RESUMEN
OBJECTIVE: Minimally invasive mitral valve surgery (mini-MVS) is typically reserved for patients who have not undergone open cardiac surgery. In the reoperative setting, using intrapericardial dissection for crossclamping the aorta through a minimally invasive approach can be difficult and, at times, risky. Cold fibrillatory cardiac arrest (CFCA) with systemic cardiopulmonary bypass without cross-clamping is a well-described technique; however, data about its safety for patients who undergo reoperative mini-MVS are limited. METHODS: Data for 34 patients who underwent reoperative mini-MVS with CFCA from March 2017 to March 2022 were reviewed retrospectively. A mini right thoracotomy (n = 30) or robotic (n = 4) approach was used. Systemic hypothermia was induced to a target temperature of 25 °C. RESULTS: Patient mean (SD) age was 64.5 (9.6) years, and 15 of 34 (44.1%) patients were women. Of those 34 patients, 23 (67.6%) had severe regurgitation, and 11 (32.4%) had severe stenosis. Before mini-MVS, 28 patients had undergone valve surgery, and 8 had undergone coronary artery bypass graft surgery. The mitral valve was repaired in 5 of 34 (14.7%) and replaced in 29 of 34 (85.3%) patients. No difference was observed in preoperative and postoperative left ventricular function (P = .82). In 1 patient, kidney failure developed that necessitated dialysis. No postoperative stroke or mortality at 30 days occurred. CONCLUSION: Mini-MVS with CFCA is well tolerated in patients with prior cardiac surgery. Myocardial function was not impaired, nor was the risk of stroke increased in this cohort, indicating that CFCA is a safe alternative in this high-risk population.
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Procedimientos Quirúrgicos Mínimamente Invasivos , Válvula Mitral , Humanos , Femenino , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Válvula Mitral/cirugía , Válvula Mitral/fisiopatología , Válvula Mitral/diagnóstico por imagen , Procedimientos Quirúrgicos Mínimamente Invasivos/métodos , Resultado del Tratamiento , Procedimientos Quirúrgicos Cardíacos/métodos , Procedimientos Quirúrgicos Cardíacos/efectos adversos , Anciano , Insuficiencia de la Válvula Mitral/cirugía , Insuficiencia de la Válvula Mitral/fisiopatología , Insuficiencia de la Válvula Mitral/diagnóstico , Implantación de Prótesis de Válvulas Cardíacas/métodos , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Paro Cardíaco Inducido/métodos , Reoperación , Hipotermia Inducida/métodos , Estudios de SeguimientoAsunto(s)
Soluciones Cardiopléjicas , Daño por Reperfusión Miocárdica , Animales , Soluciones Cardiopléjicas/administración & dosificación , Soluciones Cardiopléjicas/farmacología , Daño por Reperfusión Miocárdica/prevención & control , Daño por Reperfusión Miocárdica/metabolismo , Daño por Reperfusión Miocárdica/patología , Daño por Reperfusión Miocárdica/fisiopatología , Nanopartículas , Portadores de Fármacos , Paro Cardíaco Inducido/efectos adversos , Paro Cardíaco Inducido/métodos , Gases , Humanos , Modelos Animales de Enfermedad , Infarto del Miocardio/prevención & control , Infarto del Miocardio/metabolismo , Infarto del Miocardio/tratamiento farmacológico , Cardiotónicos/farmacología , Cardiotónicos/administración & dosificaciónRESUMEN
BACKGROUND: This study examined the efficacy of del Nido cardioplegia compared with traditional blood cardioplegia in adult cardiac surgery for isolated coronary artery bypass grafting by evaluating the early postoperative outcomes. METHODS: A total of 119 patients who underwent isolated conventional coronary artery bypass grafting were enrolled and divided into two groups (del Nido cardioplegia group [n = 36] and blood cardioplegia group [n = 50]) based on the type of cardioplegia used. This study compared the preoperative characteristics, intraoperative data, and early postoperative outcomes. Further subgroup analyses were conducted for high-risk patient groups. RESULTS: The 30-day mortality and morbidity rates were not significantly different between groups. The del Nido cardioplegia group exhibited advantageous myocardial protection outcomes, demonstrated by a significantly smaller rise in Troponin I levels post-surgery (2.8 [-0.4; 4.2] vs. 4.5 [2.9; 7.4] ng/mL, p = 0.004) and fewer defibrillation attempts during weaning off of cardiopulmonary bypass (0.0 ± 0.2 vs. 0.4 ± 1.1 times, p = 0.011) when compared to the blood cardioplegia group. Additionally, the del Nido group achieved a reduction in surgery duration, as evidenced by the reduced aortic cross-clamping time (64.0 [55.5; 75.5] vs. 77.5 [65.0; 91.0] min, p = 0.001) and total operative time (287.5 [270.0; 305.0] vs. 315.0 [285.0; 365.0] min, p = 0.008). Subgroup analyses consistently demonstrated that the del Nido cardioplegia group had a significantly smaller postoperative increase in Troponin I levels across all subgroups (p < 0.05). CONCLUSIONS: del Nido cardioplegia provided myocardial protection and favorable early postoperative outcomes compared to blood cardioplegia, making it a viable option for conventional coronary artery bypass grafting. Establishing a consensus on the protocol for Del Nido cardioplegia administration in adult surgeries is needed.
