Antegrade Blood Cardioplegia Research Articles

Antegrade versus Retrograde Blood Cardioplegia in Left Main Coronary Artery Disease Patients Underwent CABG

Antegrade versus Retrograde Blood Cardioplegia in Left Main Coronary Artery Disease Patients Underwent CABG

Correlation of Post-Operative Outcomes in patients undergoing CABG Receiving Antegradecardioplegia alone Versus Combined Antegrade Plus Retrograde Cardioplegia: A Prospective Review

Aim: To compare the mean ejection fraction and cardiac enzymes level in patients with Ischemic heart disease undergoing elective coronary artery bypass graft surgery (CABG) having antegrade blood cardioplegia versus antegrade plus retrograde Cardioplegia. Study design: Randomized Controlled Trial Place and duration: This study was performed from 7th February, 2020 to 7th August, 2020 at the Cardiac Surgery Department, PIC, Jail Road, Lahore. Methodology: After receiving informed consent, all patients undergoing CABG were enrolled in this study. In order to compare the mean ejection fraction and cardiac enzyme levels between patients who had antegrade blood cardioplegia and those who had antegrade plus retrograde cardioplegia, preoperative, intraoperative, and postoperative characteristics were recorded into the predesigned proforma. Results: The total number of patients 72 was enrolled in this study who were divided into two groups. There were 36(50%) patients of who have given Cardioplegia through antegrade route while CABG and 36(50%) patients who have given Cardioplegia through antegrade plus retrograde route while CABG in this study. According to Table 1, the mean age of the patients in Group A was 51.86±9.35 years, whereas the mean ages of the participants in Group B 52.92±7.70 years. There were 26(72%) male and 10(28%) females in Group A and 30(83%) male and 6(17%) females in Group B. The mean BMI in Group A was 25.65±5.18 and 25.02±3.97 in Group B. There were 35(97%) hypertensive and 1(3%) non hypertensive patients in Group A and B respectively. Similarly, there were 33(92%) diabetic and 3(8%) non diabetic patients in Group A and 28 (78%) diabetic and 8(22%) non diabetic patients were in Group B. There were 26(72%) smokers and 10(28%) non- smokers in Group A and 24 (67%) smokers and 12(33%) non-smokers in this Group B. Practical Implication: The comparison of CKMB(IU/L) levels in Antegrade route group and antegrade plus retrograde group baseline and after 48 hours shows insignificant p-values of 0.17 and 0.12 respectively which shows that there is no significant difference in CKMB levels regarding these two routes chosen for giving Cardioplegia to patients undergoing coronary artery bypass grafting. Conclusion: Although both required additional surgical manoeuvres, however, the antegrade and antegrade plus retrograde cardioplegia approaches were equally effective and safe. Prior research demonstrated that multiple infusions offer superior protection to either antegrade or retrograde cardioplegia alone. Keywords: Coronary artery Bypass grafting surgery, Antegrade route, Retrograde Route, Antegrade plus Retrograde route.

Surgical Maneuver for Ventricular Septal Defect Exposure During Congenital Heart Surgery Through the Right Axillary Transverse Minithoracotomy.

Right axillary transverse minithoracotomy is not conventionally used for ventricular septal defect (VSD) repair because of complicated VSD exposure and the need for a temporary tricuspid valve leaflet detachment to facilitate VSD exposure. Recently, our team developed a new, not previously described surgical maneuver that markedly facilitates perimembranous VSD exposure without any need for tricuspid valve leaflet detachment. The above-mentioned VSD exposure maneuver was used in 21 patients with a median age of 5 months (range, 1.5 to 132 months) and a median body weight of 7 kg (range, 4 to 47 kg). The length of the incision varied from 3 to 4.5 cm over the fourth intercostal space within the anterior and posterior axillary lines. Central cardiopulmonary bypass cannulation and antegrade blood cardioplegia were performed in all patients. Bent/angled instruments were used throughout the procedure to facilitate the surgeon's view. Pericardial sutures and suspension of tricuspid valve chords were used as general exposure maneuvers. A special surgical maneuver aimed at changing the general plane of the ventricular septum was used. It consisted of one intraventricular exposing suture. Sufficient exposure of perimembranous VSD was obtained in all patients and was comparable with what is usually obtained through the median sternotomy. With the use of this new maneuver, all perimembranous VSDs could be safely exposed and repaired with the conventional suturing technique through the right axillary transverse minithoracotomy starting from 2 months of age.

