Cold Crystalloid Cardioplegia Research Articles

Del Nido versus cold crystalloid cardioplegia for myocardial protection during ventricular septal defect repair in children under one year of age: a prospective randomized trial

Rationale: The choice of strategy for myocardial protection during procedures with cardiopulmonary bypass and cardioplegic arrest in children is not regulated by clinical guidelines due to insufficient data from clinical studies. The issue of methods to assess myocardial injury remains unresolved.
 Aim: To assess the frequency and specifics of the development of intraoperative myocardial injury syndrome in children of the first year of life with ventricular septal defect depending on the strategy for cardioplegia.
 Materials and methods: In a single center, prospective, randomized controlled trial we compared two cardioplegia strategies during surgical closure of ventricular septal defect in infants aged from 1 to 12 months: del Nido blood cardioplegia (n = 102) and cold crystalloid cardioplegia with Custodiol solution (n = 102). The primary endpoint was a persistent over 10-fold increase above the upper limit of the normal in the plasma concentration of high-sensitivity troponin I at 6 hours after surgery persisting after 24 hours. The secondary combined endpoint was myocardial damage verified by persistent increase in troponin I level more than 10-fold above the upper limit of the normal, persisting at 6 and 24 hours, accompanied by new pathological Q waves, acute complete left bundle branch block, abnormalities of the end part of the ventricular complex on the electrocardiography (ST segment elevation 1 mm or ST depression of 1 mm in more than 2 adjacent leads), and a decrease in the global longitudinal strain of the left ventricle by 50% from the initial value at 6 hours after surgery.
 Results: In 53/204 (26%) patients, the increase in troponin I persisted at 24 hours after the surgery and was associated with electrocardiography abnormalities, changes in the parameters of left ventricle longitudinal mechanics, and in some cases required greater inotropic support. By the end of the 1st postoperative 24 hours, the longitudinal strain of the left ventricle showed more negative changes over time in the Custodiol group compared to that in the del Nido group (-10 [-14.1; -6.27] versus -14.8 [- 16.5; -10]%; p 0.0001). The same was true for the left ventricle global strain rate (-0.71 [-0.9; -0.52] s-1 in the del Nido group and -0.57 [-0.760; - 0.44] s-1 in the Custodiol group; p = 0.0049). The primary endpoint was achieved by 21 (20.6%) and 55 (53.9%) patients in the del Nido and Custodiol groups, respectively (p = 0.032). The combined endpoint in the Custodiol group was achieved by 34 (33.3%) versus 19 (18.6%) patients in the del Nido group (p = 0.049, χ2 = 3.875, DF = 1, φ = 0.191).
 Conclusion: Del Nido blood cardioplegia compared to cold crystalloid cardioplegia with Custodiol has advantages in terms of preventing intraoperative myocardial damage and minimizing its severity. When assessing myocardial damage, such indicators as left ventricle global longitudinal strain and left ventricle global strain rate are informative, along with an increase in the troponin I level.

Redo extended thoracic aortic replacement from aortic root to descending aorta via anterolateral thoracotomy with partial sternotomy for graft infection

A 59-year-old male underwent Bio-Bentall + total arch replacement with a frozen elephant trunk for acute type A aortic dissection before at another hospital. He was diagnosed as mediastinitis and previous graft infection, followed by wound closure with omental flap installation. However, the recurrent graft infection from the aortic root to the FET in the descending aorta was diagnosed by 18-fluorodeoxyglucose positron emission tomography. Redo modified Bio-Bentall procedure, total arch replacement, and descending aortic replacement for previous graft infection using anterolateral thoracotomy with partial sternotomy was successfully performed. Anterolateral thoracotomy with partial sternotomy provided not only the excellent exposure from the aortic root to the descending aorta but also sure myocardial protection with antegrade and selective delivery of cold crystalloid cardioplegia and stable brain protection with antegrade selective cerebral perfusion. The patient is doing well without recurrent of infection after 2 years of the operation.

