Crystalloid Cardioplegia Research Articles

Independent factors for the development of vasoplegic syndrome in patients undergoing coronary artery bypass surgery.

Vasoplegic syndrome remains a common complication of cardiac surgery. It has serious implications for the healthcare system and individual patients, as it leads to rising healthcare costs and higher mortality. A better understanding of factors triggering vasoplegic syndrome is essential for the development of effective prevention strategies. We aimed to identify clinical characteristics and intraoperative parameters associated with the development of vasoplegic syndrome in coronary artery bypass graft surgery and the influence of vasoplegia on outcome. We retrospectively analyzed the data of all patients who underwent isolated coronary artery bypass graft surgery or coronary artery bypass graft surgery combined with atrial appendage occlusion, using the heart-lung machine at our institution from 04/2019 to 12/2020. Vasoplegic syndrome was defined as MAP ≤60 mmHg and norepinephrine equivalence dosage of ≥0.2 μg/kg/min with a central venous saturation ≥60% within 2 days from surgery. Of 647 patients included in this study, 72 (11.1%) developed vasoplegic syndrome. Patients experiencing vasoplegia had longer stay in ICU, more frequently underwent tracheostomy and suffered more often from pneumonia. The duration of extracorporeal circulation, intraoperative application of platelet concentrates and usage of cold crystalloid cardioplegia (Bretschneider) independently predicted development of vasoplegic syndrome. Even in relatively low-risk cardiac surgery, vasoplegic syndrome is a common complication and was associated with serious adverse effects. The use of warm blood cardioplegia (Calafiore) seems to be safer than cold crystalloid cardioplegia (Bretschneider) and might be preferable in patients that are vulnerable to the consequences of vasoplegic syndrome.

Comparison of "Huaxi-1" or "histidine-tryptophan-ketoglutarate" cardioplegia in an animal model.

Using a pig model of cardiopulmonary bypass, we compared outcomes after cardioplegia either with our in-house "Huaxi-1" solution containing natural blood and crystalloid or with the entirely crystalloid, commercially available "histidine-tryptophan-ketoglutarate" solution. Cardiopulmonary bypass was established in 12 healthy male pigs, who were randomized to receive a single dose of either Huaxi-1 or entirely crystalloid. All animals were then subjected to whole-heart ischemia for 90 min, followed by 2 h of reperfusion, after which myocardial injury was assessed in terms of cardiac function, myocardial pathology and levels of biomarkers in plasma, while levels of high-energy phosphate in myocardium were assayed using liquid chromatography. Animals given Huaxi-1 cardioplegia required significantly less time to be weaned off bypass, they received significantly lower doses of norepinephrine, and they showed significantly higher levels (mean ± SD) of adenosine triphosphate (14 ± 4 vs. 8 ± 2 µg/mg, P = 0.005), adenosine diphosphate (16 ± 2 vs. 13 ± 2 µg/mg, P = 0.046), and total adenine nucleotide (37 ± 4 vs. 30 ± 3 µg/mg, P = 0.006) in myocardium after 2 h of reperfusion. They also showed less severe bleeding, edema and injury to mitochondria and myofibers in myocardium. The two groups did not differ significantly in doses of inotropic drugs received, cardiac output or levels of biomarkers in plasma. In this animal model of healthy hearts subjected to 90 min of ischemia, Huaxi-1 cardioplegia may be superior to entirely crystalloid cardioplegia for promoting energy generation and attenuating ischemia/reperfusion injury in myocardium.

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.

Comparison of Del Nido (a different application) and crystalloid blood cardioplegia on arrhythmia and early results.

