Cardioprotection: A Review of Current Practice in Global Ischemia and Future Translational Perspective

Abstract

The idea of protecting the heart from ischemic insult during heart surgery to allow elective cardiac arrest is as old as the idea of cardiac surgery itself. The current gold standard in clinical routine is a high potassium regimen added either to crystalloid or blood cardioplegic solutions inducing depolarized arrest. Ongoing patient demographic changes with increasingly older, comorbidly ill patients and increasing case complexity with increasingly structurally abnormal hearts as morphological correlate paired with evolutions in pediatric cardiac surgery allowing more complex procedures than ever before redefine requirements for cardioprotection. Many, in part adversarial, regimens to protect the myocardium from ischemic insults have entered clinical routine; however, functional recovery of the heart is still often impaired due to perfusion injury. Myocardial reperfusion damage is a key determinant of postoperative organ functional recovery, morbidity, and mortality in adult and pediatric patients. There is a discrepancy between what current protective strategies are capable of and what they are expected to do in a rapidly changing cardiac surgery community. An increased understanding of the molecular players of ischemia reperfusion injury offers potential seeds for new cardioprotective regimens and may further displace boundaries of what is technically feasible.

The Effects of Cold Blood Cardioplegia with and without Adenosine on Hemodynamic Status of Patients Undergoing Mitral Valve Surgery

“…This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License (http://creativecommons.org/licenses/by-nc/4.0/) which permits copy and redistribute the material just in noncommercial usages, provided the original work is properly cited. less environment for the action required by a solution called cardioplegia (5). During the surgery, oxygenating the bloodstream in the rest of the body is supplied by cardiopulmonary bypass.…”

Coronary Sinus Lactate as Marker of Myocardial Ischemia in Cardiac Surgery: Correlation with Morbidity and Mortality after Cardiac Surgery / Lactatul din sinusul coronarian - marker al ischemiei miocardice în chirurgia cardiacă: corelaţii cu morbiditatea şi mortalitatea postoperatorie

“…Lactate levels showed a rapid decline immediately after removal of the aortic crossclamp, in most cases returning to normal in 10 minutes of reperfusion. Increasing lactate levels during myocardial ischemia suggest that despite properly infused cardioplegic solution, minor myocardial injuries occur leading to myocardial apoptosis or necrosis if aortic crossclamping lasts longer (17). Metabolic acidosis occurs due to the anaerobic metabolism during ischemia and may induce an inflammatory response following reperfusion, which may contribute to the development of hemodynamic disorders in the postoperative period.…”

“…From a theoretical perspective, retrograde cardioplegia has many advantages, its use being particularly recommended in patients with severe proximal coronary stenosis and low left ventricular contractility, but its use implies a correct insertion of the catheter into the coronary sinus to infuse the entire myocardium and to maintain a perfusion pressure of 40 mmHg during administration, in order to prevent perivascular hemorrhage and edema (17,21). The disadvantage of this method is the direct shunting of blood in atrial and ventricular cavities due to arterial-sinusoidal and thebesiene vessels, therefore delivery of the cardioplegic solution with a flow of 100 ml/min being necessary, in order to compensate for physiological shunting and decrease the lactate production (22).…”

Cardioprotection conferred by rooibos (Aspalathus linearis): A mini review to highlight a potential mechanism of action

“…In the case of a heart attack (myocardial ischaemia), oxygen availability to the myocardium is markedly reduced. 2 The heart normally generates energy through both glucose oxidation and fatty acid oxidation, while the latter uses less oxygen for the production of a similar amount of energy (adenosine triphosphate, ATP). 42 Thus, if fatty acid (beta) oxidation is elevated during a heart attack and not altered, the already limited oxygen will be used to produce ATP, which will produce more severe ischaemic effects on the heart.…”

“…Cardioprotection is the manipulation of cellular processes with various therapeutic interventions to protect the heart before, during or after disease. [1][2][3] These interventions include pre-and post-conditioning 4-6 , remote ischaemic conditioning [4][5][6] , and intake of antioxidants like melatonin 7,8 and rooibos (Aspalathus linearis) 9,10 . Rooibos is an endemic South African fynbos plant species that grows exclusively in the Cederberg mountain region.…”