Cardioplegia Application with A Hand-Squeezed Cardioplegia Bag. Is It Safe?

OBJECTIVES: Cardioplegia solutions have a role not only in arresting the heart but also in protecting the myocardium from ischemia. While antegrade cardioplegia is given by the heart-lung machine in many centers, it is given by a hand-squeezed bag in very few centers. The pressure of cardioplegia given antegrade from the heart-lung machine is certain (60-90 mmHg). The pressure applied in the cardioplegia method, which is given antegrade with a hand-squeezed bag, is uncertain and variable. We compared the antegrade cardioplegia method applied with a hand-squeezed bag with the antegrade cardioplegia method applied with a roller pump from the heart-lung machine in terms of protecting the myocardium from ischemia. METHODS: Seventy-six patients who did not have an acute myocardial infarction, had normal preoperative cardiac marker (troponin and CK-MB) values, did not undergo redo open heart surgery, had an ejection fraction of 50% and above, and underwent elective two or three-vessel isolated coronary artery bypass surgery were evaluated. While tepid (30-32°C) blood cardioplegia was administered antegrade to 33 patients (Group A) with a hand-squeezed bag, the other 34 patients (Group B) received tepid (30-32°C) antegrade blood cardioplegia from the heart-lung machine. The perioperative and postoperative data of the patients were recorded and compared. To evaluate myocardial damage, postoperative cardiac markers and echocardiography data were evaluated and compared at the fourth hour after the cross-clamp was removed in both groups. RESULTS: When evaluated in terms of preoperative demographic data, preoperative mean EF values and intraoperative data, there was no statistical difference between both groups. When we evaluated in terms of myocardial protection, the mean TnT level was 4.31 ± 1.95 at the 4th hour in Group A and 3.91 ± 1.69 in Group B. Mean 4th hour CK-MB level was 40.84 ± 9.07 in Group A and 38.56 ± 8.07 in Group B. Mean change in EF (%) was -4.09 ± 4.41 in Group A and 3.53 ± 4.53 in Group B. In line with the current data when we evaluated in terms of myocardial protection, we found that there is no statistical difference between the two groups (P = 0.373; P = 0.158; P = 0.523). There was no statistical difference between both groups, in terms of postoperative arrhythmias. None of the patients died, and no patients required an intra-aortic balloon pump. RESULTS: As a result of our study, cardioplegia administration with a certain constant pressure from the roller pump and hand-squeezed bag with uncertain pressure does not make a difference, in terms of myocardial protection. We think that the content and amount of cardioplegia and the preferred time for repeated cardioplegia applications are more important for the protection of the myocardium. METHODS: 76 patients who did not have an acute myocardial infarction, had normal preoperative cardiac marker (troponin and CK-MB) values, did not undergo redo open heart surgery, had an ejection fraction of 50% and above, and underwent elective two or three-vessel isolated coronary artery bypass surgery were evaluated. While tepid(30-32 ° C) blood cardioplegia was administered antegrade to 33 patients(Group A) with a hand-squeezed bag, the other 34 patients(Group B) received tepid(30-32 °C) antegrade blood cardioplegia from the heart-lung machine. The perioperative and postoperative data of the patients were recorded and compared. To evaluate myocardial damage, postoperative cardiac markers and echocardiography data were evaluated and compared at the fourth hour after the cross-clamp was removed in both groups. RESULTS: When evaluated in terms of preoperative demographic data, preoperative mean EF values and intraoperative data there was no statistical difference between both groups. When we evaluated in terms of myocardial protection, the mean TnT level was 4.31 ± 1.95 at the 4th hour in group A and 3.91 ± 1.69 in group B. Mean 4th hour CK-MB level was 40.84 ± 9.07 in group A and 38.56 ± 8.07 in group B. Mean change in EF (%) was -4.09 ± 4.41 in group A and 3.53 ± 4.53 in group B. In line with the current data when we evaluated in terms of myocardial protection; we found that there is no statistical difference between the two groups (p = 0.373; p = 0.158; p = 0.523). There was no statistical difference between both groups in terms of postoperative arrhythmia's. None of the patients died and none of the patients required an intra-aortic balloon pump.

Coronary Sinus Rupture Repair: Patency Is Important.