COMPARISON OF THE EFFECT OF ANTEGRADE AND ANTEGRADE/RETROGRADE CARDIOPLEGIA ON THE OUTCOME OF CORONARY ARTERY BYPASS GRAFT SURGERY FOR SEVERE CORONARY ARTERY DISEASE

Objective: To compare the early outcome of Coronary Artery Bypass Graft surgery using a combination of antegrade and retrograde cardipoplegia with that utilizing antegrade cardioplegia alone in triple vessel coronary artery disease.
 Study Design: Comparative cross-sectional study.
 Place and Duration of Study: Department of Adult Cardiac Surgery of Armed Forces Institute of Cardiology and National Institute of Heart Diseases, Rawalpindi, from Sep 2013 to Apr 2019.
 Methodology: A total of 160 patients with triple vessel coronary artery disease who underwent CABG surgery for 90% or greater stenos is in at least one major vessel in each of the three territories, namely the left anterior descending, the circumflex and the right coronary artery were investigated retrospectively. These were divided into 2 equal groups on the basis of the technique of administration of cardioplegia: in group-1 only ante grade blood cardioplegia was administered for myocardial protection and group-2 was given ante grade and retrograde cardiolplegia. Clinical outcomes like peri-operative mortality and morbidity were recorded, and serum creatine kinase MB, lactate, and mixed venous oxygen saturation levels were monitored. Two dimensional echocardiogram was performed on the 6th post-operative day and follow-up visits were planned 1 week and 4 weeksafter discharge from hospital.
 Results: There were 2 (2.5%) early deaths in group-1 and no peri-operative mortality in group-2. Five patients in group-1 (6.25%) and 2 (2.5%) in group-2 had non-fatal peri-operative myocardial infarction. However, significant differences included increased incidence of intra-operative ventricular dysrythmias, higher CK-MB levels at 24 hours after surgery, and increased requirement of intra-aortic balloon pump and inotropic support in Group-1.
 Conclusion: We conclude from this study that the combined delivery of ante grade and retrograde cardioplegia during CABG surgery for triple vessel coronary artery disease provides better myocardial protection and hence better outcome than antegrade cardioplegia alone.Keywords: , , ,

Does Ice Slush Placed Inside Pericardial Well During Mitral Valve Replacement Cause Injury to Phrenic Nerve

Objective of the study was to determine frequency of phrenic nerve injury during mitral valve replacement, with application of Ice Slush, and compare it with international data. This study was performed at Punjab Institute of Cardiology Pakistan from January 2010 to December 2015. A total of 1105 patients with only primary rheumatic mitral valve disease were prospectively observed. A total of 931 patients were enrolled into the study. After sternotomy & cardiopulmonary bypass (CPB) at 28-32°C, antegrade blood cardioplegia with potassium, Ice slush was applied all the time during repair or replacement of the mitral valve. A pre-designed proforma was used, that recorded phrenic nerve injury. Statistical Package for Social Sciences (SPSS) for Windows version 21 was used for the analysis of data. Out of 931 patients who underwent mitral valve repair or replacement, 466 (50.1%) were males. Time spent on CPB ranged from 40 to 120 min; in 58.1% patients the time remained less than 80 minutes. As far as the ascending aortic cross clamp time was concerned, 83.1% patients had less than 40 minutes of cross clamp time. Post-operative chest X-ray remained normal in 97.5% patients whereas it showed atelectasis in 2.3% and elevated left hemidiaphragm in 0.2% of the patients. The total in-hospital mortality was 3.2% during study period. No patient was found to have phrenic nerve injury, unilateral or bilateral, during the study period.Topical cooling of heart, during mitral valve replacement, with Ice slush per se is not responsible for Phrenic nerve injury.

Myocardial preservation methods in isolated minimal invasive mitral valve surgery: Society of Thoracic Surgeons (STS) database outcomes.

