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CARDIOPLEGIA TYPES AND METHODS OF ADMINISTRATION

AUGUST 2017 FATHEENA
ABDULREHMAN MOHAMMED

CARDIOPLEGIA TYPES AND METHODS OF ADMINISTRATION

August 2017 FATHEENA
ABDULREHMAN MOHAMMED

CARDIOPLEGIA TYPES AND METHOD OF ADMINISTRATION

Submitted to:

MANlPAL UNIVERSITY

A Project submitted in partial fulfillment for the award of

BACHELOR OF SCIENCE IN PERFUSION TECHNOLOGY

Degree to

MANIPAL UNIVERSITY

AUGUST 2017

By

Ms. FATHEENA ABDULREHMAN MOHAMMED

JUNE 2017

Roll number - 141177001

SCHOOL OF ALLIED HEALTH SCIENCES,
MANIPAL UNIVERSITY, MANIPAL

CERTIFICATE

This is to certify that this project “CARDIOPLEGIA METHODS AND TYPES
OF ADMINISTARTION” is a bonafide work done by Ms. FATHEENA AB, Roll
number-141177001 in the Department of perfusion technology, School of Allied
Health Sciences, Manipal.

DEAN

DR. B. RAJASHEKHAR
School of Allied Health Sciences
Manipal University
Manipal- 576104

SIGNATURE: DATE:

JUNE 2017
SCHOOL OF ALLIED HEALTH SCIENCES,
MANIPAL UNIVERSITY, MANIPAL

CERTIFICATE

This is to certify that this project “CARDIOPLEGIA TYPES AND METHOD
OF ADMINISTRATION” is a bonafide work done by Ms. FATHEENA
ABDULREHMAN MOHAMMED, Roll number-141177024 under our
supervision and guidance. We are satisfied with the work presented by the
candidate towards the partial fulfillment of Bachelor of Science in Perfusion
Technology.

HEAD OF THE DEPARTMENT INCHARGE

Dr. S. GANESH KAMATH Mr. B. SHIVASHANKAR PAI

Manipal University KMC.Professor and Head Assistant Professor and Co-ordinator Department of Cardiovascular Department of Perfusion Technology and Thoracic Surgery SOAHS. Manipal Manipal SIGNATURE: SIGNATURE: DATE: DATE: DECLARATION I hereby declare that this project titled “CARDIOPLEGIA METHODS AND TYPES OF ADMINISTATION” has been carried out by me and this work has not been submitted earlier to any other University for the award of degree or diploma Manipal FATHEENA June 2017 .

A Project submitted in partial fulfillment for the award of BACHELOR OF SCIENCE IN PERFUSION TECHNOLOGY Degree to MANIPAL UNIVERSITY August 2017 By Ms. FATHEENA ABDULREHMAN MOHAMMED EXTERNAL EXAMINER INTERNAL EXAMINER SIGNATURE: SIGNATURE: NAME: NAME: .

DESIGNATION: DESIGNATION: DATE: DATE CONTENTS • INTRODUCTION • HISTORY • PHYSIOLOGY OF CARDIOPLEGIA • CARDIOPLEGIA TECHNIQUES • CARDIOPLEGIA CANNULAS • TYPES OF SOLUTION • CARDIOPLEGIA IN PEDIATRICS • CONCLUSION .

ACCRONYMS  AI.Antegrade Injection  RI.hyroxymethyl aminomethane  HTK -Histidine-tryptophan-ketoglutarate .Retrograde Injection  DI – Direct Injection  IM – Internal Mammary Artery  AMI.Acute Myocardial Infraction  CABG –Coronary artery bypass grafting  CPK – Creatinine phosphokinase  THAM – Tris.

. The main goals of hypothermic cardioplegia are: • Immediate and sustained electromechanical quiescence • Rapid and sustained homogenous myocardial cooling • Maintenance of therapeutic additives in effective concentrations • Periodic washout of metabolic inhibitors The most common procedure for accomplishing asystole is infusing cold cardioplegic solution into the coronary circulation. This process protects the myocardium. Most commonly. however. or heart paralysis. this means arresting or stopping the heart so that surgical procedures can be done in a still and bloodless field. the word cardioplegia refers to the solution used to bring about asystole of the heart. Technically. or heart muscle. from damage during the period of ischemia. and plegia "paralysis". INTRODUCTION The word cardioplegia combines the Greek cardio meaning the "heart".

. Among myocardial protection modalities used during cardiac surgeries. few therapeutic interventions have shown to be clinically effective. Subsequently. During this period of heart isolation. arrhythmias. Since then. takes over the functions of gas exchange by the lung and blood circulation by the heart. As the cardioplegia solution distributes to the entire myocardium. The importance of limiting ischemia-reperfusion injuries has been discussed for more than three decades. The goal is to attenuate the magnitude of ischemia-reperfusion-induced injuries and their noxious early and late consequences. ventricular dysfunction. drugs and anesthetic techniques improving tolerance to ischemia and contributing to protect myocardial function are becoming increasing important for the clinical practice and may influence better postoperative outcomes. the heart is not receiving any blood flow.To achieve this. a large number of experimental studies have investigated ischemic mechanisms and myocardial protection modalities. cardiogenic shock and increased perioperative mortality. However. . Cardioplegia lowers the metabolic rate of the heart muscle. thus no oxygen for metabolism. the patient is first placed on cardiopulmonary bypass. in 1971. Maroko et al. This device. otherwise known as the heart-lung machine. such as acute myocardial infarction (AMI). but rather they could be changed by therapeutic manipulations during ischemia. the ECG will change and eventually asystole will ensue. the heart is isolated from the rest of the blood circulation by means of an occlusive cross- clamp placed on the ascending aorta proximal to the innominate artery. Myocardial protection during cardiac surgery is defined as the set of strategies aiming at decreasing myocardial oxygen consumption adapting it to the momentary tissue supply and/or at making cardiac cells more resistant to ischemic episodes. have proposed that the extension and severity of tissue injury alter coronary occlusion were not determined at ischemia onset. thereby preventing cell death during the ischemic period of time.

and better hemodynamic management .Ischemia reperfusion injuries are can be broadly grouped into two distinct categories .The objective of this review was to address injury mechanisms and myocardial protection modalities with special emphasis to anesthetic techniques able to promote heart protection. The term myocardial protection encompasses more than just cardioplegia and can be said to include things such as the perioperative management of patients with medical treatment (such as beta–blockers.either in hypokinetic or dyskinetic segments of the ventricle. Mechanism of myocardial protection with cardioplegia  Mechanical arrest (potassium induced ) will reduce oxygen consumption . and the results in electrocardiographic changes . Myocardial protection does not exist in isolation.most obviously demonstrated by the recent expansion of off-pump techniques for coronary artery bypass grafting (CABG ). better anesthetic agents .Reversible injury is manifested by a transient depression in cardiac performance . release of myocardial specific enzymes such as creatinine phosphokinase (CPK) or troponin into the circulation and lasting abnormalities of ventricular function .) or support devices (such as intra- aortic balloon pumps).and to get a sick patient through a major operation . Additionally the development and evolution of myocardial protection have not been linear .reversible and irreversible .The pathophysiology and underlying molecular biology of myocardial injury are complex . Irreversible cardiac injury involves apoptosis or myocardial necrosis. Techniques that have been used to offset myocardial protection have effects on the other organ systems and vice versa.and in regard to cardiac surgery this is manifested as ischemia – reperfusion injury .myocardial edema and resolves without long term squeal. etc. non-cardiac organ protection for the patient must be considered as well. This very term myocardial protection implies the potential for myocardial injury of some type .All of these treatment contribute to making cardiac surgery safer .

