Administration Of Cardioplegia Research Articles

Cannulation of the Middle Cardiac Vein during MICS

Coronary sinus cannulation for retrograde cardioplegia administration during cardiac surgery is common practice. Several of the cannulas that are placed by the cardiac surgeon on open procedures are now placed by the cardiac anesthesiologist during minimally invasive cardiac surgery, including the coronary sinus catheter. The understanding of the cardiac venous anatomy is very important during coronary sinus catheter placement. We present a case where a percutaneously placed coronary sinus catheter was inadvertently placed into the middle cardiac vein but detected with the use of fluoroscopy.

Multiple floating thrombi of the ascending aorta revealed by embolisms

Fig. 1. Intraoperative views. After median sternotomy, aortic cross clamping was performed, guided by transesophageal echocardiography, with administration of retrograde cardioplegia. After the aortotomy was made, the pedicle thrombus was visible, hung to the left anterior part of the mid ascending aorta (a). Exploration revealed many other thrombi, requiring an en-bloc cuneiform resection of the aorta (b). A complementary resection extended to the non coronary sinus was performed because of severe atheroma of the ascending aorta. Replacement by a Dacron graft was performed.

Management of Cold-Induced Urticaria During Cardiac Surgery

General body cooling and local hypothermia during cardiopulmonary bypass in theory could precipitate a severe systemic anaphylaxis in the case of cold-induced urticaria. We present a case of cold-induced urticaria and describe how preanesthetic single-dose steroid, H(2) antagonist, and antihistamine, normothermic retrograde, and antegrade cardioplegia administration were all employed with normothermic conditions in the prevention of life-threatening anaphylaxis during coronary artery bypass grafting.

A Simple Method for Cardioplegia Administration and Suture Control Using Foley Catheter During Ascending Aorta Replacement and Aortic Root Surgery

There is no standardised approach for cardioplegia administration during ascending aorta replacement (AAR) and the techniques used so far are quite variable and show important limitations. In order to overcome these limitations, we propose a simple and inexpensive technique using a Foley catheter for cardioplegia administration and bleeding control in case of AAR or aortic root surgery. The benefits of our technique are the technical simplicity and the low cost that makes this approach an ideal solution for cardioplegia administration in all cases of AAR.

Traumatic Atrial Septal Defect and Coronary Sinus to Left Atrium Fistula from Coronary Sinus Pacing Lead Removal

Traumatic Atrial Septal Defect and Coronary Sinus to Left Atrium Fistula from Coronary Sinus Pacing Lead Removal

The Endovascular Coronary Sinus Catheter in Minimally Invasive Mitral and Tricuspid Valve Surgery: A Case Series

To determine the safety and efficacy of a standardized approach to the use of an endovascular coronary sinus (CS) catheter during minimally invasive cardiac surgery. Case series. University hospital. Patients undergoing mitral and/or tricuspid valve surgery using a minimally invasive cardiac surgery approach. An endovascular CS catheter was placed to enable the administration of retrograde cardioplegia using transesophageal echocardiography (TEE), fluoroscopy, and CS pressure measurements. Data were collected from 96 patient records. A total of 95 (99.0%) endovascular coronary sinus catheters were positioned. The mean time to insert the catheter into the sinus ostium under TEE guidance was 6.3 ± 8.4 minutes. Confirmation of adequate positioning with fluoroscopy took an average of 9.1 ± 10.6 minutes for a mean total procedure time of 16.1 ± 14.1 minutes. Successful positioning, as defined by the ability to generate a perfusion pressure in the CS greater than 30 mmHg during surgery, was achieved in 87.5% of cases. During positioning, ventricularization of the CS pressure curve was observed in 86.0% of cases. The presence of ventricularization was associated with an increase in positioning success (odds ratio = 15.8; 95% confidence interval, 3.713-67.239). One patient developed extravasation of contrast agent after CS catheter placement, without evidence of CS rupture. Endovascular CS catheter insertion can be performed with a high rate of success for positioning and a low complication rate. During positioning, obtaining ventricularization is associated with an increased success rate.