Minimal invasive mitral valve surgery (MIMVS) has become a commonly used approach for mitral valve surgery. Several techniques of myocardial preservation were described in patients undergoing MIMVS. We aim to evaluate preservation technique and short term outcomes. A retrospective analysis of patients who underwent isolated MIMVS and were included in the Society of Thoracic Surgeons (STS) database. The final cohort included 4976 patients. Mean age was 63.1 years (SD, 12.5) and 42.6% were females. Antegrade delivery method (71.3% of the patients) was the most common, follow by antergrade/retrograde (19.9%). Blood, crystalloid solution, and combination of blood-crystalloid were used in 62.4%, 13.2%, and 13.7%, respectively. In multivariate analysis, cardioplegia technique was associated with mortality (P = .011), pleural effusion (P = .045), and length of ICU stay (P < .001). Antegrade-crystalloid (OR, 3.37; 95%CI, 1.70-6.68) and antegrade/retrograde-blood/crystalloid (OR, 3.28; 95%CI, 1.15-9.38) were associated with increased risk for mortality compared with antegrade-blood cardioplegia. Data on postoperative ejection fraction (EF), CPK-MB, and Troponin was available only in 30%, 9%, and 5% of the patients, respectively, and were not included in the analysis. Ante-grade-blood was the most common preservation technique in MIMVS. Ante-grade-crystalloid and ante-grade/retrograde-blood/crystalloid are associated with increased risk for mortality. The results suggest that using crystalloid solutions for cardioplegia should be carefully considered. The STS database as a source for MIMVS outcome analysis is lacking, both in detailed specification of different surgical technique aspects, and in actual data collection of already existing categories.

Left ventricular dysfunction after two hours of polarizing or depolarizing cardioplegic arrest in a porcine model.

Introduction:This experimental study compares myocardial function after prolonged arrest by St. Thomas’ Hospital polarizing cardioplegic solution (esmolol, adenosine, Mg2+) with depolarizing (hyperkalaemic) St. Thomas’ Hospital No 2, both administered as cold oxygenated blood cardioplegia.Methods:Twenty anaesthetized pigs on tepid (34°C) cardiopulmonary bypass (CPB) were randomised to cardioplegic arrest for 120 min with antegrade, repeated, cold, oxygenated, polarizing (STH-POL) or depolarizing (STH-2) blood cardioplegia every 20 min. Cardiac function was evaluated at Baseline and 60, 150 and 240 min after weaning from CPB, using a pressure-conductance catheter and epicardial echocardiography. Regional tissue blood flow, cleaved caspase-3 activity and levels of malondialdehyde were evaluated in myocardial tissue samples.Results:Preload recruitable stroke work (PRSW) was increased after polarizing compared to depolarizing cardioplegia 150 min after declamping (73.0±3.2 vs. 64.3±2.4 mmHg, p=0.047). Myocardial tissue blood flow rate was high in both groups compared to the Baseline levels and decreased significantly in the STH-POL group only, from 60 min to 150 min after declamping (p<0.005). Blood flow was significantly reduced in the STH-POL compared to the STH-2 group 240 min after declamping (p<0.05). Left ventricular mechanical efficiency, the ratio between total pressure-volume area and blood flow rate, gradually decreased after STH-2 cardioplegia and was significantly reduced compared to STH-POL cardioplegia after 150 and 240 min (p<0.05 for both).Conclusion:Myocardial protection for two hours of polarizing cardioplegic arrest with STH-POL in oxygenated blood is non-inferior compared to STH-2 blood cardioplegia. STH-POL cardioplegia alleviates the mismatch between myocardial function and perfusion after weaning from CPB

Our modified technique of combined antegrade-vein graft cardioplegia infusion versus conventional antegrade method in coronary artery bypass grafting. A randomized clinical trial

BackgroundTo determine the efficacy of antegrade cardioplegia supplemented with venous graft perfusion in patients scheduled for coronary artery bypass grafting (CABG). Methods223 consecutive patients scheduled for isolated CABG were randomized to receive either continuous crystalloid cardioplegia via vein grafts on completion of each distal anastomosis plus intermittent blood cardioplegia through aortic root (group 1, n = 110) or antegrade blood cardioplegia alone (group 2, n = 113). Two groups were similar in terms of preoperative patients' and procedural characteristics. The primary end-points were low output syndrome (LOS) variables. ResultsThe inotrope and intra-aortic balloon pump demand during weaning were significantly higher in the control group (31.8% vs. 20%, p = 0.043 and 7.9% vs. 1.8%, p = 0.034 respectively). Postoperative level of potassium and arterial base excess (BE), stood in the normal range in both groups, despite significant inter-group differences. Peak serum level of myocardial injury biomarkers (CK, CK-MB, and cTnI) at 12 h following operation, though markedly greater in the group 2, did not reach the cut-off point of myocardial necrosis. Postoperative arrhythmia was more commonly encountered in the control group (p = 0.045).The duration of ventilation and hospital stay were considerably longer in the group 2. In a subgroup with LVEF<30%, the length of ICU stay was more prolonged in the control group, as well (p = 0.0145). The significant differences among groups regarding LOS parameters were more remarkable in the two high-risk subgroups (LVEF<30%, left main coronary stenosis). ConclusionsGiven the better postoperative cardiac performance, we recommend this method to all CABG candidates, particularly in higher-risk patients.

