Myocardial protection during aortic surgery: comparison between Bretschneider-HTK and cold blood cardioplegia

Abstract

The ideal cardioplegic strategy in thoracic aorta operations requiring long cardiopulmonary bypass and cross-clamp time has not been established. Suboptimal myocardial protection may lead to myocardial damage and possible post-operative complications. We evaluate post-operative cardiac Troponin I (cTnI) release, low cardiac output syndrome (LCOS) and mortality, using a cold crystalloid single-dose intracellular or cold blood multidose cardioplegia in 112 elective or emergent thoracic aorta operation patients. Fifty-four patients (HTK group) received Custodiol® cardioplegic solution and 58 received cold blood cardioplegia (CB group). Cross-clamp time, cardiopulmonary bypass (CPB) time and cTnI peak release were similar in both groups. No differences were found for atrial and ventricular arrhythmias, inotropic support, LCOS and in-hospital mortality. Two-way ANOVA analysis revealed an interactive effect on cTnI peak (p=0.012) of cardioplegic solution type across the cross-clamp time quintile. In the fifth quintile, cross-clamp time patient (>160 min) cTnI peak value was higher in CB patients (p=0.044). HTK and CB cardioplegic solutions assure similar myocardial protection in patients undergoing thoracic aorta operations. In long cross-clamp times, the lower post-operative cTnI release detected using HTK may be indicative of a better myocardial protection in these extreme conditions.

The Comparison of the Effects of Bretschneider's Histidine‐Tryptophan‐Ketoglutarate and Conventional Crystalloid Cardioplegia on Pediatric Myocardium at Tissue Level

“…Hypocalcemic solutions like Bretshcneider's HTK avoid these effects by inducing polarized arrest. This is also consistent with a previous study on patients undergoing open heart surgery for thoracic aorta (14). HTK and cold blood cardioplegic solutions-yet another hyperkalemic cardioplegic solution-assure similar myocardial protection in patients undergoing thoracic aorta operations.…”

Histidine Metabolism After Bretschneider Cardioplegia in Cardiac Surgical Patients

“…Bretschneider (histidine-tryptophan-ketoglutarate, HTK) solution is frequently used for the induction of cardioplegic arrest in cardiac surgery (Careaga et al 2001). The high histidine concentration of 198 mM in Bretschneider solution was shown to buffer acidosis in the ischemic period (Scrascia et al 2011). This way, the prolonged existence of anaerobic glycolysis is favored, which would be otherwise inhibited by an acidic milieu.…”

Which Is the Better Option During Neonatal Cardiopulmonary Bypass

“…14 For cases with cross-clamping time over 160 minute, HTK can provide a better myocardial protection when compared to CBC. 5 However, another study showed that there was significantly positive correlation between the cross-clamping times and the serum enzyme levels in the patients receiving HTK 3 ; the reason for these contradictory results is unclear.…”

“…Although more spontaneous ventricular fibrillation after aortic unclamping had been found in adult patients receiving HTK cardioplegia, one single dose of cold HTK gives equally good myocardial protection in cardiac surgery as multidose cold blood cardioplegia (CBC). [3][4][5] Experimental studies have shown, however, that HTK solution provides inadequate cardioprotection when compared to CBC. 6,7 The relative advantage of blood cardioplegia in relation to crystalloid cardioplegia is still the subject of debate in pediatric cardiac surgery.…”