Surgical intervention utilizing cardiopulmonary bypass for coronary unroofing of anomalous coronary artery

Coronary arteries originating from the opposite coronary cusp and crossing the path between the aorta and the pulmonary artery are associated with ischemia and sudden cardiac death. An increased prevalence of these cases may be attributed to diagnostic advances in computed tomographic angiography (CTA). We report a retrospective review of ten patients referred for surgical intervention from March 2008 to present. Nine patients were diagnosed with right coronary arteries arising from the left coronary cusp and one patient with a left coronary artery arising from the right coronary cusp. Seven patients were male and the median age was 40 years (range, 21 to 51). Symptoms included atypical chest pain, tachy-arrythmias, diaphoresis, and dyspnea on exertion. CTA demonstrated anomalous coronary arteries arising from the opposite coronary cusp and traveling between the aorta and the pulmonary artery. Surgical intervention was performed on all ten patients with no mortality and only one re-operation requiring bypass grafting. The sixth patient in the series had concomitant atherosclerotic disease, requiring left internal mammary artery grafting to the left anterior descending coronary artery. Cardiopulmonary bypass (CPB) was utilized with moderate hypothermia in all ten patients, with retrograde and/or coronary ostial cardioplegia administration. At routine surgical follow-up, all patients were without original presenting symptoms. Patients with anomalous coronary arteries arising from the opposite coronary cusp are at risk of acute myocardial infarction and sudden cardiac death. Surgical unroofing is a viable option for this patient population and avoids coronary artery bypass grafting. Since March 2008, we have operated on ten patients presenting with this anomaly and have had excellent short-term results. Further long-term follow-up is necessary.

Animal Models of Cardiopulmonary Bypass: Development, Applications, and Impact

Neurologic and neurocognitive complications after cardiac surgery have been reported repeatedly. To better understand its etiology and design protective strategies, small animal models have been developed. This study describes the development of a survival rat cardiopulmonary bypass (CPB) model, along with the introduction of an appropriately sized oxygenator. This model led the way for even more complicated models with CPB, facilitating full cardiac arrest with anterograde cardioplegia administration, air embolization, and deep hypothermic circulatory arrest. In addition, the results of several of those rat CPB studies are summarized and their preclinical relevance is pointed out.

Effect of arterial oxygen tension during reperfusion on myocardial recovery in patients undergoing valvular heart surgery

BackgroundValvular heart surgery (VHS) utilizing cardiopulmonary bypass (CPB) is inevitably associated with ischemic-reperfusion injury, which is known to depend on oxygen tension during reperfusion. The aim of this study was to evaluate the effect of arterial oxygen tension during reperfusion on myocardial recovery in patients undergoing VHS.MethodsFifty-six patients undergoing isolated VHS were randomly exposed to an oxygen fraction of 0.7 (hyperoxic group, n = 28) or 0.5 (normoxic group, n = 28) during reperfusion. All patients received an oxygen fraction of 0.7 during CPB. In the normoxic group, the oxygen fraction was lowered to 0.5 from the last warm cardioplegia administration to 1 minute after aortic unclamping, and was then raised back to 0.7. Hemodynamic data were measured after induction of anesthesia, weaning from CPB, and sternum closure. The frequency of cardiotonic medications used during and after weaning from CPB, and the short-term outcomes during the hospital stay were also assessed.ResultsThe frequency of vasopressin and milrinone use during weaning from CPB, but not norepinephrine, was significantly less in the normoxic group. The post-operative cardiac enzyme levels and short-term outcomes were not different between the groups.ConclusionsNormoxic reperfusion from the last cardioplegia administration to 1 minute after aortic unclamping in patients undergoing VHS resulted in significantly less frequent use of vasopressin and inotropics during weaning from CPB than hyperoxic reperfusion, although it did not affect the post-operative myocardial enzyme release or short-term prognosis.