 Hypothermia will reduce consumption  Aerobic metabolism can be maintained with oxygenated cardioplegia  Given just prior to the removal of the aortic cross clamp  “Hot shot” is delivered retrograde at 150-200ml/min at a temperature of 32- 37degreeC  Total dose of 30 ml/kg is ideally delivered over a 2-4 minute. the year that John Gibbon first successfully closed an atrial septal defect in Philadelphia using cardiopulmonary bypass. The ensuing flurry. Surgeons soon learned that opening a chamber in a beating heart rapidly led to lethal air embolism. Discoveries are frequently made in response to a need. Another problem for the surgeon was poor visibility in a blood-filled operative field. Frequently a new development or contribution opens new vistas for further study and uncovers hitherto unrealized problems that had not existed previously. of activity worldwide led to the rather rapid use of a variety of pumps and oxygenators as the era of open heart surgery began. which could be prevented successfully only by stopping the heart. Both of these problems stimulated efforts to provide a quiet and dry field. For example. HISTORY When developments in a scientific field are studied historically. which could best be achieved by arresting the heart and temporarily stopping . there was no need to concentrate on preserving myocardium prior to 1953. making this tedious operation even more difficult. it becomes apparent that discoveries generally follow each other sequentially and for good reason. and the historic development of techniques in myocardial preservation is no exception.

Interestingly. most surgeons lost sight of the cause of significant perioperative mortality and were generally unaware that inadequate intraoperative protection of the myocardium during the procedure was a significant factor in a patient's demise. using total body hypothermia with transient circulatory. they were the first to use the term "cardioplegia" in the course of these studies. Such heat exchangers allowed rapid cooling and rewarming. Their legendary animal experiments led them to standardize potassium citrate as a method to achieve cardiac arrest. to develop a practical heat exchanger with help from the Harrison Radiator Division of the General Motors Corporation. Shumway's . Bigelow and associates in Canada. magnesium. The profound hypothermic techniques of Drew and Anderson in the United Kingdom also emphasized the importance of cold in protecting the heart as well as the body as a whole. Being skeptical of potassium-containing solutions because of increasing reports that they caused myocardial damage. The concept of perfusion hypothermia stimulated Brown and colleagues in Durham. and neostigmine. Unfortunately the high concentration of potassium produced focal areas of necrosis in the myocardium. In the course of these studies.circulation to the myocardium. Before the advent of pump oxygenators. Lewis and colleagues in Chicago. Swan and co-workers in Denver. Lam's group in Detroit used acetylcholine for short-lived elective cardiac arrest. and colleagues in Durham were working with various drugs to prevent ventricular fibrillation. interruption to perform cardiac operations. that value being both the prevention of air embolism and the production of a quiet operative field. Sealy . Melrose and colleagues in England were among the first to realize the potential value of arresting the heart and restarting it at will. Doctor Sealy (personal communication) recounts that they used this solution routinely until cardioplegia went out of fashion in the 1960s. Young. and this finding served to slow progress in the use of cardiac arrest infusions for 10 years. they developed a solution containing potassium. however. some thoughtful investigators had begun to work with various means of inducing hypothermia to protect the myocardium. but its effect proved to be too short to make it practical for regular use. and used the solution for elective cardiac arrest along with hypothermia. NC. In the mid-1950s. In their zeal to master perfusion techniques and operative procedures. and heat exchangers remain in use to this day. and Brock and Ross in London had already gained significant clinical experience from 1950 to 1956. The obvious way to achieve that objective was to cross-clamp the aorta during the time required for the intracardiac repair.

However. particularly at a time when continuous coronary perfusion and the use of ventricular fibrillation were popular. Ebert has recalled their early experimental problems in dogs after 60 minutes of normothermic cardioplegia . metabolic. the effectiveness and safety of cold potassium cardioplegia were realized. In most of these cases of myocardial contracture. and the term "stone heart" was coined. and Dr Roe recounts that. credit for a "second look" at potassium-induced cardioplegia in the United States should go to Gay and Ebert . it was becoming universally accepted (personal communication). To their dismay. particularly in Europe. From 1966 to 1972. at that time. This lavage technique proved to be so successful that they have used it ever since. intensive studies were being carried out in German cardiac centers by Holscher and associates Bretschneider and Kirsch and colleagues who worked with various chemical additives to cardioplegic solutions to provide safer cardiac arrest. and morphologic effects of potassium-induced cardioplegia. termed Bretschneider's solution. 6 months later. However. this caused ischemic contractures. however. This experiment resulted in a publication outlining functional. in conjunction with hypothermia. The resulting multicomponent cardioplegic solution. Benson Roe and associates in San Francisco were infusing cold Ringer's solution containing 20 mEq of potassium to cool the myocardium to 15°C. physiologically. Although there were some centers in which chemical cardioplegia was actively used. and its use continues today. Denton Cooley and associates in Houston experimented with simply cross-clamping the aorta at normothermic temperatures to produce arrest. the surviving animals were completely normal functionally. From 1961 until 1972. when the mortality rate was 40%. and pathologically. Gradually. the patients had severe left ventricular hypertrophy in the presence of far advanced aortic valve disease with congestive failure. It is interesting that in 1970. In 1973. there was little favorable use of this cardioprotective approach in the United States. They thought that this was a completely safe cardioplegic mixture. It was a slow process to attract surgeons back to potassium as a vehicle for achieving cardiac arrest. findings that made him quite skeptical of interpreting .group in California began using topical hypothermia with simultaneous aortic cross clamping by circulating cold saline solution through the pericardial sac . would allow rapid and safe elective arrest. became the standard in many centers. they undertook a series of experiments performed in New York with the initial idea that some type of chemical arresting agent. while chemical cardioplegia and noncardioplegic techniques were being tried.

( personal communication). and control of the composition of blood cardioplegia with various additives to protect the myocardium during long periods of arrest. calcium. and subsequent reperfusion . aspartate. remarking that although it might be of some help to the coronary. glucose. it certainly was of immense help to his own arteries! Hearse's continued productivity at the Rayne Institute of St. In contrast to the aforementioned investigations. these findings have been applied to resuscitation of cardiogenic shock after acute myocardial infarction. including the effects of and optimal levels of hypothermia. and their attempts to prevent and treat reperfusion injury based on the pathophysiologic mechanisms. and osmolality. different administration techniques.Indeed. It is interesting that David Hearse had been introduced to Mark Braimbridge. It was Hearse's distress at the "medieval" way in which the myocardium had been protected that set him to evaluating possible worthwhile cardioplegic formulations with the aforementioned isolated rat heart preparation. Gerald Buckberg and his group in Los Angeles reported reduced post ischemic myocardial damage after modification of calcium. Their studies using this preparation. by Sir Ernst Chain. Thomas Hospital is an excellent example of the scientific achievement that can result from close cooperation between physiologists and surgeons. and other additives for enrichment to energy-depleted myocardium represent major milestones in myocardial preservation. potassium . More recently.physiologic and histologic studies acutely after cardioplegia. but what is more important. Along with Dr Vinten-Johansen. a cardiac surgeon at St. and osmolality in a blood cardioplegic mixture. In 1978. Mr Braimbridge had been using cold coronary perfusion with intermittent aortic clamping and was overjoyed with Hearse's cardioplegic solution. arteries of his patients. Their monumental studies emphasizing the importance of blood as a cardioplegic vehicle along with the addition of glutamate. Hearse and colleagues described their development of an isolated rat heart perfusion preparation that allowed them to evaluate a multitude of cardioplegic formulations. Their achievements in identifying surgical ischemic-reperfusion injury. the basic tenets of surgical myocardial protection had been established by this group. cardioplegic arrest. pH. they contributed immensely to our knowledge of physiology and chemistry of myocardial cells subjected to ischemia. it is of interest that Dr . potassium. Thomas Hospital. these investigators have evaluated different modifications of blood cardioplegia. Thomas solution . and was invited to view their open heart operations at St. In 1976. are truly noteworthy. Thomas (Hearse resulted in the development of the St.