Warm blood cardioplegia versus cold crystalloid cardioplegia for myocardial protection during coronary artery bypass grafting surgery

We retrospectively analyzed early results of coronary artery bypass grafting (CABG) surgery using two different types of cardioplegia for myocardial protection: antegrade intermittent warm blood or cold crystalloid cardioplegia. From January 2015 to October 2016, 330 consecutive patients underwent isolated on-pump CABG. Cardiac arrest was obtained with use of warm blood cardioplegia (WBC group, n = 297) or cold crystalloid cardioplegia (CCC group, n = 33), according to the choice of the surgeon. Euroscore II and preoperative characteristics were similar in both groups, except for the creatinine clearance, slightly lower in WBC group (77.33 ± 27.86 mL/min versus 88.77 ± 51.02 mL/min) (P < 0.05). Complete revascularization was achieved in both groups. In-hospital mortality was 2.0% (n = 6) in WBC group, absent in CCC group. The required mean number of cardioplegia’s doses per patient was higher in WBC group (2.3 ± 0.8) versus CCC group (2.0 ± 0.7) (P = 0.045), despite a lower number of distal coronary artery anastomoses (2.7 ± 0.8 versus 3.2 ± 0.9) (P = 0.0001). Cardiopulmonary and aortic cross-clamp times were similar in both groups. The incidence of perioperative myocardial infarction (WBC group 3.4% versus CCC group 3.0%) and low cardiac output syndrome (4.4% versus 3.0%) were similar in both groups. As compared with WBC group, in CCC group CK-MB/CK ratio >10% was lower during each time points of evaluation, with a statistical significant difference at time 0 (4% ± 1.6% versus 5% ± 2.5%) (P = 0.021). In presence of complete revascularization, despite the value of CK-MB/CK ratio >10% was less in the CCC group, clinical results were not affected by both types of cardioplegia adopted to myocardial protection. As compared with cold crystalloid, warm blood cardioplegia requires a shorter interval of administration to achieve better myocardial protection.

L-carnitine on myocardial function after coronary artery bypass grafting.

This study aims to evaluate the effect of L-carnitine on postoperative cardiac performance and morbidity and complications in patients undergoing coronary artery bypass grafting. Between April 2005 and June 2008, a total of 60 patients (36 males, 24 females; mean age 60.6 years; range 57 to 65) who were scheduled for coronary artery bypass grafting were prospectively randomized to receive one of three different strategies of myocardial preservation. Group A (n=20) received antegrade crystalloid cardioplegia, Group B (n=20) received antegrade blood cardioplegia, and Group C (n=20) received antegrade blood cardioplegia with carnitine. Samples for lactate dehydrogenase (LDH), creatinine phosphokinase (CPK), creatinine phosphokinasemyocardial band (CK-MB), and Troponin-I were taken from coronary sinus during the operation and from peripheral venous line postoperatively. Blood samples were obtained before CPB, just after CPB and postoperative 1, 6, 12, 24 and 48 hours. Levels of CPK, CK-MB and Troponin-T levels were studied by immunoassay method. The patients who received carnitine had significantly improved cardiac output, cardiac index, and right and left ventricular stroke work immediately after cardiopulmonary bypass and at the first postoperative hour (p=0.01). Troponin-T levels decreased in all patients after 12 hours postoperatively, and this change was most prominent in Group C (p=0.001). Intravenous supplementation of carnitine during cardioplegia provides better results on the recovery of cardiac function and metabolic parameters after coronary artery bypass grafting.