We report a case of coronary sinus (CS) injury with a retrograde cardioplegia catheter and repair that compromised CS patency. This resulted in acute global cardiac dysfunction shortly after weaning from bypass, which reversed after patch repair with confirmed CS patency. The case report shows that acute CS occlusion may not be tolerated in some humans.

The practicalities of establishing a porcine isolated heart model.

BACKGROUND: The isolated heart apparatus is over 100 years old, but remains a useful research tool today. While designs of many large animal systems have been described in the literature, trouble-shooting and refining such a model to yield a stable, workable system has not been previously described. This paper outlines the issues, in tabular form, that our group encountered in developing our own porcine isolated heart rig with the aim of assisting other workers in the field planning similar work. The paper also highlights some of the modern applications of the isolated heart apparatus. Methods Landrace pigs (50-80 kg) were used in a pilot project to develop the model. The model was then used in a study examining the effects of various cardioplegic solutions on function after reanimation of porcine hearts. During the two projects, non-protocol issues were documented as well as their solutions. These were aggregated in this paper. RESULTS: Issues faced by the group without explicit literature solutions included pig size selection, animal acclimatisation, porcine transoesophageal echocardiography, cannulation and phlebotomy for cross-clamping, cardioplegia delivery, heart suspension and rig tuning. CONCLUSION: Prior recognition of issues and possible solutions faced by workers establishing a porcine isolated heart system will speed progress towards a useable system for research. The isolated heart apparatus remains applicable in transplant, ischaemia reperfusion, heart failure and organ preservation research.

Retrospective analysis of eliminating modified ultrafiltration after pediatric cardiopulmonary bypass.

Modified ultrafiltration (MUF) is a technique which is commonly used immediately post-cardiopulmonary bypass (CPB) for open heart surgery in children. There are many advantages of MUF, but there are also a number of less reported disadvantages. At our institution, after considering all of the available data, a decision was made to no longer perform MUF. The primary motivation being the simplified and miniaturized CPB circuit would reduce hemodilution, decrease our likelihood of reaching our transfusion trigger during CPB and, potentially, improve safety. This study reports the before and after data from this practice change. A total of 160 patients less than 8kg were studied over 38 months and divided into neonatal and pediatric cohorts. Parameters reported in this study include: demographics, hematocrit, blood product transfusion, hemostasis, hemodynamics and outcomes. Although retrospective, our analysis supports an advantage of preventing hemodilution (via circuit miniaturization) versus reversing hemodilution (via MUF) at our institution with the patient population we examined.

Left atrial dissection related to retrograde cardioplegia cannula insertion.

Left atrial dissection (LAD) is a rare complication and is defined as a gap from the mitral or tricuspid annular area to the interatrial septum or left atrial wall. Because of its low incidence, this entity is not fully understood. LAD is related to mitral valve surgery as well as coronary artery disease, arrhythmia, trauma, and tumors, and occurs spontaneously. Transesophageal echocardiography is the most useful diagnostic modality for LAD, but multimodality investigation supports accurate diagnosis. We experienced a case of LAD related to retrograde cardioplegia cannula insertion which was treated successfully with internal drainage.

The "tube-in-tube" circuit: a new method for delivering cold blood cardioplegia in neonates and small infants.

PURPOSE: To conceive a method to deliver cold blood cardioplegia in neonates and young infants. DESCRIPTION: The "tube-in-tube" circuit consists of a 3-mm line (bloodline) which is inserted inside a 1/2 -in tube where cold water flows continuously (waterline). This circuit includes a filling volume of 18 mL of static prime and 15 mL for the collecting line (pump raceway). Several temperature samples were taken at different blood flows from 20 to 100 mL/min. EVALUATION: Temperatures (in °C) at the needle tip were significantly lower when using the tube-in-tube cooling circuit if compared to standard cardioplegia circuit at flows up to 60 mL/min. CONCLUSIONS: The tube-in-tube circuit proved to be an effective strategy for low-flow cardioplegia delivery (<60 ml/min), which is particularly useful in neonates and young infants; the lower is the flow, the better is the cooling effect on the cardioplegia.

Use of del Nido Cardioplegia for Adult Cardiac Surgery at the Cleveland Clinic: Perfusion Implications.

