• European board of cardiovascular perfusion-certificate
• education perfusionist
• logbook European board of cardiovascular perfusion

• Humans
• Germany
• Perfusion/methods
• Internship and Residency

• HTK
• aortic dissection
• cardioplegia
• cardiopulmonary bypass, custodiol
• myocardial protection

• Humans
• Male
• Female
• Cardioplegic Solutions/therapeutic use
• Cardioplegic Solutions/pharmacology
• Middle Aged
• Heart Arrest, Induced/methods
• Procaine/pharmacology
• Procaine/therapeutic use
• Mannitol/therapeutic use
• Mannitol/pharmacology
• Potassium Chloride/pharmacology
• Potassium Chloride/therapeutic use
• Aorta/surgery
• Glucose/therapeutic use
• Glucose/pharmacology
• Aged
• Aortic Dissection/surgery

• Adult
• Humans
• Cardioplegic Solutions/adverse effects
• Prospective Studies
• Treatment Outcome
• Heart Arrest, Induced/adverse effects
• Potassium Chloride/adverse effects
• Glucose
• Creatine Kinase, MB Form
• Mannitol/adverse effects
• Edema
• Procaine

• Cardioprotection
• Infarct size
• Ischemic conditioning
• Mitochondrion
• Myocardial infarction
• Myocardial ischemia
• Reperfusion

• Humans
• Reactive Oxygen Species/metabolism
• Myocardium/metabolism
• Myocardial Infarction/metabolism
• Myocardial Reperfusion Injury/prevention & control
• Myocardial Reperfusion Injury/metabolism
• Oxidation-Reduction

• PG/21/10798 British Heart Foundation
• RG/20/3/34823 British Heart Foundation
• R01 HL128831 NHLBI NIH HHS
• PG/16/85/32471 British Heart Foundation
• RG/13/11/30384 British Heart Foundation
• RG/19/11/34633 British Heart Foundation
• CH/1999001/11735 British Heart Foundation
• PG/18/44/33790 British Heart Foundation
• PG/19/51/34493 British Heart Foundation
• RE/18/2/34213 British Heart Foundation
• G00913 Medical Research Council

• cardioplegic solution
• cardiopulmonary bypass
• energy metabolism
• potassium
• reactive oxygen species

• R01 GM126165 NIGMS NIH HHS
• P30 ES006694 NIEHS NIH HHS
• R01 GM125212 NIGMS NIH HHS
• GM125212 NIGMS NIH HHS
• GM126165 NIGMS NIH HHS

Blood cardioplegia (BC) and Custodiol cardioplegia (CC) have been used for a long time in open heart surgery and are highly effective solutions. The most controversial issue among these two is whether there is any difference between them regarding myocardial damage after ischemia surgery. In this study, autophagy, apoptosis, and hypoxia markers were investigated and that way we evaluated the differences between BC and CC patients.

A total of 30 patients were included in this study, using two different cardioplegic solutions. Three different whole blood samples of the patients were taken from a central vein (preoperatively, immediately postoperatively, and one day after surgery). Total ribonucleic acid was extracted from these samples. Quantitative real-time polymerase chain reaction was performed, and changes in gene expression were determined by the 2-∆∆Ct method of relative quantification.

In the CC group, Beclin gene expression level was found to be higher and this difference was statistically significant (P=0.0024). Similarly, cysteine-aspartic acid protease (caspase) 9 and hypoxia-inducible factor 1α messenger ribonucleic acid (mRNA) gene expression level increased and were significantly different in the CC group. In the BC group, Beclin and microtubule-associated protein light chain 3 expressions were higher in the samples taken one day after surgery. Caspases 3 and 8 gene expressions were significantly different in the BC group.

As a result of the analysis performed between the two cardioplegia groups, it has been shown that CC harms the myocardium more than BC at the level of mRNA expression of related markers.