Early outcome of mini aortic valve replacement surgery

BackgroundMinimally invasive aortic valve surgery (MIAVS) has evolved into a well-tolerated, efficient surgical treatment option in experienced centers, providing greater patient satisfaction and lower complication rates. Potential advantages of MIAVR arise from the concept that patient morbidity and potential mortality could be reduced without compromising the excellent results of the conventional procedure which include improved cosmetic results, safer access in the case of reoperation, less postoperative bleeding, lower intensive care unit (ICU) and in-hospital stays, as well as the absence of sternal wound infection. These results were achievable also in high-risk patients. Reduced pain and hospital length of stay, decreased time until return to full activity and decreased blood product use have also been demonstrated. MethodsSixty patients with aortic valve disease randomized into two equal groups; group “A” underwent aortic valve surgery through a minimally invasive limited upper sternotomy. Group “B” underwent aortic valve surgery through a full median sternotomy. The Pain was evaluated on 2nd, 3rd day post-operatively and at the 3rd, 6th month after discharge. Echocardiographic data were performed preoperatively and at the 3rd, 6th month after discharge in all patients. Standard aortic and bicaval cannulation with cold antegrade crystalloid cardioplegia was adopted in group“B”, while in group “A” femoral vein with ascending aortic cannulation was adopted with antegrade blood cardioplegia. ResultsThere was no statistical difference between the two groups preoperatively regarding their age, sex, NYHA class, EF%, LA dimension, spirometric study. There was no operative mortality in both groups but few postoperative complications occurred in both groups. Total hospital stay, ICU stay, postoperative bleeding, inotropic requirement, ventilatory support, blood transfusion was less in group “A”, with better cosmetic appearance, and more cost effective. ConclusionsLimited upper sternotomy minimally invasive technique for aortic valve replacement provides excellent exposure of the aortic valve and offers a better cosmetic scar. In addition, minimally invasive limited upper sternotomy is as safe as full median sternotomy for aortic valve surgery, with fewer complications and postoperative pain, less ICU and hospital stay, fast recovery to work with limited movement restriction after surgery. It is better to use the limited upper sternotomy incision as an initial approach for aortic valve surgery.

Clinical Results of Different Myocardial Protection Techniques in Aortic Stenosis.

BackgroundHypertrophied myocardium is especially vulnerable to ischemic injury. This study aimed to compare the early and late clinical outcomes of three different methods of myocardial protection in patients with aortic stenosis.MethodsThis retrospective study included 225 consecutive patients (mean age, 65±10 years; 123 males) with severe aortic stenosis who underwent aortic valve replacement. Patients were excluded if they had coronary artery disease, an ejection fraction <50%, more than mild aortic regurgitation, or endocarditis. The patients were divided into three groups: group A, which was treated with antegrade and retrograde cold blood cardioplegia; group B, which was treated with antegrade crystalloid cardioplegia using histidine-tryptophan-ketoglutarate (HTK) solution; and group C, treated with retrograde cold blood cardioplegia.ResultsGroup A contained 70 patients (31.1%), group B contained 74 patients (32.9%), and group C contained 81 patients (36%). The three groups showed significant differences with regard to the proportion of patients with a New York Heart Association functional classification ≥III (p=0.035), N-terminal pro-brain natriuretic peptide levels (p=0.042), ejection fraction (p=0.035), left ventricular dimensions (p<0.001), left ventricular mass index (p<0.001), and right ventricular systolic pressure (p<0.001). Differences in cardiopulmonary bypass time (p=0.532) and aortic cross-clamp time (p=0.48) among the three groups were not statistically significant. During postoperative recovery, no significant differences were found regarding the use of inotropes (p=0.328), mechanical support (n=0), arrhythmias (atrial fibrillation, p=0.347; non-sustained ventricular tachycardia, p=0.1), and ventilator support time (p=0.162). No operative mortality occurred. Similarly, no significant differences were found in long-term outcomes.ConclusionAlthough the three groups showed some significant differences with regard to patient characteristics, both antegrade crystalloid cardioplegia with HTK solution and retrograde cold blood cardioplegia led to early and late clinical results similar to those achieved with combined antegrade and retrograde cold blood cardioplegia.

Effects of antegrade versus integrated blood cardioplegia on left ventricular function evaluated by echocardiographic real-time 3-dimensional speckle tracking

