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Honikman R, Pawale AA, Itagaki S, Lin HM, Rodriguez-Diaz C, Weiss AJ, Fischer GW, Weiner MM. Using near-infrared spectroscopy myocardial oximetry to monitor myocardial oxygen balance in a swine model of cardiac surgery: a descriptive study. J Clin Monit Comput 2020; 35:1367-1380. [PMID: 33169311 DOI: 10.1007/s10877-020-00610-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 10/20/2020] [Indexed: 11/29/2022]
Abstract
Monitoring of the adequacy of myocardial protection with cardioplegia is nearly non-existent in clinical cardiac surgical practice and instead relies on well-defined protocols for delivery of cardioplegia often resulting in inadequate protection. We hypothesized that Near Infrared Spectroscopy technology could be useful in the monitoring of the myocardial oxygen state by attaching the monitors to the epicardium in a porcine model of cardiac surgery. The experiments were conducted with 3 different protocols of 2 pigs each for a total of 6 pigs. The objective was to induce episodic, oxygen supply-demand mismatch. Methods for decreased supply included decreasing coronary blood flow, coronary blood hypoxemia, coronary occlusion, hypovolemia, and hypotension. Methods for increase demand included rapid ventricular pacing and the administration of isoproterenol. Changes in myocardial tissue oximetry were measured and this measurement was then correlated with blood hemoglobin saturations of oxygen from coronary sinus blood samples. We found that decreases in myocardial oxygen supply or increases in demand due to any of the various experimental conditions led to decreases in both myocardial tissue oximetry and hemoglobin oxygen saturation of coronary sinus blood with recovery when the conditions were returned to baseline. Correlation between myocardial tissue oximetry and hemoglobin oxygen saturation of coronary sinus blood was moderate to strong under all tested conditions. This may have translational applications as a monitor of adequacy of myocardial protection and the detection of coronary occlusion.
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Affiliation(s)
- Rafael Honikman
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | - Amit A Pawale
- Division of Cardiac Surgery, Department of Surgery, Bluhm Cardiovascular Institute, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Shinobu Itagaki
- Department of Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Hung-Mo Lin
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Cesar Rodriguez-Diaz
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Aaron J Weiss
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Gregory W Fischer
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Menachem M Weiner
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Whittaker A, Aboughdir M, Mahbub S, Ahmed A, Harky A. Myocardial protection in cardiac surgery: how limited are the options? A comprehensive literature review. Perfusion 2020; 36:338-351. [DOI: 10.1177/0267659120942656] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
For patients undergoing cardiopulmonary bypass, myocardial protection is a key for successful recovery and improved outcomes following cardiac surgery that requires cardiac arrest. Different solutions, components and modes of delivery have evolved over the last few decades to optimise myocardial protection. These include cold and warm and blood and crystalloid solution through antegrade, retrograde or combined cardioplegia delivery approach. However, each method has its own advantages and disadvantages, posing a challenge to establish a gold-standard cardioplegic solution with an optimised mode of delivery for enhanced myocardial protection during cardiac surgery. The aim of this review is to provide a brief history of the development of cardioplegia, explain the electrophysiological concepts behind myocardial protection in cardioplegia, analyse the current literature and summarise existing evidence that warrants the use of varying cardioplegic techniques. We provide a comprehensive and comparative overview of the effectiveness of each technique in achieving optimal cardioprotection and propose novel techniques for optimising myocardial protection in the future.