in Boston in 1984. Menasch6 and colleagues in Paris also reported a large experience using retrograde coronary sinus perfusion and emphasized its particular value in aortic valve operations. Using this retrograde technique. Even though Gott and associates had described this technique in 1957. For such we should be most grateful! . Nevertheless. vehicles. Panos and colleagues in Toronto began experimenting with warm continuous cardioplegia in 1989. and this approach may well emerge as a preferred one in certain clinical situations. His statistics are impressive and exemplify an alternative method of myocardial protection. Advantages of the retrograde route in facilitating the operative procedure as well as in protecting the myocardium have attracted many cardiac surgeons. it is hoped. a flurry of research activity continues. it had largely been unused until this group reported their experience. and. Application of such findings should allow safer operations and a higher recovery rate for patients around the world. have slowed its adoption in many centers. when they induced the concept of retrograde coronary sinus perfusion as an adjunct to myocardial protection. had accumulated significant patient data using his technique of hypothermic fibrillatory arrest without cardioplegia. Potential technical problems with the technique. delivery modalities. should spawn future generations of clinical as well as basic science investigators as we continue to study and learn. along with a lack of safe metabolic monitoring for the myocardium. The controversies thus generated by different cardioplegic solutions. Solorzano and colleagues in Toronto gained the attention of cardiac surgeons in 1978. and reported their results in 1990. and the method has been in widespread use for the past 10 years. Their monumental contributions over the past 40 years have also demonstrated that numerous methods of myocardial protection can be used successfully in given situations. and additives continued to stimulate further investigation and clinical trials.Akins. with very low mortality. It is apparent from this historical review that we owe a great debt of gratitude to the aforementioned investigators and clinicians worldwide.

alters the Na + /Ca 2+ exchange mechanisms in such a way as to promote intracellular Ca 2+ accumulation causing damage to sarcolemma membranes. The composition of cardioplegic solutions has been described as being similar to either the ionic composition of extracellular or of intracellular fluid depending on the content of sodium. which causes membrane depolarization. THAM). for example one of the most established blood cardioplegia preparations contains citrate phosphate dextrose CPD). Cardioplegia solutions can be further categorized according to whether they are crystalloid or blood based. an essential ingredient of all cardioplegia solutions. Other components common to cardioplegia solutions include sodium (100–200 mEq/l) and chloride ions. however. together with excessive potassium-induced membrane depolarisation. Sodium minimizes the transcellular sodium gradient and so reduces intracellular edema. Modification of cardioplegia to produce a solution that provides optimal preservation of myocardial function has led to a variety of additions to the “basic” ingredients. calcium and magnesium of a given type of cardioplegia. The essential requirement for attainment of rapid diastolic cardiac arrest. potassium. marked extracellular hyponatremia (<50 mEql). Chloride ions maintain the electroneutrality of the solution. to limit calcium infl ux during ischemia. renders potassium (20–40 mEq/l). a . COMPONENTS OF CARDIOPLEGIA The constitution of cardioplegia solutions varies according to individual surgeons and institutional preferences. and tromethamine (tris-hydroxymethyl aminomethane.

has advantageous rheological properties and is a free radical scavenger. The Kreb’s cycle amino acids glutamate and aspartate are depleted during episodes of intermittent blood cardioplegia administration. to counteract the vasoconstrictive effects of particulate contaminants in the infusion and so promote even distribution. Magnesium may help stabilize the myocardial membrane by inhibiting a myosin phosphorylase. which is intrinsic to the function of transmembrane ion pumps. does not totally avoid injury. Procaine. St. is a natural buffering agent. which protects ATP reserves for post ischemic activity. but differ slightly from the original St Thomas’ preparation. The original cardioplegic solutions used for many years consisted of crystalloid solutions with various additives. is included in low concentration. Cold blood cardioplegia alone. “captures” the CO2 produced by metabolic acidosis and improves myocardial performance. including the fact that it inhibits the enzyme Na + /K + adenosine triphosphatase. Calcium. The most widely used is the St.buff er that prevents acidosis. THAM diff uses into the intravascular space. It also limits reperfusion injury in the acutely ischemic myocardium. however. The protective effects of magnesium and potassium have been shown to be additive. leukocytes and complement. Blood cardioplegia maintains oncotic pressure. Thomas’ solution is usually buffered by the addition of sodium bicarbonate just prior to use. Hypothermic crystalloid cardioplegia has certain disadvantages. Commercially prepared bags of ready diluted St. Experimental studies have shown that normal hearts subjected to up to 4 hours of ischemia have complete recovery of function when intermittent cold blood cardioplegia is infused. It consists of four parts of blood to one-part crystalloid cardioplegia solution. The is limits the systemic hemodilution seen with crystalloid cardioplegia during repeated infusions. in low concentration. Thomas cardioplegia are available as an alternative to diluting the concentrate with Ringer’s. thereby producing myocardial edema and consequent activation of platelets. a local anesthetic. this renders the solution slightly alkaline and helps compensate for the metabolic acidosis that accompanies ischemia. Thomas’ Hospital solution. Th ey are especially depleted in chronically ischemic hearts and may be replenished by . Blood cardioplegia largely replaced crystalloid cardioplegia in most centers several years ago. is included in the solution to ensure that there is no likelihood of calcium paradox during reperfusion and to maintain integrity of cell membranes.

. provides a more physiological delivery of oxygen and substrates for the period of ischemia . at the end of the intended ischemic period. augmenting the rate of recovery of myocardial contractility.” Blood cardioplegia. on the basis that this “feeds” the heart. Some surgeons also infuse a small volume of warm blood cardioplegia followed by cold cardioplegia to induce cardiac arrest at the commencement of the ischemic period. oft en referred to as “substrate-enhanced cardioplegia. It enhances cellular assimilation of the substrates. just prior to removal of the aortic cross-clamp. The warm phase has been referred to as the “hot shot” of cardioplegia .using blood cardioplegia with added glutamate and aspartate.e. i. may be infused as a warm solution to optimize the metabolic rate of repair. with or without substrate enhancement.

a cannula for antegrade cardioplegia is placed high and slightly to the right side of the ascending aorta. which prevent uniform delivery of cardioplegia. which is tied at the end of the operation. The cannula may include a pressure line and a vent port to suction air and blood between infusions.and also causes loss of cardioplegia into the left ventricle . Accurate infusion pressure . even when mild. secured with a purse–suture. However. lowers aortic root pressure . Monitoring pressure in the cardioplegia delivery system allows detection of inadvertent line occlusion by clamping or kinking. using the delivery system line pressure alone to estimate aortic or coronary sinus pressure is inaccurate. High pressures (>80mmHg) may cause endothelial damage and myocardial edema. Antegrade infusion pressure during delivery of cardioplegia must be monitored. and aortic regurgitation. Aortic regurgitation. CARDIOPLEGIA TECHNIQUES To be effective the desire volume of cardioplegic solutions must be evenly distributed throughout the myocardium. so reducing the perfusion pressure of cardioplegia infused into the aortic root . often to the most vulnerable regions of the myocardium.Hence . Obstacles to this goal include coronary stenosis. ANTIGRADE DELIVERY Typically.the time honored method of antegrade aortic root infusion of cardioplegia alone can be combined with “retrograde cardioplegia” infusion into the coronary sinus to overcome the potential for inadequate myocardial preservation.

