Chapter 26
Current Concepts in Pediatric Myocardial Protection
Bradley S. Allen MD,
Bradley S. Allen MD
Search for more papers by this authorBradley S. Allen MD,
Bradley S. Allen MD
Search for more papers by this authorBook Editor(s):Tomas A. Salerno MD,
Marco Ricci MD,
Tomas A. Salerno MD
Professor and Chief, Division of Cardiothoracic Surgery, University of Miami, Jackson Memorial Hospital, Miami, Florida
Search for more papers by this authorMarco Ricci MD
Assistant Professor of Surgery, Division of Cardiothoracic Surgery, Staff Surgeon, Section of Pediatric Cardiac Surgery, University of Miami, Jackson Memorial Hospital, Miami, Florida
Search for more papers by this authorFirst published: 13 November 2003
Summary
This chapter contains sections titled:
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Preoperative considerations
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Cardioplegia
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Clinical studies
References
- Buckberg GD, Allen BS. Myocardial protection management during adult cardiac operations. In: AE Baue, AS Geha, GL Hammond, H Laks, KS Naunheim, eds. Glenn's Thoracic and Cardiovascular Surgery, 6th edn. Stamford, CT: Appleton & Lange, 1995: 1653–87.
- Castaneda AR, Jonas RA, Mayer JE Jr, Hanley FL. Myocardial preservation in the immature heart. In: AR Castaneda, RA Jonas, JE Mayer, FL Hanley, eds. Cardiac Surgery of the Neonate and Infant. Philadelphia: WB Saunders, 1994: 41–54.
- Bull C, Cooper J, Stark J. Cardioplegia protection of the child's heart. J Thorac Cardiovasc Surg 1984; 88: 287–93.
- Hammon JW Jr. Myocardial protection in the immature heart. Ann Thorac Surg 1995; 60: 839–42.
- Buckberg GD. A proposed “solution” to the cardio-plegic controversy. J Thorac Cardiovasc Surg 1979; 77: 803–15.
- Romero TE, Friedman WF. Limited left ventricular response to volume overload in the neonatal period: a comparative study with the adult animal. Pediatr Res 1979; 13: 910–15.
- Yee ES, Ebert PA. Effect of ischemia on ventricular function, compliance, and edema in immature and adult canine hearts. Surg Forum 1979; 30: 250–2.
- Fujiwara T, Kurtts T, Anderson W, Heinle J, Mayer Jr. Myocardial protection in cyanotic neonatal limbs. J Thorac Cardiovasc Surg 1988; 96: 700–10.
- Del Nido PJ, Mickle DAG, Wilson GJ et al. Inadequate myocardial protection with cold cardioplegic arrest during repair of tetralogy of Fallot. J Thorac Cardiovasc Surg 1988; 95: 223–9.
- Silverman N, Kohler J, Levitsky S et al. Chronic hypox-emia depresses global ventricular function and predisposes to depletion of high energy phosphates during cardioplegic arrest: implications for surgical repair of cyanotic congenital heart defects. Ann Thorac Surg 1984; 37: 304–8.
- Wittnich C, Maitland A, Vincente W, Salerno T. Not all neonatal hearts are equally protected from ischemic damage during hypothermia. Ann Thorac Surg 1991; 52: 1000–4.
- Friedman WF. The intrinsic physiologic properties of the developing heart. Prog Cardiovasc Dis 1972; 15: 87–111.
- Nienaber CA, Gambhir SS, Mody FV et al. Regional myocardial blood flow and glucose utilization in symptomatic patients with hypertrophic cardiomyopathy [abstract]. Circulation 1993; 87: 1580–90.
- Sink JD, Pellom GL, Currie WD et al. Response of hypertrophied myocardium to ischemia. J Thorac Cardiovasc Surg 1981; 81: 865–72.
- Peyton RB, Jones RB, Attarian D et al. Depressed high-energy phosphate content in hypertrophied ventricles of animal and man. Ann Thorac Surg 1982; 196: 278–84.
- Hammon JJW, Graham JTP, Boucek JRJ et al. Myocardial adenosine triphosphate content as a measure of metabolic and functional myocardial protection in children undergoing cardiac operation. Ann Thorac Surg 1987; 44: 467–70.
- Allen BS, Ilbawi MN. Hypoxia, reoxygenation and the role of systemic leukodepletion in pediatric heart surgery. Perfusion 2001; 16 (Suppl): 19–29.
- Teoh KH, Mickle DAG, Weisel RD et al. Effect of oxygen tension and cardiovascular operations on the myocar-dial antioxidant enzyme activities in patients with tetralogy of Fallot and aorta-coronary bypass. J Thorac Cardiovasc Surg 1992; 104: 159–64.
- Del Nido PJ, Mickle DAG, Wilson G et al. Evidence of myocardial free radical injury during elective repair of tetralogy of Fallot. Circulation 1987; 76: 174–9.
- Lee J, Halloran K, Taylor J et al. Coronary flow and myocardial metabolism in newborn lambs: effect of hypoxia and acidemia. Am J Physiol 1973; 224: 1381.
- Graham JTP, Erath HG Jr, Buckspan GS, Fisher RD. Myocardial anaerobic metabolism during isoprenaline infusion in a cyanotic animal model: possible cause of myocardial dysfunction in cyanotic congenital heart disease. Cardiovasc Res 1979; 13: 401–6.