Endoscopically assisted selective antegrade cardioplegia in minimally invasive aortic valve replacement for patients with aortic insufficiency

In minimally invasive aortic valve replacement via a right minithoracotomy for patients with significant aortic insufficiency, optimal cardioplegia delivery procedures remain controversial. This study aimed to describe and evaluate endoscopically assisted selective cardioplegia delivery in minimally invasive aortic valve replacement for aortic insufficiency. Between September 2015 and February 2022, 104 patients (mean age, 66.0±14.3 years) with moderate or greater aortic insufficiency underwent endoscopically assisted minimally invasive aortic valve replacement at our institutions. For myocardial protection, potassium chloride and landiolol were systemically administered before aortic crossclamping, and cold crystalloid cardioplegia was delivered selectively to the coronary arteries using step-by-step endoscopic procedures. The early clinical outcomes were also evaluated. Eighty-four patients (80.7%) had severe aortic insufficiency, and 13 patients (12.5%) had aortic stenosis and moderate or greater aortic insufficiency. A regular prosthesis was used in 97 cases (93.3%), and a sutureless prosthesis was used in 7 cases (6.7%). The mean operative, cardiopulmonary bypass, and aortic crossclamping times were 169.3±36.5, 102.4±25.4, and 72.5±21.8minutes, respectively. No patients underwent a conversion to full sternotomy or required mechanical circulatory support during or after surgery. No operative deaths or perioperative myocardial infarctions occurred. The median intensive care unit and hospital stays were 1 and 5 days, respectively. Endoscopically assisted selective antegrade cardioplegia delivery is safe and feasible for treating minimally invasive aortic valve replacement in patients with significant aortic insufficiency.

BNP, TnI and Lactic Acid variations in Warm Blood Cardioplegia vs Cold Crystalloid Cardioplegia in Coronary Artery Bypass Grafting (CABG)

Introduction: Myocardial protection is one of the key points during cardiac surgery. Inadequate myocardial protection in cross-clamping period is an issue of concern in cardiac surgery. Cardioplegic solutions improve the tolerance of ischemia and reperfusion by preserving myocardial energy reserves, preventing osmotic, electrolyte imbalances and acidosis. Warm blood cardioplegia (WBC) has had a profound impact, especially in coronary artery bypass surgery and there have been many studies that compared it with Cold crystalloid cardioplegia (CCC). A good myocardial protection will be reflected especially on patients outcome, on postoperative ICU strategy, morbidity and mortality as well. Brain Natriuretic Peptide (BNP), Troponin I (TnI) and Lactic Acid LA) are very significant biomarkers that reflects an adequate myocardial and organ perfusion/protection. The purpose of this study is to determine if warm blood cardioplegia offers any advantages in comparison with CCC in Coronary Artery Bypass Grafting (CABG) based primary on variations of BNP, TnI and Lactic Acid. Patients and method: 60 patients with coronary artery disease (CAD) that will have Coronary Artery Bypass Surgery (CABG), were retrospectively randomized in two groups of 30 patients with different techniques of myocardial protection: group A had CCC, and group B had warm blood cardioplegia (WBC), according to Calafiore [1] protocols). Intraoperative and postoperative variables were used to assess primary outcomes. Results: This study found benefits of warm blood cardioplegia in clinical outcome after CABG Keywords :Myocardial protection, Cardiac surgery, Cardiopulmonary Bypass, Calafiore, Cardioplegia, Coronary Artery Bypass Grafting (CABG), Brain Natriuretic Peptide (BNP), Troponin I (TnI) and Lactic Acid LA) DOI: 10.7176/ALST/95-02 Publication date: November 30 th 2022

Comparison of CKMB, Lactate Levels and Ejection Fraction with Warm and Cold Cardioplegia on First Post Operative Day in Elective CABG Cases

Objectives: The main objective of the study is to find the comparison of CKMB, Lactate levels and ejection fraction with warm and cold cardioplegia on first post OP day in elective CABG cases. Material and methods: This cross sectional study was conducted in Armed forces institute of cardiology AFIC /NIHD Rawalpindi during 1st October 2022 to 30th November 2022. Data was collected with the permission of ethical committee of hospital. The study variables were included level of troponin I during intraoperative and post-operative period, time taken for cardiac standstill, CKMB, Lactate levels and ejection fraction with warm and cold cardioplegia, post-operative improvement in ejection fraction, number of days in ICU. Results: The data was collected from 100 patients. There was no statistically significant difference between the two groups as regards bypass and cross clamp times. Mean age of group I patients was 61.3 ± 12.5 years and for group II patients was 67.4 ± 10.4 years. P value of serum lactate level is <0.01, which is statistically significant. All the patients had elevated lactate level but the range of increase in lactate level was seen in those who didn’t take adenosine as compared to those who took adenosine. Practical Implications: Enzymes play an important role in both cold and warm cardioplegia. Conclusion: It is concluded that there is less cardiac enzymes release after the application of warm blood cardioplegia for myocardial protection in patients undergoing CABG as compared to cold crystalloid cardioplegia. Keywords: Cardioplegia, CKMB, Troponin, CABG, Cold

