Myocardial protection and cardioplegia

Meet the patient

A 68-year-old with severe three-vessel disease and moderate aortic regurgitation is on bypass for a CABG plus AVR. The cross-clamp goes on, the surgeon asks for antegrade root cardioplegia, and the heart keeps fibrillating — because the regurgitant valve is letting the solution flood the left ventricle instead of perfusing the coronaries. The protection plan was never going to work through that root — taught AR failure mode of root delivery.^[6]

The two questions that define myocardial protection are ones examiner opens with: how does cardioplegia stop the heart? (hyperkalaemic diastolic arrest — taught mechanism) and how do you know if it failed? (low output and new regional wall-motion abnormality at clamp release). Hold those two and every route, solution and redose rule slots into place.^[4]

References8ShowHide

1. [1]Mazer CD, Whitlock RP, Fergusson DA, et al. Restrictive or Liberal Red-Cell Transfusion for Cardiac Surgery N Engl J Med, 2017.PMID 29130845
2. [2]Hahn RT, Abraham T, Adams MS, et al. Guidelines for performing a comprehensive transesophageal echocardiographic examination: recommendations from the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists J Am Soc Echocardiogr, 2013.PMID 23998692
3. [3]Levy JH, et al. What's fishy about protamine? Clinical use, adverse reactions, and potential alternatives J Thromb Haemost, 2023.PMID 37062523
4. [4]An KR, Rahman IA, Tam DY, et al. A Systematic Review and Meta-Analysis of del Nido Versus Conventional Cardioplegia in Adult Cardiac Surgery. Innovations (Phila), 2019.PMID 31347414
5. [5]Albadrani M Histidine-tryptophan-ketoglutarate solution versus multidose cardioplegia for myocardial protection in cardiac surgeries: a systematic review and meta-analysis. J Cardiothorac Surg, 2022.PMID 35642063
6. [6]Derryberry S, Tribble C In Through the Out Door: Tips and Tricks for Giving Retrograde Cardioplegia. Heart Surg Forum, 2018.PMID 30084786
7. [7]James TM, Nores M, Rousou JA, et al. Warm Blood Cardioplegia for Myocardial Protection: Concepts and Controversies. Tex Heart Inst J, 2020.PMID 32603472
8. [8]Shore-Lesserson L, Baker RA, Ferraris V, et al. STS/SCA/AmSECT Clinical Practice Guidelines: Anticoagulation during Cardiopulmonary Bypass. J Extra Corpor Technol, 2018.PMID 29559750