1
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Comparable prognosis in different neonatal histidine-tryptophan-ketoglutarate dosage management. Chin Med J (Engl) 2021; 134:2968-2975. [PMID: 34711715 PMCID: PMC8710314 DOI: 10.1097/cm9.0000000000001643] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Background: Histidine-tryptophan-ketoglutarate (HTK) is a solution commonly used for organ transplantation. However, there is no certified fixed regimen for on-pump heart surgery in neonates. We aimed to retrospectively evaluate the outcomes related to different HTK dosages and to analyze the safety of high-dosage perfusion. Methods: A total of 146 neonates who underwent on-pump heart surgery with single-shot HTK perfusion were divided into two groups according to HTK dosages: a standard-dose (SD) group (n = 63, 40 mL/kg < HTK ≤ 60 mL/kg) and a high-dose (HD) group (n = 83, HTK >60 mL/kg). Propensity score matching (PSM) was performed to control confounding bias. Results: The SD group had a higher weight (3.7 ± 0.4 vs. 3.4 ± 0.4 kg, P < 0.0001), a lower proportion of complete transposition of the great artery (69.8% vs. 85.5%, P = 0.022), a lower cardiopulmonary bypass (CPB) time (123.5 [108.0, 136.0] vs. 132.5 [114.8, 152.5] min, P = 0.034), and a lower aortic x-clamp time (82.9 ± 27.1 vs. 95.5 ± 26.0 min, P = 0.005). After PSM, 44 patients were assigned to each group; baseline characteristics and CPB parameters between the two groups were comparable. There were no significant differences in peri-CPB blood product consumption after PSM (P > 0.05). The incidences of post-operative complications were not significantly different between the two groups. There were no significant differences in ventilation time, intensive care unit stay, and post-operative hospital stay (P > 0.05). Follow-up echocardiography outcomes at 1 month, 3 to 6 months, and 1 year showed that left ventricular ejection fraction and end-diastolic dimension were comparable between the two groups. Conclusions: In neonatal on-pump cardiac surgery patients, single-shot HD (>60 mL/kg) HTK perfusion had a comparable heart protection effect and short-term post-operative prognosis as standard dosage perfusion of 40 to 60 mL/kg. Thus, this study provides supporting evidence of the safety of HD HTK perfusion.
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2
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Scavenging right atrial Bretschneider histidine-tryptophan-ketoglutarate cardioplegia: Impact on hyponatremia and seizures in pediatric cardiac surgery patients. J Thorac Cardiovasc Surg 2021; 162:228-237. [DOI: 10.1016/j.jtcvs.2020.08.098] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Revised: 07/30/2020] [Accepted: 08/08/2020] [Indexed: 11/16/2022]
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3
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Fletcher-Sanfeliu D, Padrol D, Hidalgo I, Vidal L, Enríquez F, Tarrío R, Ventosa G, Varela L, Barril R, Sáez de Ibarra JI. Protección miocárdica mediante cardioplejia Custodiol® frente a cristaloide convencional en cirugía cardíaca compleja. Resultados de una serie institucional. CIRUGIA CARDIOVASCULAR 2021. [DOI: 10.1016/j.circv.2020.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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4
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Lee CH, Kwon Y, Park SJ, Lee JW, Kim JB. Comparison of del Nido and histidine-tryptophan-ketoglutarate cardioplegic solutions in minimally invasive cardiac surgery. J Thorac Cardiovasc Surg 2020; 164:e161-e171. [PMID: 33487412 DOI: 10.1016/j.jtcvs.2020.11.163] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Revised: 11/20/2020] [Accepted: 11/21/2020] [Indexed: 12/01/2022]
Abstract
OBJECTIVE We examined the safety and efficacy of del Nido cardioplegic solution compared with histidine-tryptophan-ketoglutarate cardioplegic solution in minimally invasive cardiac surgery. METHODS Patients who underwent minimally invasive cardiac surgery using del Nido or histidine-tryptophan-ketoglutarate from 2015 to 2019 were enrolled. Various clinical outcomes were compared between the groups. Postoperative laboratory findings including the levels of electrolytes, cardiac enzymes (creatine kinase-MB and troponin I), and serial blood lactate were also measured and compared. Based on 28 baseline covariates, propensity score matching was performed to reduce selection bias. RESULTS Among 766 patients, del Nido and histidine-tryptophan-ketoglutarate were used in 330 patients (43.1%) and 436 patients (56.9%), respectively. There were no significant intergroup differences in postoperative clinical outcomes and early adverse outcomes among 228 pairs of propensity score-matched patients. Immediate postoperative sodium levels were within the normal range in both groups without a significant difference (P = .50). However, peak creatine kinase-MB (median, 31.9 vs 37.7 ng/mL, P = .026) and troponin I (6.9 vs 9.1 ng/mL, P = .014) levels were significantly lower in the del Nido group. Linear regression analysis revealed a significant association between the peak cardiac enzyme levels and the cardiac ischemic time depending on the cardioplegia type, with lower cardiac isoenzymes for del Nido over histidine-tryptophan-ketoglutarate (P < .001) until the crossover point at the cardiac ischemic time over 100 minutes. CONCLUSIONS In comparison with histidine-tryptophan-ketoglutarate solution, del Nido solution seems to have acceptable safety and efficacy with good myocardial protection in minimally invasive cardiac surgery. Further studies focusing on complex surgeries requiring longer cardiac ischemic time are needed.