Single-Dose Cold Modified Bretschneider Solution for Myocardial Protection in the Surgical Treatment of Patients with Aortic Valve Stenosis and Left Ventricular Hypertrophy

Summary Aortic valve stenosis (AS) is predominantly caused by degenerative calcification in patients over 70 years. It obstructs the left ventricular outflow tract. The result is concentric left ventricular hypertrophy (LVH) wall stress and ischemia-induced myocardial fibrosis. [1] According to the European Association of Cardiothoracic Surgery, all high-grade AS patients are indicated for Aortic valve intervention [2]. One of the most recommendable methods for myocardial protection during surgical aortic valve replacement is antegrade delivery of cold crystalloid cardioplegia. Our retrospective study included 173 operated patients with AS and LVH. We observed the MB fraction of the enzyme creatine phosphokinase (CPK-MB) as a postoperative marker for myocardial hypoprotection in different patients. Our results showed that a single dose of modified Bretschnaider solution provided safe and long enough myocardial protection during conventional and minimally invasive aortic valve replacement in patients with AS and LVH [3].

Myocardial Protection With Different Cardioplegia in Adult Cardiac Surgery: A Network Meta-Analysis

Cardioplegia is one of the most studied fields of myocardial protection during cardiac surgery. However, the most effective cardioplegia for protection in adult cardiac surgery remains unknown. PubMed and other databases were searched and a network meta-analysis with a Bayesian framework was performed. The primary outcomes were the serum concentrations of creatine kinase-myocardial band (CK-MB), cardiac troponin I, and cardiac troponin T (cTnT) at four time points. Several clinical outcomes were evaluated, including low output syndrome, myocardial infarction, and risk of early mortality. All studies that involved crystalloid cardioplegia without reference to St Thomas cardioplegia or histidine-tryptophan-ketoglutarate solution, and if the cardioplegia was used at a temperature between 4°C and 16°C were classified as cold crystalloid (cCCP) or cold blood cBCP cardioplegia. Warm blood cardioplegia (wBCP) was defined as the blood cardioplegia used at a temperature between 32°C and 37°C. Forty-seven (47) studies with a total of 4,175 patients were included. Seven (7) cardioplegia solutions were used, including cold CCP or BCP, del Nido solution, histidine-tryptophan-ketoglutarate solution, St Thomas cardioplegia, wBCP and warm terminal blood cardioplegia (wtBCP).Theserum concentrations of CK-MB at 2 hours (mean difference [MD], 213.56; 95% confidence interval [CI],-25.79 to-1.59) and cTnT at 24 hours of wBCP (MD,-1.50; 95% CI,-2.69 to-0.31) were significantly lower than that of cCCP. There were no significant differences in other outcomes of these six cardioplegia solutions, when compared to cCCP. The seven cardioplegia solutions analysed had similar myocardial protective effects after adult cardiac surgery, although wBCP had a lower CK-MB at 2 hours and lower cTnT at 24 hours.

Warm versus cold cardioplegia in cardiac surgery: A meta-analysis with trial sequential analysis

ObjectiveThis meta-analysis aimed to compare clinical outcomes of warm and cold cardioplegia in cardiac surgeries in adult patients, with trial sequential analysis (TSA) used to determine the conclusiveness of the results. MethodsElectronic searches were performed on PubMed, Medline, Scopus, EMBASE, and Cochrane library to identify all studies that compared warm and cold cardioplegia in cardiac surgeries. Primary end points were in-hospital or 30-day mortality, myocardial infarction, low cardiac output syndrome, intra-aortic balloon pump use, stroke, and new atrial fibrillation. Secondary end points were acute kidney injury, hospital length of stay, and intensive care unit length of stay. Prespecified subgroup analyses were performed for (1) studies published since publication of Fan and colleagues in 2010, (2) randomized controlled studies, (3) studies with low risk of bias, (4) coronary artery bypass graft surgeries, and (5) studies with cold blood versus those with cold crystalloid cardioplegia. TSA was performed to determine conclusiveness of the results, using on all outcomes without significant heterogeneity from studies of low risk of bias. ResultsNo significant differences were found between post-operative rates of mortality, myocardial infarction, low cardiac output syndrome, intra-aortic balloon pump use, stroke, new atrial fibrillation, and acute kidney injury between warm and cold cardioplegia. TSA concluded that current evidence was sufficient to rule out a 20% relative risk reduction in these outcomes. ConclusionsConcerning safety outcomes, current evidence suggests that the choice between warm and cold cardioplegia remains in the surgeon's preference.