Antigrade infusion pressure should be kept between 60 and 80 mmHg. performing proximal grafting before aortic clamping and administering cardioplegic infusions via the aorta after each distal graft. Each aforementioned technique protects jeopardized myocardium when vein grafts are employed. .the aortic root can be partially opened and cardioplegia directly infused into the coronary ostia using handheld or self-inflating balloon catheters. These strategies do not. High pressure during is most likely to be due to extensive coronary stenotic lesions . The perfusionist can confirm that cardioplegia is flowing through myocardium by checking aortic pressure and observing myocardial temperature change.antegrade cardioplegia will be infused partially into the left ventricle and will not distributed into the myocardium effectively .the rate of infusion should be slowed to permit infusion of the required volume (usually 300 ml/minute for 2 minutes ).These limitations can be overcome by delivering cardioplegia by direct graft perfusion (as described by the authors). and our cardiologic colleagues desire their routine use.If there is mild aortic insufficiency . even during the increasing number of emergency coronary operations performed currently in critically ill patients. Alternatively .is obtained through a line directly attached to the infusion port. or performing sequential distal and proximal anastomoses during aortic clamping and giving cardioplegia via the aorta after each proximal and distal connection is complete. ensure adequate distribution of antegrade cardioplegia if there is diffuse coronary disease and all areas of contracting myocardium cannot be revascularized. or if the internal mammary artery graft is the desired conduit without risking damage to jeopardized muscle. Further antegrade infusions of cardioplegia may be administered during CABG via the proximal ends of vein grafts on completion of each distal anastomosis The limitations of antegrade cardioplegia without provision for its distribution beyond coronary stenosis are well recognized . however. Light manual pressure applied to the right ventricle will often help close the left ventricular outflow tract. Long-term studies document the superior patency of internal mammary artery (IMA) grafts. Such systems are widely available commercially.

adhesions can be dissected away from the heart and the cannula positioned more readily .it should be withdrawn slightly and reinserted .if the posterior ventricular wall is adherent to the pericardium . When this occurs .Alternatively .The cannula tip is palpated as it passes by the junction of the inferior vena cava and right atrium into the coronary sinus .If the cannula is directed into the posterior descending vein .but prove difficult .The surgeon can then directly view and palpate the tip of the cannula making it easier to insert .it is helpful to commence CPB and lift the apex of the heart .after CPB is instituted .If difficulty is encountered during placement .or manually inflated . bicaval cannulation may be used .with a malleable stylet and a self inflating .placement of the retrograde cannula may be attempted prior to the CPB .A cannula . Failure to intubate the coronary sinus is rare (under 2%of cases) and indicates a fenestrated thebesian valve or a flap over the coronary sinus ostium.In re – operations . RETROGRADE DELIVERY A cannula for retrograde administration of cardioplegia is inserted through the lower part of the right atrium into the coronary sinus .permitting opening of the right atrium and direct insertion of the retrograde cannula into ostium of the coronary sinus .balloon is commonly used .usually before cardiopulmonary bypass is started .The retrograde cannula is is directed at a 45 –degree angle towards the left shoulder in the path of the coronary sinus and positioned distally beneath the left atrial appendage .designed for the placement in the coronary sinus .

cardioplegia is delivered to an area presumably underserved by antegrade coronary flow .the Perfusionist should monitor the infusion pressure and reduce flow .The cannula tip and balloon should then be palpated and repositioned .Perforation can be directly repaired with a 5-0 suture or with pericardial pledgets if the tear site is not distinct .If a hematoma is noted .thus fixing it in place and preventing regurgitation of cardioplegia into the atrium ..through bypass conduit is relatively nonobtrusive and can therefore be delivered either intermediately or continuously without disruption of the surgery .only antegrade cardioplegia is used .Finally . DELIVERY THROUGH BYPASS GRAFT Antegrade cardioplegia can be delivered through previously placed bypass grafts and then utilized as an adjunct to both root delivered antegrade and retrograde cardioplegia doses.During infusion of retrograde cardioplegia .retrograde infusions should be discontinued .Added maneuvers to improve retrograde infusion include finger compression of the junction of the coronary sinus and the right atrium or placement of a snared suture around the coronary sinus .if pressure and flow monitoring are .This is usually determined before cardiopulmonary bypass and the vessel occluded with a tourniquet only if an intact innominate vein is present .If the innominate vein is absent . Delivery of cardioplegia through bypass conduits offers several advantages .Secondly .A rare cause of low retrograde infusion pressure is the presence of the left superior vena cava .perforation of the sinus is manifest noting blood within pericardial well during cardioplegia infusions .High pressure usually indicate that the catheter is advanced too far and should be withdrawn slightly The coronary sinus can be injured by forceful cannulation or continued infusion of cardioplegia with coronary sinus pressures exceeding 40mmHg .if needed . The catheter may have migrated out of the coronary sinus into the right atrium .so as not to exceed a pressure of about 40mmHg.No further action is needed because low venous pressure allows self –containment after heparin reversal .Firstly . Coronary sinus pressure <20mmHg infers that the balloon is not inflated or not occluding the coronary sinus.

.the delivery rate at a given flow can give an indication regarding the runoff and patency of the bypass graft.simultaneous delivery of both antegrade and retrograde cardioplegia appears to be safe .Initial concerns speculated that combined delivery of both antegrade and retrograde cardioplegia could result in high pressures within the cardiac vasculature and subsequent edema .available .The technique is designed to eliminate the potential for under-perfusion of the right ventricle and septum that exist when only retrograde cardioplegia is delivered .Infact .the simultaneous delivery of antegrade and retrograde cardioplegia provide more homogenous delivery of cardioplegia and superior myocardial protection compared with other techniques .and myocardial injury . COMBINED ANTEGRADE AND RETROGRADE CARDIOPLEGIA The use of combined retrograde and antegrade cardioplegia allows the surgeon to capitalize on the advantages of each method and eliminate many of the shortcomings present when only technique is used .antegrade and retrograde cardioplegia are delivered independently as the operative situation dictates.hemorrhage .Most frequently .One technique of simultaneous antegrade and retrograde delivery of retrograde cardioplegia involves the delivery of retrograde cardioplegia while antegrade cardioplegia is delivered through a completed bypass graft to the right side . However .

Simply repositioning the cannula in the field will correct this problem. e. . Adequacy of cardioplegia distribution can be confirmed by monitoring myocardial temperature . and then moved according to the surgeon’s preferences to other regions of the heart . cold blood solution at 10 -16°C and warm blood solutions at 37°C.Temperature is generally kept below 15°C .resulting in aortic regurgitation during cardioplegia infusion.Inadequate cooling is sometimes seen if the two staged venous cannula indirectly distorts the non-coronary cusp of the aortic valve . the most vulnerable area. in the face of severe left ventricular hypertrophy commonly seen in hypertensive patients or in the setting of severe aortic stenosis .The temperature probe can be placed in the septum first. CARDIOPLEGIA TEMPERATURE Crystalloid cardioplegia solutions are usually delivered at 4°C.g. Excessive blood accumulating in the heart during cardioplegic arrest leads to inadvertent myocardial re-warming and can be prevented by judicious use of vent suckers to drain the ventricles.Sometimes more cardioplegia needs to be infused to reach low temperatures .

Advantages  Normal Perfusion  Increased post-operative left ventricular function  Decreased inotropic requirement . Additionally. patients in the continuous cardioplegia group were found to require less inotropic support and had lower levels of lactate and hypoxanthine in coronary sinus effluent following aortic unclamping. Additionally.Continuous cardioplegia was found to be superior in terms of postoperative left ventricular stroke work index. increases in myocardial acidosis have been noted between cardioplegia doses . METHODS OF ADMINISTRATION A) CONTINOUS CARDIOPLEGIA The Heart is normally perfused in a continuous manner.

or blower devices can be applied in the vicinity of the opened vessel to improve visibility but despite this . admit to temporarily interrupting the infusion of warm blood for periods of up to 15 minutes. Yau and colleagues have also used warm blood cardioplegia in a multidose fashion. Disadvantages  Wet operative field  Complexity B) INTERMITTENT CARDIOPLEGIA Lichtenstein and co-workers. who originally described the technique.One solution is to use retrograde perfusion which increase visibility due to decreased coronary artery flow but the perfusion of the right ventricle will be suboptimal.conditions will not optimal . Continuous saline irrigations. suction. Advantages  Improved surgical procedure  Low cardioplegia volume Disadvantages  Increase interdose myocardial acidosis . A problem with continuous infusions of cardioplegia is that the operating field will be flooded with blood .