Reply

In their letter to the editor, Sheehy and colleagues [1Sheehy A.M. Coursin D.B. Keegan M.T. Risks of tight glycemic control during adult cardiac surgery (letter).Ann Thorac Surg. 2009; 88: 1384-1385Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar] express their concern about hypoglycemia that occurs during tight glycemic control (TGC). They also draw our attention to the fact that large amounts of insulin administered intraoperatively may induce postcardiopulmonary bypass hypoglycemia. Finally, they note the importance of the methodology used for glucose measurement. We agree with the authors that adopting a tight glucose range is a cause of concern and, therefore, have made the focus of our guidelines the importance of avoiding glucose levels exceeding 180 mg/dL without strict guidance on a set goal range [2Lazar H.L. McDonnell M. Chipkin S.R. et al.The Society of Thoracic Surgeons Practice Guideline Series: blood glucose management during adult cardiac surgery.Ann Thorac Surg. 2009; 87: 663-669Abstract Full Text Full Text PDF PubMed Scopus (326) Google Scholar]. Our practice at the Boston Medical Center is to maintain blood glucose levels between 120 and 180 mg/dL during cardiac operations and in the postoperative period in the intensive care unit (ICU). Using this regimen, we have had a low incidence of hypoglycemia (< 80 mg/dL) and no complications related to this event. We also agree with the authors that the administration of large amounts of insulin intraoperatively, especially in patients who have had no preoperative history of diabetes, can result in severe hypoglycemia in the ICU. The key to avoiding this problem is frequent and judicious monitoring of serum glucose. In Section VI of the guidelines, “Intraoperative Control Recommendations,” we specifically mentioned, “patients receiving IV infusions of insulin should have their blood glucose monitored every 30 to 60 minutes. More frequent monitoring, as often as every 15 minutes, should be made during periods of rapidly fluctuating sensitivity, such as during the administration of cardioplegia and systemic cooling and rewarming.” Furthermore, we caution that “patients with no history of diabetes prior to surgery may exhibit transient elevation of blood glucose >180 mg/dl during cardiopulmonary bypass. These patients may have insulin resistance and should be treated with a single or intermittent dose of IV insulin to maintain glucose <180 mg/dl. Caution should be exercised in initiating a continuous IV insulin drip in these patients, because insulin requirements may decrease rapidly in the immediate postoperative period resulting in serious hypoglycemia.” In the study of Gandhi and colleagues [3Gandhi G.Y. Nuttall G.A. Abel M.D. et al.Intensive intraoperative insulin therapy versus conventional glucose management during cardiac surgery: a randomized trial.Ann Intern Med. 2007; 146: 233-243Crossref PubMed Scopus (481) Google Scholar], only 20% of patients had diabetes mellitus. The increased number of strokes seen in their study was unrelated to hypoglycemia because the frequency of hypoglycemia was low and not associated with any clinical event. It is also important to note that it is as yet unclear how, or if, hypoglycemia due to insulin therapy affects morbidity or mortality. Hypoglycemia in critically ill patients may be more reflective of widespread organ dysfunction and not insulin therapy [4Kosiborod M. Inzucchi S. Goyal A. et al.Relationship between spontaneous iatrogenic hypoglycemia and mortality in patients hospitalized with acute myocardial infarction.JAMA. 2009; 301: 1556-1564Crossref PubMed Scopus (282) Google Scholar]. Patients receiving TGC during cardiac operations receive this protocol for short periods, and their blood glucose levels are more frequently checked. This contrasts with the medical ICU, where TGC protocols are used in patients requiring long-term care in whom glucose monitoring is less frequent. Finally, although we have noted in our own practice fluctuations in glucose levels due to changes in temperature, cardiac index, and the need for inotropic support, glucose values obtained from arterial, venous, or subcutaneous sources appear to vary little and have had no effect on clinical outcomes. In summary, we agree with the authors that more moderate control is a more judicious approach, but that the potential side effects of hypoglycemia are negated by more frequent glucose monitoring, which is a key component of all surgical TGC protocols. Risks of Tight Glycemic Control During Adult Cardiac SurgeryThe Annals of Thoracic SurgeryVol. 88Issue 4PreviewThe recent guidelines of The Society of Thoracic Surgeons Practice Guideline Series on glucose control deserve cautionary comment [1]. Consideration of the adverse events reported by Gandhi and colleagues [2] (STS guideline reference 17), when tight glucose control (TGC) was maintained in cardiac surgical patients intraoperatively seems merited. The incidence and risks of hypoglycemia in TGC protocols in other critically ill adult patients should also be highlighted. Full-Text PDF