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Affiliation(s)
- Chee-Hoon Lee
- Department of Cardiovascular and Thoracic Surgery, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Seoul, South Korea
| | - Youngkern Kwon
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan, College of Medicine, Seoul, South Korea
| | - Sung Jun Park
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan, College of Medicine, Seoul, South Korea
| | - Jae Won Lee
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan, College of Medicine, Seoul, South Korea.
| | - Joon Bum Kim
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan, College of Medicine, Seoul, South Korea
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van Houte J, Bindels AJ, Houterman S, Dong PV, den Ouden M, de Bock NE, Verberkmoes NJ, Curvers J, Bouwman AR. Acute isotonic hyponatremia after single dose histidine-tryptophan-ketoglutarate cardioplegia: an observational study. Perfusion 2020; 36:440-446. [PMID: 32755277 DOI: 10.1177/0267659120946952] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Histidine-tryptophan-ketoglutarate cardioplegia is used for prolonged myocardial protection in complex cardiac surgery. Administration leads to acute hyponatremia in a majority of patients, because of its low sodium concentration (15 mmol/L). However, histidine-tryptophan-ketoglutarate solution's osmolality is slightly hypertonic (310 mOsm/kg). Hypothesized was that acute isotonic hyponatremia will be induced, which does not need to be corrected with hypertonic saline. METHODS Cardiac surgery patients who received histidine-tryptophan-ketoglutarate cardioplegia were included in this prospective single center study. Serial blood samples were taken from each patient at five different time points: after induction of anesthesia (T1) and 10 minutes (T2), 6 hours (T3), 12 hours (T4), and 18 hours (T5) after administration of histidine-tryptophan-ketoglutarate cardioplegia, respectively. Blood samples were analyzed for sodium concentration, osmolality, and acid-base balance. RESULTS Twenty-five patients were included. Median blood sodium levels decreased from 140 [138-141] at T1 to 128 [125-130] mmol/L at T2 (p < 0.001). At T3, T4, and T5, median blood sodium concentrations were 136 [134-138], 139 [137-140], and 140 [137-142] mmol/L, respectively. Median osmolality was 289 [286-293] at T1 and increased to 296 [291-299] mOsm/kg (p < 0.001) at T2. At T3, T4, and T5, osmolality was 298 [292-302], 298 [294-304], and 300 [297-306] mOsm/kg, respectively. Median pH decreased from 7.38 [7.36-7.40] at T1 to 7.30 [7.27-7.32] at T2 (p < 0.001). CONCLUSION Administration of histidine-tryptophan-ketoglutarate cardioplegia during cardiac surgery leads to acute moderate to severe isotonic hyponatremia, which resolves spontaneously in the first 18 hours perioperatively. Correction with hypertonic saline is not necessary.
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Affiliation(s)
- Joris van Houte
- Department of Anaesthesiology, Catharina Hospital, Eindhoven, The Netherlands.,Department of Intensive Care, Catharina Hospital, Eindhoven, The Netherlands
| | - Alexander J Bindels
- Department of Intensive Care, Catharina Hospital, Eindhoven, The Netherlands
| | - Saskia Houterman
- Department of Research and Education, Catharina Hospital, Eindhoven, The Netherlands
| | - Phi Vu Dong
- Department of Anaesthesiology, Catharina Hospital, Eindhoven, The Netherlands
| | - Monique den Ouden
- Department of Anaesthesiology, Catharina Hospital, Eindhoven, The Netherlands
| | - Nina E de Bock
- Department of Extra Corporeal Circulation and Blood management, Catharina Hospital, Eindhoven, The Netherlands
| | - Niels J Verberkmoes
- Department of Cardiothoracic Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | - Joyce Curvers
- Department of Clinical Chemistry, Catharina Hospital, Eindhoven, The Netherlands
| | - Arthur R Bouwman
- Department of Anaesthesiology, Catharina Hospital, Eindhoven, The Netherlands
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Bibevski S, Mendoza L, Ruzmetov M, Tayon K, Alkon J, Vandale B, Scholl F. Custodiol cardioplegia solution compared to cold blood cardioplegia in pediatric cardiac surgery: a single-institution experience. Perfusion 2019; 35:316-322. [PMID: 31581896 DOI: 10.1177/0267659119878006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Custodiol is an intracellular, crystalloid cardioplegia solution that is a single-dose alternative to multi-dose cold blood cardioplegia; however, there is scarce data regarding its use in infants and children. The objective of this study was to compare its impact on myocardial function in infants. METHODS Single-center retrospective review including 132 patients <12 months old undergoing biventricular repair. There were 106 patients who received single-dose Custodiol and 27 patients who received multi-dose blood cardioplegia. Demographic and echocardiographic data were compared between the two groups. RESULTS Patients receiving Custodiol were slightly younger (100 ± 62 days) and lower weight (4.7 ± 1.3 kg) compared to 152 ± 86 days and 5.2 ± 1.3 kg for blood cardioplegia (p < 0.05). The Society of Thoracic Surgeons/European Association for Cardio-Thoracic Surgery Congenital Heart Surgery score was similar between both groups. Average cardiopulmonary bypass time was similar between both groups (Custodiol 93 ± 54 minutes vs. blood 81 ± 44 minutes, p = 0.46) as was aortic cross-clamp time (Custodiol 58 ± 33 minutes vs. cold blood 53 ± 33 minutes, p = 0.62). Pre-operative left ventricular ejection fraction was similar for blood 73 ± 8% versus Custodiol 70 ± 9%, p = 0.21. There was also no intergroup difference in left ventricular ejection fraction 24 hours post op (blood 64 ± 9% vs. Custodiol 65 ± 12%, p = 0.53) or at discharge (blood 66 ± 10% vs. Custodiol 66 ± 11%, p = 0.95). The pre-operative right ventricle function by fractional area change was also similar in blood cardioplegia (46 ± 13%) versus Custodiol (48 ± 9%, p = 0.38) and showed similar drops in parameters in the two groups 24 hours after surgery and at discharge. CONCLUSION Single-dose Custodiol is as safe as blood cardioplegia for myocardial protection in congenital cardiac surgery for the cross-clamp times evaluated in this study. Evaluation at longer cross-clamp times would be helpful to determine if there is a greater benefit to single-dose Custodiol versus more repeated doses of blood cardioplegia for longer cross-clamp times.
