oxygen species production, apoptosis, immunity, cytokine production, and inflammatory response. Conclusions: The authors have shown that the human left ventricle exhibits significant changes in gene expression in response to cold cardioplegia-induced ischemia during cardiopulmonary bypass, which provides great insight into the pathophysiology of ventricular ischemia, and thus, may help guide efforts to reduce myocardial damage during surgery.

BIOELECTRIC IMPEDANCEMETRY AS A METHOD OF ASSESSMENT OF THE MYOCARDIUM DURING OPEN-HEART SURGERY

The article analyses the possibility of using direct bioelectric impedancemetry of the right ven- tricle (RV) as an intra-operation method for evaluation of myocardial protection effectiveness in open-heart surgery. The results of intra-operation monitoring of bioelectric impedancemetry indi- cators of RV in 40 patients underwent surgical treatment with the use of cardioplegia were ana- lyzed. Bioelectrical impedance of myocardium has been studied during the whole period of artificial blood circulation. The analysis of the results showed that the bioelectric myocardium impedancemetry allows to assess the level of the interstitial space filling during the infusion of cardioplegia solution, providing an opportunity to assess the perfusion adequacy and also the level of reperfusion cells damage and myocardium swelling degree at the stage of coronary blood flow restoration. Using the method of myocardium bioelectric impedancemetry we found that blood cardioplegia with the "thermal induction" more reliably protects the myocardium in the period of anoxia in comparison with the cold cardioplegia.