Multicentre Investigation of Myocardial Protection with Cold Cardioplegia: A Computerized Study of 144 Patients Undergoing Isolated Aortic Valve Replacement

Abstract

In order to analyze factors of importance for the efficiency of myocardial protection during open-heart surgery, a study was made of 144 patients undergoing isolated aortic valve replacement with various cardioplegic techniques. The cardioplegia was of Bretschneider type in 54 cases, St Thomas in 31 and Ringer-potassium type in 11 cases. Single or multi-dose blood cardioplegia was used in 11 cases and continuous blood cardioplegia in 30 cases. Local cardiac hypothermia was additionally employed in all patients. The efficiency of myocardial protection was assessed mainly from the incidence of postoperative conduction disturbances, myocardial enzyme release and need for inotropic support. All patients survived the operation. In 20% surgery was followed by transient or persistent disturbance of conduction, in 9% by abnormally increased CK-MB release and in 5% by requirement for inotropic support. Preoperative risk factors such as high age or severe left ventricular (LV) hypertrophy or dysfunction had little influence on the results. Patients in whom aortic stenosis (AS) was dominant in the complex with aortic insufficiency (AS + AI) showed 20-hour postoperative CK-MB enzyme activity twice as high as those with pure aortic insufficiency. The most important factors in myocardial protection were the duration of aortic occlusion and the myocardial temperature during cardioplegia. When the aortic occlusion lasted more than 80 min there was a 32% incidence of conduction disturbances and 20-hour CK-MB activity thrice as high as after shorter occlusion. Patients with mean myocardial temperature below 18°C during cardioplegia invariably had low enzyme activities, which indicated good myocardial protection. The best overall results were obtained in patients operated on during hypothermia at 25-27°C, with single or multi-dose blood cardioplegia and with efficient local cooling of the heart.