Cardiac arrest by cardioplegia provides a reproducible and safe method to induce and maintain electromechanical cardiac quiescence. Techniques of intraoperative myocardial protection are constantly evolving. For the past three decades, modified Buckberg cardioplegia solution has been used for adult cardiac surgery at the Cleveland Clinic. This formulation serves as the crystalloid component, which is delivered 4:1 with oxygenated patient's blood to crystalloid. Meanwhile, our use of the del Nido cardioplegia solution in adult patients, heretofore primarily used in pediatric cardiac surgical centers, has been increasing over the past several years. Single-dose, cold blood del Nido cardioplegia can be delivered antegrade if the duration of the operation will be limited and if there is no significant coronary artery disease or aortic insufficiency that would limit the distribution of cardioplegia. The addition of del Nido cardioplegia to our cardioplegia armamentarium allows us to customize our myocardial protection strategies for different surgical needs. This article aims to provide information on technical aspects of del Nido cardioplegia in adult cardiac surgery and its use at the Cleveland Clinic in the adult surgical population.

Use of del Nido cardioplegia solution and a low-prime recirculating cardioplegia circuit in pediatrics.

The evolution of myocardial protection techniques has been both the source of milestone advancements and controversial debate in cardiac surgery. Our institution has modified a low-prime cardioplegia system (CPS) and adopted a single-dose cardioplegia solution (del Nido cardioplegia) for our congenital heart disease population. The goal of this article is to describe our CPS and outline our myocardial protection protocol. These techniques have allowed us to minimize circuit surface area, operate uninterrupted, and safely protect the myocardium during extended ischemic periods.

Iatrogenic coronary ostial stenosis of left main stem following aortic valve replacement: visualization with optical coherence tomography.

Iatrogenic coronary ostial stenosis following aortic valve replacement (AVR) occurs in up to 3.4% of cases and usually presents within the first 6months following surgery. We present the case of an 85year old man who developed an acute coronary syndrome 2months following AVR. Coronary angiography revealed a severe de novo lesion in the left main stem, which, on optical coherence tomography, was shown to be due to severe intimal hyperplasia. The most likely underlying mechanism is vessel wall trauma caused by the rigid tip cannula used for administration of cardioplegia solution. Surgeons should be aware of this possibility when administering this solution via the antegrade approach.

History and use of del Nido cardioplegia solution at Boston Children's Hospital.

Cardioplegia is an integral and essential method of myocardial protection for patients of all ages requiring cardiac surgery in which the heart must be stopped. Numerous cardioplegia solutions and delivery methods have been developed. The del Nido cardioplegia solution has been in use for 18 years at Boston Children's Hospital. This is a unique four parts crystalloid to one part whole blood formulation that is generally used in a single-dose fashion. Although the formulation was originally developed for use in pediatric and infant patients, its use for adult cardiac surgery has been expanding. National and international inquiries to our institution regarding this cardioplegia have been increasing over the last 2 years. We present the developmental history, supporting theory, and current protocol for use of what is now referred to as del Nido cardioplegia.

A dental mirror provides excellent exposure of the right coronary artery during cardioplegia.

It sometimes is very difficult to achieve good exposure of the orifice of the right coronary artery through a typical aortotomy when inserting the cannula for the selective antegrade administration of cardioplegic solution to the right coronary artery. A simple technique of exposing the orifice of the right coronary artery using a dental mirror is described.

Retrograde coronary sinus cardioplegia cannula placement under short-time circulatory arrest in surgery for a ruptured type A dissection with a previous coronary artery bypass.

A 79-year-old woman was referred to undergo surgery for a type A dissection. The patient had a history of previous coronary artery bypass. She was in shock and had a hematoma surrounding the ascending aorta and the heart. In this case, a coronary sinus cardioplegia cannula was placed under a short period of circulatory arrest via a small atriotomy, and the atriotomy was closed immediately to establish selective cerebral perfusion.

Left ventricular pacing lead insertion via the coronary sinus cardioplegia cannula: a novel method for temporary biventricular pacing during reoperative cardiac surgery.