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Soluciones Cardiopléjicas , Puente de Arteria Coronaria , Paro Cardíaco Inducido , Humanos , Paro Cardíaco Inducido/métodos , Puente de Arteria Coronaria/métodos , Masculino , Femenino , Persona de Mediana Edad , Anciano , Estudios Retrospectivos , Resultado del Tratamiento , Complicaciones Posoperatorias/prevención & control , Enfermedad de la Arteria Coronaria/cirugía , Troponina I/sangre , Cloruro de Potasio , Manitol , Lidocaína , Soluciones , Electrólitos , Sulfato de Magnesio , Bicarbonato de SodioRESUMEN
OBJECTIVE: Systematic evaluation of the safety of del Nido cardioplegia compared to cold blood cardioplegia in adult cardiac surgery. METHODS: We systematically searched PubMed, EMbase, The Cochrane Library and ClinicalTrials.gov for randomized clinical trials (published by 14 January 2024) comparing del Nido cardioplegia to cold blood cardioplegia in adult. Our main endpoints were myocardial injury markers and clinical outcomes. We assessed pooled data by use of a random-effects model or a fixed-effects model. RESULTS: A total of 10 studies were identified, incorporating 889 patients who received del Nido cardioplegia and 907 patients who received cold blood cardioplegia. The meta-analysis results showed that compared with the cold blood cardioplegia, the del Nido cardioplegia had less volume of cardioplegia, higher rate of spontaneous rhythm recovery after cross clamp release, lower levels of postoperative cardiac troponin T and creatinine kinase-myocardial band, all of which were statistically significant. However, there was no statistically significant difference in postoperative troponin I and postoperative left ventricular ejection fraction. The clinical outcomes including mechanical ventilation time, intensive care unit stay time, hospital stay time, postoperative stroke, postoperative new-onset atrial fibrillation, postoperative heart failure requiring intra-aortic balloon pump mechanical circulation support, and in-hospital mortality of both are comparable. CONCLUSION: Existing evidence suggests that del Nido cardioplegia reduced volume of cardioplegia administration and attempts of defibrillation. The superior postoperative results in CTnT and CK-MB may provide a direction for further research on improvement of the composition of cardioplegia.
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Procedimientos Quirúrgicos Cardíacos , Soluciones Cardiopléjicas , Paro Cardíaco Inducido , Ensayos Clínicos Controlados Aleatorios como Asunto , Humanos , Paro Cardíaco Inducido/métodos , Procedimientos Quirúrgicos Cardíacos/métodos , Soluciones Cardiopléjicas/uso terapéutico , Adulto , Cloruro de Potasio , Manitol , Lidocaína , Soluciones , Electrólitos , Sulfato de Magnesio , Bicarbonato de SodioRESUMEN
Background and Objectives: The relationship between histidine-tryptophan-ketoglutarate (HTK)-induced hyponatremia and brain injury in adult cardiac surgery patients is unclear. This study analyzed postoperative neurological outcomes after intraoperative HTK cardioplegia infusion. Materials and Methods: A prospective cohort study was conducted on 60 adult patients who underwent cardiac surgery with cardiopulmonary bypass. Of these patients, 13 and 47 received HTK infusion and conventional hyperkalemic cardioplegia, respectively. The patients' baseline characteristics, intraoperative data, brain injury markers, Mini-Mental State Examination (MMSE) scores, and quantitative electroencephalography (qEEG) data were collected. Electrolyte changes during cardiopulmonary bypass, the degree of hyponatremia, and any associated brain insults were evaluated. Results: The HTK group presented with acute hyponatremia during cardiopulmonary bypass, which was intraoperatively corrected through ultrafiltration and normal saline administration. Postoperative sodium levels were higher in the HTK group than in the conventional cardioplegia group. The change in neuron-specific enolase levels after cardiopulmonary bypass was significantly higher in the HTK group (p = 0.043). The changes showed no significant differences using case-control matching. qEEG analysis revealed a significant increase in relative delta power in the HTK group on postoperative day (POD) 7 (p = 0.018); however, no significant changes were noted on POD 60. The MMSE scores were not significantly different between the two groups on POD 7 and POD 60. Conclusions: HTK-induced acute hyponatremia and rapid correction with normal saline during adult cardiac surgeries were associated with a potential short-term but not long-term neurological impact. Further studies are required to determine the necessity of correction for HTK-induced hyponatremia.