ObjectiveThe objective of this study was to evaluate left ventricular free wall and interventricular septal function by 2-dimensional transthoracic echocardiography and live/real-time 3-dimensional transthoracic speckle tracking echocardiography before and after on-pump cardiac surgery and to assess the effect of mode of cardioplegia delivery. MethodsA total of 22 patients were studied 1 day before and 4 to 5 days after surgery. Cold blood cardioplegia was delivered by intermittent antegrade infusion or by the integrated method. The latter includes a combination of intermittent antegrade and retrograde cardioplegia with a terminal warm amino acid–enriched reperfusion. ResultsThe overall group displayed significant deterioration of septal function after surgery by 2-dimensional transthoracic echocardiography, as assessed by wall motion score index, yet subgroup analysis by 3-dimensional transthoracic speckle tracking echocardiography permitted distinction of outcomes achieved by antegrade or integrated delivery methods. Analysis after surgery showed that only the antegrade group displayed statistically significant deterioration in the strain parameters of some of the segments of the septum and free wall when strain was measured in the free wall and septum in the longitudinal, circumferential, and radial modes of deformation (P < .05). In contrast, only the integrated group displayed significant improvement in global radial, circumferential, and longitudinal strain (P < .05). ConclusionsThese findings by 3-dimensional transthoracic speckle tracking echocardiography indicate that integrated cardioplegia offers superior myocardial protection of the left ventricular free wall and septum compared with the antegrade mode of cardioplegia delivery.

HVAD continuous flow assist device for ischemic ventricular septal rupture

HVAD continuous flow assist device for ischemic ventricular septal rupture

Surgical abscess enolization for complex mitroaortic endocarditis treatment in a high risk patient

We know that the mitroaortic endocarditis is one of the worse and risky surgical situation, particularly when it happens in patients previously operated and whether is involved the mitroaortic continuity and atrial septum. In this paper we describe here the surgical solution applied to one patient. We present here a 79-year old man with symptoms of fever, leukocytosis, confusional state, vomits, artralgia, A-V blockage with transient pacemaker implantation, renal insufficiency and peripheral embolization treated by embolectmy. His medical history included aortic valve replacement, two years before, by Mitroflow biological prosthesis, diabetes, and asymptomatic prostatic carcinoma. Blood cultures detected streptococcus bovis. Transeophageal echocardiography showed images of endocarditis of the aortic prosthesis with one abscess in the posterolateral aortic annulus that extends in to the the atrial septum and the anterior mitral annulus with suspected vegetations and mitral mild regurgitation. The patient was treated with levofloxacin, gentamycine, vancomycin and ceftriaxone. After 20 days of conservative therapy, the patient underwent surgery. A median sternotomy and standard cannulation were performed Moderate hypothermia and antegrade blood cardioplegia were administered. After the opening of the aorta, previous aortic biological prosthesis was extracted and the abscess affecting posterolateral part of the ring was cleaned without extraction of solid material of the rest of the abscess. After this we injected 20 cc of ethylic alcohol for embolism the abscess and for tanning the affected aortic annulus. Previous Aortic prosthesis was replaced by a mechanical 20- mm ATS (ATS Medical, Inc.Minneapolis USA), then we opened the left atrium and proceeded to remove the vegetation inserted into the anterior annulus After this, injected again 10 cc of alcohol in the abscess from the left atrium until the liquid appeared on the aortic face of the abscess .In the postoperative course during the initial 24 hours presented low cardiac output and needed inotropic support and intraortic balloon pump assistance. The patient was weaned from respirator machine five days later with a good recovery. Permanent pacemaker was implanted twelve days later. The patients was discharged from the hospital 48 days later after surgery, without fever had recovered renal function and good clinical situation Predischarge echocardiography, one month later, showed excellent function of the prosthesis and one posterior residual cavity in the outflow tract of left ventricle corresponding to previous abscess zone. Mitral valve function was successful without regurgitation. Ejection fraction was 0.4

Our emergency surgical approach in a case with migration of the atrial septal defect occluder device into left atrium and displacement on mitral valve

Results After median sternotomy and vertical incision of the pericardium, standard aortic and bicaval venous cannulation was carried out. Following the cross-clamping of the aorta antegrade blood cardioplegia was introduced. Right atriotomy was done. ASD occluder device was detected within the left atrium settled on the mitral valve which was observed through 50 x 25 mm fossa ovalis type secundum ASD. After transseptal removal of the device from the left atrium, the defect was repaired using a polytetrafluoroethylene cardiac patch. His intensive care unit stay was 2 days and he was discharged from the hospital on 7th postoperative day. His 1st, 3rd and 6th follow-up visits were free of events and repeated echocardiographic examinations revealed no residual shunting. Conclusions One must keep in mind that transcatheter closure has such complications as migration of the device and development of residual shunting. In case of occurrence of such complications, the problem may be solved by standard open cardiac surgery under cardiopulmonary bypass.