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Affiliation(s)
- Abigail Whittaker
- Department of Medicine, St George’s, University of London, London, UK
| | - Maryam Aboughdir
- Department of Medicine, St George’s, University of London, London, UK
- Department of Medicine, Imperial College London, London, UK
| | - Samiha Mahbub
- Department of Medicine, St George’s, University of London, London, UK
| | - Amna Ahmed
- Department of Medicine, Imperial College London, London, UK
| | - Amer Harky
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK
- School of Medicine, University of Liverpool, Liverpool, UK
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Alvarez NH, Guy TS. Commentary: Elevated atrial temperature in robotic assisted mitral valve surgery: Is it significant? JTCVS Tech 2020; 1:44-45. [PMID: 34317708 PMCID: PMC8288747 DOI: 10.1016/j.xjtc.2019.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Revised: 12/01/2019] [Accepted: 12/03/2019] [Indexed: 11/04/2022] Open
Affiliation(s)
- Nkosi H Alvarez
- Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, Pa
| | - T Sloane Guy
- Division of Cardiovascular Surgery, Thomas Jefferson University Hospital, Philadelphia, Pa
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Gojayev F, Solgun HA, Ak K, Midi A, Canillioglu Y. Comparison of heat monitoring-based myocardial protection strategy with classic myocardial protection method in isolated coronary artery bypass surgery patients. Cardiovasc Pathol 2019; 45:107161. [PMID: 31810046 DOI: 10.1016/j.carpath.2019.107161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Revised: 09/26/2019] [Accepted: 10/11/2019] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE In this study, we aimed to compare patients who have a myocardial protection strategy based on myocardial temperature monitorization with those who had myocardial protection with conventional intermittent cardioplegia. METHODS Twenty-six patients undergoing coronary artery bypass graft surgery were included into the study. Patients were prospectively grouped into two; myocardial protection based on temperature monitoring (group 1, n = 11) and those who had cardioplegia every 20 min (group 2, n = 15) during aortic cross-clamping. In all patients, cold blood cardioplegia was used. Coronary sinus blood sampling was performed immediately before aortic cross-clamping, after 2, 20, and 40 min of aortic clamping and tumor necrosis factor-alpha, malondialdehyde, creatinine kinase-myocardial band isoenzyme (MB), troponin I, lactate, and pH were studied. In addition, myocardial biopsy was taken before and immediately after cross-clamping to evaluate cardiomyocyte apoptosis with caspase-3 tunnel immunostaining. RESULTS There were no differences in clinical parameters like early mortality, extubation time, inotropic requirements, postoperative drainage, intensive care unit, and hospitalization time between two groups. In addition, blood and blood products were similar in two groups. In group 2, after cross-clamping, troponin I and creatinine kinase-MB values were significantly higher than the other group. In myocardial biopsies, the caspase immunostaining score, before removal of aortic cross-clamp was significantly higher in group 2 than the samples taken before aortic clamping. CONCLUSION Our results show that there is no difference between temperature-based myocardial protection strategy with conventional intermittent cardioplegia delivery. We think that the number of patients in our study is less and that the patient population is not a homogeneous structure is the most important limiting factor of our study. Increasing the number of patients, with particularly those who have myocardial dysfunction would help augment the possible different effects of two cardioplegic techniques on myocardial protection.
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Affiliation(s)
- Farid Gojayev
- Department of Cardiovasculer Surgery, Altınbas University Medicine Faculty, Medical Park Bahcelievler Hospital, Istanbul, Turkey
| | - Huseyin Avni Solgun
- Department of Pediatrics, Altınbas University Medicine Faculty, Medical Park Bahcelievler Hospital, Istanbul, Turkey.
| | - Koray Ak
- Department of Pediatric Cardiovasculer Surgery, Marmara University Medicine Faculty, Istanbul, Turkey
| | - Ahmet Midi
- Department of Patology, Bahçeşehir University Medicine Faculty, Istanbul, Turkey
| | - Yasemin Canillioglu
- Department of Histology, Bahçeşehir University Medicine Faculty, Istanbul, Turkey
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Okamoto H, Tamenishi A, Nishi T, Niimi T. Analysis of myocardial temperature changes in conventional isolated coronary artery bypass grafting. Gen Thorac Cardiovasc Surg 2014; 62:706-12. [PMID: 24876065 PMCID: PMC4254168 DOI: 10.1007/s11748-014-0424-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2014] [Accepted: 04/30/2014] [Indexed: 11/29/2022]
Abstract
Backgrounds
To determine whether cold blood cardioplegia (CBCP) can get over coronary artery lesions, we analyzed the relationship between myocardial temperature changes and lesion severity of major coronary arteries. Methods and results From April 1991 to October 2003, we measured myocardial temperature before and after antegrade and retrograde delivery of CBCP in 492 patients undergoing conventional coronary artery bypass grafting. Stenotic severity of three major coronary arteries was classified into four grades according to preoperative coronary arteriography; grade 0 for 50 % or less, 1 for 75 %, 2 for 90 %, 3 for 99 % or 100 %. We analyzed relationships between myocardial temperature changes [ΔT-A (antegrade) & ΔT-R (retrograde)] and the coronary artery lesion’s severity. Average ΔT-A of the right coronary artery had no relationship with stenotic grades. Mean ΔT-A of the left anterior descending (LAD) became less and less in proportion to its stenotic grade [9.7 °C for grade 0, 8.2 °C for grade 1, 7.1 °C for grade 2, and 6.0 °C for grade 3, respectively, (p = 0.0042)]. ΔT-A of the circumflex artery showed similar but weaker tendency than those of LAD. Significant inverse correlations were found between ΔT-A and ΔT-R1 in each territory (p < 0.001). Conclusions Antegrade delivery was less effective in situations with tight proximal lesion, especially in the LAD territory. Retrograde delivery supplemented antegrade delivery. Myocardial temperature monitoring enables us to deal with inadequate cardioplegic delivery, and is a good indicator of myocardial protection.