Is repeated administration of blood-cardioplegia really necessary?

The aim of this work was to question the necessity of repeated administration of warm blood cardioplegia in modern cardiac surgery. A consecutive series of 4014 patients underwent cardiosurgical procedures in the period from January 2001 to December 2006 in our centre, where modified Calafiore warm blood-cardioplegic solution was used. 1708 patients received a single shot of cardioplegia instead of repeated blood cardioplegia (every 20 min). A multivariate analysis was performed using logistic regression models to reveal the statistical significance of the effect of single-shot cardioplegia on the occurrence of: death, intraoperative need of inotropics, intraoperative intra-aortic balloon pump (IABP), postoperative infarction, arrhythmia, postoperative need for inotropics and postoperative IABP. The results showed statistical insignificance concerning mortality (P=0.704), intraoperative IABP (P=0.247), postoperative inotropics (P=0.273), postoperative IABP (P=0.678), postoperative arrhythmia (P=0.661). Single-shot cardioplegia showed a positive effect concerning postoperative myocardial infarction (P=0.003). However, it showed an unfavourable effect concerning intraoperative inotropics (P=0.038) and postoperative dialysis (P=0.015). The clinical safety of the first shot of warm blood cardioplegia might be exceeding 20 min. In the light of increasingly short cross-clamping time, the safety of the first shot might be long enough to cover the whole cross-clamping time.

EComment: Individualization of blood cardioplegia administration mode

eComment: Individualization of blood cardioplegia administration mode

“Directed” Cardioplegia: A New Approach in Myocardial Protection in Left Main Coronary Artery Disease

"Directed cardioplegia" is a novel approach in myocardial protection in which a certain volume of cardioplegic solution is diverted into a severely diseased coronary artery after surgical occlusion of the other main branches that can be accessed by the surgeon. In this way, the surgeon is able to eliminate the cardioplegic steal from a severely stenosed vessel through other less severely diseased and/or patent arteries during the nonselective antegrade administration of cardioplegia and to protect myocardial regions, which are poorly perfused. We performed this new technique in 2 patients with severe left main coronary artery disease with excellent results.

A novel survival model of cardioplegic arrest and cardiopulmonary bypass in rats: a methodology paper

BackgroundGiven the growing population of cardiac surgery patients with impaired preoperative cardiac function and rapidly expanding surgical techniques, continued efforts to improve myocardial protection strategies are warranted. Prior research is mostly limited to either large animal models or ex vivo preparations. We developed a new in vivo survival model that combines administration of antegrade cardioplegia with endoaortic crossclamping during cardiopulmonary bypass (CPB) in the rat.MethodsSprague-Dawley rats were cannulated for CPB (n = 10). With ultrasound guidance, a 3.5 mm balloon angioplasty catheter was positioned via the right common carotid artery with its tip proximal to the aortic valve. To initiate cardioplegic arrest, the balloon was inflated and cardioplegia solution injected. After 30 min of cardioplegic arrest, the balloon was deflated, ventilation resumed, and rats were weaned from CPB and recovered. To rule out any evidence of cerebral ischemia due to right carotid artery ligation, animals were neurologically tested on postoperative day 14, and their brains histologically assessed.ResultsThirty minutes of cardioplegic arrest was successfully established in all animals. Functional assessment revealed no neurologic deficits, and histology demonstrated no gross neuronal damage.ConclusionThis novel small animal CPB model with cardioplegic arrest allows for both the study of myocardial ischemia-reperfusion injury as well as new cardioprotective strategies. Major advantages of this model include its overall feasibility and cost effectiveness. In future experiments long-term echocardiographic outcomes as well as enzymatic, genetic, and histologic characterization of myocardial injury can be assessed. In the field of myocardial protection, rodent models will be an important avenue of research.