• Aspartic Acid
• Cardiac Surgical Procedures
• Cardioplegic Solutions
• Heart Arrest,Induced
• RNA, Messenger, Caspase 9
• Real-Time Polymerase Chain Reaction

• Cardioplegic solutions
• coronary artery bypass
• heart arrest
• induced

• Blood cardioplegia
• Crystalloid cardioplegia
• Ischemia-reperfusion injury
• Myocardial infarction
• Myocardial revascularization

• cardioplegia
• cardioprotective agents
• coronary artery bypass grafting surgery
• ischemic heart disease
• myocardial protection

• Cold crystalloid cardioplegia (CCC)
• aortic valve replacement
• myocardial protection
• warm blood cardioplegia (WBC)

We retrospectively analyzed early results of coronary artery bypass grafting (CABG) surgery using two different types of cardioplegia for myocardial protection: antegrade intermittent warm blood or cold crystalloid cardioplegia. From January 2015 to October 2016, 330 consecutive patients underwent isolated on-pump CABG. Cardiac arrest was obtained with use of warm blood cardioplegia (WBC group, n = 297) or cold crystalloid cardioplegia (CCC group, n = 33), according to the choice of the surgeon. Euroscore II and preoperative characteristics were similar in both groups, except for the creatinine clearance, slightly lower in WBC group (77.33 ± 27.86 mL/min versus 88.77 ± 51.02 mL/min) (P < 0.05). Complete revascularization was achieved in both groups. In-hospital mortality was 2.0% (n = 6) in WBC group, absent in CCC group. The required mean number of cardioplegia’s doses per patient was higher in WBC group (2.3 ± 0.8) versus CCC group (2.0 ± 0.7) (P = 0.045), despite a lower number of distal coronary artery anastomoses (2.7 ± 0.8 versus 3.2 ± 0.9) (P = 0.0001). Cardiopulmonary and aortic cross-clamp times were similar in both groups. The incidence of perioperative myocardial infarction (WBC group 3.4% versus CCC group 3.0%) and low cardiac output syndrome (4.4% versus 3.0%) were similar in both groups. As compared with WBC group, in CCC group CK-MB/CK ratio >10% was lower during each time points of evaluation, with a statistical significant difference at time 0 (4% ± 1.6% versus 5% ± 2.5%) (P = 0.021). In presence of complete revascularization, despite the value of CK-MB/CK ratio >10% was less in the CCC group, clinical results were not affected by both types of cardioplegia adopted to myocardial protection. As compared with cold crystalloid, warm blood cardioplegia requires a shorter interval of administration to achieve better myocardial protection.

Myocardial protection is the most important in cardiac surgery. We compared our modified single-dose long-acting lignocaine-based blood cardioplegia with short-acting St Thomas 1 blood cardioplegia in patients undergoing single valve replacement.

A total of 110 patients who underwent single (aortic or mitral) valve replacement surgery were enrolled. Patients were divided in two groups based on the cardioplegia solution used. In group 1 (56 patients), long-acting lignocaine based-blood cardioplegia solution was administered as a single dose while in group 2 (54 patients), standard St Thomas IB (short-acting blood-based cardioplegia solution) was administered and repeated every 20 minutes. All the patients were compared for preoperative baseline parameters, intraoperative and all the postoperative parameters.

We did not find any statistically significant difference in preoperative baseline parameters. Cardiopulmonary bypass time were 73.8±16.5 and 76.4±16.9 minutes (P=0.43) and cross clamp time were 58.9±10.3 and 66.3±11.2 minutes (P=0.23) in group 1 and group 2, respectively. Mean of maximum inotrope score was 6.3±2.52 and 6.1±2.13 (P=0.65) in group 1 and group 2, respectively. We also did not find any statistically significant difference in creatine-phosphokinase-MB (CPK-MB), Troponin-I levels, lactate level and cardiac functions postoperatively.

This study proves the safety and efficacy of long-acting lignocaine-based single-dose blood cardioplegia compared to the standard short-acting multi-dose blood cardioplegia in patients requiring the single valve replacement. Further studies need to be undertaken to establish this non-inferiority in situations of complex cardiac procedures especially in compromised patients.

Several strategies are still being introduced to cardiac surgery techniques to reduce the signs of the inflammatory response and oxidative stress. Many efforts have been made to develop the best possible method for myocardial protection.

To assess the effect of the cardioplegia strategy on the systemic inflammatory response and oxidative stress.