The effect of cold crystalloid versus warm blood cardioplegia on the myocardium during coronary artery bypass grafting

Background: The optimal cardioplegic solution is still debated. The objective of this study was to compare the effect of cold crystalloid versus warm blood cardioplegia on the myocardial injury during coronary artery bypass grafting.
 Methods: The study included 34 consecutive patients who underwent elective primary on-pump isolated coronary artery bypass grafting from 2016 to 2019. We randomly assigned the patients into two groups. Group (ICCC) (n= 17) received intermittent antegrade cold crystalloid cardioplegia and Group (IWBC) (n= 17) received intermittent antegrade warm blood cardioplegia.
 Results: There was no difference in the preoperative and operative variables between groups. The time taken by the heart to regain normal sinus rhythm was significantly longer in the cold crystalloid group (7.06 ± 1.8 vs. 2.17 ± 0.8 minutes, p<0.001) with a higher rate of reperfusion ventricular arrhythmia (35% versus 6%; p=0.03) compared to the warm blood cardioplegia group. Both coronary sinus acid production and lactate level were significantly higher in the warm blood group than in the cold crystalloid group (p< 0.001 and 0.043, respectively). The ischemic ECG changes and the severity of new segmental wall motion abnormalities were non-significantly different between both groups (p= 0.68 and 0.67, respectively). Postoperative CK-MB and cTnI levels in all-time points were not significantly different between groups (p= 0.46 and 0.37, respectively). ICU (2.29 ± 0.77 vs. 2.41 ± 0.87 days, p= 0.68) and hospital stay (9.28 ± 0.76 vs. 9.42 ± 0.88 days, p= 0.62) were non-significantly different between both groups.
 Conclusion: Intermittent antegrade cold crystalloid cardioplegia was associated with attenuated myocardial metabolism. However, it was associated with a longer time to regain normal sinus rhythm and more reperfusion ventricular arrhythmias. We did not find differences in the clinical and echocardiographic outcomes and cardiac enzymes between cold crystalloid and warm blood cardioplegia.

Effect of Cardioplegia for Myocardial Protection in Pediatric Cardiac Surgery: A Network Meta-Analysis

Cardioplegia has been widely used to reduce myocardial injury during pediatric cardiac surgery; however, which cardioplegia solution has the best protective effect has not been established. Thus, we compared the myocardial protective effects of different cardioplegia solutions used in pediatric cardiac surgery. Seven databases were searched to identify the relevant randomized controlled trials. A network meta-analysis with a Bayesian framework was conducted. The outcomes included the following biochemical and clinical outcomes: serum concentrations of the creatine kinase-myocardial band at 6 h postoperatively; cardiac troponin I (cTnI) at 4, 12, and 24 h postoperatively; spontaneous beating after declamping; postoperative arrhythmias; inotropic support percentage and duration; mechanical ventilation hours; intensive care unit stay in days; hospital stay in days; and mortality. The group treated with cold crystalloid cardioplegia (cCCP) was chosen as the control group. The 22 studies involved 1529 patients. Six types of cardioplegia solutions were described in these studies, including cold blood cardioplegia, cCCP, del Nido, histidine-tryptophan-ketoglutarate (HTK), terminal warm blood cardioplegia, and warm blood cardioplegia (wBCP). The serum concentrations of the 24-h cTnI with wBCP (MD = −2.52, 95% CI: −4.74 to −0.27) was significantly lower than cCCP. The serum concentrations of the 24-h cTnI with HTK (MD = 4.91, 95%CI: 2.84–7.24) was significantly higher than cCCP. There was no significant difference in other biochemical and clinical outcomes when compared to cCCP. In conclusion, wBCP may have a superior myocardial protective effect with lower 24-h cTnI levels postoperatively and similar clinical outcomes after pediatric cardiac surgery.