OBJECTIVE: Temporary biventricular pacing to treat low output states after cardiac surgery is an active area of investigation. Reoperative cases are not studied due to adhesions, which preclude left ventricular mobilization to place epicardial pacing wires. In such patients, inserting a temporary left ventricular lead via the coronary sinus cardioplegia cannula may allow for biventricular pacing. We developed a novel technique for intraoperative left ventricular lead placement. METHODS: Eight domestic pigs underwent median sternotomy and pericardiotomy. Temporary pacing wires were sewn to the right atrium and right ventricle. Complete heart block was induced by ethanol ablation of the atrioventricular node. A 13-French retrograde cardioplegia catheter was introduced via the right atrial free wall into the coronary sinus. A 6-French left ventricular pacing lead was inserted into the cardioplegia catheter and advanced into the coronary sinus during biventricular pacing until left ventricular capture was detected by electrocardiogram and arterial pressure monitoring. Left ventricular capture success rate and electrical performance were recorded during five placement attempts. RESULTS: Left ventricular capture was achieved on 80% of insertion attempts. Left ventricular capture without diaphragmatic pacing was achieved in 7 pigs. Lead tip locations were mostly in lateral and posterior basal coronary vein branches. There were no arrhythmias, bleeding, or perforation associated with lead insertion. CONCLUSIONS: Intraoperative biventricular pacing with a left ventricular pacing lead inserted via the coronary sinus cardioplegia cannula is feasible, using standard instrumentation and without requiring cardiac manipulation. This approach merits further study in patients undergoing reoperative cardiac surgery.

A simple method for cardioplegia administration and suture control using foley catheter during ascending aorta replacement and aortic root surgery.

There is no standardised approach for cardioplegia administration during ascending aorta replacement (AAR) and the techniques used so far are quite variable and show important limitations. In order to overcome these limitations, we propose a simple and inexpensive technique using a Foley catheter for cardioplegia administration and bleeding control in case of AAR or aortic root surgery. The benefits of our technique are the technical simplicity and the low cost that makes this approach an ideal solution for cardioplegia administration in all cases of AAR.

Air-handling capabilities of blood cardioplegia delivery systems in a simulated pediatric model.

Blood cardioplegia delivery systems are employed in most pediatric open heart cases to arrest the heart and keep it preserved during aortic cross-clamping. They are also used as part of a modified ultrafiltration system at the end of cardiopulmonary bypass. We evaluated and compared the air-handling capabilities of different types of blood cardioplegia delivery devices. A simple circuit incorporating a cardiotomy reservoir, a roller pump, a cardioplegia test system, and two emboli detection and classification sensors were used to investigate the air-handling capabilities of the following cardioplegia delivery systems: GISH Vision, Maquet Plegiox, Medtronic Trillium MYOtherm XP, Sorin Group BCD Vanguard, Sorin Group CSC14, and Terumo Sarns Conducer and Bubble Trap. The 0.25-in. circuit was primed with 400mL of Lactated Ringer's. Outdated packed red blood cells were added to obtain a hematocrit of 24-28%. System pressure was maintained at 50mmHg. Air (0.1, 0.3, 0.5mL) was injected at a speed of 0.1mL/s into the circuit just after the pump head. Gaseous microemboli (GME) were measured prior to the cardioplegia system and after the device to evaluate the air-handling characteristics. The tests were run at 100, 200, and 400mL/min blood flow for both 4 and 37°C. There were no significant differences among the groups when comparing precardioplegia delivery system GME, thus demonstrating that all devices received the same amount of injected air. When comparing the groups for postcardioplegia delivery system GME, significant differences were noted especially at the 400mL/min blood flow rate. These results suggest that for the devices compared in this study, the Maquet Plegiox and the Medtronic Trillium MYOtherm XP eliminated GME the best.

A strategy for safe sternal reentry in patients with pseudoaneurysms of the ascending aorta using the PORT-ACCESS EndoCPB system.

Pseudoaneurysms of the ascending aorta developing after previous aortic or aortic valve surgery pose a high risk of exsanguination upon sternal reentry. In the past, femorofemoral bypass and hypothermic circulatory arrest before sternotomy was the preferred approach. Today, however, availability of the PORT-ACCESS EndoCPB system (Edwards Lifesciences, Irvine, CA, USA) allows for endovascular clamping and cardioplegia before sternotomy, avoiding circulatory arrest.