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Affiliation(s)
- Steven Bibevski
- Joe DiMaggio Children's Hospital Heart Institute, Hollywood, FL, USA
| | - Laura Mendoza
- Joe DiMaggio Children's Hospital Heart Institute, Hollywood, FL, USA
| | - Mark Ruzmetov
- Joe DiMaggio Children's Hospital Heart Institute, Hollywood, FL, USA
| | - Kevin Tayon
- Joe DiMaggio Children's Hospital Heart Institute, Hollywood, FL, USA
| | - Jaime Alkon
- Joe DiMaggio Children's Hospital Heart Institute, Hollywood, FL, USA
| | - Breanna Vandale
- Joe DiMaggio Children's Hospital Heart Institute, Hollywood, FL, USA
| | - Frank Scholl
- Joe DiMaggio Children's Hospital Heart Institute, Hollywood, FL, USA
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7
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Valente AS, Lustosa GP, Mota LAM, Lima A, Mesquita FAD, Gondim A, Rodrigues FA, Pompeu RG, Branco KC. Comparative Analysis of Myocardial Protection with HTK Solution and Hypothermic Hyperkalemic Blood Solution in the Correction of Acyanogenic Congenital Cardiopathies - A Randomized Study. Braz J Cardiovasc Surg 2019; 34:271-278. [PMID: 31310464 PMCID: PMC6629237 DOI: 10.21470/1678-9741-2018-0243] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE The goal of the present study was to compare the myocardial protection obtained with histidine-tryptophan-ketoglutarate (HTK) cardioplegic solution (Custodiol®) and with intermittent hypothermic blood solution. METHODS Two homogenous groups of 25 children with acyanotic congenital heart disease who underwent total correction with mean aortic clamping time of 60 minutes were evaluated in this randomized study. Troponin and creatine kinase-MB curves, vasoactive-inotropic score, and left ventricular function were obtained by echocardiogram in each group. The values were correlated and presented through graphs and tables after adequate statistical treatment. RESULTS It was observed that values of all the studied variables varied over time, but there was no difference between the groups. CONCLUSION We conclude that in patients with acyanotic congenital cardiopathies submitted to total surgical correction, mean aortic clamping time around one hour, and cardiopulmonary bypass with moderate hypothermia, the HTK crystalloid cardioplegic solution offers the same myocardial protection as the cold-blood hyperkalemic cardioplegic solution analyzed, according to the variables considered in our study model.
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Affiliation(s)
- Acrisio Sales Valente
- Hospital de Messejana Dr. Carlos Alberto Studart Gomes Department of Surgery Fortaleza Ceará Brazil Department of Surgery, Hospital de Messejana Dr. Carlos Alberto Studart Gomes, Fortaleza, Ceará, Brazil.,Centro Universitário Unichristus Fortaleza Ceará Brazil Centro Universitário Unichristus, Fortaleza, Ceará, Brazil
| | - Gustavo Porto Lustosa
- Centro Universitário Unichristus Fortaleza Ceará Brazil Centro Universitário Unichristus, Fortaleza, Ceará, Brazil
| | - Lia Alves Martins Mota
- Centro Universitário Unichristus Fortaleza Ceará Brazil Centro Universitário Unichristus, Fortaleza, Ceará, Brazil
| | - Adriano Lima
- Hospital de Messejana Dr. Carlos Alberto Studart Gomes Department of Surgery Fortaleza Ceará Brazil Department of Surgery, Hospital de Messejana Dr. Carlos Alberto Studart Gomes, Fortaleza, Ceará, Brazil
| | - Fernando Antônio de Mesquita
- Hospital de Messejana Dr. Carlos Alberto Studart Gomes Department of Surgery Fortaleza Ceará Brazil Department of Surgery, Hospital de Messejana Dr. Carlos Alberto Studart Gomes, Fortaleza, Ceará, Brazil
| | - Aloísio Gondim
- Hospital de Messejana Dr. Carlos Alberto Studart Gomes Department of Surgery Fortaleza Ceará Brazil Department of Surgery, Hospital de Messejana Dr. Carlos Alberto Studart Gomes, Fortaleza, Ceará, Brazil
| | - Fábio Alércio Rodrigues
- Hospital de Messejana Dr. Carlos Alberto Studart Gomes Department of Surgery Fortaleza Ceará Brazil Department of Surgery, Hospital de Messejana Dr. Carlos Alberto Studart Gomes, Fortaleza, Ceará, Brazil
| | - Ronald Guedes Pompeu
- Hospital de Messejana Dr. Carlos Alberto Studart Gomes Department of Congenital Heart Disease Fortaleza Ceará Brazil Department of Congenital Heart Disease, Hospital de Messejana Dr. Carlos Alberto Studart Gomes, Fortaleza, Ceará, Brazil
| | - Klébia Castelo Branco
- Hospital de Messejana Dr. Carlos Alberto Studart Gomes Department of Congenital Heart Disease Fortaleza Ceará Brazil Department of Congenital Heart Disease, Hospital de Messejana Dr. Carlos Alberto Studart Gomes, Fortaleza, Ceará, Brazil
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8
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Protective effect of HTK solution on postoperative pulmonary function in infants with CHD and PAH. Biosci Rep 2017; 37:BSR20170984. [PMID: 29089468 PMCID: PMC5740778 DOI: 10.1042/bsr20170984] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Revised: 10/30/2017] [Accepted: 10/31/2017] [Indexed: 12/02/2022] Open
Abstract
Objective: In the present study, we aimed to investigate the effect of pulmonary arterial perfusion (PAP) with Histidine–tryptophan–ketoglutarate (HTK) on lung protection in infants with congenital heart disease (CHD) and pulmonary arterial hypertension (PAH) after cardiopulmonary bypass (CPB). Methods: Fifty infant patients with CHD and PAH at our hospital from January, 2016 to February, 2017 were randomly divided into control group and HTK group. The levels of interleukin-6 (IL-6), malondialdehyde (MDA), and endothelin-1 (ET-1) in serum were detected using ELISA Kit. Oxygen index (OI) and respiratory index (RI) were calculated at each time point. The time of postoperative mechanical ventilation and ICU stay was counted, and the right lower lung tissues in patients were taken for pathological examination. Results: Compared with preanesthesia, the levels of IL-6, MDA, and ET-1 in the two groups were significantly increased after CPB, and their levels in HTK group were significantly lower than that in control group. Moreover, OI in control group decreased markedly and RI in control group increased significantly after CPB. Compared with control group, the postoperative mechanical ventilation time, postoperative ICU stay, and total hospital stay in HTK group were markedly short. In addition, inflammatory cells infiltration decreased and pulmonary interstitial showed mild edema in HTK group. Conclusion: PAP with HTK could effectively reduce CPB-induced lung injury and improve lung function.