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Affiliation(s)
- Hiroshi Okamoto
- Department of Thoracic and Cardiovascular Surgery, Yokkaichi Municipal Hospital, Shibata, Yokkaichi, 2-2-37, Japan,
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Lomivorotov VV, Shmirev VA, Efremov SM, Ponomarev DN, Moroz GB, Shahin DG, Kornilov IA, Shilova AN, Lomivorotov VN, Karaskov AM. Hypothermic versus normothermic cardiopulmonary bypass in patients with valvular heart disease. J Cardiothorac Vasc Anesth 2013; 28:295-300. [PMID: 23962460 DOI: 10.1053/j.jvca.2013.03.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2013] [Indexed: 11/11/2022]
Abstract
OBJECTIVE The aim of this study was to test the hypothesis that normothermic cardiopulmonary bypass (CPB) is as effective as hypothermic CPB in terms of cardiac protection (cTnI level) and outcome in patients with valvular heart disease. DESIGN Prospective randomized study. SETTING A tertiary cardiothoracic referral center. PARTICIPANTS 140 patients who had valvular heart disease, with/without coronary artery disease, surgically treated under CPB. INTERVENTIONS The patients were allocated randomly to undergo either hypothermic (temperature [T], 31 °C-32 °C) or normothermic CPB (T>36 °C). MEASUREMENTS AND MAIN RESULTS The primary endpoint was the dynamics of troponin I. The secondary endpoints were ventilation time, the need for inotropic support, intensive care unit (ICU) and hospital stay durations, complications, and mortality. There were no significant intergroup differences in dynamics of troponin I. Ventilation time was significantly lower in the hypothermic group (6 (5-9) and 8 (5-12); p = 0.01). CONCLUSIONS Normothermic CPB in patients with valvular heart disease was as effective as hypothermic perfusion in terms of myocardial protection after the surgery assessed by cTnI release. The short ventilation duration in patients who underwent hypothermic CPB needs to be confirmed in a future investigation.
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Affiliation(s)
- Vladimir V Lomivorotov
- Department of Anesthesiology and Intensive Care, Research Institute of Circulation Pathology, Novosibirsk, Russia
| | - Vladimir A Shmirev
- Department of Anesthesiology and Intensive Care, Research Institute of Circulation Pathology, Novosibirsk, Russia
| | - Sergey M Efremov
- Department of Anesthesiology and Intensive Care, Research Institute of Circulation Pathology, Novosibirsk, Russia.