The results of the use of del-Nido(DN) solution using a different method or crystalloid blood cardioplegia in coronary bypass patients were compared. We aimed to investigate the effects on intraoperative and postoperative arrhythmias, arrhythmia durations and early results. The study included 175 patients using crystalloid blood cardioplegia (Group 1) and 150 patients using DN solution(Group 2). In the DN group, 75% of the calculated plegia dose was given first. the remaining part was applied by giving from grafts. Intraoperative/postoperative data were compared. There was no significant difference between the groups in terms of demographic characteristics. Preop troponin level was similar.(p = 0.190) However, there was a statistical difference between the postoperative 6th hour.(p = 0.001) There was no difference in troponin values at the postoperative 24th hour. (p = 0.631) Spontaneous rhythm occurred at the cardiopulmonary by pass (CPB) weaning stage in most of the patients in Group 2 (95.3%). Although the need for temporary pacing was less in Group 2, it was not significant.(p = 0.282) No patient required permanent pacing. CPB duration, cross clamp times and intraoperative glucose levels, intensive care follow-up times and hospitalization times were found to be shorter in Group 2. Although the postoperative atrial fibrillation frequency was similar (p = 0.261), the time to return to sinus was lower in Group 2.(p = 0.001). The use of DN cardioplegia solution provides significant positive contributions to avoid arrhythmias compared to crystalloid blood cardioplegia. DN solution applied with this method may contribute to reducing the anxieties associated with its use in isolated coronary artery bypass surgery.

Blood cardioplegia reduces intraoperative ventricular fibrillation and transfusion requirements compared to crystalloid cardioplegia in canine mitral valve repair.

Cardioplegic solutions are indispensable for open-heart surgeries, including mitral valve repair (MVR), a potentially curative treatment for myxomatous mitral valve disease in dogs. However, procedural methodologies are not fully established, and complications are yet to be comprehensively understood. Cardioplegic solutions contain various substances to protect the myocardium under temporal cardiac arrest. Nevertheless, ventricular fibrillation (VF) occurs as a common complication after releasing the crossclamp. Based on these backgrounds, the search for optimal cardioplegic solutions in dogs undergoing MVR is an urgent issue. This study aims to evaluate the occurrence of VF in dogs treated with blood cardioplegia (BCP) versus crystalloid cardioplegia (CCP) during MVR. A total of 251 client-owned dogs who underwent MVR from November 2015 to November 2017 were included. We retrospectively assessed the relationship between VF and type of cardioplegia (CCP or BCP) based on surgical records, including VF incidence, transfusion use, crossclamp time, and echocardiographic measurements. Logistic regression analysis showed that the CCP group was associated with the occurrence of VF (OR, 2.378; CI, 1.133-4.992; P = .022). In addition, the CCP group was associated with transfusion use (OR, 2.586; CI, 1.232-5.428, P = .022). There was no difference between the groups for the pre- and postoperative echocardiographic measurements. The BCP group had a lower incidence of VF and less transfusion use than the CCP group. This finding indicates that BCP may be a superior cardioplegic technique for MVR in dogs.

Effect of Urine Output on the Predictive Precision of NephroCheck in On-Pump Cardiac Surgery With Crystalloid Cardioplegia: Insights from the PrevAKI Study

Previous studies in other settings suggested that urine output (UO) might affect NephroCheck predictive value. We investigated the correlation between NephroCheck and UO in cardiac surgery patients. Post hoc analysis of a multicenter study. University hospital. Patients who underwent cardiac surgery using cardiopulmonary bypass (CPB) and crystalloid cardioplegia. All patients underwent NephroCheck testing 4 hours after CPB discontinuation. The primary outcome was the correlation between UO, NephroCheck results, and acute kidney injury (AKI, defined according to Kidney Disease: Improving Global Outcomes). Of 354 patients, 337 were included. Median NephroCheck values were 0.06 (ng/mL)2/1,000) for the overall population and 0.15 (ng/mL)2/1,000) for patients with moderate to severe AKI. NephroCheck showed a significant inverse correlation with UO (ρ = -0.17; p = 0.002) at the time of measurement. The area under the receiver characteristic curve (AUROC) for NephroCheck was 0.60 (95% confidence interval [CI], 0.54-0.65), whereas for serum creatinine was 0.82 (95% CI, 0.78-0.86; p < 0.001). When limiting the analysis to the prediction of moderate to severe AKI, NephroCheck had a AUROC of 0.82 (95% CI, 0.77 to 0.86; p<0.0001), while creatinine an AUROC of 0.83 (95% CI, 0.79-0.87; p = 0.001). NephroCheck measured 4 hours after the discontinuation from the CPB predicts moderate to severe AKI. However, a lower threshold may be necessary in patients undergoing cardiac surgery with CPB. Creatinine measured at the same time of the test remains a reliable marker of subsequent development of renal failure.

