To the content
3 . 2022

Analysis of the use of cold crystalloid cardioplegia and own modification of warm, low-volume blood cardioplegia in coronary artery bypass surgery in patients with poor myocardial reserve

Abstract

Aim – to compare the effectiveness of using our own modification of blood, warm, low-volume, single-dose and cold crystalloid cardioplegia with NTC-solution in isolated primary coronary artery bypass grafting in adult patients with poor myocardial reserve and LVEF <35%.

Material and methods. The study was based on a single-center analysis of data from 199 adult patients with LV ejection fraction <35%, aged 35–76 years, who underwent primary planned aortocoronary bypass grafting under cardiopulmonary bypass in the period from 2015 to 2020. Depending on the method of myocardial protection, patients were randomized into two groups: a group that used its own modification of a thermal blood low-volume single-dose CP (blood CP) – 120 patients and a group of pharmaco-cold crystalloid CP with NTK-solution (crystalloid CP) – 79 patients.

Results. All patients had multivessel occlusive stenotic lesions of the coronary bed with comparable values on the scale (Syntax SCORE, p=0.8), revascularization index of 2 or more, and received CABG. The duration of the periods of MI did not differ. In the group with blood CP, a significantly smaller volume of CP was required (p<0.001) in all patients (p<0.001), the main mechanism for the asystole during the induction of cardioplegia was AV blockade. In the crystalloid CP group, induction of cardioplegic solution resulted in 84% cardiac arrest due to ventricular fibrillation (p<0.001). After removal clamp from the aorta in the blood CP group, spontaneous recovery of cardiac activity was observed in 93.3% (112 patients) versus 41% (32 patients) in the crystalloid CP group (p=0.001), the need for defibrillation, respectively, 6% of cases versus 32% (p=0.03). The need for cardiotonic and/or vasopressor support >24 hours, enzymatic response (increase in CK, CK-MB, Troponin T) were higher in the crystalloid CP group. The incidence of MI, low output cardiac syndrome, AF, stroke, abdominal complications, hospital mortality had no differences. The blood CP group demonstrated lower mortality during the year (p<0.001).

Conclusion. The proposed own modification of low-volume, blood cardioplegia is a reliable way to protect the myocardium during coronary artery bypass surgery in patients with poor myocardial reserve (LV EF <35%).

Keywords:low left ventricular ejection fraction; myocardial protection

Funding. The study had no sponsor support.
Conflict of interest. The authors declare no conflict of interest.
For citation: Basylev V.V., Evdokimov M.E., Pantyuhina M.A. Analysis of the use of cold crystalloid cardioplegia and own modification of warm, low-volume blood cardioplegia in coronary artery bypass surgery in patients with poor myocardial reserve. Clinical and Experimental Surgery. Petrovsky Journal. 2022; 10 (3): 48–58. DOI: https://doi.org/10.33029/2308-1198-2022-10-3-48-58  (in Russian)

References

1.     Nishi Н., Miyamoto S., Takanashi S., Minamimura H., Ishikawa H.,  Shimizu Y. Complete revascularization in patients with severe left ventricular dysfunction. Ann Thorac Cardiovasc Surg. 2003; 9 (2): 111–6.

2.     Lozonschi L., Kohmoto T., Osaki S., De Oliveira S., Dhingra S., Akhter S., et al. Coronary bypass in left ventricular dysfunction and differential cardiac recovery. Asian Cardiovasc Thorac Ann. 2017; 25 (9): 586–93. DOI: https://doi.org/10.1177/0218492317744472   

3.     Farkouh M., Domanski M., Dangas G.; FREEDOM Follow-On Study Investigators. Long-term survival following multivessel revascularization in patients with diabetes: the FREEDOM follow-on study. J Am Coll Cardiol. 2019; 73 (6): 629–38.