| | - Dmitry N Ponomarev
- Department of Anesthesiology and Intensive Care, Research Institute of Circulation Pathology, Novosibirsk, Russia
| | - Gleb B Moroz
- Department of Anesthesiology and Intensive Care, Research Institute of Circulation Pathology, Novosibirsk, Russia
| | - Denis G Shahin
- Department of Anesthesiology and Intensive Care, Research Institute of Circulation Pathology, Novosibirsk, Russia
| | - Igor A Kornilov
- Department of Anesthesiology and Intensive Care, Research Institute of Circulation Pathology, Novosibirsk, Russia
| | - Anna N Shilova
- Department of Anesthesiology and Intensive Care, Research Institute of Circulation Pathology, Novosibirsk, Russia
| | - Vladimir N Lomivorotov
- Department of Anesthesiology and Intensive Care, Research Institute of Circulation Pathology, Novosibirsk, Russia
| | - Alexander M Karaskov
- Department of Anesthesiology and Intensive Care, Research Institute of Circulation Pathology, Novosibirsk, Russia
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Rangaraj AT, Ghanta RK, Umakanthan R, Soltesz EG, Laurence RG, Fox J, Cohn LH, Bolman RM, Frangioni JV, Chen FY. Real-time visualization and quantification of retrograde cardioplegia delivery using near infrared fluorescent imaging. J Card Surg 2009; 23:701-8. [PMID: 19016995 DOI: 10.1111/j.1540-8191.2008.00767.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND AIM Homogeneous delivery of cardioplegia is essential for myocardial protection during cardiac surgery. Presently, there exist no established methods to quantitatively assess cardioplegia distribution intraoperatively and determine when retrograde cardioplegia is required. In this study, we evaluate the feasibility of near infrared (NIR) imaging for real-time visualization of cardioplegia distribution in a porcine model. METHODS A portable, intraoperative, real-time NIR imaging system was utilized. NIR fluorescent cardioplegia solution was developed by incorporating indocyanine green (ICG) into crystalloid cardioplegia solution. Real-time NIR imaging was performed while the fluorescent cardioplegia solution was infused via the retrograde route in five ex vivo normal porcine hearts and in five ex vivo porcine hearts status post left anterior descending (LAD) coronary artery ligation. Horizontal cross-sections of the hearts were obtained at proximal, middle, and distal LAD levels. Videodensitometry was performed to quantify distribution of fluorophore content. RESULTS The progressive distribution of cardioplegia was clearly visualized with NIR imaging. Complete visualization of retrograde distribution occurred within 4 minutes of infusion. Videodensitometry revealed retrograde cardioplegia, primarily distributed to the left ventricle (LV) and anterior septum. In hearts with LAD ligation, antegrade cardioplegia did not distribute to the anterior LV. This deficiency was compensated for with retrograde cardioplegia supplementation. CONCLUSIONS Incorporation of ICG into cardioplegia allows real-time visualization of cardioplegia delivery via NIR imaging. This technology may prove useful in guiding intraoperative decisions pertaining to when retrograde cardioplegia is mandated.
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Affiliation(s)
- Aravind T Rangaraj
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts 02115, USA
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Abstract
During ischemia, myocardial fatty acid metabolism ceases, rapidly depleting the other primary fuel, glucose. No technique has existed to continuously monitor myocardial glucose. Needle-tip enzymatic glucose biosensors have been developed for subcutaneous use in diabetic management. To study the utility of these sensors for real-time myocardial glucose monitoring in clinically relevant applications, 40 kg Yorkshire swine were cannulated for cardiopulmonary bypass. Biosensors were placed in the left anterior descending artery distribution (LAD) and posterior descending artery distribution (PD), and a third in the liver. Selective ischemia was induced by ligation of the LAD artery. Glucose levels were monitored during ischemia and reperfusion in the setting of cardioplegic arrest (n = 7) and in the normal beating heart (n = 14). In the normal beating heart, glucose levels fall to 6.5% +/- 7.4% baseline at 1 minute and 29.0% +/- 23.0% at 5 minutes of ischemia. In both arrested and beating heart scenarios, biosensors show distinct metabolic states in specific regions of the heart and liver. Biosensors can track regional glucose metabolism in the beating and arrested heart. This novel application of these sensors allows real-time determination of myocardial glucose levels to guide cardioplegia administration and monitor ischemic states for clinical and experimental use.
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Soltesz EG, Laurence RG, De Grand AM, Cohn LH, Mihaljevic T, Frangioni JV. Image-guided quantification of cardioplegia delivery during cardiac surgery. Heart Surg Forum 2007; 10:E381-6. [PMID: 17855203 PMCID: PMC2726619 DOI: 10.1532/hsf98.20071099] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Homogenous distribution of cardioplegia delivered to the myocardium has been identified as an important predictor of post-cardiopulmonary bypass ventricular recovery and function. Presently, a method to determine adequate distribution of cardioplegia in patients during cardiac surgery does not exist. The goal of this study was to evaluate the feasibility of quantifying cardioplegia delivery using a novel, noninvasive optical method. Such a system would permit instantaneous imaging of jeopardized myocardium and allow immediate, intraoperative corrective measures. METHODS We have previously developed a portable, intraoperative near-infrared (NIR) fluorescence imaging system for use in large animal cardiac surgery that simultaneously displays color video and NIR fluorescent images of the surgical field. By introducing exogenous, NIR fluorophores, specific cardiac functions can be visualized in real-time. RESULTS In a porcine cardiopulmonary bypass model, we demonstrate that the FDA-approved intravascular fluorophore indocyanine green (ICG) permits real-time assessment of cardioplegia delivery. ICG was injected into an aortic root and/or transatrial coronary sinus catheter during delivery of crystalloid cardioplegia solution. Segmental distribution was immediately noted at the time of injection. In a subset of animals, simulated coronary occlusions resulted in imaging defects consistent with poor cardioplegia delivery and jeopardized myocardium. Videodensitometric analysis was performed on-line to quantify distribution to the right ventricle and left ventricle. CONCLUSION We report the development of a novel, noninvasive, intraoperative technique that can easily and safely provide a visual assessment of cardioplegia delivery (antegrade and/or retrograde) and that offers the potential to quantify the relative segmental distribution during cardiac surgical procedures.