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9
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Lin YZ, Huang JB, Li XW, Tang XM, Lu WJ, Wen ZK, Liang J, Li DY, Wang H. Clinical comparative analysis of histidine-tryptophan-ketoglutarate solution and St. Thomas crystalloid cardioplegia: A 12-year study from a single institution. Exp Ther Med 2017; 14:2677-2682. [PMID: 28962211 DOI: 10.3892/etm.2017.4814] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2015] [Accepted: 11/18/2016] [Indexed: 11/06/2022] Open
Abstract
Cardioplegic reperfusion during a long-term ischemic period interrupts cardiac surgery and increases cellular edema due to repeated administration. The present clinical study compared the protective effects of histidine-ketoglutarate-tryptophan (HTK) solution and St. Thomas crystalloid cardioplegia. Clinical experiences of the myocardial protection induced by one single perfusion with HTK were reviewed in high-risk patients with severe pulmonary arterial hypertension associated with complex congenital heart disease. This retrospective study included 88 high-risk patients (aortic cross-clamp time, >120 min) between March 2001 and July 2012. The cohort was divided into two groups according to the technique used. Either myocardial protection was performed with one single perfusion with HTK solution (HTK group) or with conventional St. Thomas crystalloid cardioplegia (St group). The duration of cardiopulmonary bypass did not differ between the two groups. The mortality, morbidity, intensive care unit (ICU) stay, postoperative hospitalization, and transfusions of HTK group are significantly lower than those of the St group (P<0.05). Univariate and multivariate analysis demonstrated that HTK is a statistically significant independent predictor of decreased early mortality and morbidity (P<0.05). In conclusion, the present findings suggested that HTK solution decreases mortality, morbidity, ICU stay, postoperative hospitalization, and transfusions in high-risk patients with severe pulmonary arterial hypertension associated with complex congenital heart disease.
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Affiliation(s)
- Ying-Zhong Lin
- Department of Cardiothoracic Surgery, People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi 530021, P.R. China
| | - Jing-Bin Huang
- Department of Cardiothoracic Surgery, People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi 530021, P.R. China.,Department of Cardiothoracic Surgery, Ruikang Hospital Affiliated to Guangxi University of Chinese Medicine, Nanning, Guangxi 530011, P.R. China
| | - Xiang-Wei Li
- Department of Cardiothoracic Surgery, People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi 530021, P.R. China
| | - Xian-Ming Tang
- Department of Cardiothoracic Surgery, People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi 530021, P.R. China
| | - Wei-Jun Lu
- Department of Cardiothoracic Surgery, People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi 530021, P.R. China
| | - Zhao-Ke Wen
- Department of Cardiothoracic Surgery, People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi 530021, P.R. China
| | - Jian Liang
- Department of Cardiothoracic Surgery, Ruikang Hospital Affiliated to Guangxi University of Chinese Medicine, Nanning, Guangxi 530011, P.R. China
| | - Dian-Yuan Li
- Pediatric Center of Cardiac Surgery, Cardiovascular Institute and Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, P.R. China
| | - Hao Wang
- Department of Cardiothoracic Surgery, People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi 530021, P.R. China
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10
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De Palo M, Guida P, Mastro F, Nanna D, Quagliara TAP, Rociola R, Lionetti G, Paparella D. Myocardial protection during minimally invasive cardiac surgery through right mini-thoracotomy. Perfusion 2016; 32:245-252. [PMID: 28327076 DOI: 10.1177/0267659116679249] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Myocardial damage is an independent predictor of adverse outcome following cardiac surgery and myocardial protection is one of the key factors to achieve successful outcomes. Cardioplegia with Custodiol is currently the most used cardioplegia during minimally invasive cardiac surgery (MICS). Different randomized controlled trials compared blood and Custodiol cardioplegia in the context of traditional cardiac surgery. No data are available for MICS. AIM The aim of this study was to compare the efficacy of cold blood versus Custodiol cardioplegia during MICS. METHOD We retrospectively evaluated 90 patients undergoing MICS through a right mini-thoracotomy in a three-year period. Myocardial protection was performed using cold blood (44 patients, CBC group) or Custodiol (46 patients, Custodiol group) cardioplegia, based on surgeon preference and complexity of surgery. RESULTS The primary outcomes were post-operative cardiac troponin I (cTnI) and creatine kinase MB (CKMB) serum release and the incidence of Low Cardiac Output Syndrome (LCOS). Aortic cross-clamp and cardiopulmonary bypass times were higher in the Custodiol group. No difference was observed in myocardial injury enzyme release (peak cTnI value was 18±46 ng/ml in CBC and 21±37 ng/ml in Custodiol; p=0.245). No differences were observed for mortality, LCOS, atrial or ventricular arrhythmias onset, transfusions, mechanical ventilation time duration, intensive care unit and total hospital stay. CONCLUSIONS Custodiol and cold blood cardioplegic solutions seem to assure similar myocardial protection in patients undergoing cardiac surgery through a right mini-thoracotomy approach.