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.

Thirty-five years of single-center experience in cardiac myxoma surgery and related postoperative complications.

Myxoma is the most common benign primary cardiac tumor. To present a single center's 35-year experience with myxoma surgery in terms of surgical technique and postoperative complications. The data of 166 patients (56.7 ±12.6 years old, 68.1% female) with surgically removed myxoma were retrospectively analyzed. Information on blood transfusions, additional procedures and postoperative complications was collected. A median sternotomy was performed in 97.5% of patients. A right mini-thoracotomy was performed in 4 patients. Most (95.2%) patients were semi-urgent. The reason for truly urgent surgery was hemodynamic instability in 4.8% of patients. Crystalloid cardioplegia was used in 62% of cases. Postoperative complications were observed in 12% of patients. One death was observed on the first postoperative day. During hospitalization, 6 deaths (3.6%) were observed. The most common cause of death was multisystemic organ failure. There were no gender differences in mortality and complications. Surgical treatment of myxomas is a relatively safe procedure with a mortality rate comparable to other types of cardiac surgery. The postoperative complication rate is low. Gender has no influence on the complication rate or type.

Blood cardioplegia may be better than crystalloid cardioplegia during cardiac surgery for infective endocarditis

Abstract Background Cardioplegia is an indispensable element in cardiac surgery for left sided infective endocarditis (IE). Crystalloid cardiolegia (CC) as a single or dual-dose is more attractive in complicated IE surgery than repeated, every 15-20 min, administration of blood cardioplegia (BC). Recently, blood cardioplegia was shown to reduce the systemic inflammatory response to cardiopulmonary (CPB) compared to crystalloid cardioplegia. As the systemic inflammatory response after surgery for IE endocarditis is more exaggerated than in non-IE valve surgery, it is important to investigate impact of the two solutions on outcome after IE surgery. Methods We retrospectively analyzed data of all patients (n=581) with endocarditis who underwent cardiac valve surgery at our institution between January 2007 and March 2018. The primary endpoint was 30-day mortality, secondary endpointwas the length of intensive care unit (ICU) stay. Nearest neighbor propensity matching with a caliper of 0.01 was performed to adjust for differences in basal characteristics between patients who received Calafiore BC vs Bretschneider CC. Results Patients who received CC were older (67 vs 63, p&amp;lt;0.01) had greater incidence of large vegetations (42.7% vs 32.3%, p&amp;lt;0.01), prosthetic valve endocarditis (30.8% vs 17.3%, p&amp;lt;0.01) and mitral valve endocarditis (54.6 vs 43.6 p&amp;lt;0.01). Logistic regression in the raw data revealed a higher mortality rate and longer LOS in ICU for the patients who received CC. After matching, CC was still associated with higher 30-day mortality (24.4% vs 15.9%, p=0.01) and longer ICU-stay (median: 6, IQR: 9 vs median: 3, IQR: 6, p&amp;lt;0.01). Conclusions Administration of blood cardioplegia during cardiac surgery for infective endocarditis may be associated with lower 30-day mortality and shorter ICU-stay compared to using crystalloid solution.

Blood versus crystalloid cardioplegia during triple valve surgery: A single center experience.