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Affiliation(s)
- Edward G. Soltesz
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women’s Hospital, Boston, MA 02115
| | - Rita G. Laurence
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women’s Hospital, Boston, MA 02115
| | - Alec M. De Grand
- Division of Hematology/Oncology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA 02215
| | - Lawrence H. Cohn
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women’s Hospital, Boston, MA 02115
| | - Tomislav Mihaljevic
- Division of Cardiac Surgery, Department of Surgery, Brigham and Women’s Hospital, Boston, MA 02115
| | - John V. Frangioni
- Division of Hematology/Oncology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA 02215
- Department of Radiology, Beth Israel Deaconess Medical Center, Boston, MA 02215
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Ozeki T, Kwon MH, Gu J, Collins MJ, Brassil JM, Miller MB, Gullapalli RP, Zhuo J, Pierson RN, Griffith BP, Poston RS. Heart Preservation Using Continuous Ex Vivo Perfusion Improves Viability and Functional Recovery. Circ J 2007; 71:153-9. [PMID: 17186994 DOI: 10.1253/circj.71.153] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Cold static storage (CS) is a proven preservation method for heart transplantion, yet early postoperative graft dysfunction remains prevalent, so continuous perfusion (CP) during ex vivo transport may improve viability and function of heart grafts. METHODS AND RESULTS Canine hearts underwent CP (n=9) or CS (n=9) for 6 h while intramyocardial pH was continuously monitored. Biopsies were assayed for ATP, caspase-3, malondialdehyde (MDA), and endothelin-1 (ET-1) levels at baseline, after preservation (t1), and after 1 h of blood reperfusion on a Langendorff model (t2). Functional recovery was determined at t2 by +dP/dt, -dP/dt, developed pressure, peak pressure and end-diastolic pressure. CP resulted in higher tissue pH and ATP stores and reduced caspase-3, MDA and ET-1 levels compared with CS at both t1 and t2. Post reperfusion recovery was significantly greater in CP vs CS for all myocardial functional parameters except end-diastolic pressure. Weight gain was significantly increased in CP vs CS at t1, but not at t2. CONCLUSIONS Low-grade tissue acidosis and energy depletion occur during CS and are associated with oxidative injury and apoptosis during reperfusion. CP attenuates these biochemical and pathologic manifestations of tissue injury, together with improved myocardial recovery, despite mild, transient edema.
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Affiliation(s)
- Toshinaga Ozeki
- Division of Cardiac Surgery, University of Maryland School of Medicine and VA Medical Center at Baltimore 21201, USA
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Dunning J, Hunter S, Kendall SWH, Wallis J, Owens WA. Coronary bypass grafting using crossclamp fibrillation does not result in reliable reperfusion of the myocardium when the crossclamp is intermittently released: a prospective cohort study. J Cardiothorac Surg 2006; 1:45. [PMID: 17118183 PMCID: PMC1676000 DOI: 10.1186/1749-8090-1-45] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2006] [Accepted: 11/21/2006] [Indexed: 11/29/2022] Open
Abstract
Background Cross-clamp fibrillation is a well established method of performing coronary grafting, but its clinical effect on the myocardium is unknown. We sought to measure these effects clinically using the Khuri Intramyocardial pH monitor. Methods 50 episodes of cross-clamping were recorded in 16 patients who underwent CABG with crossclamp-fibrillation. An Intramyocardial pH probe measured the level of acidosis in the anterior and posterior myocardium in real-time. The pH at the start and end of each period of cross-clamping was recorded. Results It became very apparent that the pH of some patients recovered quickly while others entirely failed to recover. Thus the patients were split into 2 groups according to whether the pH recovered to above 6.8 after the first crossclamp-release (N = 8 in each group). Initial pH was 7.133 (range 6.974–7.239). After the first period of crossclamping the pH dropped to 6.381 (range 6.034–6.684). The pH in recoverers prior to the second XC application was 6.990(range 6.808–7.222) compared to only 6.455 (range 6.200–6.737) in patient's whose myocardium did not recover (P < 0.0005). This finding was repeated after the second XC release (mean pH 7.005 vs 6.537) and the third (mean pH 6.736 vs 6.376). However prior to separation from bypass the pH was close to the initial pH in both groups (7.062 vs 7.038). Conclusion Crossclamp fibrillation does not result in reliable reperfusion of the myocardium between periods of crossclamping.