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Procedimientos Quirúrgicos Cardíacos , Paro Cardíaco Inducido , Hiponatremia , Manitol , Procaína , Humanos , Masculino , Hiponatremia/etiología , Femenino , Manitol/administración & dosificación , Manitol/efectos adversos , Manitol/uso terapéutico , Estudios Prospectivos , Persona de Mediana Edad , Procaína/efectos adversos , Procaína/administración & dosificación , Procaína/uso terapéutico , Anciano , Paro Cardíaco Inducido/métodos , Paro Cardíaco Inducido/efectos adversos , Procedimientos Quirúrgicos Cardíacos/efectos adversos , Procedimientos Quirúrgicos Cardíacos/métodos , Soluciones Cardiopléjicas/administración & dosificación , Soluciones Cardiopléjicas/efectos adversos , Soluciones Cardiopléjicas/uso terapéutico , Electroencefalografía/métodos , Glucosa/administración & dosificación , Glucosa/uso terapéutico , Adulto , Estudios de Cohortes , Puente Cardiopulmonar/métodos , Puente Cardiopulmonar/efectos adversos , Cloruro de PotasioRESUMEN
OBJECTIVES: 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. DESIGN: Post hoc analysis of a multicenter study. SETTING: University hospital. PARTICIPANTS: Patients who underwent cardiac surgery using cardiopulmonary bypass (CPB) and crystalloid cardioplegia. MEASUREMENTS AND MAIN RESULTS: 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). CONCLUSIONS: 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.
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Lesión Renal Aguda , Procedimientos Quirúrgicos Cardíacos , Puente Cardiopulmonar , Soluciones Cristaloides , Paro Cardíaco Inducido , Valor Predictivo de las Pruebas , Humanos , Masculino , Femenino , Anciano , Procedimientos Quirúrgicos Cardíacos/efectos adversos , Procedimientos Quirúrgicos Cardíacos/métodos , Persona de Mediana Edad , Paro Cardíaco Inducido/métodos , Soluciones Cristaloides/administración & dosificación , Lesión Renal Aguda/prevención & control , Lesión Renal Aguda/etiología , Lesión Renal Aguda/diagnóstico , Puente Cardiopulmonar/métodos , Puente Cardiopulmonar/efectos adversos , Estudios ProspectivosRESUMEN
OBJECTIVES: In this study, we evaluated if modified Del Nido cardioplegia delivers comparable cardiac protection in comparison to Custodiol® in patients undergoing isolated minimally invasive mitral valve repair. METHODS: From January 2018 to October 2021, all patients undergoing non-emergent isolated minimally invasive mitral valve repair were included in this study. The cardioplegia was chosen at the surgeons' discretion. The primary end points of this study were peak postoperative cardiac enzyme levels. Secondary end points were in-hospital mortality, hospital stay, occurrence of cardiac arrhythmias, pacemaker implantations, postoperative lactate and sodium levels and postoperative incidence of renal failure requiring dialysis. RESULTS: A total of 355 patients were included in this study. The mean age of patients was 57. After propensity score matching, a total of 156 pairs were identified. There was no difference in cross-clamp time between both groups. Postoperative creatine kinase levels were higher in patients receiving Custodiol on the 1st and 2nd postoperative days. Creatine kinase isoenzyme MB levels were higher in patients receiving Custodiol on the 2nd postoperative day (0.5 ± 0.2 vs 0.4 ± 0.1 µmol/l s; P < 0.001). Postoperative Troponin T concentrations were similar between both groups. Maximum lactate concentrations were higher in patients receiving Custodiol on the day of surgery (2.4 ± 1.9 vs 2.0 ± 1.1 mmol/l; P = 0.04). The overall hospital stay was longer in patients receiving Del Nido cardioplegia (10.6 ± 3.2 vs 8 ± 4.1 days; P < 0.01). CONCLUSIONS: Modified Del Nido cardioplegia based on Ionosteril® solution offers equivalent protection compared to Custodiol for isolated minimally invasive mitral valve repair.