The efficacy of different cardioplegia solutions on outcomes of complex cardiac operations such as triple valve surgery (TVS) is scarce. Here we compared the outcomes in TVS patients receiving either crystalloid (Bretschneider) or blood (Calafiore) cardioplegia. Screening of our institutional database with prospectively entered data identified 471 consecutive patients (mean age 70.3 ± 9.2 years; 50.9% male), who underwent TVS (replacement or repair of aortic, mitral and tricuspid valve) between December 1994 and January 2013. In 277 patients, cardiac arrest was induced with HTK-Bretschneider solution (HTK, n = 277, 58.8%), whereas 194 received cold blood cardioplegia (BCP) according to Calafiore (n = 194, 41.2%). Comparisons of perioperative and follow up outcomes were made between cardioplegia groups. Preoperative patient characteristics and comorbidities were equally balanced between groups. 30-days mortality was similar between groups (HTK: 16.2%; BCP: 18.2%; p = 0.619). Incidence of the cumulative endpoint (30days mortality, myocardial infarction (MI), arrhythmia, low cardiac output syndrome or need for permanent pacemaker implantation) was also comparable (HTK: 47.6%; BCP: 54.8%, p = 0.149). In patients with reduced left ventricular ejection fraction (LVEF <40%), 30days mortality was higher in the HTK group (HTK 18/71 22.5%; BCP 5/50 10%; p = 0.037). Five-year survival was similar between groups (52 ± 6% for HTK and 55 ± 5% for BCP patients). In-Hospital mortality was best predicted by length of surgery and reperfusion ratio. Decreased age, shorter bypass time, preserved LVEF and concomitant surgical procedures have been found to be protective from long-term mortality. Myocardial protection with HTK shows equivalent outcomes compared to BCP during TVS. Patients with reduced left ventricular function may benefit from BCP during TVS.

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.

Cardioplegia in Open Heart Surgery: Age Matters

Cardioplegia is a pharmacological approach essential for the protection of the heart from ischemia-reperfusion (I-R) injury. Over the years, numerous cardioplegic solutions have been developed, with each cardioplegic approach having its advantages and disadvantages. Cardioplegic solutions can be divided into crystalloid and blood cardioplegic solutions, and an experienced surgeon chooses the type of solution based on the individual needs of patients in order to provide optimal heart protection. Importantly, the pediatric immature myocardium is structurally, physiologically, and metabolically different from the adult heart, and consequently its needs to achieve cardioplegic arrest strongly differ. Therefore, the present review aimed to provide a summary of the cardioplegic solutions available to pediatric patients with a special focus on emphasizing differences in heart injury after various cardioplegic solutions, the dosing strategies, and regimens. The PubMed database was searched using the terms cardioplegia, I-R, and pediatric population, and studies that investigated the influence of cardioplegic strategies on markers of cardiac muscle damage were further analyzed in this review. A large body of evidence suggested more prominent benefits achieved with blood compared to those with crystalloid cardioplegia in pediatric myocardium preservation. However, standardized and uniform protocols have not been established so far, and an experienced surgeon chooses the type of cardioplegia solution based on the individual needs of patients, while the severity of myocardial damage strongly depends on the type and duration of the surgical procedure, overall patient condition, and presence of comorbidities, etc.

Validation of the slaughterhouse porcine heart model for ex-situ heart perfusion studies.

To validate slaughterhouse hearts for ex-situ heart perfusion studies, we compared cold oxygenated machine perfusion in less expensive porcine slaughterhouse hearts (N = 7) to porcine hearts that are harvested following the golden standard in laboratory animals (N = 6). All hearts received modified St Thomas 2 crystalloid cardioplegia prior to 4hours of cold oxygenated machine perfusion. Hearts were perfused with homemade modified Steen heart solution with a perfusion pressure of 20-25mmHg to achieve a coronary flow between 100-200mL/min. Reperfusion and testing was performed for 4 hours on a normothermic, oxygenated diluted whole blood loaded heart model. Survival was defined by a cardiac output above 3L with a mean aortic pressure above 60mmHg. Both groups showed 100% functional survival, with laboratory hearts displaying superior cardiac function. Both groups showed similar decline in function over time. We conclude that the slaughterhouse heart can be used as an alternative to laboratory hearts and provides a cost-effective method for future ex-situ heart perfusion studies.

A novel versatile concept of cardioplegia delivery in cardiac surgery: The ReverseTWO cardioplegia circuit system.