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Affiliation(s)
- Joel Dunning
- Department of Cardiothoracic Surgery, James Cook University Hospital, Middlesbrough, UK
| | - Steven Hunter
- Department of Cardiothoracic Surgery, James Cook University Hospital, Middlesbrough, UK
| | - Simon WH Kendall
- Department of Cardiothoracic Surgery, James Cook University Hospital, Middlesbrough, UK
| | - John Wallis
- Department of Cardiothoracic Surgery, James Cook University Hospital, Middlesbrough, UK
| | - W Andrew Owens
- Department of Cardiothoracic Surgery, James Cook University Hospital, Middlesbrough, UK
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Abstract
BACKGROUND The effects of exogenous L-aspartate and L-glutamate-enriched cardioplegia on postoperative left ventricular functions after coronary artery bypass surgery in patients with moderate left ventricular dysfunction (left ventricular ejection fraction [LVEF]= 30-40%) were studied. METHODS In this prospective randomized study, 22 patients with moderate left ventricular dysfunction (mean LVEF = 37.27%+/- 3.43%), who underwent elective coronary artery bypass surgery, were examined. Isothermic substrate-enriched [L-aspartate and L-glutamate (13 mmol/L)] blood cardioplegia was used in 11 patients (Group AG), and cardioplegia including only potassium and sodium bicarbonate was used in 11 patients (Group C). All hemodynamic parameters for left and right heart were studied in both groups. Total perfusion time was 126.63 +/- 44.91 minutes versus 114.81 +/- 43.66 minutes (p = 0.54). The aortic cross-clamp time was 77.09 +/- 28.02 minutes versus 67.81 +/- 22.77 minutes (p = 0.4), respectively. The amount of cardioplegic solutions were 7218.2 +/- 3043.6 mL versus 5454.5 +/- 3048.1 mL (p = 0.167). Mean number of distal anastomosis were 3 +/- 0.89 versus 2.9 +/- 0.7 (p = 0.793). RESULTS There was no difference between both groups in intra- and postoperative periods. In coronary sinus blood gas measures, myocardial acidosis caused by the aortic cross-clamp was found to be more severe in the Group C, but delta pH (0.12 +/- 0.14 vs. 0.092 +/- 0.058; p = 0.613) and delta lactate (1.39 +/- 1.03 vs. 1.62 +/- 0.85; p = 0.579) were similar in both groups. Free oxygen radical production caused by aortic cross-clamp was significant in the Group C. Not all myocardial enzymes, but Troponin-T levels were found higher in control group than the study group (0.6 +/- 0.36 vs. 0.36 +/- 0.25; p = 0.1). CONCLUSIONS Although L-aspartate and L-glutamate favor myocardial metabolic functions, they do not have any affect on myocardial functional recovery in patients with moderate left ventricular dysfunction.