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Affiliation(s)
- Micaela De Palo
- Department of Emergency and Organ Transplant, Division of Cardiac Surgery, University of Bari Aldo Moro, Bari, Italy
| | - Pietro Guida
- Department of Emergency and Organ Transplant, Division of Cardiac Surgery, University of Bari Aldo Moro, Bari, Italy
| | - Florinda Mastro
- Department of Emergency and Organ Transplant, Division of Cardiac Surgery, University of Bari Aldo Moro, Bari, Italy
| | - Daniela Nanna
- Department of Emergency and Organ Transplant, Division of Cardiac Surgery, University of Bari Aldo Moro, Bari, Italy
| | - Teresa A P Quagliara
- Department of Emergency and Organ Transplant, Division of Cardiac Surgery, University of Bari Aldo Moro, Bari, Italy
| | - Ruggiero Rociola
- Department of Emergency and Organ Transplant, Division of Cardiac Surgery, University of Bari Aldo Moro, Bari, Italy
| | - Giosuè Lionetti
- Department of Emergency and Organ Transplant, Division of Cardiac Surgery, University of Bari Aldo Moro, Bari, Italy
| | - Domenico Paparella
- Department of Emergency and Organ Transplant, Division of Cardiac Surgery, University of Bari Aldo Moro, Bari, Italy
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11
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Li XW, Lin YZ, Lin H, Huang JB, Tang XM, Long XM, Lu WJ, Wen ZK, Liang J, Li DY, Zhao XF. Histidine-tryptophan-ketoglutarate solution decreases mortality and morbidity in high-risk patients with severe pulmonary arterial hypertension associated with complex congenital heart disease: an 11-year experience from a single institution. ACTA ACUST UNITED AC 2016; 49:e5208. [PMID: 27191607 PMCID: PMC4869826 DOI: 10.1590/1414-431x20165208] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Accepted: 03/11/2016] [Indexed: 11/25/2022]
Abstract
Cardioplegic reperfusion during a long term ischemic period interrupts cardiac
surgery and also increases cellular edema due to repeated solution administration. We
reviewed the clinical experiences on myocardial protection of a single perfusion with
histidine-tryptophan-ketoglutarate (HTK) for high-risk patients with severe pulmonary
arterial hypertension associated with complex congenital heart disease. This
retrospective study included 101 high-risk patients undergoing arterial switch
operation between March 2001 and July 2012. We divided the cohort into two groups:
HTK group, myocardial protection was carried out with one single perfusion with HTK
solution; and St group, myocardial protection with conventional St. Thomas'
crystalloid cardioplegic solution. The duration of cardiopulmonary bypass did not
differ between the two groups. The mortality, morbidity, ICU stay, post-operative
hospitalization time, and number of transfusions in HTK group were lower than those
in St group (P<0.05). Univariate and multivariate analysis showed that HTK is a
statistically significant independent predictor of decreased early mortality and
morbidity (P<0.05). In conclusion, HTK solution seems to be an effective and safe
alternative to St. Thomas' solution for cardioplegic reperfusion in high-risk
patients with complex congenital heart disease.