CARDIOPLEGIA CANNULA Retrograde Cardioplegia Cannula retrograde cardioplegia cannulae are intended to be connected to the cardioplegia line in order to infuse cardioplegic solution and blood into the patient's coronary sinus during open heart procedure. .

self-inflating .14Fr Features & Benefits .Specifications .length: 31cm .silicone balloon .balloon diameter: 18mm .malleable stylet ANTEGRADE CANNULA Antegrade cannulae are designed to deliver cardioplegia solution to the heart via the coronary ostia in the normal direction of blood flow (antegrade perfusion) .

Features Suture flange Luer locking needle CORONARY OSTIA CANNULA Cardioplegia Coronary Ostium Cannulae from Sorin is used for the direct cannulation of the coronary ostium to deliver cardioplegic solution. .

5 and 5.5. 4. 11. 3. 4. 12.0 mm)  Length: 26 cm AORTIC ROOT CANNULA .0. 14 and 15 French (3.Features:  Silicone ensures no sensitivity to cold and adaptation to anatomical conditions  Additional openings ensure homogeneous perfusion of the cardioplegia solution  Available with tip angle 90° or 135°  Available with malleable stainless steel tube or flexible plastic tube  Available with 1/4" connector or female luer lock connector  Available sizes: 9.0.

A needle secures a precise and quick insertion and a flange guarantees a predetermined insertion depth and a safe point to secure the cannula. The cannula may also be used to aspirate air from te aorta at the conclusion of the cardiac procedure.Antegrade delivery of cardioplegia solutions and venting of the heart Andocor aortic root cannulae are intended for use during cardiopulmonary bypass for antegrade delivery of cardioplegia solutions and venting of the heart. Different configurations . 7Fr.with or without vent line .6Fr. 9Fr .length 15cm or 28cm .1 or 2 clamps CARDIOPLEGIA ADAPTER .

1 female luer lock and color-coded clamps .Cardioplegia adapters connect to the aortic root cannula or vessel cannulae and are intended for the delivery of cardioplegia solution or venting the heart during cardiopulmonary bypass. A perfusion adapter with 2 male luer lock.Multiple perfusion adapter for aortic root and three vein grafts .

. MINIMIALLY INVASIVE CARDIAC SURGERY CANNULA  Provide optimal blood flow with the smallest possible size Facilitate femoral and direct cannulation of vessels.

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USP. It is required that 10 mL (840 mg) of 8. USP(10mEq each of sodium and bicarbonate) be added aseptically and thoroughly mixed with each 1000 mL of Cardioplegic solution to adjust pH. electrocardiographic abnormalities. Spontaneous recovery after Cardioplegic cardiac arrest may be delayed or absent when circulation is restored.4% Sodium Bicarbonate Injection. Defibrillation by electric shock may be required to restore norm TYPES OF SOLUTION . After this addition. it is suitable for cardiac instillation (usually with hypothermia) to induce arrest during open heart surgery. Available dosage form in the hospital: 20ML AMP Common side effect: Intraoperative and perioperative potential hazards of open heart surgery includes myocardial infarction. When smaller amounts are required. the unused portion should be discarded. buffers ischemic acidosis and protects energy sources for functional recovery after ischemia. formulation of electrolytes in Water for Injection. CARDIOPLEGIC SOLUTION Cardioplegic Solution is a sterile. or antimicrobial agent and is intended only for use (after adjusting pH with sodium bicarbonate) in a single operative procedure. After buffering with sodium bicarbonate. including ventricular fibrillation. combats ischemic ionic disturbances. essentially isotonic. Cardioplegic solution with added sodium bicarbonate used as a coronary artery infusate induces cardiac arrest. and arrhythmias. The solution contains no bacteriostat. It is a “core solution” intended for use only after addition of sodium bicarbonate to adjust pH prior to administration. the solution must be stored under refrigeration and be used within 24 hours. nonpyrogenic.

However. liver. The knowledge of anti-rejection drugs was limited. liver transplants. one of them being organ transplants. organ transplantation comes with its share of problems. lung and pancreas during organ transplantation. The success rate is high for kidney transplants. The credit for high success rate of transplantation can be given to the new technology which involves preserving the organs in the right manner. . nurses. many people died because doctors could not successfully complete a transplant and prevent rejection of the new organ. Today. heart. Custodiol® HTK Solution is used by leading Transplant Centers worldwide for the preservation of the kidney. and the surgery involved was extremely difficult. science has made improvement in the field of transplantation to the point that most transplant operations are considered low risk. and the general public the term life support calls up the image of a ventilator. Forty years ago. kidney tumor resection and split liver donation. As with any other type of life support. CRYSTALLOID SOLUTION  BLOOD  MICROPLEGIA Custodiol® HTK Solution – Multi Organ Transplantation For many doctors. there are many types of life support. In-situ protection: Due to high systemic tolerance all kinds of operation procedures in ischemic organs may be perfomed such as heart surgery. cornea transplants. and even heart and lung transplants.

Transplantation Multi organ procurement using Custodiol® HTK solution Reliable preservation of donor organs Easier handling due to simultaneous in-situ perfusion of all organs Increased organ availability due to excellent postoperative function. even with kidney of non-heart beating donors Autologous graft protection with Custodiol® HTK solution Excellent preservation of venous and arterial grafts Reduced rise in permeability of the endothelial cell layer Effective even at room temperature Custodiol® HTK solution for Cardiac surgery and Transplantation High rate of spontaneous return to sinus rhythm Minimized cell necrosis Less depletion of ATP stores Remarkably increased protective potency Liver Transplantation with Custodiol® HTK solution Extended cold preservation time Better preservation of micro-circulation Low degree of cell edema Prevention of leukocyte adhesion Reduced biliary tract complications Kidney Transplantation with Custodial® HTK solution Rapid graft function Prolongation of ischemic tolerance Lower frequency of post-operative dialysis Shortened hospitalization Good Structural protection even at 25 °C .

ketoglutarate serves as a substrate for aerobic energy production during the induction of cardioplegia. and when restarting the heart . culture and transplantation 3) Reliable graft function in a porcine model after upto 24 hours cold storage Properties of Custodiol® HTK solution 1) Low potassium concentration to minimize risks 2) Low sodium concentration for safe organ inactivation 3) Extended buffer capacity only possible with high histidine / histidine-Hcl concentration 4) Tryptophane supports membrane integrity 5) Alpha. Excellent postoperative functional result Low post-transplant pulmonary edema Good preservation of combined heart-lung graft Pancreas Transplantation with Custodiol® HTK solution 1) Good endocrine and exocrine function of pancreatic tissue post- operatively 2) Suitable for in-situ flush of human pancreases prior to subsequent islet isolation. High rate of long time graft survival Heart Transplantation with Custodiol® HTK solution  High rate of spontaneous return to sinus rhythm 2) Minimized cell necrosis 3) Less depletion of ATP stores 4) Remarkably increased protective potency Lung Transplantation with Custodiol® HTK solution Good pulmonary tissue preservation in conjunction with prostaglandins.

extremely durable with a wide range of superior physical properties. is made of a new generation of advanced films for medical solutions. therefore no toxic effects have ever been observed Advantages of Custodiol® HTK solution 1) Use in-situ and during hypothermic storage 2) Rapid homogenous cooling due to low viscosity 3) Superior recovery of function 4) Excellent ischemic tolerance 5) High buffering capacity 6) Easier surgical handling due to excellent visibility 7) Reduced risk of post-aggression syndrome 8) Virtual absence of side effects 9) Simple perfusion technique (ready-to-use. additives and staff time 10) Shortened postoperative intensive care period Presentation of Custodiol® HTK solution  5 litre bag (cartons of 2 bags) 2) 2 litre bag (cartons of 4 bags) 3) 1 litre bottle (cartons of 6 bottles) 4) 500 ml bottle (cartons of 10 bottles) The Custodiol® bag. Storage 8 – 15 °C . so that its hypothermic effect contributes to a decreased metabolic rate 7) All components of HTK solution are naturally occurring physiological substances except for the inert mannitol.6) HTK is perfused as a cold solution. no additives or preparation) saves cost of filters. Cryovac M312. The material is based on exclusive multilayer technology resulting in a film that is exceptionally clear.