Nowadays, the necessity of having a cardioplegia circuit capable of being adapted in order to administer different types of cardioplegia is strategically fundamental, both for the perfusionist and for the cardiac surgeon. This allows to avoid cutting tubes, guarantees sterility and, most of all, limits the number of cardioplegia circuits for the different strategies of cardiac arrest. The novel "ReverseTWO cardioplegia circuit system" is the development of the precedent "Reverse system" where mainly the 4:1 and crystalloid cardioplegia were used, It has the advantage of allowing immediate change of cardioplegia set-up versus four types of cardioplegia technique, when the strategy is unexpectedly changed before the beginning of cardiopulmonary bypass (CPB), is safe and enables the perfusionist to use one single custom pack of cardioplegia. Two pediatric roller pumps are usually used in our centre for cardioplegia administration; they have a standardized calibration (the leading with ¼ inch and the follower with 1/8 inch) and the circuit consequently has two different tube diameters for the two different pumps. The presence in the circuit of two different shunts coupled with two different coloured clamps allows the immediate set-up for different cardioplegia administration techniques utilizing a colour-coding mechanism The aim of this manuscript is to present the new ReverseTWO Circuit. This novel system allows to administer four different cardioplegic solutions (4:1, 1:4, crystalloid, ematic) based on multiple tubes, which can be selectively clamped, identified through a color-coding method. The specificity of this circuit is the great versatility, which leads to numerous advantages, such as reduced risk of perfusion accident and reduced costs related not only to the purchase of different cardioplegia kits but also to the storage. https://youtu.be/ovJBE4ok2Ds.

Comparative study between conventional crystalloid cardioplegic solution with modified del nido cardioplegia in mitral valve regurgitation surgery

Background: Cardioplegia is crucial for protecting the heart. Long-term cardiac protection is offered by the Del Nido Cardioplegia solution (dNCS). Aim: To compare conventional crystalloid cardioplegia with modified del Nido cardioplegia in mitral valve regurgitation replacement surgery. Objectives and Methods: This randomized clinical study included 80 patients undergoing to elective mitral regurgitation replacement surgery of both sex and age from 21 to 60 years with ASA (III and IV). All 80 patients were randomly assigned to receive conventional cardioplegia (St. Thomas’ cardioplegic solutions) or to obtain a modified del Nido cardioplegia (using normal saline) (groups A and B, respectively). The laboratory data for assessment of myocardial protection were obtained through measurements of preoperative serum levels of cardiac enzymes as, CK-MB, troponin, and lactate, immediately after operation, 12 and 24 hours postoperatively. Results: There was a significant increase in CK-MB only after 1 h (p &lt; .001) in group (A) and after 12 h. CK-MB and lactate levels were significantly increased (p &lt; 0.05). Also, after 24 h. CK-MB and Troponin T levels were significantly increased (p &lt; .001). Regarding complications, one patient had atrial fibrillation and one case had permanent stroke in group (A), and two patients died in group (A), while one patient died in group (B) without a significant difference between the groups. Conclusions: We report that Modified Del Nido Cardioplegia has better postoperative chemical parameters as CK-MB, Troponin T and Lactate in mitral valve surgery in adults. DNC is a safe alternative to conventional cardioplegia and has achieved at least the same results.

The Reaction of Myocardial Capillaries to Crystalloid Cardioplegia of Different Durations in Patients with Valvular Pathology and Coronary Heart Disease

The aim. To study the morphological manifestations of the response of the myocardial capillaries to cardioplegia in patients with valvular defects and coronary heart disease.&#x0D; Materials and methods. Morphological research of operative and sectional material was carried out. Myocardium fragments for microscopical study were obtained from patients at different stages of an open-heart surgery and patients who died at the stage of conservative treatment without surgical intervention. Similar samples of the myocardium of a healthy young man who died from injuries incompatible with life were studied as a control. For electron microscopy study, samples of myocardium were taken from patients at the 185th minute of perfusion.&#x0D; Results. Histological preparations of the myocardium showed pronounced diffuse hypertrophy of cardiomyocytes (CMCs), sometimes at the stage of decompensation (perinuclear edema, loss of myofibrils, apoptosis). This transformation of CMCs was obviously related to their functional overload caused by combined defects of the mitral and aortic valves. Changes in muscle fibers were accompanied by interstitial and perinuclear fibrosis. In the pool of coronary arteries affected by atherosclerosis, signs of small focal coronary fibrosis were visible, as well as rough post-infarction scars in 3 patients. All the patients had signs of acute hypoxic damage to the myocardium in the form of CMCs shortening and interstitial edema.&#x0D; Conclusions. In patients with combined defects of the aortic and mitral valves of the heart with coronary artery disease, the phenomena of myocardial fibrosis prevail. Heart valve disease combined with coronary heart disease lead to the development of both alterative and compensatory-adaptiveprocesses in the vessels of the microcirculatory bed. The greatest loss of vital organelles in small vessels is observed at 185 min after administration of cardioplegic solution, irreversible changes develop 3 h after perfusion.