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Affiliation(s)
- X W Li
- Department of Cardiothoracic Surgery, Guangxi University, Nanning, Guangxi, China
| | - Y Z Lin
- Department of Cardiothoracic Surgery, Guangxi University, Nanning, Guangxi, China
| | - H Lin
- Department of Cardiothoracic Surgery, Guangxi University, Nanning, Guangxi, China
| | - J B Huang
- Department of Cardiothoracic Surgery, Guangxi University, Nanning, Guangxi, China
| | - X M Tang
- Department of Cardiothoracic Surgery, Guangxi University, Nanning, Guangxi, China
| | - X M Long
- Department of Cardiothoracic Surgery, Guangxi University, Nanning, Guangxi, China
| | - W J Lu
- Department of Cardiothoracic Surgery, Guangxi University, Nanning, Guangxi, China
| | - Z K Wen
- Department of Cardiothoracic Surgery, Guangxi University, Nanning, Guangxi, China
| | - J Liang
- Ruikang Hospital, Department of Cardiothoracic Surgery, Guangxi University, Nanning, Guangxi, China
| | - D Y Li
- Chinese Academy of Medical Sciences and Peking Union Medical College, Pediatric Center of Cardiac Surgery, Cardiovascular Institute and Fuwai Hospital, Beijing, China
| | - X F Zhao
- Ruikang Hospital, Department of Cardiothoracic Surgery, Guangxi University, Nanning, Guangxi, China
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Janssen C, Kellermann S, Münch F, Purbojo A, Cesnjevar RA, Rüffer A. Myocardial Protection During Aortic Arch Repair in a Piglet Model: Beating Heart Technique Compared With Crystalloid Cardioplegia. Ann Thorac Surg 2015; 100:1758-66. [DOI: 10.1016/j.athoracsur.2015.06.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2015] [Revised: 05/19/2015] [Accepted: 06/01/2015] [Indexed: 11/26/2022]
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Valooran GJ, Nair SK, Chandrasekharan K, Simon R, Dominic C. del Nido cardioplegia in adult cardiac surgery - scopes and concerns. Perfusion 2015; 31:6-14. [PMID: 26445810 DOI: 10.1177/0267659115608936] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The convenience offered by a single-dose cardioplegia strategy is the avoidance of interruption of the flow of surgery and, more importantly, a significant reduction in the cross-clamp time. del Nido cardioplegia is an extracellular cardioplegic solution which serves these purposes and has been used successfully in pediatric cardiac surgery. The subsequent extrapolation of its use in adult cardiac surgery has returned encouraging results, as evidenced by recent literature. The use of del Nido cardioplegia in adults has been reported to shorten the cross-clamp time, cardiopulmonary bypass time and overall operating time. Intraoperative peak glucose value and insulin requirement have also been reported to be lower with del Nido cardioplegia, which can have prognostic significance. There have been reports of lesser incidence of atrial fibrillation and the number of defibrillations required with use of this technique. However, some unique concerns still remain. The lack of prospective randomized trials, the trend of elevation in CKMB (as reported by one study) and the need for a protocol-based approach to its use in adults are to be given due consideration while adopting its use in adults. This review attempts to have an overview on del Nido cardioplegia, its advantages, the recent studies comparing it with conventional cardioplegia techniques and the potential areas of concern with its use in adult cardiac surgery.
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Affiliation(s)
- George Jose Valooran
- Department of Cardiovascular and Thoracic Surgery, Rajagiri Hospital, Aluva, Kochi, Kerala, India
| | - Shiv Kumar Nair
- Department of Cardiovascular and Thoracic Surgery, Rajagiri Hospital, Aluva, Kochi, Kerala, India
| | - Krishnan Chandrasekharan
- Department of Cardiovascular and Thoracic Surgery, Rajagiri Hospital, Aluva, Kochi, Kerala, India
| | - Rahul Simon
- Perfusion, Department of Cardiovascular and Thoracic Surgery, Rajagiri Hospital, Aluva, Kochi, Kerala, India
| | - Cyril Dominic
- Perfusion, Department of Cardiovascular and Thoracic Surgery, Rajagiri Hospital, Aluva, Kochi, Kerala, India
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Savini C, Murana G, Di Eusanio M, Suarez SM, Jafrancesco G, Castrovinci S, Castelli A, Di Bartolomeo R. Safety of Single-Dose Histidine-Tryptophan-Ketoglutarate Cardioplegia during Minimally Invasive Mitral Valve Surgery. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2014; 9:416-20. [DOI: 10.1177/155698451400900604] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective Minimally invasive mitral valve surgery may require a prolonged period of myocardial ischemia. Cardioplegic solutions that necessitate a single dose for adequate myocardial protection are evoked to simplify surgery and result to be appealing in this setting. The aim of this study was to assess early outcomes after minimally invasive mitral valve surgery using one single dose of histidine-tryptophanketoglutarate solution (HTK; Custodiol) for myocardial protection. Methods Between February 2003 and October 2012, a total of 49 consecutive patients underwent minimally invasive mitral valve surgery using a single dose of HTK solution for myocardial protection. The patients’ mean (SD) age was 57 (14) years; the preoperative ejection fraction was normal in all cases. The mean (SD) CPB time and aortic cross-clamp time were 148 (45) minutes and 97 (45) minutes, respectively. Results The heart spontaneously restarted after cross-clamp removal in 37 patients (75.5%). Five patients (10.2%) required prolonged inotropic drug support. Postoperatively, no significant increase in myocardial cytonecrosis enzymes was found [mean (SD) creatine kinase isoenzyme MB, 77.14 (53.67) μg/L at 3 hours, 71.2 (55.67) μg/L at 12 hours, and 42.53 (38.38) μg/L at 24 hours)], and no ischemic electrocardiogram modifications were observed before discharge. Conclusions During minimally invasive mitral valve surgery, HTK solution provided excellent myocardial protection even after prolonged periods of cardioplegic arrest. The avoidance of repetitive infusions may reduce the risk for coronary malperfusion due to dislodgement of the endoaortic clamp (if used) and increase the surgeon's comfort during the procedure.