Tepid antegrade intermittent blood cardioplegia as an alternative for intermittent crossclamping with Lidoflazine

Background: Blood cardioplegia is a technique with many variations in its use. Intermittent cross clamping with Lidoflazine has proven to deliver good cardioprotection in our center. Question: Is tepid (32°C) antegrade intermittent blood cardioplegia an efficient, safe and easy-to-use alternative to intermittent cross-clamping with Lidoflazine in elective isolated CABG in low-risk patients? Primary outcomes are heart enzymes (cTnI, CK-MB). Secondary outcomes are operation times, length of hospital stay, major complications and in-hospital mortality. Methods: From January 2012 until November 2012, 40 patients with LVEF ≥50%, EuroSCORE II

Myocardial Protection Era: From Valve Surgery to Heart Transplantation

Myocardial Protection Era: From Valve Surgery to Heart Transplantation

Cardiopulmonary Bypass Transiently Inhibits Intraventricular Vortex Ring Formation in Patients Undergoing Coronary Artery Bypass Graft Surgery

Transmitral blood flow during early left ventricular (LV) filling produces an intraventricular rotational body of fluid known as a "vortex ring" that enhances the hydraulic efficiency of early LV filling. The authors tested the hypothesis that exposure to cardiopulmonary bypass (CPB) attenuates intraventricular vortex formation time (VFT) in patients with normal preoperative LV systolic and diastolic function undergoing coronary artery bypass graft (CABG) surgery. A prospective, observational study. Ten men (65 ± 4 years, 91 ± 11 kg, and 175 ± 8 cm) with a normal preoperative LV ejection fraction (58% ± 6%) scheduled for elective CABG surgery were studied after institutional review board approval. None. Anesthesia was induced with etomidate, fentanyl, and rocuronium and maintained with isoflurane. Myocardial protection during CPB consisted of antegrade and retrograde cold blood cardioplegia administered at 15-minute intervals, systemic and topical hypothermia, and warm continuous antegrade cardioplegia before aortic cross-clamp removal. The peak early LV filling and atrial systole blood flow velocities (E and A, respectively) and corresponding velocity-time integrals (VTI-E and VTI-A, respectively) were obtained with pulse-wave Doppler echocardiography and used to determine E/A and atrial filling fraction (β, VTI-A/[VTI-E + VTI-A]), respectively. Mitral valve diameter (D) was calculated as the average of minor and major axis lengths obtained in the midesophageal bicommissural and long-axis transesophageal echocardiographic imaging planes, respectively. VFT was calculated 30 minutes before and 15, 30, and 60 minutes after CPB as 4 × (1 - β) × stroke volume (SV)/πD(3), where SV is the stroke volume measured using thermodilution. All patients separated from CPB in sinus rhythm without pacing or vasoactive drug support. Systemic and pulmonary hemodynamics were similar before compared with all times after CPB. CPB significantly (p < 0.05) reduced VFT (5.3 ± 1.8 to 4.0 ± 1.5 15 minutes after CPB); the recovery of VFT (to 4.7 ± 1.6, p > 0.05 v baseline) was noted 60 minutes after CPB. A reduction in E/A (1.26 ± 0.22 to 0.96 ± 0.27) and an increase in β (0.33 ± 0.04 to 0.41 ± 0.07) occurred 15 minutes after CPB. E/A and β also recovered gradually toward control values after CPB (1.25 ± 0.22 and 0.36 ± 0.04, respectively, 60 minutes after CPB; p > 0.05 v. baseline). The results indicated that CPB transiently attenuate VFT in patients with normal preoperative LV systolic and diastolic function undergoing CABG surgery. These data suggest that CPB adversely affects diastolic transmitral flow efficiency by reducing intraventricular vortex ring formation in vivo.

Left Main Disease Associated With An Anomalous Left Anterior Descending Artery

Coronary artery anomalies are very rare. Recognizing these anomalies are clinically relevant as they can mimic symptoms of coronary artery disease, and sporadic cases of sudden death have been described in these patients. This report describes a 55-year-old patient with left main disease and an anomalous left anterior descending artery arising from anterior coronary sinus who presented with palpitations. Patient underwent coronary artery bypass grafting with left internal mammary artery to the ramus intermedius with cardiopulmonary bypass using antegrade blood cardioplegia. The anomalous left anterior descending artery was crossing the right ventricular outflow tract and running on the interventricular groove. The diagnosis and management of coronary artery anomalies is the subject of this review.