Chapter category: Heart
Interrupting Warm Blood Cardioplegia
Ischemia-Reperfusion Injury in Cardiac Surgery
Edited by: Friedhelm BeyersdorfISBN: 1-58706-002-7
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Chapter authors:
Harold L. Lazar
Warm blood cardioplegia has emerged as an alternative method of myocardial protection. Initial retrospective clinical studies using warm blood techniques showed good myocardial protection; however, prospective studies comparing warm blood cardioplegia with cold blood cardioplegia were lacking.1,2 Furthermore, the ability of warm blood cardioplegia to adequately protect acutely ischemic myocardium was unknown. This prompted us to undertake an experimental study to compare the effectiveness of warm blood cardioplegia versus cold blood cardioplegia in protecting areas of ischemic myocardium.3 In 40 adult pigs, the second and third diagonal coronary arteries were occluded with snares for 90 minutes, followed by 45 minutes of cardioplegic arrest and 180 minutes of reperfusion during which time the coronary snares were released. During the period of cardioplegic arrest, 10 pigs received antegrade continuous warm blood cardioplegic solution (37½C) at 100 ml/min; 10 animals received retrograde continuous warm blood cardioplegic solution at 100 ml/min; 10 received intermittent, antegrade cold blood cardioplegic solution (4½C), and 10 received intermittent, antegrade/ retrograde cold blood cardioplegic solution. Our results showed that antegrade continuous warm blood cardioplegia resulted in the least optimal myocardial protection in the area at risk. Although retrograde continuous warm blood cardioplegia resulted in significantly lower areas of necrosis than in the antegrade warm blood cardioplegia group, it did not achieve any superior protection to that obtained with antegrade/retrograde cold blood cardioplegic techniques. During the period of cardioplegic arrest, both warm cardioplegic techniques had significantly lower tissue pH values in both the area at risk and in unobstructed myocardium than the cold cardioplegia groups. Upon reperfusion, pH values returned to preischemic values in the unobstructed myocardium in all cardioplegic groups. In addition, wall motion scores were not significantly different in the unobstructed myocardial segments, suggesting that temperature and the route of delivery are not as critical in myocardial tissue with normal coronary anatomy. In contrast, the method of cardioplegic delivery was an important determinant in the degree of necrosis seen in the area at risk. All retrograde cardioplegic techniques, regardless of temperature, had much lower areas of necrosis when compared with antegrade delivery. This suggested that it was the adequacy of distribution and not the temperature of the cardioplegic solution that is most critical in achieving optimal myocardial protection.
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