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 &lt;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

Myocardial protection with histidine-tryptophan-ketoglutarate solution in comparison with hypothermic hyperkalemic blood solution in the correction of acyanotic congenital heart diseases

BackgroundIntraoperative myocardial preservation is essential in pediatric cardiac surgeries. The combination of hypothermia and hyperkalemic cardioplegia is commonly used. Histidine-tryptophan-ketoglutarate (HTK–Custodiol) is a long-acting crystalloid cardioplegia which induces cardiac arrest by reducing the extracellular sodium concentration. Cold blood cardioplegia has many modifications differing in the blood: crystalloid ratio, buffers, substrates, and final potassium concentration which induces cardiac arrest in diastole as the main role. We compared cold histidine-tryptophan-ketoglutarate crystalloid (HTK) solution with hypothermic hyperkalemic blood (HHB) cardioplegia solution regarding their efficacy in myocardial preservation in patients undergoing total repair of non-cyanotic congenital cardiac defects. We assessed postoperative cardiac troponin level, myocardial function, inotropic support, intensive care unit (ICU) length of stay, hospital length of stay, and the incidence of prolonged postoperative mechanical ventilation as indicators of myocardial protection.ResultsThis interventional, single-blinded, randomized, comparative, and prospective clinical study was conducted randomly on 60 patients, aged between 6 and 24 months undergoing total surgical repair. We found no statistically significant difference regarding patients’ personal, demographics, and operative details (surgery duration, cardiopulmonary bypass time, aorta clamp time). However, patients who were given HTK cardioplegia were found to stay less in the ICU (with a p value <0.05). However, there was no statistically significant difference between both groups as regards hospital length of stay. Also, all patients were extubated in less than 24-h duration. There was a statistically significant difference between both groups regarding troponin levels after 8, 12, and 24 h post-bypass in favor of the HHB solution. Interestingly, no significant correlation was proved between both groups regarding myocardial function (EF%, FS) and level of inotropic support (assessed by maximum vasoactive inotropic score).ConclusionsHypothermic hyperkalemic blood cardioplegia showed better results in myocardial preservation than the cold histidine-tryptophan-ketoglutarate solution in the repair of noncyanotic congenital cardiac defects.Trial registrationPan African Clinical Trial Registry, PACTR202109777317416. Registered on 28 September 2021—Retrospectively registered, https://pactr.samrc.ac.za/TrialDisplay.aspx?TrialID=16154

The Use of Blood and Crystalloid Cardioplegia in Adult Open-Heart Surgery on Postsurgical Outcomes

Abstract Background: Myocardial ischemia can occur due to hypotension, shock, coronary heart disease, and aortic cross-clamping during open-heart surgery using a cardiopulmonary bypass machine. As the cardioprotective method, cardioplegia is classified into blood or crystalloid base. This systematic review is aimed to describe the effectiveness of blood and crystalloid cardioplegic solutions in adult open-heart surgery procedures by focusing on their effects on cardiac enzymes. Materials and Methods: This study investigated the effect of blood and crystalloid cardioplegia on troponin (cTn) and creatinine kinase myocardial bound. The literature search was carried out on several Cochrane, PubMed, PMC, and Google Scholar databases from January 2014 to August 2020 using the MeSH keywords and Boolean operator. Results: We obtained 346 articles and identified six prospective randomized studies from four countries. The majority discussed the comparison of blood cardioplegia and crystalloids in coronary revascularization cardiac surgery (coronary artery bypass grafting). Overall, the articles used have a low risk of bias despite their high level of homogenicity. Conclusions: The current literatures on cardioplegia in adults do not provide adequate advanced-phase trials. Both types of cardioplegia provide a reasonable protection for myocardium. However, several studies reveal that crystalloid cardioplegia increases cardiac enzymes more significantly than blood cardioplegia. This research has been registered with PROSPERO with the number CRD42022312548.