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Soluciones Cardiopléjicas , Electrólitos , Paro Cardíaco Inducido , Lidocaína , Procedimientos Quirúrgicos Mínimamente Invasivos , Válvula Mitral , Cloruro de Potasio , Procaína , Bicarbonato de Sodio , Soluciones , Humanos , Femenino , Masculino , Persona de Mediana Edad , Paro Cardíaco Inducido/métodos , Soluciones Cardiopléjicas/uso terapéutico , Válvula Mitral/cirugía , Cloruro de Potasio/uso terapéutico , Procedimientos Quirúrgicos Mínimamente Invasivos/métodos , Manitol/uso terapéutico , Glucosa/administración & dosificación , Anciano , Histidina , Estudios Retrospectivos , Complicaciones Posoperatorias/prevención & control , Cloruro de Calcio/administración & dosificación , Insuficiencia de la Válvula Mitral/cirugía , Sulfato de Magnesio/uso terapéuticoRESUMEN
BACKGROUND: St. Thomas cardioplegia is commonly administered to adults, yet repeated dosing at brief intervals is required. Del Nido's cardioplegic solution provides a prolonged duration of safe myocardial arrest, yet it was primarily intended for pediatric cardiac surgery. Recently, there has been an increasing interest in using Del Nido's in adults; this might be due to its ease of administration and extended re-dosing intervals. This study contrasted Del Nido's to modified St. Thomas cardioplegia in adults. METHODS: This study was conducted on 200 patients. Troponin-T was the primary outcome within the first 24 and 48 h post-surgery. Cardiopulmonary bypass time, cross-clamp time, intraoperative use of inotropic support, defibrillator and/or intra-aortic balloon were the secondary outcomes of the study. RESULTS: There was a significant reduction in post-operative Troponin-T levels in the first 24 and 48 h within Del Nido's group compared to the modified St. Thomas group. The cross-clamp and cardiopulmonary bypass times were also found to be lower within Del Nido's group. CONCLUSION: This study has demonstrated a significant reduction in early postoperative Troponin-T levels as well as operative times favoring Del Nido's in adults.
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Procedimientos Quirúrgicos Cardíacos , Soluciones Cardiopléjicas , Electrólitos , Paro Cardíaco Inducido , Lidocaína , Sulfato de Magnesio , Manitol , Bicarbonato de Sodio , Soluciones , Troponina T , Humanos , Paro Cardíaco Inducido/métodos , Estudios Retrospectivos , Masculino , Femenino , Persona de Mediana Edad , Procedimientos Quirúrgicos Cardíacos/métodos , Troponina T/sangre , Adulto , Puente Cardiopulmonar/métodos , Anciano , Cloruro de Potasio , Resultado del Tratamiento , Bicarbonatos , Cloruro de Calcio , Cloruro de Sodio , MagnesioRESUMEN
OBJECTIVE: 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. ANIMALS: A total of 251 client-owned dogs who underwent MVR from November 2015 to November 2017 were included. METHODS: 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. RESULTS: 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. CLINICAL RELEVANCE: 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.
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Transfusión Sanguínea , Soluciones Cardiopléjicas , Soluciones Cristaloides , Enfermedades de los Perros , Paro Cardíaco Inducido , Válvula Mitral , Fibrilación Ventricular , Perros , Animales , Paro Cardíaco Inducido/métodos , Paro Cardíaco Inducido/veterinaria , Enfermedades de los Perros/prevención & control , Estudios Retrospectivos , Fibrilación Ventricular/veterinaria , Fibrilación Ventricular/prevención & control , Masculino , Femenino , Soluciones Cardiopléjicas/farmacología , Transfusión Sanguínea/veterinaria , Soluciones Cristaloides/administración & dosificación , Soluciones Cristaloides/uso terapéutico , Válvula Mitral/cirugía , Insuficiencia de la Válvula Mitral/veterinaria , Insuficiencia de la Válvula Mitral/cirugíaRESUMEN
BACKGROUND: The ProMPT-2 trial (Propofol for Myocardial Protection Trial #2) aims to compare the safety and efficacy of low- and high-dose propofol supplementation of the cardioplegia solution during adult cardiac surgery versus sham supplementation. This update presents the statistical analysis plan, detailing how the trial data will be analysed and presented. Outlined analyses are in line with the Consolidated Standards of Reporting Trials and the statistical analysis plan has been written prior to database lock and the final analysis of trial data to avoid reporting bias (following recommendations from the International Conference on Harmonisation of Good Clinical Practice). METHODS/DESIGN: ProMPT-2 is a multi-centre, blinded, parallel three-group randomised controlled trial aiming to recruit 240 participants from UK cardiac surgery centres to either sham cardioplegia supplementation, low dose (6 µg/ml) or high dose (12 µg/ml) propofol cardioplegia supplementation. The primary outcome is cardiac-specific troponin T levels (a biomarker of cardiac injury) measured during the first 48 h following surgery. The statistical analysis plan describes the planned analyses of the trial primary and secondary outcomes in detail, including approaches to deal with missing data, multiple testing, violation of model assumptions, withdrawals from the trial, non-adherence with the treatment and other protocol deviations. It also outlines the planned sensitivity analyses and exploratory analyses to be performed. DISCUSSION: This manuscript prospectively describes, prior to the completion of data collection and database lock, the analyses to be undertaken for the ProMPT-2 trial to reduce risk of reporting and data-driven analyses. TRIAL REGISTRATION: ISRCTN ISRCTN15255199. Registered on 26 March 2019.