Continuing experimental development of the solution resulted in a refined formulation. Shelf-Life 1 year St. reperfusion-induced arrhythmias. Thomas' Hospital cardioplegic solution No. has been shown to confer beneficial. Continuing experimental studies have shown that STH2 is substantially more eficacious than STH1 in terms of both myocardial protection and antiarrhythmic effects . or both. Despite the evidence that STH2 provides better myocardial protection. creatine phosphate (CP) alone or in combination with adenosine triphosphate (ATP) when used as an additive to STH2 enhanced the protective properties of STH2 in terms of both function and antiarrhythmic effects. Thomas' Hospital cardioplegic solution (now termed St. We hypothesized that the use of CP as an additive to STH1 might considerably enhance the myocardial protective properties of that solution.THOMAS CARDIOPLEGIC SOLUTION The original St.Thomas' Hospital cardioplegic solution No. Addition of exogenous high-energy phosphate compounds. Thus. commercial cost implications have meant that STH1 is used in the majority of cardiac centers in the United Kingdom and in some European units in preference to STH2. 2 [STH2]). which became commercially available under the name of Plegisol (St. This solution was approved by the Food and Drug Administration for use in the United States and remains the most widely used crystalloid cardioplegic solution in the world. like many other metabolic additives. and previously observed changes at the cellular level should also be . Differences might be detectable in terms of post ischemic function. These experimental studies were confirmed clinically but only at the cellular level and not on clinically measurable variables. 1 [STH1]) was developed in the early 1970s by Hearse and colleagues and was first used clinically in 1976 . despite controversy regarding the ability of these compounds to enter the cell.

0 MAGNESIUM CHLORIDE 16. Deerfield. observed. IL).0 Ph 5.4 PROCAINE HYDROCHLORIDE 1.5-7. The aim of the present study was to determine in a clinical study whether the addition of CP to STH1 could enhance the protective effect of STH1 COMPOSITION: COMPOUND CONCENTRATION (mmol/L) SODIUM CHLORIDE 144. which has an electrolyte composition similar to the extracellular fluid (Baxter Healthcare Corporation.0 CALCIUM CHLORIDE 2.0 POTASSIUM CHLORIDE 20. 5 mEq/L potassium. The concentrations of electrolytes before the addition of cardioplegic additives are 140 mEq/L sodium.0 OSMOLARITY (mosm)/kgH2O 300-320 DEL NIDO CARDIOPLEGIA SOLUTION The del Nido cardioplegia contains a base solution of Plasma-Lyte A. 3 mEq/L .

27 mEq/L acetate. Hyperosmotic mannitol has been shown to both scavenge free radicals and reduce myocardial cell swelling. hydrogen peroxide. Additionally. This formulation serves as the crystalloid component. The cardioplegia additives to this base solution. This is an important consideration because trace of calcium in cardioplegic solutions has been shown to be preferable as compared with acalcemic or normal levels 1 L Plasma-Lyte A base solution to which the following are added:  Mannitol 20%. 13 mL  Lidocaine 1%. 16.magnesium.4. These radicals are normally countered enzymatically within the cell but this is inhibited during myocardial arrest . and 23 mEq/L gluconate. 4 mL  Sodium bicarbonate 8. 13 mL  Potassium chloride (2 mEq/mL). myocardial edema has also been implicated in post ischemic myocardial impairment. at Boston Children’s Hospital. 98 mEq/L chloride. which is mixed with blood in a ratio of four parts crystalloid to one part fully oxygenated patient whole blood (usually obtained from the bypass circuit). 13 mL  Mannitol Myocardial injury during cardioplegic arrest and subsequent reperfusion may be in part the result of oxygen-free radicals including superoxide anion.4%. To note.5 g/kg mannitol to the bypass circuit shortly before the removal of the cross-clamp owing to these properties and also its osmotic diuretic effects. The manufacturer lists a pH value of 7. The final calcium concentration of this cardioplegia can be described as trace because 20% of the delivered volume contains patient blood.3 mL  Magnesium sulfate 50%. It is important to note that there is no calcium in the base solution. we also deliver . and hydroxyl. .

 Sodium Bicarbonate Aerobic metabolism is not usually possible for the entire myocardial arrest period. relaxation may be interrupted and diastolic stiffness with poor recovery may result . anaerobic glycolysis must be supported. It is also important to note that red blood cells contain a high concentration of carbonic anhydrase.  Potassium Chloride Hyperkalemia is the most common arresting method for cardiac surgery because it provides rapid arrest and reliable recovery but it has been shown to have limitations. This effect is likely how magnesium has been shown to improve ventricular recovery in hypothermic cardioplegia solutions when coupled with a low calcium level . It provides a depolarized arrest.  Magnesium Sulfate Myocardial function is intimately related to intracellular calcium concentration. Therefore. If calcium is allowed to accumulate in the myocardium. Magnesium has been shown to be a natural calcium channel blocker . an enzyme that facilitates the scavenging of hydrogen ions with bicarbonate to generate carbon dioxide and water. Anaerobic glycolysis and its production of ATP has been shown to be inhibited by excess hydrogen ion accumulation. The del Nido cardioplegia mix incorporates sodium bicarbonate as a buffering solution to scavenge excess hydrogen ions and to assist in maintaining intracellular pH. This property of red blood cells may in fact be its most important role in cardioplegia. The normal calcium flux in the myocardium increases intracellular calcium for contraction and decreases it for relaxation. Depolarized arrest has been associated with poor myocardial recovery as a result of intracellular sodium and calcium .

 Patient Blood Additive The del Nido cardioplegia is delivered with 20% by volume fully oxygenated patient blood. Sodium channel blockade increases the refractory period of the cardiac myocyte . this action is prolonged because the lidocaine remains in adequate concentrations to continually affect the myocardium.accumulation during the arrest period . Additionally.5 mEq/L K***) = 24 mEq/L K+ * Potassium added to the plasmalyte base solution 13 ml or 26 mEq. *** 4. Depolarized arrest can allow for sodium and calcium accumulation through exchange mechanisms and blocking the sodium channels helps prevent this. Lidocaine likely inhibits these negative effects while enhancing the period of time in which electromechanical activity is absent. (0. primarily as a result of the properties of lidocaine and magnesium. When cardioplegia is given in an ideal environment without washout. The potassium level in del Nido cardioplegia is 24 mEq/L (see subsequent equation). showed that del Nido cardioplegia reduced calcium accumulation during myocardial ischemia in a setting of a depolarized arrest.5 mEq/L is an estimate of the patients serum potassium level  Lidocaine Lidocaine is classified as a sodium channel blocker and is a frequently used antiarrhythmic. A 2009 study by O’Brien et al. which supports aerobic metabolism for a finite period of time and .2 bl ood component) (4. ** 5mEq is the potassium concentration in the Plasmalyte base solution used to formulate the del Nido solution.8 crystalloid component)×(26 MEQ added K* + 5mEq Plasmalyte K**)+ (0. Total solution volume 1059ml. It may be helpful to note that del Nido cardioplegia can therefore be classified as a modified depolarizing agent. sodium channel blockade helps counteract the negative effects of a hyperkalemic depolarized arrest by polarizing the cell membrane to some degree and preventing sodium and calcium accumulation within the cell.