The Efficacy and Safety of Extending the Ischemic Time with a Modified Cardioplegic Technique for Coronary Artery Surgery

The need to intermittently discontinue the administration of cardioplegia in order to complete the surgical procedure is a major drawback of antegrade warm blood cardioplegia. An ischemic time of 15 minutes is generally considered safe based on empirical observation. The aim of this study was the evaluation of the efficacy and safety of an intermittent warm blood cardioplegia with intervals between administrations prolonged to 25 minutes. Ninety-seven patients undergoing primary elective coronary artery revascularization were prospectively randomized into two groups. The first, Intermittent Antegrade Warm Blood Cardioplegia (IAWBC) group, comprising 49 patients, received standard intermittent antegrade warm blood cardioplegia repeated every 15 minutes. The second, Modified Intermittent Antegrade Warm Blood Cardioplegia (M-IAWBC) group, comprising 48 patients, received intermittent antegrade warm blood cardioplegia supplemented with magnesium sulfate (MgSO(4)), delivered in volumes proportional to the ventricular mass and repeated every 25 minutes. The clinical outcomes were evaluated. The levels of creatine kinase-MB (CK-MB) isoenzyme, in addition to the echocardiographic assessment of septal dyskinesia and tricuspid annulus plane systolic excursion (TAPSE), have been used as markers of myocardial damage. There were no statistically significant differences in clinical outcomes, need for inotropes and vasodilators, length of stay in the intensive care unit, and postoperative levels of CK-MB between the two groups. Likewise, postoperative echocardiographic assessment showed no relevant differences. Administration of warm antegrade cardioplegic solution supplemented with MgSO(4), delivered in volumes proportional to ventricular mass every 25 minutes, provides adequate myocardial protection for coronary artery surgery.

A cardioplegia circuit with versatility: the ‘ReVerse’ system. How to do it

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.

Real-Time Myocardial Glucose Measurement Using Biosensors

During ischemia, myocardial fatty acid metabolism ceases, rapidly depleting the other primary fuel, glucose. No technique has existed to continuously monitor myocardial glucose. Needle-tip enzymatic glucose biosensors have been developed for subcutaneous use in diabetic management. To study the utility of these sensors for real-time myocardial glucose monitoring in clinically relevant applications, 40 kg Yorkshire swine were cannulated for cardiopulmonary bypass. Biosensors were placed in the left anterior descending artery distribution (LAD) and posterior descending artery distribution (PD), and a third in the liver. Selective ischemia was induced by ligation of the LAD artery. Glucose levels were monitored during ischemia and reperfusion in the setting of cardioplegic arrest (n = 7) and in the normal beating heart (n = 14). In the normal beating heart, glucose levels fall to 6.5% +/- 7.4% baseline at 1 minute and 29.0% +/- 23.0% at 5 minutes of ischemia. In both arrested and beating heart scenarios, biosensors show distinct metabolic states in specific regions of the heart and liver. Biosensors can track regional glucose metabolism in the beating and arrested heart. This novel application of these sensors allows real-time determination of myocardial glucose levels to guide cardioplegia administration and monitor ischemic states for clinical and experimental use.