A group of 238 consecutive, elective on-pump coronary artery bypass graft patients (CABG; 183 men, aged 64.6 ±8.1 years) were prospectively studied. Patients were enrolled in two groups: with warm blood cardioplegia (n = 124) and with cold crystalloid cardioplegia (n = 114). In each group, pre- and postoperative levels of plasma C-reactive protein, fibrinogen, interleukin 6 and 8-iso-prostaglandin F_2α (8-iso-PGF_2α) were measured.

All studied markers significantly increased 18–36 h following CABG and then decreased in 5–7 postoperative days but remained above baseline levels. No differences in terms of studied markers and clinical outcomes were noted for the different types of cardioplegia. Regression analysis showed a significant correlation between preoperative level of oxidative stress measured by 8-iso-PGF_2α and postoperative myocardial infarction as well as in-hospital cardiovascular death (p = 0.047 and p = 0.041 respectively).

This study extends previous reports by showing that the type of cardioplegia does not affect the systemic inflammatory response or oxidative stress, which are associated with the CABG procedure. It might be speculated that preoperative screening of oxidative stress could be helpful in identifying patients at increased risk of an unfavorable course after CABG.

• cardioplegia
• coronary artery bypass graft
• inflammatory response
• oxidative stress

• cardioplegia
• cardiopulmonary bypass
• del Nido solution
• inflammation
• myocardial damage

The safety of perioperative hyperoxia is currently unclear. Previous studies in patients undergoing coronary artery bypass surgery suggest reduced myocardial damage when avoiding extreme perioperative hyperoxia (>400 mmHg). In this study we investigated whether an oxygenation strategy from moderate hyperoxia to a near-physiological oxygen tension reduces myocardial damage and improves haemodynamics, organ dysfunction and oxidative stress.

This was a single-blind, single-centre, open-label, randomised controlled trial in patients undergoing elective coronary artery bypass surgery. Fifty patients were randomised to a partial pressure of oxygen in arterial blood (P_aO₂) target of 200–220 mmHg during cardiopulmonary bypass and 130–150 mmHg during intensive care unit (ICU) admission (control group) versus lower targets of 130–150 mmHg during cardiopulmonary bypass and 80–100 mmHg at the ICU (conservative group). Primary outcome was myocardial injury (CK-MB and Troponin-T) at ICU admission and 2, 6 and 12 hours thereafter.

Weighted P_aO₂ during cardiopulmonary bypass was 220 mmHg (interquartile range (IQR) 211–233) vs. 157 (151–162) in the control and conservative group, respectively (P < 0.0001). During ICU admission, weighted P_aO₂ was 107 mmHg (86–141) vs. 90 (84–98) (P = 0.03), respectively. Area under the curve of CK-MB was median 23.5 μg/L/h (IQR 18.4–28.1) vs. 21.5 (15.8–26.6) (P = 0.35) and 0.30 μg/L/h (0.25–0.44) vs. 0.39 (0.24–0.43) (P = 0.81) for Troponin-T. Cardiac index, systemic vascular resistance index, creatinine, lactate and F2-isoprostane levels were not different between groups.

Compared to moderate hyperoxia, a near-physiological oxygen strategy does not reduce myocardial damage in patients undergoing coronary artery bypass surgery. Conservative oxygen administration was not associated with increased lactate levels or hypoxic events.

Netherlands Trial Registry NTR4375, registered on 30 January 2014

The online version of this article (doi:10.1186/s13054-016-1240-6) contains supplementary material, which is available to authorized users.