Protección miocárdica mediante cardioplejia Custodiol® frente a cristaloide convencional en cirugía cardíaca compleja. Resultados de una serie institucional

IntroductionCustodiol® cold crystalloid cardioplegia offers myocardial protection for up to three hours with one single dose, allowing to perform complex procedures without interruption. There is concern about the adequacy of single dose cardioplegia in terms of myocardial protection. ObjectiveTo compare results of perioperative morbidity and mortality of conventional crystalloid cardioplegia used in our hospital (St.Thomas 2 [ST2]) versus Custodiol in complex cardiac surgery. MethodsA retrospective comparative study was conducted between patients who underwent cardiac surgery with aortic cross-clamping times over 80 minutes, from May 2016 until December 2019. They were divided into two groups of cardioplegia: ST2 group versus Custodiol group. ResultsThe study included 712 patients, of whom 548 were in ST2 group and 164 in Custodiol group. Preoperative variables showed a greater number of women, re-interventions, and emergent cases, with the highest EuroSCORE ii (4.90% vs. 7.19%, p = 0.000) in the Custodiol group.The Custodiol group also had longer cardiopulmonary bypass times (127 vs. 149 minutes, p = 0.000) and aortic cross-clamping times (106 vs. 124 minutes, p = 0.0001), and a greater number of ventricular arrhythmias that needed defibrillation (16.2% vs. 34.6%, p = 0.000).Surgical mortality did not show any differences (3.8% vs. 6.1%, p = 0.152). Hospital stay was two days longer in the Custodiol group.In multivariate analysis, type of cardioplegia did not result in an independent risk factor for post-operative morbidity and mortality. ConclusionsThis hospital centre proposes the use of Custodiol in complex cardiac surgery with prolonged aortic cross-clamping times as a safe alternative to conventional crystalloid cardioplegia, as it offers good myocardial protection for surgeons, with same incidence of post-operative complications.

Custodiol (Histidine-Tryptophan-Ketoglutarate) versus Modified St. Thomas Cold Crystalloid Cardioplegia: Short-term Results

Abstract Background: Myocardial protection refers to strategies used to avoid post-ischemic myocardial dysfunction. One dose approach for myocardial safety is attractive in long operations. Purpose: to assess differences among the custodial cardioplegia and the cold crystalloid cardioplegia according to myocardial protection in cases listed for Double Valve Replacement Surgery. Patient and methods: This prospective cohort trial included 50 cases had double valve replacement surgery between August 2017 and July 2019. Twenty-nine patients were males (58%), and the mean age was 57.66±8.81 years. The mean ejection fraction was 41.43±9.25 %. Results: The mean CPB time in custodial group was 99.4±8.46 while in cold crystalloid cardioplegia group was 95.6±12.27 minutes. The mean DC shocks that was required in custodial group was 9(36%) while in cold crystalloid cardioplegia group was 17 (68%) times. Mean days of ICU stay in custodial group were 1.28±0.46 while in cold crystalloid cardioplegia group were 1.72±0.61 days. The mean duration of mechanical ventilation in custodial group was 4.64±0.86 while in cold crystalloid cardioplegia group was 7.04±0.84 hours. Troponin elevation mean in the immediate post-operative: in custodiol group was 8.46±2.21 while in the cold crystalloid group was 10.08±2.18. Conclusion: This study showed that the evidence supporting the superiority of custodial over cold crystalloid cardioplegia are limited however, Custodiol cardioplegia is appealing as it gives lengthy myocardial protection with a single-dose. The present work demonstrated that Histidine-Tryptophan-Ketoglutarate cardioplegia is related with less ICU stay, mechanical ventilation, postoperative hospitalization and troponin T release in low-risk patients who had double valve replacement.

Association between cardioplegia and postoperative atrial fibrillation in coronary surgery

ObjectiveThe aim of this multicenter study was to evaluated whether cold or warm cardioplegia are associated with postoperative atrial fibrillation (POAF) and the prognostic role of the latter on early stroke and neurological mortality. MethodThis was a retrospective analysis of prospective collected data from 9 cardiac centers in Italy and the United States including patients undergoing surgery between 2010 and 2018. From the 9 institutional databases, 17,231 patients underwent isolated CABG on-pump, using either warm cardioplegia (n = 7730) or cold cardioplegia (n = 9501); among the latter group blood and crystalloid cardioplegia were used in 691 and 8810 patients, respectively. After matching, two pairs of 4162 patients (overall cohort 8324) were analyzed. ResultsIn matched population, the rate of POAF was 18% (1472 cases), 15% (608) in warm group versus 21% (864) in cold group (p < 0.001). Multivariable analysis confirmed that cold cardioplegia was associated with higher rate of POAF, along with age, hypercholesterolemia, LVEF, reoperation, preoperative IABP, previous stroke, cardiopulmonary and cross-clamp. Moreover, cold cardioplegia as well as POAF increased the rate of postoperative stroke as well as early mortality and neurological mortality Propensity-weighted cohort included 11,830 (70%) patients out of 17,231. After adjustment, both cold blood and cold crystalloid cardioplegia negatively influenced POAF, stroke and neurological mortality. ConclusionsWarm cardioplegia may reduce the rate of POAF in CABG patients with respect to cold cardioplegia, either blood or crystalloid. This has a prognostic impact on postoperative stroke and neurological mortality.