4.     Nagendran J., Norris C., Graham M., Ross D., Macarthur R., Kieser T.,  et al. Coronary revascularization for patients with severe left ventricular dysfunction. Randomized Controlled Trial. Ann Thorac Surg. 2013; 96 (6): 2038–44. DOI: https://doi.org/10.1016/j.athoracsur.2013.06.052  

5.     Bangalore S., Guo Y., Samadashvili Z., Blecker S., Hannan E. Revascularization in patients with multivessel coronary artery disease and severe left ventricular systolic dysfunction. Circulation. 2016; 133: 2132–40. DOI: https://doi.org/10.1161/CIRCULATIONAHA.115.021168  

6.     Sousa-Uva M., Neumann F., Ahlsson A., Alfonso F., Banning A., Benedetto U. ESC/EACTS guidelines on myocardial revascularization. The Task Force on myocardial revascularization of the European Society of Cardiology (ESC) and European Association for Cardio-Thoracic Surgery (EACTS). Developed with the special contribution of the European Association for Percutaneous Cardiovascular Interventions (EAPCI). Eur J Cardiothorac Surg. 2019; 55 (1): 4–90. DOI: https://doi.org/10.1093/ejcts/ezy289  

7.     Kunadia V., Zaman A., Qiu W. Revascularization among patients with severe left ventricular dysfunction: a meta-analysis of observational studies. Eur J Heart Fail. 2011; 13 (7): 773–84. DOI: https://doi.org/10.1093/eurjhf/hfr037  

8.     Allen B.S. Myocardial protection: a forgotten modality. Eur J Cardiothorac Surg. 2020; 57 (2): 263–70. DOI: https://doi.org/10.1093/ejcts/ezz215  

9.     Elvenes O.P., Korvald C., Myklebust R. Warm retrograde blood cardioplegia saves more ischemic myocardium but may cause a functional impairment compared to cold crystalloid. Eur J Cardiothorac Surg. 2002; 22: 402–9.

10. De Bruyn H., Gelders F., Gregoir T., Waelbers V., Starinieri P., et al. Myocardial protection during cardiac surgery: warm blood versus crystalloid cardioplegia. World J Cardiovasc Dis. 2014; 4: 422–31. DOI: https://doi.org/10.4236/wjcd.2014.49053  

11. Nardi Р., Pisano С., Bertoldo F., Vacirca S., Saitto G., Costantino A., et al. Warm blood cardioplegia versus cold crystalloid cardioplegia for myocardial protection during coronary artery bypass grafting surgery. Cell Death Discov. 2018; 4: 23. DOI: https://doi.org/10.1038/s41420-018-0031-z  

12. Calafiore A., Teodori G., Mezzetti A., Bosco G., Verna A., Di Giammarco G. Intermittent antegrade warm blood cardioplegia. Ann Cardiothorac Surg. 1995; 59: 398–402.

13. Ad N., Holmes S., Massimiano P., Rongione A., Fornaresio L., Fitzgerald D. The use of del Nido cardioplegia in adult cardiac surgery: a prospective randomized trial. J Thorac Cardiovasc Surg. 2018; 155 (3): 1011–8. DOI: https://doi.org/10.1016/j.jtcvs.2017.09.146  

14. Buckberg G. Myocardial temperature management during aortic clamping for cardiac surgery. Protection, preoccupation, and perspective. J Thorac Cardiovasc Surg. 1991; 102: 895– 903.

15. Koechlin L., Rrahmani B., Gahl B., Berdajs D., Eckstein F., Reuthebuch O. Microplegia versus cardioplexol in coronary artery bypass surgery with minimal extracorporeal circulation: comparison of two cardioplegia concepts. Thorac Cardiovasc Surg. 2020; 68 (3): 223–31. DOI: https://doi.org/10.1055/s-0039-1687843  

16. Zeriouh M., Heider A., Rahmanian P., Choi Y., Sabashnikov A., Scherner M., et al. Six-years survival and predictors of mortality after CABG using cold vs. warm blood cardioplegia in elective and emergent settings. J Cardiothorac Surg. 2015; 10: 180. DOI: https://doi.org/10.1186/s13019-015-0384-9  