• CABG
• Cardiac surgery
• Hyperoxia
• Intensive care unit
• Oxygen

While cardioplegia has been used on millions of patients during the last decades, the debate over the best technique is still going on. Cardioplegia is not only meant to provide a non-contracting heart and a field without blood, thus avoiding the risk of gas emboli, but also used for myocardial protection. Its electromechanical effect is easily confirmed through direct vision of the heart and continuous electrocardiogram monitoring, but there is no consensus on the best way to assess the quality of myocardial protection. The optimal approach is thus far from clear and the considerable amount of literature on the subject fails to provide a definite answer. Cardioplegia composition (crystalloid vs blood, with or without various substrate enhancement), temperature and site(s) of injection have been extensively researched. While less frequently studied, re-dosing interval is also an important factor. A common and intuitive idea is that shorter re-dosing intervals lead to improved myocardial protection. A vast majority of surgeons use re-dosing intervals of 20-30 min, or even less, during coronary artery bypass graft and multidose cardioplegia has been the “gold standard” for decades. However, one-shot cardioplegia is becoming more commonly used and is likely to be a valuable alternative. Some surgeons prefer the comfort of single-shot cardioplegia while others feel more confident with shorter re-dosing intervals. There is no guarantee that a single strategy can be safely applied to all patients, irrespective of their age, comorbidities or cardiopathy. The goal of this review is to discuss the rationale for short re-dosing intervals.

• Myocardial protection
• Del Nido cardioplegia
• Continuous cardioplegia
• Intermittent cardioplegia
• Single-shot cardioplegia
• Multidose cardioplegia
• Crystalloid cardioplegia
• Blood cardioplegia
• Custodiol^®
• Histidine-ketoglutarate-tryptophan

• cardioplegia
• free radicals
• ischemia-reperfusion syndrome
• myocardial protection
• oxidative stress
• reperfusion injury

• Cardiopulmonary Bypass/adverse effects
• Free Radical Scavengers/therapeutic use
• Heart Arrest, Induced/methods
• Humans
• Hypothermia, Induced/adverse effects
• Nitric Oxide/therapeutic use
• Oxidative Stress/physiology

Hypertrophied myocardium is especially vulnerable to ischemic injury. This study aimed to compare the early and late clinical outcomes of three different methods of myocardial protection in patients with aortic stenosis.

This retrospective study included 225 consecutive patients (mean age, 65±10 years; 123 males) with severe aortic stenosis who underwent aortic valve replacement. Patients were excluded if they had coronary artery disease, an ejection fraction <50%, more than mild aortic regurgitation, or endocarditis. The patients were divided into three groups: group A, which was treated with antegrade and retrograde cold blood cardioplegia; group B, which was treated with antegrade crystalloid cardioplegia using histidine-tryptophan-ketoglutarate (HTK) solution; and group C, treated with retrograde cold blood cardioplegia.

Group A contained 70 patients (31.1%), group B contained 74 patients (32.9%), and group C contained 81 patients (36%). The three groups showed significant differences with regard to the proportion of patients with a New York Heart Association functional classification ≥III (p=0.035), N-terminal pro-brain natriuretic peptide levels (p=0.042), ejection fraction (p=0.035), left ventricular dimensions (p<0.001), left ventricular mass index (p<0.001), and right ventricular systolic pressure (p<0.001). Differences in cardiopulmonary bypass time (p=0.532) and aortic cross-clamp time (p=0.48) among the three groups were not statistically significant. During postoperative recovery, no significant differences were found regarding the use of inotropes (p=0.328), mechanical support (n=0), arrhythmias (atrial fibrillation, p=0.347; non-sustained ventricular tachycardia, p=0.1), and ventilator support time (p=0.162). No operative mortality occurred. Similarly, no significant differences were found in long-term outcomes.

Although the three groups showed some significant differences with regard to patient characteristics, both antegrade crystalloid cardioplegia with HTK solution and retrograde cold blood cardioplegia led to early and late clinical results similar to those achieved with combined antegrade and retrograde cold blood cardioplegia.

• Aortic valve
• Cardioplegic solutions
• Myocardial reperfusion injury
• Replacement
• Retrograde

• Blood cardioplegia
• Calafiore
• Cold crystalloid
• Congenital
• Contractility

The number of patients presenting with acute myocardial infarction (AMI) and being untreatable by interventional cardiologists increased during the last years. Previous experience in emergency coronary artery bypass grafting (CABG) in these patients spurred us towards a more liberal acceptance for surgery. Following a prospective protocol, patients were operated on and further analysed.