Mitral Valve Replacement Surgery in Redo Patients with Mix Blood Cardioplegia (MBC) Protection

Aim of Study : Redo patient undergoing valve surgery are always a challenge for both cardiac surgeon and anesthesiologists. Mix blood cardioplegia has had a profound impact on cardiac surgery. but there have been few studies on its use in mitral valve replacement, especially in redo patient. The purpose of this study was to determine whether mix blood cardioplegia offers any advantages in redo patient undergoing mitral valve replacement. Patients and Methods : 20 patient, who have had a previous mitral valve surgery and were scheduled for mitral valve replacement with or without tricuspid repair, were randomized retrospectively to one of two groups of 10 with different technique of myocardial protection: group A (10 patients) had cold crystalloid cardioplegia, and group B(10 patients) had mix blood cardioplegia, a technique modified on our clinic condition (made by mixing 400-500ml oxygenated blood from oxygenator and 10ml KCL 7.5%) . Systemic hypothermia was 28°C in Group A and between 32°C and 33°C in Group B. The results were primarily assessed on the basis of clinical outcome, such as hematocrit level intra and post CPB, maximum dose of inotropic support, spontaneous rhythm recovery after aortic cross clamping, length of intensive care unit stay and secondly on postoperative blood loss and blood requirements. Results : There were no preoperative or operative differences between the groups with regard to age, sex, diagnosis, rhythm, New York Heart Association functional class, left ventricular ejection fraction, estimated pulmonary artery systolic pressure, operation, or duration of the operation, CPB, or aortic cross clamping and the time when the patients underwent the first operation. There was one death in group A (10% mortality). The changes in hematocrit level differs significantly between the two groups on the post CPB period (p=0,02) There appeared to be a trend towards better spontaneous recovery of sinus rhythm after removal of the aortic cross clamp in group B compared with group A, the difference did reach statistical significance. (p=0.002). Patients on group A required more inotropic support than Group B (p=0.005). There were differences even on blood requirements postoperatively, more dominant these requirement were in group A (p=0.02). Discussion : Mix Blood Cardioplegia had beneficial effects in clinical outcome in redo patients undergoing mitral valve replacement surgery. This may be due to its better preservation of high-energy phosphates and endogenous amino acids, less anerobic metabolic activity on reperfusion, reduced release of cardiac troponin T, and improved post-ischemic functional recovery. Keywords: Miocardial protection, cardiopulmonary bypass CPB, Mix Blood Cardioplegia (MBC) DOI: 10.7176/ALST/82-04 Publication date: October 31 st 2020

Custodiol (Histidine-Tryptophan-Ketoglutarate) Versus Crystalloid (Saint. Thomas) Cardioplegia on Myocardial Protection in Mitral Valve Replacement Surgeries

ABSTRACT Background: Cardioplegia is the solution used to arrest and protect myocardial function during cardiac surgery. Cardioplegia is widely used in open-heart surgery. Myocardial protection is a critical approach to reduce the myocardial complications that occur during and after cardiac surgery. Aim: This study was designed to assess the use of custodial (HTK) versus cold crystalloid cardioplegia (Saint-Thomas) on myocardial protection in mitral valve replacement surgeries. METHODS: A total 50 patients undergoing mitral valve replacement surgeries (MVR) aged 25 to 60 years, ASA class II-III was randomly divided into two equal groups: Custodiol (HTK group, n =25) or cold crystalloid cardioplegia (CCC group, n =25) to produce cardiac arrest. RESULT: No significant difference was identified intraoperatively in (ACC time, CPB time, duration of surgery) but there was a significantly higher number of return to a spontaneous rhythm in the custodiol compared to CCC group (56% versus 28%; p = 0.045) and low volume in the HTK group (1412.1 ± 108.7 vs. 1782.9 ± 214.7; p = 0.0001). There were no significant differences between the two groups in CK-MB and troponin I preoperative or postoperatively, but there was a higher increase in their level at 24 h and 48h postoperative in the CCC group versus HTK group. Duration of inotropic support postoperatively significantly higher in the CCC group. CONCLUSIONS: The use of custodiol is effective than cold crystalloid cardioplegia for myocardial protection in mitral valve replacement surgeries Keywords: Mitral valve surgeries; custodial; crystalloid cardioplegia; myocardial protection.

