Myocardial protection in adult cardiac surgery: current options and future challenges

Abstract

Current techniques of myocardial protection are evolving with the use of less conventional modalities of cardioplegia and have reduced the morbidity and mortality of cardiac operations. Blood cardioplegic solutions appear superior to cold cardioplegia in terms of myocardial protection and adjuncts as glutamate/aspartate enhancement, antioxidant supplementation, nitric oxide donors and maintenance of calcium homeostasis seem effective. In the near future, further experimental and clinical investigations about pharmacological preconditioning, sodium-hydrogen exchangers inhibition and gene therapy need to be addressed to well define their potential role in the improvement of current techniques of myocardial protection that are suboptimal in high-risk clinical settings.

Coronary Sinus Lactate as Marker of Myocardial Ischemia in Cardiac Surgery: Correlation with Morbidity and Mortality after Cardiac Surgery / Lactatul din sinusul coronarian - marker al ischemiei miocardice în chirurgia cardiacă: corelaţii cu morbiditatea şi mortalitatea postoperatorie

“…From a theoretical perspective, retrograde cardioplegia has many advantages, its use being particularly recommended in patients with severe proximal coronary stenosis and low left ventricular contractility, but its use implies a correct insertion of the catheter into the coronary sinus to infuse the entire myocardium and to maintain a perfusion pressure of 40 mmHg during administration, in order to prevent perivascular hemorrhage and edema (17,21). The disadvantage of this method is the direct shunting of blood in atrial and ventricular cavities due to arterial-sinusoidal and thebesiene vessels, therefore delivery of the cardioplegic solution with a flow of 100 ml/min being necessary, in order to compensate for physiological shunting and decrease the lactate production (22). With all these drawbacks, retrograde cardioplegia is frequently used in patients with coronary and valvular heart disease.…”

Perioperative Organ Protection in Cardiac Surgery

“…Recently, it has been proposed the infusion of retrograde cardioplegic solutions in the coronary sinus. This technique assumes the possibility of maintaining uninterrupted infusion and distribution of the solution to regions irrigated by stenotic coronary vessels, improving the sub-endocardial protection (51). The optimal temperature for cardioplegia is controversial.…”

Cirugía coronaria. Evolución en la última década. Indicaciones y resultados actuales

“…A estos principios se han sumado controversias técnicas que han mostrado resultados comparables: cardioplejía caliente o a 4 °C, perfusión continua o discontinua, vía anterógrada o retrógrada 74 . Varias propuestas que produjeron entusiasmo, como la adición de L-arginina, moléculas antioxidantes, insulina, inhibidores del intercambio sodio-protones, filtros leucocitarios o el preacondicionamiento isquémico, no han conseguido la corroboración clínica 74,75 . Diferentes alternativas están actualmente en marcha, pendientes de resultados clínicos, como la adición a la cardioplejía de esmolol o de anticuerpos monoclonales inhibidores del complemento 74 .…”