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Procedimientos Quirúrgicos Cardíacos , Propofol , Adulto , Humanos , Biomarcadores , Procedimientos Quirúrgicos Cardíacos/efectos adversos , Puente Cardiopulmonar/efectos adversos , Paro Cardíaco Inducido/efectos adversos , Paro Cardíaco Inducido/métodos , Estudios Multicéntricos como Asunto , Propofol/efectos adversos , Propofol/uso terapéutico , Ensayos Clínicos Controlados Aleatorios como Asunto , Resultado del Tratamiento , Troponina TRESUMEN
In the case of mitral repair with severe aortic regurgitation, aortotomy and selective cardioplegia are necessary for myocardiac protection. In this situation, the saline test for mitral valve repair cannot be accomplished due to incomplete left ventricular filing. In patients undergoing mitral valve repair concomitant with severe aortic valve insufficiency, after cardiac stand still was achieved by selective cardioplegia. Each center of the aortic leaflet, termed the node of Arantius, was stitch up using a 5-0 polypropylene suture, forming a clover leaflet shape. This stitch inhibits aortic valve opening and reduces saline leakage thorough aortic valve. We have termed this procedure as the "Clover Stitch Technique". Upon completion of this technique, mitral valve repair can be undertaken via a right-side left atrial incision. This technique enables accurate evaluation of mitral valve morphology or the extent of regurgitation, repeatedly without complicated manipulations during and after mitral valve repair.
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Insuficiencia de la Válvula Aórtica , Válvula Aórtica , Insuficiencia de la Válvula Mitral , Válvula Mitral , Técnicas de Sutura , Humanos , Insuficiencia de la Válvula Aórtica/cirugía , Insuficiencia de la Válvula Mitral/cirugía , Válvula Aórtica/cirugía , Válvula Aórtica/diagnóstico por imagen , Válvula Mitral/cirugía , Válvula Mitral/diagnóstico por imagen , Resultado del Tratamiento , Implantación de Prótesis de Válvulas Cardíacas/métodos , Paro Cardíaco Inducido/métodos , AncianoRESUMEN
INTRODUCTION: The evidence for using del Nido cardioplegia protocol in high-risk patients with reduced ejection fraction undergoing isolated coronary surgery is insufficient. METHODS: The institutional database was searched for isolated coronary bypass procedures. Patients with ejection fraction < 40% were selected. Propensity matching (age, sex, infarction, number of grafts) was used to pair del Nido (Group 1) and cold blood (Group 2) cardioplegia patients. Investigation of biomarker release, changes in ejection fraction, mortality, stroke, perioperative myocardial infarction, composite endpoint (major adverse cardiac and cerebrovascular events), and other perioperative parameters was performed. RESULTS: Matching allowed the selection of 45 patient pairs. No differences were noted at baseline. After cross-clamp release, spontaneous sinus rhythm return was observed more frequently in Group 1 (80% vs. 48.9%; P=0.003). Troponin values were similar in both groups 12 and 36 hours after surgery, as well as creatine kinase at 12 hours. A trend favored Group 1 in creatine kinase release at 36 hours (median 4.9; interquartile range 3.8-9.6 ng/mL vs. 7.3; 4.5-17.5 ng/mL; P=0.085). Perioperative mortality, rates of myocardial infarction, stroke, or major adverse cardiac and cerebrovascular events were similar. No difference in postoperative ejection fraction was noted (median 35.0%; interquartile range 32.0-38.0% vs. 35.0%; 32.0-40.0%; P=0.381). There was a trend for lower atrial fibrillation rate in Group 1 (6.7% vs. 17.8%; P=0.051). CONCLUSION: The findings indicate that del Nido cardioplegia provides satisfactory protection in patients with reduced ejection fraction undergoing coronary bypass surgery. Further prospective trials are required.
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Infarto del Miocardio , Accidente Cerebrovascular , Humanos , Soluciones Cardiopléjicas , Paro Cardíaco Inducido/métodos , Puente de Arteria Coronaria/métodos , Creatina Quinasa , Accidente Cerebrovascular/etiología , Estudios RetrospectivosRESUMEN
OBJECTIVES: The use of del Nido cardioplegia has been increasing in popularity for adult cardiac surgery. However, the base solution, Plasma-Lyte A, is not always available in many countries. This prospective randomized controlled trial evaluated myocardial preservation and clinical outcomes when using lactated Ringer's solution (LRS) compared to Plasma-Lyte A as a base solution for del Nido cardioplegia. METHODS: Adult patients undergoing first-time elective cardiac surgery for acquired heart disease, including isolated coronary artery bypass grafting, isolated valve surgery, combined valve surgery or concomitant coronary artery bypass grafting and valve surgery were randomized to receive either LRS (n = 100) or Plasma-Lyte A (n = 100). RESULTS: There were no significant differences between the 2 groups in terms of age, comorbidities, Society of Thoracic Surgeons risk score and type of procedures. The primary outcome, postoperative troponin-T at 24 h, was similar in both groups (0.482 vs 0.524 ng/ml; P = 0.464). Other cardiac markers were also similar at all time points. The LRS group had a lower pH (7.228 vs 7.246; P = 0.005) and higher calcium levels (0.908 vs 0.358 mmol/l; P < 0.001) in the delivered cardioplegia, but there were no significant differences in clinical outcomes, such as ventricular fibrillation, left ventricular ejection fraction, inotrope/vasopressor requirement, intra-aortic balloon pump support, intensive care unit stay, hospital stay, atrial fibrillation, red cell transfusion and complications. CONCLUSIONS: The results suggest that LRS can be used as an alternative to Plasma-Lyte A as the base solution for del Nido cardioplegia, with similar myocardial preservation and clinical outcomes.