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Affiliation(s)
- Ibrahim Uyar
- Department of Cardiovascular Surgery, Koşuyolu Heart and Research Hospital, Istanbul, Turkey
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Khuri SF, Healey NA, Hossain M, Birjiniuk V, Crittenden MD, Josa M, Treanor PR, Najjar SF, Kumbhani DJ, Henderson WG. Intraoperative regional myocardial acidosis and reduction in long-term survival after cardiac surgery. J Thorac Cardiovasc Surg 2005; 129:372-81. [PMID: 15678049 DOI: 10.1016/j.jtcvs.2004.05.020] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Regional myocardial acidosis, as measured with tissue pH electrodes during cardiac surgery, has been shown to be reflective of regional myocardial ischemia. This study examined the relationship between intraoperative regional myocardial acidosis and long-term survival of patients undergoing cardiac surgery with cardiopulmonary bypass. METHODS A total of 496 adult patients who underwent valve replacement, coronary artery revascularization, or both with intraoperative myocardial pH monitoring in the anterior and posterior left ventricular walls were followed up for 3 to 17 years (average 10.2 +/- 4.9 years) for all cause mortality. Regional myocardial acidosis in each patient was defined by the lower of the anterior and posterior wall pH values. RESULTS A bivariate automatic interaction detection analysis identified three significant regional myocardial acidosis thresholds that affected long-term mortality: pH 37C less than 6.63 before aortic crossclamping, integrated mean pH 37C less than 6.34 during the period of aortic crossclamping, and pH 37C less than 6.73 at discontinuation of cardiopulmonary bypass. Cox proportional hazard regression analysis identified each of these thresholds to be independently determinant of survival, with pH 37C during aortic crossclamping having the highest risk ratio (risk ratio 2.15, 95% confidence interval 1.37-3.37). Raising pH 37C from lower than threshold before aortic crossclamping to higher than threshold during clamping increased the median survival by 40.2%. CONCLUSION In adult patients undergoing cardiac surgery with cardiopulmonary bypass, regional myocardial ischemic acidosis before aortic crossclamping, during aortic crossclamping, and at discontinuation of cardiopulmonary bypass are independently associated with reduced long-term postoperative survival. Reversing or avoiding myocardial acidosis during cardiac surgery improves long-term patient survival.
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Mukherjee R, Yarbrough WM, Reese ES, Leiser JS, Sample JA, Mingoia JT, Hardin AE, Stroud RE, McLean JE, Hendrick JW, Spinale FG. Myocyte contractility with caspase inhibition and simulated hyperkalemic cardioplegic arrest. Ann Thorac Surg 2004; 77:1684-9; discussion 1689-90. [PMID: 15111166 DOI: 10.1016/j.athoracsur.2003.10.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/08/2003] [Indexed: 10/26/2022]
Abstract
BACKGROUND Exposure of left ventricular (LV) myocytes to simulated hyperkalemic cardioplegic arrest (HCA) has been demonstrated to perturb ionic homeostasis and adversely affect myocyte contractility on rewarming. Altered ionic homeostasis can cause cytosolic activation of the caspases. While caspases participate in apoptosis, these proteases can degrade myocyte contractile proteins, and thereby alter myocyte contractility. Accordingly, this study tested the hypothesis that caspase inhibition during HCA would attenuate the degree of myocyte contractile dysfunction upon rewarming, independent of a loss in myocyte viability. METHODS Porcine (n = 8) LV myocytes were isolated and assigned to the following treatment groups: normothermic control: incubation in cell culture media for 2 hours at 37 degrees C; HCA only: incubation for 2 hours in hypothermic HCA solution (4 degrees C, 24 mEq K(+)); or incubation in hypothermic HCA solution supplemented with 10 microM of the caspase inhibitor, z-VAD (z-Val-Ala-Asp-fluoromethyl-ketone, HCA+zVAD). Myocyte viability, assayed as a function of mitochondrial function, was determined to be similar in the normothermic and both HCA groups. RESULTS The HCA caused a significant reduction in myocyte shortening velocity compared with normothermic control values (41 +/- 6 versus 86 +/- 8 microm/s, p < 0.05). The HCA+zVAD group had significantly improved myocyte shortening velocity compared with the HCA only group (63 +/- 7 microm/s, p < 0.05). CONCLUSIONS Independent of changes in viability, caspase inhibition attenuated myocyte contractile dysfunction after HCA and rewarming. Thus, caspase activation during HCA contributes, at least in part, to impaired myocyte contractility with rewarming. Supplementation of HCA with caspase inhibitors may provide a means to preserve myocyte contractile function after cardioplegic arrest.
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Affiliation(s)
- Rupak Mukherjee
- Division of Cardiothoracic Surgery Research, Medical University of South Carolina, Charleston, South Carolina 29425, USA.
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Affiliation(s)
- S F Khuri
- VA Boston Healthcare System, West Roxbury, Massachusetts 02132, USA.
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