Cold crystalloid versus warm blood cardioplegia in patients undergoing aortic valve replacement

Abstract

Background: Myocardial protection techniques during cardiac arrest have been extensively investigated in the clinical setting of coronary revascularization. Fewer studies have been carried out of patients affected by left ventricular hypertrophy, where the choice of type and temperature of cardioplegia remain controversial.We have retrospectively investigated myocardial injury and short-term outcome in patients undergoing aortic valve replacement plus or minus coronary artery bypass grafting with using cold crystalloid cardioplegia (CCC) or warm blood cardioplegia (WBC). Methods: From January 2015 to October 2016, 191 consecutive patients underwent aortic valve replacement plus or minus coronary artery bypass grafting in normothermic cardiopulmonary bypass.Cardiac arrest was obtained with use of intermittent antegrade CCC group (n=32) or WBC group (n=159), according with the choice of the surgeon. Results: As compared with WBC group, in CCC group creatine-kinase-MB (CK-MB), cardiac troponin I (cTnI), aspartate aminotransferase (AST) release, and their peak levels, were lower during each time points of evaluation, with the greater statistically significant difference at time 0 (P<0.05, for all comparisons). A time 0, CK-MB/CK ratio >10% was 5.9% in CCC group versus 7.8% in WBC group (P<0.0001). At time 0 CK-MB/CK ratio >10% in patients undergoing isolated aortic valve replacement was 6.0% in CCC group versus 8.0% in WBC group (P<0.01). No any difference was found in perioperative myocardial infarction (0% versus 3.8%), postoperative (PO) major complications (15.6% versus 16.4%), in-hospital mortality (3.1% versus 1.3%). Conclusions: In aortic valve surgery a significant decrease of myocardial enzymes release is observed in favor of CCC, but this difference does not translate into different clinical outcome. However, this study suggests that in presence of cardiac surgical conditions associated with significant left ventricular hypertrophy, i.e., the aortic valve disease, a better myocardial protection can be achieved with the use of a cold rather than a warm cardioplegia. Therefore, CCC can be still safely used.

Single-Dose Del Nido Cardioplegia vs. Blood Cardioplegia in Aortic Valve Replacement Surgery

“…It appears that the use of autologous blood as cardioplegia is the most plausible option since it is more physiological and has high oxygen-carrying capacity and lower haemodilution, contrary to its crystalloid counterparts. However, no clear superiority has been demonstrated in any comparative studies with BC and crystalloid-based formulas 13 , 14 . A current meta-analysis has indicated that smaller volumes of cardioplegia should be used in patients receiving DNC 8 .…”

Warm versus cold cardioplegia in cardiac surgery: A meta-analysis with trial sequential analysis

“…Sensitivity analysis was performed for all the outcomes using the leave-one-out method. Removal of individual studies from the analysis did not alter the statistical significance, except for the exclusion of Nardi and colleagues 9 in hospital LOS, which would result in statistically significant (P ¼ .04) shorter LOS in warm cardioplegia arm.…”

Warm Blood Cardioplegia for Myocardial Protection: Concepts and Controversies

“…56,57 However, many results of animal studies have since shown that warm cardioplegia may be safely interrupted for about 10 min without det rimental effects. 10,58,59 In one animal study, no detrimen tal effects were seen after ischemic periods of up to 15 Better myocardial protection and less frequent use of IABP and lower peak CK-MB level in early postoperative period in warm group than in cold group Zeriouh M, et al 50 (2015) Evaluation of warm and cold cardioplegia in emergency vs elective settings Similar short-and long-term outcomes in cold and warm cardioplegia across elective and emergency settings Nardi P, et al 39 (2018) Investigation of myocardial injury and short-term outcome in patients undergoing cold crystalloid or warm blood cardioplegia Lower CK-MB, troponin I, and aspartate aminotransferase levels at time 0 in cold crystalloid group than in warm blood group; no significant difference in perioperative MI, postoperative major complications, or in-hospital mortality rates AVR = aortic valve replacement; CK-MB = creatine kinase-myocardial band enzyme; IABP = intra-aortic balloon pump; MI = myocardial infarction min. 60 These findings correlated with those in human studies.…”

“…38 These results were mirrored by those of a recent study in which warm blood cardioplegia was found to be inferior to cold crystalloid cardioplegia in patients with severely hypertrophic LVs who underwent aortic valve surgery. 39 These differences in myocardial markers of ischemia, however, do not appear to translate into inferior clini cal outcomes. Calafiore and coauthors 40 retrospectively compared patients who underwent intermittent ante grade warm or intermittent antegrade cold cardioplegia for valve surgery and found significantly lower cardiac related mortality rates in the warm cardioplegia group (P <0.01).…”