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Soluciones Cardiopléjicas , Electrólitos , Función Ventricular Izquierda , Adulto , Humanos , Lactato de Ringer , Soluciones Cardiopléjicas/uso terapéutico , Estudios Prospectivos , Volumen Sistólico , Paro Cardíaco Inducido/métodos , Estudios RetrospectivosRESUMEN
Myocardial protection and specifically cardioplegia have been extensively investigated in the beginnings of cardiac surgery. After cardiopulmonary bypass had become routine, more and more cardiac operations were possible, requiring reliable and reproducible protection for times of blood flow interruptions to the most energy-demanding organ of the body. The concepts of hypothermia and cardioplegia evolved as tools to extend cardiac ischaemia tolerance to a degree considered safe for the required operation. A plethora of different solutions and delivery techniques were developed achieving remarkable outcomes with cross-clamp times of up to 120 min and more. With the beginning of the new millennium, interest in myocardial protection research declined and, as a consequence, conventional cardiac surgery is currently performed using myocardial protection strategies that have not changed in decades. However, the context, in which cardiac surgery is currently performed, has changed during this time. Patients are now older and suffer from more comorbidities and, thus, other organs move more and more into the centre of risk assessment. Yet, systemic effects of cardioplegic solutions have never been in the focus of attention. They say hindsight is always 20-20. We therefore review the biochemical principles of ischaemia, reperfusion and cardioplegic extension of ischaemia tolerance and address the concepts of myocardial protection with 'hindsight from the 2020s'. In light of rising patient risk profiles, minimizing surgical trauma and improving perioperative morbidity management becomes key today. For cardioplegia, this means accounting not only for cardiac, but also for systemic effects of cardioplegic solutions.
Asunto(s)
Procedimientos Quirúrgicos Cardíacos , Soluciones Cardiopléjicas , Paro Cardíaco Inducido , Humanos , Procedimientos Quirúrgicos Cardíacos/efectos adversos , Procedimientos Quirúrgicos Cardíacos/métodos , Soluciones Cardiopléjicas/uso terapéutico , Paro Cardíaco Inducido/métodos , Isquemia , MiocardioRESUMEN
Objective: To explore the safety and myocardial protection efficacy of del Nido cardioplegia in adult cardiac and major vascular surgery with long aortic cross-clamp (ACC) time. Methods: A total of 2 536 patients who underwent adult cardiac and major vascular surgery with ACC time>90 min at Beijing Anzhen Hospital from March 2018 to March 2023 were collected. The patients were divided into two groups according to the type of cardioplegia solution: the del Nido cardioplegia solution group (DC group) and the cold blood cardioplegia solution group (BC group). Preoperative baseline data of the patients (age, gender, comorbidities, ejection fraction, etc) were adjusted using propensity score matching (PSM). Cardiopulmonary bypass (CPB) time, ACC time, total amount of cardioplegia solution, in-hospital mortality rate, length of intensive care unit (ICU) stay, mechanical ventilation time, postoperative complications, left ventricular ejection fraction, and troponin levels were compared between the two groups. Results: After PSM, a total of 306 patients were included, including 223 males and 83 females, with a mean age of (52.0±12.3) years. There were 153 cases in the DC group and 153 cases in the BC group. Compared with the DC group, the cross-clamp time was longer [109(100, 150) min vs 102(91, 133) min, P<0.001], the rate of return to spontaneous rhythm was lower [51.6% (79/153) vs 86.9%(133/153), P<0.001], and intraoperative peak glucose was higher [12.6 (6.5, 15.9) mmol/L vs 10.1 (8.5, 12.4) mmol/L, P=0.005] in the BC group. In addition, perioperative mortality [4.6% (7/153) vs 3.3% (5/153), P=0.132], stroke[3.9% (6/153) vs 3.3% (5/153), P=0.759], renal insufficiency [3.3% (5/153) vs 6.5% (10/153), P=0.186], atrial fibrillation [4.6% (7/153) vs 2.6% (4/153), P=0.652] and low cardiac output syndrome [3.9% (6/153) vs 4.6% (7/153), P=0.716] did not differ between the two groups. Compared with BC group, DC group had lower level of high sensitivity troponin (hsTnI) [1.2 (0.8, 1.8) µg/L vs 1.3 (0.9, 2.3) µg/L, P=0.030] and creatine kinase isoenzyme (CK-MB) [31.0 (20.0, 48.9) µg/L vs 37.0 (24.0, 58.9) µg/L, P=0.011] at 24 h postoperatively, and shorter length of ICU stay [35.6 (19.8, 60.5) h vs 42.6 (21.9, 83.6) h, P=0.015] and mechanical ventilation time [20.5 (15.5, 41.0) h vs 31.5 (17.1, 56.0) h, P=0.012]. Subgroup analysis showed that in the 120-180 minute subgroup, patients in the DC group had a shorter cross-clamp time [132 (124, 135) min vs 136 (124, 138) min, P<0.001], while levels of hsTnI [1.6 (1.1, 2.0) µg/L vs 1.4 (1.0, 2.6) µg/L, P=0.030] and CK-MB [38.8 (23.5, 55.5) µg/L vs 37.0 (24.5, 62.3) µg/L, P=0.011] were higher than those in the BC group. Conclusions: In adult cardiac and major vascular surgery with ACC times>90 min, comparable myocardial protection is observed with the use of DC compared with BC. Additional advantages in glycemic control, return to spontaneous rhythm, and improved surgical procedures make DN an attractive alternative for myocardial protection in adult cardiac surgery.
Asunto(s)
Paro Cardíaco Inducido , Función Ventricular Izquierda , Masculino , Adulto , Femenino , Humanos , Persona de Mediana Edad , Volumen Sistólico , Paro Cardíaco Inducido/métodos , Soluciones Cardiopléjicas , Troponina , Procedimientos Quirúrgicos Vasculares , Estudios RetrospectivosRESUMEN
Objetivo: La cardioprotección es esencial en la revascularización coronaria quirúrgica. En este estudio exploramos la relación existente entre el tiempo que una masa miocárdica permanece en situación de isquemia y la dosis de cardioplejía utilizada para su preservación, reflejada a través del índice de cardioplejía infundida, con el desarrollo de bajo gasto cardiaco postoperatorio. Diseño: Se incluyeron todos los pacientes sometidos a revascularización coronaria quirúrgica entre enero de 2013 y diciembre de 2015. El síndrome de bajo gasto cardiaco postoperatorio se definió siguiendo los criterios del documento de consenso de la SEMYCIUC. Se analizaron los factores perioperatorios asociados al síndrome de bajo gasto cardiaco y, mediante la curva ROC, se determinó el punto de corte del índice de cardioplejía infundida para predecir la ausencia del mismo. Resultados: De los 360 pacientes incluidos, 116 (32%) presentaron bajo gasto postoperatorio. Los factores de riesgo independientes fueron: clasificación funcional de la New York Heart Association (OR 1,8 [IC 95%=1,18-2,55]), la fracción de eyección del ventrículo izquierdo (OR 0,95 [IC 95%=0,93-0,98]), el empleo de cardioplejía retrógrada (OR 1,2 [IC 95%=1,03-1,50]) y el índice de cardioplejía infundida (OR 0,99 [IC 95%=0,991-0,996]), que mostró un área bajo la curva ROC de 0,77 (0,70-0,83; p<0,001) para la ausencia de síndrome de bajo gasto cardiaco postoperatorio, usando como punto de corte óptimo 23,6ml·min-1(100g/m2 de VI)-1. Conclusiones: El índice de cardioplejía infundido es inversamente proporcional a los requerimientos postoperatorios de inotropos, pudiendo constituir una estrategia para optimizar la cardioprotección. El volumen total de cardioplejía intermitente debería calcularse, de forma individualizada, en base al índice de masa del ventrículo izquierdo y el tiempo de isquemia
Background: Strategies for cardio-protection are essential in coronary artery bypass graft surgery. The authors explored the relationship between cardioplegia volume, left ventricular mass index and ischemia time by means of the infused cardioplegia index and its relationship with post-operative low cardiac output syndrome. Design: All patients undergoing coronary artery bypass graft surgery between January 2013 and December 2015 were included. Low cardiac output syndrome was defined according to criteria of the SEMICYUC's consensus document. The perioperative factors associated with low cardiac output syndrome were estimated, and using a ROC curve, the optimum cut-off point for the infused cardioplegia index to predict the absence of low cardiac output syndrome was calculated. Results: Of 360 patients included, 116 (32%) developed low cardiac output syndrome. The independent risk predictors were: New York Heart Association Functional Classification (OR 1.8 [95% CI=1.18-2.55]), left ventricle ejection fraction (OR 0.95 (95% CI=0.93-0.98]), ICI (OR 0.99 [95% CI=0.991-0.996]) and retrograde cardioplegia (OR 1.2 [95% CI=1.03-1.50]). The infused cardioplegia index showed an area under the ROC curve of 0.77 (0.70-0.83; P<.001) for the absence of postoperative low cardiac output syndrome using the optimum cut-off point of 23.6ml·min-1(100g/m2 of LV)-1. Conclusions: The infused cardioplegia index presents an inverse relationship with the development of post-operative low cardiac output syndrome. This index could form part of new strategies aimed at optimising cardio-protection. The total volume of intermittent cardioplegia, especially that of maintenance, should probably be individualised, adjusting for ischemia time and left ventricle mass index