17. Kuhn E., Liakopoulos O., Slottosch Y., Deppe A., Choi Y.-H., Madershahian N., et al. Buckberg versus calafiore cardioplegia in patients with acute coronary syndromes. Thorac Cardio-vasc Surg. 2018; 66 (6): 457–63. DOI: https://doi.org/10.1055/s-0037-1612604    

18. Bazylev V.V., Evdokimov M.E., Pantyuhina M. A. Variant of blood, warm, low-volume, single-dose cardioplegia for adult myocardial revascularization. Clinical and Experimental Surgery. Petrovsky Journal. 2021; 9 (2): 68–75. DOI: https://doi.org/10.33029/2308-1198-2021-9-2-68-75  (in Russian)

19. Caputo М., Santo К., Angelini G., et al. Warm-blood cardioplegia with low or high magnesium for coronary bypass surgery: a randomised controlled trial. Eur J Cardiothorac Surg. 2011; 40: 722–9. DOI: https://doi.org/10.1016/j.ejcts.2010.09.049  

20. Caputo M., Bryan A., Calafiore A., Suleiman M., Angelini G. Intermittent antegrade hyperkalaemic warm blood cardioplegia supplemented with magnesium prevents myocardial substrate derangement in patients undergoing coronary artery bypass surgery. Eur J Cardiothorac Surg. 1998; 14 (6): 596–601. DOI: https://doi.org/10.1016/s1010-7940(98)00247-4  

21. Dobson G., Jones M. Adenosine and lidocaine: a new concept in non-depolarizing surgical myocardial arrest, protection, and preservation. J Thorac Cardiovasc Surg. 2004; 127: 794–805. DOI: https://doi.org/10.1016/S0022-5223(03)01192-9  

22. Corvera J., Kin H., Dobson G., Karendi F., Halkos M., Katzmark S., et al. Polarized arrest with warm or cold adenosine-lidocaine blood cardioplegia is equivalent to hypothermic potassium blood cardioplegia. J Thorac Cardiovasc Surg. 2005; 129: 599–606.

23. Canyon S., Dobson G. Protection against ventricular arrhythmias and cardiac death using adenosine and lidocaine during regional ischemia in the in vivo rat. Am J Physiol. 2004; 287: 86–95. DOI: https://doi.org/10.1152/ajpheart.00273.2004   

24. Guru V., Omura J., Alghamdi A., Weisel R., Fremes S. Is blood superior to crystalloid cardioplegia? A meta-analysis of randomized clinical trials. Circulation 2006; 114 (1): I331–8. DOI: https://doi.org/10.1161/CIRCULATIONAHA.105.001644  

25. Fan Y., Zhang A., Xiao Y., Weng Y., Hetzer R. Warm versus cold cardioplegia for heart surgery: a meta-analysis. Eur J Cardiothorac Surg. 2020; 37 (4): 912–9. DOI: https://doi.org/10.1016/j.ejcts.2009.09.030  

26. Domanski M., Mahaffey K., Hasselblad V., Brener S., Smith P., Hillis G. Association of myocardial enzyme elevation and survival following coronary artery bypass graft surgery. JAMA. 2011; 305: 585–91. DOI: https://doi.org/10.1001/jama.2011.99  

27. Brat R., Tosovsky J., Januska J. Myocardial function in early hours after coronary artery bypass grafting in patients with left ventricular dysfunction: comparison of blood and crystalloid cardioplegia. J Cardiovasc Surg. 2004; 45 (3): 265–9.

28. De Jonge M., Van Boxtel A., Mokhles M, Bramer S. Intermittent warm blood versus cold crystalloid cardioplegia for myocardial protection: a propensity score-matched analysis of 12-year single-center experience. Perfusion. 2015; 30: 243–9. DOI: https://doi.org/10.1177/0267659114540023   

All articles in our journal are distributed under the Creative Commons Attribution 4.0 International License (CC BY 4.0 license)

CHIEF EDITOR
CHIEF EDITOR
Sergey L. Dzemeshkevich
MD, Professor (Moscow, Russia)

Journals of «GEOTAR-Media»