A Simple Solution for Electrocardiographic Artifacts During Cardiopulmonary Bypass and in the Intensive Care Unit

ELECTROCARDIOGRAPHIC (ECG) interference during cardiopulmonary bypass (CPB) is a well-recognized phenomenon. The continued presence of a true ECG tracing after placement of an aortic cross-clamp and administration of cardioplegia can warn of inadequate myocardial preservation, risks severe myocardial injury, and warrants immediate intervention. Thus, it is very important to distinguish between true ECG activity and ECG artifacts during this critical period to provide timely needed therapy for the former or to avoid an unnecessary intervention for the latter. ECG artifacts can be attributed to static electricity, piezo-electric effects, mechanical movements, or electric equipment interference in the operating room. In this case report, a simple and effective solution to distinguish true ECG activity from other artifacts that may originate from electrical equipment interference in the operating room and the intensive care unit (ICU) is presented.

Reconstruction of the Bicuspid Aortic Valve

Abicuspid aortic valve (BAV) occurs in 2% of the population and is a common reason for significant aortic regurgitation, particularly in the third and fourth decades of life.1 In these young patients, the choice of valve substitute is difficult. With a mechanical valve, the linearized risk of thromboembolic complications and anticoagulation-related hemorrhage is low,2 but the cumulative risk may be substantial due to a long life expectancy. Many young individuals do not wish a coumadin-based anticoagulation for lifestyle reasons. A biologic prosthesis, on the other hand, is associated with suboptimal durability in younger patients.3 Thus, for patients with a regurgitant bicuspid aortic valve, repair appears an attractive alternative to replacement. Bicuspid aortic valve anatomy is also associated with aortic dilation in more than 50% of individuals.4 Aortic dilation may induce or aggravate aortic valve regurgitation, and there is increasing evidence that a diameter of more than 4.5 cm may be associated with impaired long-term prognosis.5 Elimination of a dilated ascending aorta may also serve the purpose of stabilizing a valve repair procedure.6 Thus, any reconstructive procedure on a bicuspid aortic valve should address aortic pathology, if present. We have developed a differentiated approach to these procedures that has worked well in more than 180 patients operated over an 11-year period. Department of Thoracic and Cardiovascular Surgery, University Hospital of Saarland, Homburg/Saar, Germany. Address reprint requests to H.-J. Schafers, MD, Dept. of Thoracic and Cardiovascular Surgery, University Hospitals of Saarland, 66421 Homburg/ Saar, Germany. E-mail: h-j.schaefers@uniklinikum-saarland.de

Apoptosis Inhibition for improved Left Ventricular Function after prolonged Cold Cardioplegic Arrest

Cardioplegic arrest (CA) is associated with myocardial apoptosis induction. Data suggest that apoptosis inhibition during regional myocardial ischemia reduces infarct size and improves regional contractility. 28 adult rats were anesthetized and mechanically ventilated. Hearts were arrested by administration of ice-cold crystalloid cardioplegia (Bretschneider solution, Custodiol®, 10 ml/kg) with and without supplementation of a cell permeable non-selective caspase-inhibitor (z-VAD-fmk, 10 mM, n=7 each). Hearts were stored for 4h and 18h (n = 14 each) in cardioplegia (4°C). Subsequently, hearts were reperfused on a Langendorff-System. A balloon connected to a pressure transducer was inserted in the LV and inflated to a diastolic pressure of 10 mmHg. After 4h of cold CA, hearts with apoptosis-inhibition had higher LV pressures throughout the 60 min reperfusion as compared to those without apoptosis-inhibition. Both positive and negative dp/dtmax were significantly higher with apoptosis inhibition. After 18h cold CA, hearts with apoptosis-inhibition had higher left ventricular pressures throughout 90 min reperfusion as compared to those without apoptosis-inhibition. Dp/dtmax was significantly higher with apoptosis inhibition at 70, 80, and 90 min reperfusion. In hearts with apoptosis-inhibition heart rate recovered markedly faster. Apoptosis-inhibition preserves LV function after prolonged cold CA.