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Affiliation(s)
- Carlo Savini
- Departments of Cardiac Surgery, University of Bologna, Bologna, Italy
| | - Giacomo Murana
- Departments of Cardiac Surgery, University of Bologna, Bologna, Italy
| | - Marco Di Eusanio
- Departments of Cardiac Surgery, University of Bologna, Bologna, Italy
| | | | | | | | - Andrea Castelli
- Anesthesia and Resuscitation, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
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de Jong A, Popa BA, Stelian E, Karazanishvili L, Lanzillo G, Simonini S, Renzi L, Diena M, Tesler UF. Perfusion techniques for minimally invasive valve procedures. Perfusion 2014; 30:270-6. [PMID: 25280878 DOI: 10.1177/0267659114550326] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
In this paper, we present, in detail, the simplified perfusion technique that we have adopted since January 2009 and that we have utilized in 200 cases for cardiac minimally invasive valvular procedures that were performed through a right lateral mini-thoracotomy in the 3(rd)-4(th) intercostal space. Cardiopulmonary bypass was achieved by means of the direct cannulation of the ascending aorta and the insertion of a percutaneous venous cannula in the femoral vein. A flexible aortic cross-clamp was applied through the skin incision and cardioplegic arrest was obtained with the antegrade delivery of a crystalloid solution. Gravity drainage was enhanced by vacuum-assisted aspiration. There were no technical complications related to this perfusion technique that we have adopted in minimally invasive surgical procedures.
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Affiliation(s)
- A de Jong
- Service of Perfusion, Policlinico di Monza, Clinica San Gaudenzio, Novara, Italy
| | - B A Popa
- Department of Cardiac Surgery, Policlinico di Monza, Clinica San Gaudenzio, Novara, Italy
| | - E Stelian
- Department of Cardiac Surgery, Policlinico di Monza, Clinica San Gaudenzio, Novara, Italy
| | - L Karazanishvili
- Department of Cardiac Surgery, Policlinico di Monza, Clinica San Gaudenzio, Novara, Italy
| | - G Lanzillo
- Department of Cardiac Surgery, Policlinico di Monza, Clinica San Gaudenzio, Novara, Italy
| | - S Simonini
- Department of Cardiac Surgery, Policlinico di Monza, Clinica San Gaudenzio, Novara, Italy
| | - L Renzi
- Service of Perfusion, Policlinico di Monza, Clinica San Gaudenzio, Novara, Italy
| | - M Diena
- Department of Cardiac Surgery, Policlinico di Monza, Clinica San Gaudenzio, Novara, Italy
| | - U F Tesler
- Department of Cardiac Surgery, Policlinico di Monza, Clinica San Gaudenzio, Novara, Italy
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Edelman JJB, Seco M, Dunne B, Matzelle SJ, Murphy M, Joshi P, Yan TD, Wilson MK, Bannon PG, Vallely MP, Passage J. Custodiol for myocardial protection and preservation: a systematic review. Ann Cardiothorac Surg 2014; 2:717-28. [PMID: 24349972 DOI: 10.3978/j.issn.2225-319x.2013.11.10] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2013] [Accepted: 11/10/2013] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Custodiol cardioplegia is attractive for minimally invasive cardiac surgery, as a single dose provides a long period of myocardial protection. Despite widespread use in Europe, there is little data confirming its efficacy compared with conventional (blood or crystalloid) cardioplegia. There is similar enthusiasm for its use in organ preservation for transplant, but also a lack of data. This systematic review aimed to assess the evidence for the efficacy of Custodiol in myocardial protection and as a preservation solution in heart transplant. METHODS Electronic searches were performed of six databases from inception to October 2013. Reviewers independently identified studies that compared Custodiol with conventional cardioplegia (blood or extracellular crystalloid) in adult patients for meta-analysis; large case series that reported results using Custodiol were analyzed. Next, we identified studies that compared Custodiol with other organ preservation solutions for organ preservation in heart transplant. RESULTS Fourteen studies compared Custodiol with conventional cardioplegia for myocardial protection in adult cardiac surgery. No difference was identified in mortality; there was a trend for increased incidence of ventricular fibrillation in the Custodiol group that did not reach statistical significance. No difference was identified in studies that compared Custodiol with other solutions for heart transplant. CONCLUSIONS Despite widespread clinical use, the evidence supporting the superiority of Custodiol over other solutions for myocardial protection or organ preservation is limited. Large randomised trials are required.
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Affiliation(s)
- J James B Edelman
- Department of Cardiothoracic Surgery, Sir Charles Gairdner Hospital, Nedlands, Australia; ; The Baird Institute; Sydney Medical School, University of Sydney, Sydney, Australia
| | - Michael Seco
- The Baird Institute; Sydney Medical School, University of Sydney, Sydney, Australia
| | - Ben Dunne
- Department of Cardiothoracic Surgery, Royal Perth Hospital, Perth, Australia
| | - Shannon J Matzelle
- Department of Anaesthesia, Sir Charles Gairdner Hospital, Nedlands, Australia
| | - Michelle Murphy
- Department of Anaesthesia, Sir Charles Gairdner Hospital, Nedlands, Australia
| | - Pragnesh Joshi
- Department of Cardiothoracic Surgery, Sir Charles Gairdner Hospital, Nedlands, Australia
| | - Tristan D Yan
- The Baird Institute; Sydney Medical School, University of Sydney, Sydney, Australia; ; Cardiothoracic Surgical Unit, Royal Prince Alfred Hospital, Sydney, Australia
| | - Michael K Wilson
- The Baird Institute; Sydney Medical School, University of Sydney, Sydney, Australia; ; Cardiothoracic Surgical Unit, Royal Prince Alfred Hospital, Sydney, Australia; ; Australian School of Advanced Medicine, Macquarie University, Sydney, Australia
| | - Paul G Bannon
- The Baird Institute; Sydney Medical School, University of Sydney, Sydney, Australia; ; Cardiothoracic Surgical Unit, Royal Prince Alfred Hospital, Sydney, Australia