Warm blood cardioplegia versus cold crystalloid cardioplegia for coronary artery bypass grafting (CABG) in patients with low ejection fraction

BackgroundPatients with reduced ejection fraction (EF) undergoing CABG are more likely to develop postoperative morbidity and mortality. It is controversial about which cardioplegia solution, temperature, and method of administration ensure optimal cardiac muscle preservation during CABG surgery.Aim of the studyThe aim of the study was to compare intermittent antegrade warm blood cardioplegia with cold crystalloid cardioplegia during CABG in patients with low EF (30–40%).MethodsPatients (n = 100) undergoing elective isolated on-pump CABG were prospectively randomized into group I (n = 50) which received antegrade cold crystalloid cardioplegia and group II (n = 50) which received antegrade warm blood cardioplegia. Blood samples were collected immediately and 12 and 24 h postoperatively. CK-MB and cardiac troponin I were measured and compared between the two groups. Other indicators such as use of inotropic support and use of intra-aortic balloon counter pulsation (IABC) were also documented.ResultsPreoperative demographic and clinical variables were matched in both groups. However, postoperative CK-MB and troponin I were higher in group I compared to group II. There was less need for inotropic support and IABC with better postoperative course in group II than in group I.ConclusionThere was a significant reduction in the release of cardiac enzymes and less need for inotropic support with better postoperative outcome in patients who received antegrade warm blood cardioplegia versus cold crystalloid cardioplegia.

Comparison of Custodiol® and modified St. Thomas cardioplegia for myocardial protection in coronary artery bypass grafting

Background/Aim. Custodiol? is a hyperpolarizing cardioplegic solution which has been used in our national cardiac surgical practice exclusively for the heart transplant surgery. Owing to its numerous advantages over the standard depolarizing solutions, Custodiol? became cardioplegic solution of choice for all other cardiac surgical procedures in many cardio-surgical centers. This study evaluated myocardial protection by Custodiol? compared to modified St. Thomas cardioplegic solution in coronary artery bypass surgery. Methods. In a prospective four-month study, 110 consecutive adult patients who underwent primary isolated elective on-pump coronary artery bypass grafting (CABG) were randomized into the Custodiol? group (n = 54) and the St. Thomas groupa (n = 50), based on the type of administered cardioplegia; six patients were excluded. Cardiac protection was achieved as antegrade cold crystalloid cardioplegia by one of the solutions. Myocardial preservation was assessed through following outcomes: spontaneous rhythm restoration post cross-clamp, and postpoperative cardiac specific enzymes level, ejection fraction (EF) change, inotropic support, myocardial infarction (MI), atrial fibrillation (AF), and death. Results. Preoperative and intraoperative characteristics of patients in both groups were similar except for a considerably longer cross-clamp time in the Custodiol? group (49.1 ? 19.0 vs. 41.0 ? 12.9 minutes; p = 0.022). The Custodiol? group exhibited a higher rate of return to spontaneous rhythm compared to the St. Thomas group (31.5% vs. 20.0%, respectively; p = 0.267), lower rates of AF (20.4% vs. 28%, respectively; p = 0.496), MI (1.8% vs. 10.0%, respectively; p = 0.075) and inotropic support (9.0% vs. 12.0%, respectively; p = 0.651), albeit not statistically significant. There was an insignificant difference in peak value of troponin I between the Custodiol? and Thee St. Thomas group (5.0 ? 3.92 ?g/L vs. 4.5 ? 3.39 ?g/L, respectively; p = 0.755) and creatine kinase-MB (26.9 ? 15.4 ?g/L vs. 28.5 ? 24.2 ?g/L, respectively; p = 0.646) 6 hours post-surgery. EF reduction was comparable (0.81% vs. 1.26%; p = 0.891). There were no deaths in both groups. Conclusions. Custodiol? and modified St.Thomas cardioplegic solution have comparable cardioprotective effects in CABG surgery. The trends of less frequent MI, AF and ino-tropic support, despite the longer cross-clamp time in the Custodiol? group may suggest that its benefits could be ascertained in a larger study.

Comparison of Custodiol vs warm blood cardioplegia and conditioning of donor hearts during transportation with the organ care system.