Within a two year interval, 127 patients (38 female, age 68±12 years, EuroScore (ES) II 6.7±7.2%) presenting with AMI (86 non-ST-elevated myocardial infarction (NSTEMI), 41 STEMI) were immediately accepted for emergency CABG and operated on within six hours after cardiac catheterisation (77% three-vessel-disease, 47% left main stem stenosis, 11% cardiogenic shock, 21% preoperative intraaortic balloon pump (IABP), left ventricular ejection fraction 48±15%).

30-day-mortality was 6% (8 patients, 2 NSTEMI (2%) 6 STEMI (15%), p=0.014). Complete revascularisation could be achieved in 80% of the patients using 2±1 grafts and 3±1 distal anastomoses. In total, 66% were supported by IABP, extracorporal life support (ECLS) systems were implanted in two patients. Logistic regression analysis revealed the ES II as an independent risk factor for mortality (p<0.001, HR 1.216, 95%-CI-Intervall 1.082-1.366).

Quo ad vitam, results of emergency CABG for patients presenting with NSTEMI can be compared with those of elective revascularisation. Complete revascularisation obviously offers a clear benefit for the patients. Mortality in patients presenting with STEMI and cardiogenic shock is substantially high. For these patients, other concepts regarding timing of surgical revascularisation and bridging until surgery need to be taken into consideration.

• Adult
• Creatinine/blood
• Death, Sudden, Cardiac
• Female
• Follow-Up Studies
• Humans
• Kaplan-Meier Estimate
• Kidney Transplantation/methods
• Male
• Middle Aged
• Postoperative Period
• Reperfusion
• Resuscitation
• Time Factors
• Tissue Donors

• cardioplegic solution
• ischemia/reperfusion
• myocardial protection
• organ preservation
• troponin I

The Krebs-Henseleit buffer is the best perfusion solution for isolated mammalian hearts. We hypothesized that a Krebs-Henseleit buffer-based cardioplegic solution might provide better myocardial protection than well-known crystalloid cardioplegic solutions because of its optimal electrolyte and glucose levels, presence of buffer systems, and mild hyperosmolarity.

Isolated Langendorff-perfused rat hearts were subjected to either global ischemia without cardioplegia (controls) or cardioplegic arrest for either 60 or 180 min, followed by 120 min of reperfusion. The modified Krebs-Henseleit buffer-based cardioplegic solution (mKHB) and St. Thomas’ Hospital solution No. 2 (STH2) were studied. During global ischemia, the temperatures of the heart and the cardioplegic solutions were maintained at either 37°C (60 min of ischemia) or 22°C (moderate hypothermia, 180 min of ischemia). Hemodynamic parameters were registered throughout the experiments. The infarct size was determined through histochemical examination.

Cardioplegia with the mKHB solution at moderate hypothermia resulted in a minimal infarct size (5 ± 3%) compared to that in the controls and STH2 solution (35 ± 7% and 19 ± 9%, respectively; P < 0.001, for both groups vs. the mKHB group). In contrast to the control and STH2-treated hearts, no ischemic contracture was registered in the mKHB group during the 180-min global ischemia. At normothermia, the infarct sizes were 4 ± 3%, 72 ± 6%, and 70 ± 12% in the mKHB, controls, and STH2 groups, respectively (P < 0.0001). In addition, cardioplegia with mKHB at normothermia prevented ischemic contracture and improved the postischemic functional recovery of the left ventricle (P < 0.001, vs. STH2).

The data suggest that the Krebs-Henseleit buffer-based cardioplegic might be superior to the standard crystalloid solution (STH2).

• Adenosine/pharmacology
• Adult
• Anti-Arrhythmia Agents/pharmacology
• Cardiac Surgical Procedures
• Cardioplegic Solutions/adverse effects
• Cardioplegic Solutions/chemistry
• Cardiovascular Diseases/metabolism
• Cardiovascular Diseases/surgery
• Child
• Endothelium, Vascular/pathology
• Heart Arrest, Induced/adverse effects
• Heart Arrest, Induced/methods
• Humans
• Hyperkalemia/etiology
• Hyperkalemia/metabolism
• Inflammation/etiology
• Inflammation/metabolism
• Lidocaine/pharmacology
• Membrane Potentials/physiology
• Myocardium/pathology
• Postoperative Complications
• Potassium/adverse effects
• Potassium/metabolism
• Risk Factors