| | - Michael P Vallely
- The Baird Institute; Sydney Medical School, University of Sydney, Sydney, Australia; ; Cardiothoracic Surgical Unit, Royal Prince Alfred Hospital, Sydney, Australia; ; Australian School of Advanced Medicine, Macquarie University, Sydney, Australia
| | - Jurgen Passage
- Department of Cardiothoracic Surgery, Sir Charles Gairdner Hospital, Nedlands, Australia; ; Notre Dame Medical School, Fremantle, Australia
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Kotani Y, Tweddell J, Gruber P, Pizarro C, Austin EH, Woods RK, Gruenwald C, Caldarone CA. Current Cardioplegia Practice in Pediatric Cardiac Surgery: A North American Multiinstitutional Survey. Ann Thorac Surg 2013; 96:923-9. [DOI: 10.1016/j.athoracsur.2013.05.052] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2013] [Revised: 05/14/2013] [Accepted: 05/17/2013] [Indexed: 10/26/2022]
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Lueck S, Preusse CJ, Welz A. Clinical relevance of HTK-induced hyponatremia. Ann Thorac Surg 2013; 95:1844-5. [PMID: 23608285 DOI: 10.1016/j.athoracsur.2013.01.026] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2012] [Revised: 11/13/2012] [Accepted: 01/03/2013] [Indexed: 10/26/2022]
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Which is the better option during neonatal cardiopulmonary bypass: HTK solution or cold blood cardioplegia? ASAIO J 2013; 59:69-74. [PMID: 23263337 DOI: 10.1097/mat.0b013e3182798524] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
The optimal myocardial protection strategy for newborns/infants undergoing congenital heart surgery remains controversial. The purpose of this study was to compare myocardial protection using histidine-tryptophan-ketoglutarate (HTK) and cold blood cardioplegia in a neonatal piglet model. Twenty-one piglets were randomized to three groups: the control group (C group, n = 7), a single dose of HTK group (H group, n = 7), and multidose cold blood cardioplegia group (B group, n = 7). Animals in the two experimental groups were placed on hypothermic cardiopulmonary bypass, after which the ascending aorta was clamped for 2 hours. Immediately after declamping, both the difference between arterial and coronary sinus blood lactate concentrations and the oxygen extraction did not differ between the H group and the B group. At 3 hours after declamping, rise in serum troponin-T and creatine kinase isoenzyme MB levels showed no significant differences between the H group and the B group (p = 0.735 and p = 0.103, respectively). No significant differences were noted in the myocardial lactate content, ATP content, and histopathological score between the H group and the B group (p = 0.810, p = 0.158, and p = 0.399, respectively). Transfusion requirement in the B group was significantly more than that in the H group (p = 0.003). HTK solution provides equivalent myocardial protection to multidose cold blood cardioplegia for the neonatal heart with less transfusion requirement.
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Kim JT, Park YH. Reply: To PMID 21511247. Ann Thorac Surg 2013; 95:1845. [PMID: 23608287 DOI: 10.1016/j.athoracsur.2013.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2013] [Revised: 01/31/2013] [Accepted: 02/14/2013] [Indexed: 10/26/2022]
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Potential risk of hyponatremia using histidine-tryptophan-ketoglutarate solution during pediatric cardiopulmonary bypass. Ann Thorac Surg 2012; 93:2120-1; author reply 2121. [PMID: 22632526 DOI: 10.1016/j.athoracsur.2011.12.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2011] [Revised: 10/31/2011] [Accepted: 12/06/2011] [Indexed: 11/23/2022]
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Lindner G, Zapletal B, Schwarz C, Wisser W, Hiesmayr M, Lassnigg A. Acute hyponatremia after cardioplegia by histidine-tryptophane-ketoglutarate--a retrospective study. J Cardiothorac Surg 2012; 7:52. [PMID: 22681759 PMCID: PMC3430602 DOI: 10.1186/1749-8090-7-52] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2012] [Accepted: 06/10/2012] [Indexed: 02/03/2023] Open
Abstract
Background Hyponatremia is the most common electrolyte disorder in hospitalized patients and is known to be associated with increased mortality. The administration of antegrade single-shot, up to two liters, histidine-tryptophane-ketoglutarate (HTK) solution for adequate electromechanical cardiac arrest and myocardial preservation during minimally invasive aortic valve replacement (MIAVR) is a standard procedure. We aimed to determine the impact of HTK infusion on electrolyte and acid–base balance. Methods In this retrospective analysis we reviewed data on patient characteristics, type of surgery, arterial blood gas analysis during surgery and intra-/postoperative laboratory results of patients receiving surgery for MIAVR at a large tertiary care university hospital. Results A total of 25 patients were included in the study. All patients were normonatremic at start of surgery. All patients developed hyponatremia after administration of HTK solution with a significant drop of serum sodium of 15 mmol/L (p < 0.01). Measured osmolality did not change during all times of surgery compared to start of surgery (p = 0.28 – p = 0.79), indicating isotonic hyponatremia. After administration of HTK solution pH fell significantly due to development of metabolic acidosis. Conclusions Acute hyponatremia during cardioplegia with HTK solution is isotonic and should probably not be corrected without presence of hypotonicity as confirmed by measurement of serum osmolality.
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Affiliation(s)
- Gregor Lindner
- Department of Emergency Medicine, Inselspital University Hospital Bern, Bern, Switzerland.
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Lindner G. Isoosmotic hyponatremia after HTK-induced cardioplegia. Ann Thorac Surg 2012; 93:692-3; author reply 693. [PMID: 22269751 DOI: 10.1016/j.athoracsur.2011.06.034] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2011] [Revised: 04/26/2011] [Accepted: 06/13/2011] [Indexed: 11/28/2022]
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