ObjectivesCold crystalloid cardioplegia for donor heart harvesting and cold ischemic storage conditions during the transportation is the standard of care during heart transplantation procedure. Organ care system (OCS) was introduced for more prolonged and reliable ex vivo organ management. This study evaluated the two different techniques used for myocardial preservation during the procurement and transportation of the heart using the OCS.MethodsWe performed prospective analysis of 43 patients with heart failure undergoing heart transplantation and using the OCS for donor organ transport. Donor hearts were arrested using blood cardioplegia and conditioning (n = 30) or standard Custodiol (SC) solution ( n = 13). Perfusion and cardiac function parameters were continuously monitored while the donor hearts were perfused in the OCS. Impact of preservation techniques on biochemical parameters and clinical outcomes were evaluated.ResultsAll donor hearts had stable perfusion and lactate characteristics in the OCS, with similar measures between the two groups at the beginning of the ex vivo perfusion. Ex vivo heart perfusion mean ending concentration of Interleukin (IL)‐6 and IL‐8 was significantly lower in the blood cardioplegia group compared to the standard care group. Clinical outcomes were comparable between the two groups of patients.ConclusionsThe use of blood cardioplegia and conditioning could be a safe method for myocardial protection in distant procurement and preservation of donor hearts in the OCS.

EP11 DOES TYPE OF CARDIOPLEGIA AFFECT THE INCIDENCE OF POSTOPERATIVE PAROXYSMAL ATRIAL FIBRILLATION IN PATIENTS UNDERGOING CARDIAC SURGERY?

Abstract Background and Aim: Paroxysmal atrial fibrillation (PAF) is the most frequent complication following cardiac surgery. Despite high incidence, its etiology remains uncler. Aim of our investigation was to analyze retrospectively the pathogenetic role of different types of cardioplegia on the onset of PAF. Methods: Sixty-hundred and sixty patients underwent on-pump cardiac surgery between January 2015 and October 2016. Redo operations and emergency surgery were excluded. The types of cardiolplegic solution administered were warm blood cardioplegia (Calafiore, n = 480), cold crystalloid extracellular cardioplegia (St. Thomas, n = 71), cold crystalloid intracellular cardioplegia (Custodiol, n = 109). The way of admistation was antegrade for all types of cardioplegic solution. Results: The incidence of postoperative PAF was 36.2% (239 patients). Two-hundred patients were initially treated by mens of amiodarone infusion that successfully allowed cardioversion in 167 cases (83.5%); in the other 39 patients were initially administered other drugs (i.e. verapamil e.v./per os, beta-blokers per os). A relation between the type of cardioplegic solution and the onset of postoperative PAF was not found (Calafiore, n = 180, 37.5%; St. Thomas, n = 22, 31%; Custodiol, n = 37, 34%; p = NS). Advanced age at operation (71.3 ± 8.7 vs. 65.7 ± 11 years) was the only independent predictor of PAF (p &lt; 0.001). Non-coronary surgery was found as risk factor for PAF at the univariate analysis only (p &lt; 0.01). Conclusions: The use of different type of cardioplegic solutions, and at different temperatures, does not correlate with the onset of postoperative PAF. Initial treatment strategy with amiodarone infusion allows pharmacological cardioversion of PAF in over 80% of cases.

Effect of Fast Cardioplegic Arrest Induced by Adenosine on Cardiac Troponin Levels After Heart Valve Surgery

Cellular injury is not avoidable with current cardioplegic solutions. The effect of adenosine on reducing cardiac injury post-surgery is controversial. The objective of the current study is to evaluate the effect of fast cardioplegic arrest induced by adenosine on high sensitive cardiac troponin I after heart valve surgery. Forty-five (45) patients with rheumatic heart diseases underwent heart valve surgery using conventional approach through median sternotomy. They were classified into two groups, group I (n=21) patients received 0.25mg/kg adenosine into the aortic root just after aortic cross-clamping and before infusion of the cold hyperkalaemic crystalloid cardioplegia via antegrade route and group II (n=24) who received cold crystalloid hyperkalaemic cardioplegia without adenosine. Cardiac troponin I was measured preoperatively and on postoperative days 0, 3 and 7. There was no significant difference between both groups in the demographic, preoperative and operative data. Adenosine significantly reduced arrest time. Postoperative high sensitive cardiac troponin I increased significantly in both groups compared to the preoperative levels and the rise continued till postoperative day 3. Troponin levels were significantly lower in the adenosine group compared to the control at all measurements. The clinical outcomes were non-significant different between groups. Using adenosine in inducing fast cardioplegic arrest in heart valve surgery after aortic cross clamp and prior to infusion of the cold cardioplegia had significantly decreased postoperative cardiac troponin levels which was used as a proxy for cellular injury compared to the control group.