Asunto(s)
Humanos , Masculino , Femenino , Persona de Mediana Edad , Anciano , Paro Cardíaco Inducido/métodos , Estudios de Cohortes , Revascularización Miocárdica , Biomarcadores , Curva ROC , Factores de Riesgo , Unidades de Cuidados Intensivos , Estudios Prospectivos , Respiración Artificial/métodos , 28599 , HemodinámicaRESUMEN
Abstract Objective: The present study aimed the functional recovery evaluation after long term of cardiac arrest induced by Custodiol (crystalloid-based) versus del Nido (blood-based) solutions, both added lidocaine and pinacidil as cardioplegic agents. Experiments were performed in isolated rat heart perfusion models. Methods: Male rat heart perfusions, according to Langendorff technique, were induced to cause 3 hours of cardiac arrest with a single dose. The hearts were assigned to one of the following three groups: (I) control; (II) Custodiol-LP; and (III) del Nido-LP. They were evaluated after ischemia throughout 90 minutes of reperfusion. Left ventricular contractility function was reported as percentage of recovery, expressed by developed pressure, maximum dP/dt, minimum dP/dt, and rate pressure product variables. In addition, coronary resistance and myocardial injury marker by alpha-fodrin degradation were also evaluated. Results: At 90 minutes of reperfusion, both solutions had superior left ventricular contractile recovery function than the control group. Del Nido-LP was superior to Custodiol-LP in maximum dP/dt (46%±8 vs. 67%±7, P<0.05) and minimum dP/dt (31%±4 vs. 51%±9, P<0.05) variables. Coronary resistance was lower in del Nido-LP group than in Custodiol-LP (395%±50 vs. 307%±13, P<0.05), as well as alpha-fodrin degradation, with lower levels in del Nido-LP group (P<0.05). Conclusion: Del Nido-LP cardioplegia showed higher functional recovery after 3 hours of ischemia. The analysis of alpha-fodrin degradation showed del Nido-LP solution provided greater protection against myocardial ischemia and reperfusion (IR) in this experimental model.
Asunto(s)
Animales , Masculino , Soluciones Cardiopléjicas/farmacología , Reperfusión Miocárdica/métodos , Compuestos de Potasio/farmacología , Pinacidilo/farmacología , Paro Cardíaco Inducido/métodos , Lidocaína/farmacología , Factores de Tiempo , Resistencia Vascular/fisiología , Soluciones Cardiopléjicas/química , Proteínas Portadoras/análisis , Western Blotting , Ratas Wistar , Vasos Coronarios/fisiopatología , Glucosa/farmacología , Glucosa/química , Corazón/efectos de los fármacos , Manitol/farmacología , Manitol/química , Proteínas de Microfilamentos/análisisRESUMEN
Abstract Objective: The aim of this study was to investigate whether aortic tension estimated by palpation and cardioplegia infusion line pressure provide results equivalent to those obtained with direct aortic intraluminal pressure measurement. Methods: Sixty consecutive patients who underwent coronary artery bypass graft surgeries with extracorporeal circulation were analyzed. Sanguineous cardioplegic solution in a ratio of 4:1 was administered using a triple lumen antegrade cannula. After crossclamping, cardioplegia was infused and aortic root pressure was recorded by surgeon (A) considering the aortic tension he felt in his fingertips. At the same time, another surgeon (B) recorded his results for the same measurement. Concomitantly, the anesthesiologist recorded intraluminal pressure in the aortic root and the perfusionist recorded delta pressure in cardioplegia infusion line. None of the participants involved in these measurements was allowed to be informed about the values provided by the other examiners. Results: The Bland-Altman test showed that a considerable variation between aortic wall tension was found as measured by palpation and by intraluminal pressure, with a bias of -9.911±18.75% (95% limits of agreement: -46.7 to 26.9). No strong correlation was observed between intraluminal pressure and cardioplegia line pressure (Spearman's r=0.61, 95% confidence interval 0.5-0.7; P<0.0001). Conclusion: These findings reinforce that cardioplegia infusion should be controlled by measuring intraluminal pressure, and that palpation and cardioplegia line pressure are inaccurate methods, the latter should always be used to complement intraluminal measurement to ensure greater safety in handling the cardioplegia circuit.