In our circuit. Additional cardioplegia volume may be given for hypertrophied hearts. Furthermore. The maximum arresting dose is usually limited to 1 L for patients larger than 50 kg. A smaller arresting dose of 10 mL/kg may be used for procedures requiring a cross-clamp time less than 30 minutes. Subsequent doses are not normally given except for the rare occurrence of electrical activity or for exceptionally long cross-clamp times (greater than 3 hours) at the surgeon’s discretion.  Hypothermia Decreasing the myocardial metabolic rate with hypothermia is a common practice for cardioplegia delivery .  Dose The del Nido cardioplegia solution is generally given as a single 20-mL/kg dose. Hypothermia decreases oxygen and high-energy phosphate consumption while providing its own additional cardioplegic effect at low temperatures . studies have shown blood cardioplegia to preserve myocardial metabolism and function and result in less metabolic ischemic stress and reperfusion injury when compared with sanguineous cardioplegia in a varied population of patients undergoing congenital heart surgery The cardioplegia hematocrit can be calculated by multiplying the blood component hematocrit (drawn from the bypass circuit) by the 20% portion. Blood in cardioplegia has also been shown to improve coronary perfusion during cardioplegia delivery . or those with known coronary disease based on the effectiveness of the initial dose and surgeon preference.2 portion of cardioplegia mix = hematocrit of 6%). those with aortic insufficiency. The delivery temperature with this simple method is usually 8– 12°C.3 bypass circuit hematocrit +. The delivery hematocrit of del Nido cardioplegia will be 6% if the 20% blood portion has a hematocrit of 30% (.provides buffering properties to promote anaerobic glycolysis as well. the del Nido cardioplegia passes through a cooling coil in ice. .

We do not monitor aortic root pressure although the surgeon monitors aortic root distention closely during delivery to prevent capillary damage from high shear forces with too rapid a delivery. We generally give the 20-mL/kg cardioplegia dose over 1–2 minutes with a system pressure of 100–200 mmHg. This method results in a cardioplegia delivery flow rate of 10–20 mL/kg/min in infants and toddlers. it is clinically rather simple to estimate the initial delivery rate by taking half of the arresting dose volume and using that as the flow rate. We then add the circuit prime volume of 150 mL and divide the total by five parts to arrive at the volume of the blood component. the dose volume would be 240 mL (20 mL/kg cardioplegia × 12 kg). In other words. Then. by taking the delivery dose volume. we arrive at the crystalloid volume that should be in the cardioplegia reservoir before the addition of blood. Fully oxygenated patient blood is drawn off the bypass circuit once the patient has been on the heart–lung machine for at least 1–2 minutes. For example. The initial flow rate for root administration is limited to 300 mL/min in larger patients. is in the cardioplegia reservoir bag recirculating awaiting delivery. we multiply the patient’s weight in kilograms by 20 mL/kg to get the total cardioplegia dose volume. This precise volume is drawn from the bypass circuit through a manifold syringe and then injected into the separate recirculating cardioplegia delivery system. Cardioplegia system pressures may . at least with our custom cardioplegia circuit. The initial flow rate for ostial administration can be classified as “barely on. The result is that only the 20-mL/kg cardioplegia dose. An initial infusion rate of half that (120 mL/min) would be a proper estimate to achieve an infusion rate of 1–2 minutes with a system pressure of 100–200 mmHg.” Cardioplegia flow for all methods is adjusted from the initial flow based on the surgeon’s observation of the heart and electrical activity. in a 12-kg patient. plus the reservoir minimum of 25 mL. Clinically. Flow is controlled at the heart–lung machine by the perfusionist.It is important to mix the crystalloid cardioplegia component correctly with the patient’s blood to achieve the desired ratio of parts: four parts crystalloid to one part patient blood.  Delivery Delivery is initiated with the surgeon moving the clamp on the table lines from the outlet to the return limb. adding 25 mL to account for the minimum reservoir level. and subtracting the blood component.

can be suctioned into a cell saver instead of returning to systemic circulation when total bypass (bicaval cannulation with caval occlusion) is performed and the right atrium is opened. physicians’ assistants. del Nido cardioplegia.be higher with increased flows. When it is administrated to a small patient with a relatively low hematocrit (HCT). which drains from the coronary sinus. However. . This method limits hemodilution and requires clear communication and teamwork among surgeons. Temperature del Nido cardioplegia is delivered cold. and perfusionists. multiple doses of modified Buckberg cardioplegia can result in similar levels of hemodilution. These higher system pressures are not linearly related to root pressure. hemoconcentration should be considered in small patients with relatively low HCTs to maintain an acceptable patient hematocrit. but it is still imperative that the surgeon visually monitor delivery. the benefits of del Nido cardioplegia may be offset by the adverse effects of hemodilution. and ostial delivery. The del Nido cardioplegia is delivered at a temperature of 4°C and will produce myocardial cooling to less than 15°C. smaller root needles. up to 1000 mL for patients larger than 50 kg. In cases in which the right atrium is not opened and the cell saver cannot be used in the manner described. Myocardial oxygen consumption decreases by 50% for every 10°C decrease in myocardial temperature . del Nido Cardioplegia May Initially Increase the Level of Hemodilution del Nido cardioplegia is dosed at 20 mL/kg.

Warm cardioplegic induction Warm blood cardioplegic induction (WBCI) improves recovery of cardiogenic shock hearts by repaying their energy debt before cold ischemic arrest.rheology .and anti oxidant benefits with its capacity to augment oxygen delivery and ability to ‘resuscitate’ the heart.continuous cold blood perfusion and intermittent warm blood cardioplegia .the cardioprotective potential of blood cardioplegia is represented by the synergistic effect of its different components :  Hyperkalemia :induction and maintenance of cardioplegic arrest  Hypocalcemia :avoidance of mitochondrial calcium overload and preventionof irreversible myocyte injury .buffering . This study tests the hypothesis that despite the absence of shock.  Tris buffer : prevention of tissue acidosis  Hypersomolarity and hyperglycemia : prevention of myocardial edema  Glutamate and aspartate : these amino acids replenish key krebs cycle depleted during ischemia by enhancing aerobic metabolism and reparative process. In detail . many hearts are energy depleted and would benefit from WBCI.antegrade and retrograde delivery . The concept of warm cardioplegia .BLOOD CARDIOPLEGIA Currently .blood cardioplegia is the preferred cardio protective strategy in the United states and in most West European countries .The technical details of blood cardiplegia have evolved as a consequence of experimental studies and clinical application including multidose cold blood cardioplegia .because a blood vehicle for cardioplegic delivery blends onconicity . prevent ischemic injury and limit reperfusion damage . The fact that blood cardioplegia has emerged as the preffered cardioprotective strategy is based on its versality .warm blood cardioplegic reperfusion .warm induction .

activated leucocyte in blood cardioplegia or initial reperfusate may cause significant myocardial .This is followed by cold cardioplegic standard blood cardioplegia .Initially .warm cardioplegic pressure is applied ante and retrogradely (1min each).The coronary sinus catheter is introduced and secured with a prolene pursestring suture usuing a tourniquet .The second application of cold blood cardioplegia (2mins)is performed after 20 mins . Retrograde perfusion is continued with normothermic leucocyte filtrated blood .acute myocardial infarction .Warm cardioplegic induction is applied to patients in cardiogenic shock with severely impaired ejection fraction or in acute myocardial infarction .energy and substrate –depleted heart by maximizing the kinetics of repair and minimizing O2 demands by maintaining arrest . BLOOD CARDIOPLEGIA LEUCOCYTE FILTRARTION Myocardial ischemia and reperfusion are associated with activation of neutrophils and expression of adhesion molecules on the myocardial endothelium surface .The aortic clamp is released as the first filtrated blood .Therefore .blood cardioplegia is supplemented with the amino acids glutamate and aspartate to replenish Krebs cycyle intermediates that are depleted in compromised hearts .Thereafter .cardioplegic flow is reduced to 150 ml/min .induction was introduced to actively resuscitate the ischemically damaged . Blood cardioplegia in heart transplantation We use leucocyte depleted blood cardioplegia and start with first retrograde administration after the heart is removed from the storage solution .In the case of long cross clamp time .or in heart transplantation .cold blood cardioplegia is administered for 3 min . Normothermic blood cardioplegia is administered initially at 250 -300 ml/min via the aortic root until cardioplegic arrest is achieved .The third application is a warm terminal reperfusion with leucocyte depleted and substrate enriched blood cardioplegia for 45 s.The aortic clamp is released as the first contractions of the transplanted heart become visible .

