Myocardial Protection during Cardiac Surgery: Warm Blood versus Crystalloid Cardioplegia

Helene De Bruyn, France Gelders, Tine Gregoir, Valerie Waelbers, Pascal Starinieri, Jean-Louis Pauwels, Jeroen Lehaen, Boris Robic, Alaaddin Yilmaz, Urbain Mees, Marc Hendrikx

Department of Cardiothoracic Surgery, Jessa Hospital, Hasselt, Belgium.
Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium.

DOI: 10.4236/wjcd.2014.49053                

Abstract

Purpose: Prevention of myocardial injury is essential during cardiac surgery. Both crystalloid and blood cardioplegia are popular methods for myocardial protection. Most experimental studies have been in favor of blood cardioplegia. The objective of this study is to determine whether the use of warm blood cardioplegia (BCP) is superior to crystalloid cardioplegia (CCP) by means of myocardial injury markers and clinical outcome parameters. Materials and Methods: In a consecutive series of 293 patients, the first 150 received crystalloid cardioplegia, whereas the next 143 patients received blood cardioplegia. Postoperative myocardial injury was assessed by CTnI and CK-MB. Perioperative morbidity and mortality and clinical outcome parameters (need for inotropic support, ICU and hospital stay) were recorded. An unpaired student t-test was performed to analyse continuous postoperative variables relating to myocardial damage. The presence of possible confounders influencing the CTnI or CK-MB concentrations was tested using a student t-test for continuous variables, for categorical variables ANOVA was used. A final longitudinal model was created for CTnI and CK-MB. CTnI was analyzed by a mixed model with random intercept and slope. For all tests performed, statistical significance was 5%. Results: Both groups were well matched with respect to preoperative variables. No significant difference could be found in maximum postoperative levels of CTnI (8.8 ± 18.4 μg/l in BCP vs 9.6 ± 16.5 μg/l in CCP, p = 0.6455) or CK-MB (19.2 ± 31.0 μg/l in BCP vs 26.4 ± 41.5 μg/l in CCP, p = 0.1209). Nor was there any significant difference in other postoperative variables. Testing treatment effect over time proved only significant influence of the surgical intervention type on CTnI levels in time (p < 0.001). Conclusion: This study could not show significantly higher myocardial injury in the group of patients receiving crystalloid cardioplegia versus warm blood cardioplegia. This suggests that warm blood cardioplegia does not confer superior myocardial protection. Surgical intervention type has an important effect on CTnI concentration in time, while the type of cardioplegia does not.

Keywords

Myocardium, Protection, Ischemia/Reperfusion, Myocardial Infarction, Cardiac Surgery

Conflicts of Interest

The authors declare no conflicts of interest.

References

[1]	Giordano, P., Scrascia, G., D’Agostino, D., Mastro, F., Rotunno, C., Conte, M., Rociola, R. and Paparella, D. (2013) Myocardial Damage Following Cardiac Surgery: Comparison between Single-Dose Celsior Cardioplegic Solution and Cold Blood Multi-Dose Cardioplegia. Perfusion, 28, 496-502. http://dx.doi.org/10.1177/0267659113486827
[2]	Ferreira, R., Fraga, C., Carrasquedo, F., Hourqueble, H., Grana, D. and Milei, J. (2003) Comparison between Warm Blood and Crystalloid Cardioplegia during Open Heart Surgery. International Journal of Cardiology, 90, 253-260. http://dx.doi.org/10.1016/S0167-5273(02)00559-4
[3]	Guru, V., Omura, J., Alghamdi, A.A., Weisel, R. and Fremes, S.E. (2006) Is Blood Superior to Crystalloid Cardioplegia? A Meta-Analysis of Randomized Clinical Trials. Circulation, 114, i330-i338.
[4]	Yamamoto, H., Magishi, K., Goh, K., Sasajima, T. and Yamamoto, F. (2009) Cardioprotective Effects of Normothermic Reperfusion with Oxygenated Potassium Cardioplegia: A Possible Mechanism. Interactive Cardiovascular and Thoracic Surgery, 9, 598-604. http://dx.doi.org/10.1510/icvts.2008.201277
[5]	Dar, M.I. (2005) Cold Crystalloid versus Warm Blood Cardioplegia for Coronary Artery Bypass Surgery. Annals of Thoracic and Cardiovascular Surgery, 11,382-385.
[6]	Sa, M.P., Rueda, F.G., Ferraz, P.E., Chalegre, S.T., Vasconcelos, F.P. and Lima, R.C. (2012) Is There Any Difference between Blood and Crystalloid Cardioplegia for Myocardial Protection during Cardiac Surgery? A Meta-Analysis of 5576 Patients from 36 Randomized Trials. Perfusion, 27, 535-546. http://dx.doi.org/10.1177/0267659112453754
[7]	Hendrikx, M., Jiang, H., Gutermann, H., Toelsie, J., Renard, D., Briers, A., Pauwels, J.L. and Mees, U. (1999) Release of Cardiac Troponin I in Antegrade Crystalloid versus Cold Blood Cardioplegia. Journal of Thoracic and Cardiovascular Surgery, 118, 451-459. http://dx.doi.org/10.1016/S0022-5223(99)70182-0
[8]	Calafiore, A.M., Teodori, G., Mezzetti, A., Bosco, G., Verna, A.M., Di Giammarco, G. and Lapenna, D. (1995) Intermittent Antegrade Warm Blood Cardioplegia. Annals of Thoracic Surgery, 59, 398-402. http://dx.doi.org/10.1016/0003-4975(94)00843-V
[9]	Zeng, J., He, W., Qu, Z., Tang, Y., Zhou, Q. and Zhang, B. (2014) Cold Blood versus Crystalloid Cardioplegia for Myocardial Protection in Adult Cardiac Surgery: A Meta-Analysis of Randomized Controlled Studies. Journal of Cardiothoracic and Vascular Anesthesia, 28, 674-681. http://dx.doi.org/10.1053/j.jvca.2013.06.005
[10]	Jacquet, L.M., Noirhomme, Ph., Van Dyck, M.J., El Khoury, G.A., Matta, A.J., Goenen, M.J. and Dion, R.A. (1999) Randomized Trial of Intermittent Antegrade Warm Blood versus Cold Crystalloid Cardioplegia. Annals of Thoracic Surgery, 67, 471-477. http://dx.doi.org/10.1016/S0003-4975(98)01198-9
[11]	Braathen, B. and Tonnessen, T. (2010) Cold Blood Cardioplegia Reduces the Increase in Cardiac Enzyme Levels Compared with Cold Crystalloid Cardioplegia in Patients Undergoing Aortic Valve Replacement for Isolated Aortic Stenosis. Journal of Thoracic and Cardiovascular Surgery, 139, 874-880. http://dx.doi.org/10.1016/j.jtcvs.2009.05.036
[12]	Karthik, S., Grayson, A.D., Oo, A.Y. and Fabri, B.M. (2004) A Survey of Current Myocardial Protection Practices during Coronary Artery Bypass Grafting. Annals of the Royal College of Surgeons of England, 86, 413-415. http://dx.doi.org/10.1308/147870804669