Hypothermia is completely avoided .cardioplegic overdose is a potential problem using this technique INTERMITTENT ANTEGRADE WARM BLOOD CARDIOPLEGIA This concept was published by calafiore in 1995 and had been developed to eliminate the problem of blood in the operative field when using continuous warm blood cardioplegia .particularly when revascularization with the internal mammary artery prevents vein graft infusions to the left anterior descending artery .In addition .The presence of critical coronary stenosis limits the delivery of antegrade cardioplegia to ischemic regions of the heart . .Experimental studies have shown that atleast 90%of leucocytes must be removed to attenuate reperfusion injury markedly .damage . Repeated doses are delivered after 15 mins .Clinical studies have demonstrated the benefit of blood cardioplegia filtration in patients undergoing emergency coronary bypass surgery or prolonged cross clamping .This inadequate cardioplegic delivery using only the antegrade route may induce warm ischemic injury . OTHER CURRENT TECHNIQUE USING BLOOD CARDIOPLEGIA In addition to the classic ‘standard technique ‘ of blood cardioplegia several modifications have evolved and are used in different centres Continuous warm blood cardioplegia The goal of this technique is to prevent any myocardial ischemia during aortic cross –clamping by continuous retrograde delivery of warm cardioplegia .leucocyte depletion should be maintained for 5-10 min after the start of intial reperfusion prior to aortic clamp release .in patients with depressed ejection fraction .In addition .Normothermic blood is mixed with a K+ solution using a syringe pump.and in heart transplantation .Commercially available blood cardioplegia filters remove more than 90%of the leucocytes up to total volume of 1500 mlof blood cardioplegia . How ever most surgeons discontinue cardioplegic flow for few minutes during construction of the distal anastomoses leading to ‘unintential ‘ myocardial ischemia .

some surgeons are tempted to suspect that the contribution of the cardioplegia composition to protecting the pediatric heart may be overestimated. Although there is little doubt about the efficacy of cardioplegia in the adult heart. We examine the protective potential of cardioplegia (in various compositions).Reducing the hearts temperature from 37degree to 29degreeC did not alter myocardial oxygen consumption but did reduce myocardial lactate release. The physiology of pediatric heart muscle differs considerably from that of the adult myocardium. CARDIOPLEGIA IN PEDIATRICS Cardioplegia has become the gold standard of myocardial protection for practically every type of heart surgery during which the ascending aorta must be clamped. Considering that hypothermia is a powerful tool to prolong ischemia tolerance and that most pediatric cardiac surgeons report similar results using different types of cardioplegia. or of hypothermia. or of both in . TEPID BLOOD CARDIOPLEGIA Ante grade tepid blood cardioplegia was introduced by the Toronto group to combine the advantages of warm and cold blood cardioplegia and to minimize the detrimental effects of blood cardioplegia . This provocative statement is critically discussed in this article. there are few studies on the pediatric heart and their results are contradictory. The pediatric heart distinguishes itself from that of the adult most impressively in its greater tolerance for ischemia. This ischemia tolerance is enhanced by the use of hypothermia.

but are discussed much more controversial. decreasing calcium content adding substrate to enhance recovery or incorporating leukocyte filters in the cardiopulmonary bypass circuit In 1984. increasing osmolality. other means of extending the heart’s ischemia tolerance have been advanced. but becomes substantial when the temperature increases. depolarizing of the membrane potential by high potassium blood cardioplegia) . Bull and colleagues presented a landmark study demonstrating the efficacy of cardioplegia in pediatric cardiac surgery. irreversible ischemic damage begins to occur in the human heart after only 20 min whereas when current techniques of myocardial protection are used. The main principles of myocardial protection are the reduction of metabolic activity by hypothermia and the therapeutic arrest of the contractile apparatus and all electrical activity of the myocytes by administering cardioplegic solution (eg.pediatric cardiac surgery. arrest times of more than 4 or 5 hours may be tolerated without irreversible damage (eg. Both principles are unequivocally accepted and result in the decrease of energy consumption. Without such measures. We provide evidence that the benefit of cardioplegia over hypothermia alone is minor at low temperatures (below 15°C). We pay special attention to several key differences between the physiologies of the pediatric myocardium and the adult myocardium and attempt to relate them to the available surgical methods of myocardial protection. tested. We conclude that the composition of cardioplegia indeed is an important component of successful operative management in pediatric heart surgery. In addition to these two major principles. 4 to 5 hours of myocardial ischemia is not uncommon during heart transplantation . ischemia tolerance of the heart can be significantly prolonged. why is the efficacy of cardioplegia questioned for the heart in development? Doubts are based on several reasons: Poor myocardial protection is still considered a significant cause for in-hospital mortality in children the neonatal heart has a significantly greater tolerance for ischemia the results on the efficacy of cardioplegia in the pediatric population are contradictory hypothermia alone (by lowering perfusate . By reducing energy consumption and thus oxygen demand. If these results are so clear. and applied. These approaches consist of buffering the cardioplegic solution. Since then the achievements in this field have been tremendous and have set the ground for current practices in pediatric cardiac surgery with outstanding results.

The degree of this time frame’s extension is maximal at myocardial temperatures under 15°C. During cold cardioplegic arrest of the pediatric heart. is impressively documented by the fact that 167 different cardioplegic solutions are clinically used for heart transplantation in the United States alone .The last reason. The ischemia tolerance of the pediatric heart is significantly greater than that of the adult heart. The use of cardioplegia is of great importance to the safe conduct of pediatric cardiac surgery because it is difficult to guarantee continuous deep hypothermia of the myocardium under practical conditions. Therefore it provides an important margin of safety for every cardiac operation with cardiac arrest. The ability to improve the current techniques of myocardial protection is intimately linked to the understanding of the underlying basic mechanisms. Cardioplegia contributes to the protection of the heart at higher temperatures and older age. ischemia tolerance is primarily prolonged by hypothermia. Most pediatric cardiac surgeons report similar results using different strategies of myocardial protection as adjunct to hypothermia . which also applies to the adult heart. .temperature below 15°C) results in the arrest of contractile activity .

Retrograde cardioplegic delivery has been found to be useful in enhancing even distribution of cardioplegia .Excellent clinical outcomes have been reported and this method has been employed in many centres for the several years .The duration of cardiopulmonary bypass is shortened by this technique by eliminating the need for recovery time following unclamping of the aorta . Integrated myocardial management “is an easy and effective method of myocardial protection in adult cardiac procedures by expediting the operation and meeting the physiological needs of the myocardium .free radicals scavengers and endothelium –enhancing agents .These may include the use of preconditioning agents . Ongoing studies are needed to develop additional cardioprotective strategies ..white blood cell filter .particularly distal to coronary stenosis in vessels supplying the left ventricular myocardium .Replenishment of substrates to the energy –depleted heart is a main focus of development for cardioplegia formulations . .CONCLUSION Blood cardioplegia is an effective and widely accepted method of myocardial protection .designed to enhance recovery following the ischemia required to carry out cardiac operations.

David J. Alfered H Stammers. Myocardial protection –Tomas A. Richard F. Cook 2. Ross M. Cardiopulmonary bypass –Sunit Ghosh. Florian Falter. Cardiopulmonary bypass –Glenn P Gravlee. Salerno. Ungerleider . MD and Marco Ricci 3. Davis.BIBILOGRAPHY 1.