- Ihnken K, Morita K, Buckberg GD et al. Studies of hypoxemic/reoxygenation injury: without aortic clamping II. Evidence for reoxygenation damage. J Thorac Cardiovasc Surg 1995; 110: 1171–81.
- Feldbaum DM, Kohman LJ, Veit LJ. Recovery of hypoxic neonatal hearts after cardioplegic arrest. Cardiovasc Res 1993; 27: 1123–6.
- Allen BS, Barth MJ, Ilbawi M. Pediatric myocardial protection: an overview. Semin Thorac Cardiovasc Surg 2001; 13: 56–72.
- Bolling KS, Halldorsson A, Allen BS et al. Prevention of the hypoxic/reoxygenation injury using a leukocyte depleting filter. J Thorac Cardiovasc Surg 1997; 113: 1081–90.
- Allen BS. Hypoxia, reoxygenation and the role of leukodepletion in the intraoperative management of congenital heart disease. In: G Matheis, A Moritz, M Scholz, eds. Leukocyte Depletion in Cardiac Surgeon and Cardiology, . Basel, Switzerland: Karger, 2002: 111–34.
- Lupinetti FM, Wareing TH, Huddleston CB et al. Pathophysiology of chronic cyanosis in a canine model. J Thorac Cardiovasc Surg 1985; 90: 291–6.
- Gauduel Y, Menasche P, Duvelleroy M. Enzyme release and mitochondrial activity in reoxygenated cardiac muscle: relationship with oxygen-induced lipid periox-idation. Gen Physiol Biophy 1989; 8: 327–40.
- Hearse D, Humphrey S, Bullock G. The oxygen paradox and the calcium paradox: two facets of the same problem? J Mol Cell Cardiol 1978; 10: 641–68.
- Allen BS, Okamoto F, Buckberg GD et al. Studies of controlled reperfusion after ischemia XV. Immediate functional recovery after 6 hours of regional ischemia by careful control of conditions of reperfusion and composition of reperfusate. J Thorac Cardiovasc Surg 1986; 92 (Suppl): 621–35.
- Byrne J, Appleyard R, Lee C et al. Controlled reperfusion of the regionally ischemic myocardium with leukocyte-depleted blood reduces stunning, the no-reflow phenomenon, and infarct size. J Thorac Cardiovasc Surg 1992; 103: 66–72.
- Harlan J. Leukocyte-endothelial interactions. Blood 1985; 65: 513–25.
- Kraemer R, Mullane K. Neutrophils delay functional recovery of the post hypoxic heart of the rabbit. J Pharm Exp Ther 1989; 251: 620–6.
- Jolly S, Kane W, Hook B et al. Reduction of myocardial infarct size by neutrophil depletion: effect of duration of occlusion. Am Heart J 1988; 112: 682–90.
- Komai H, Yamamoto F, Tanaka K, Yagihara T, Kawashima Y. Prevention of lung injury during open heart operations for congenital heart defects. Ann Thorac Surg 1994; 57: 134–40.
- Bando K, Pillai R, Cameron DE et al. Leukocyte depletion ameliorates free radical-mediated lung injury after cardiopulmonary bypass. J Thorac Cardiovasc Surg 1990; 99: 873–7.
- Corno AF, Milano G, Samaja M, Tozzi P, von Segesser LK. Chronic hypoxia: a model for cyanotic congenital heart defects. J Thorac Cardiovasc Surg 2002; 124: 105–12.
- Bolling KS, Kronon M, Allen BS et al. Myocardial protection in normal and hypoxically stressed neonatal hearts: the superiority of hypocalcemic versus normo-calcemic blood cardioplegia. J Thorac Cardiovasc Surg 1996; 112: 1193–201.
- Bolling KS, Kronon M, Allen BS et al. Myocardial protection in normal and hypoxically stressed neonatal hearts: the superiority of blood versus crystalloid cardioplegia. J Thorac Cardiovasc Surg 1997; 113: 994–1005.
- Allen BS, Rahman SK, Ilbawi M et al. The detrimental effects of cardiopulmonary bypass in cyanotic infants. Preventing reoxygenation injury. Ann Thorac Surg 1997; 64: 1381–8.
- Buckberg GD. Studies of hypoxemic/reoxygenation injury: I. Linkage between cardiac function and oxidant damage. J Thorac Cardiovasc Surg 1995; 110: 1164–70.
- Ihnken K, Morita K, Buckberg GD, Sherman MP, Young HH. Studies of hypoxemic/reoxygenation injury: without aortic clamping III. Comparison of the magnitude of damage by hypoxemia/reoxygentation versus ischemia/reperfusion. J Thorac Cardiovasc Surg 1995; 110: 1182–9.
- Morita K, Ihnken K, Buckberg G, Sherman MP, Young HH. Studies of hypoxemic/reoxygenation injury: without aortic cross-clamping IX. Importance of avoiding perioperative hyperoxemia in the setting of previous cyanosis. J Thorac Cardiovasc Surg 1995; 110: 1235–44.
- Boucek RJ Jr, Kasselberg AG, Boerth RC, Parrish MD, Graham TP Jr. Myocardial injury in infants with congenital heart disease: evaluation by creatine kinase MB isoenzyme analysis. Am J Cardiol 1982; 50: 129–35.
- Martin G, Short B, Abbott C, O'Brien A. Cardiac stun in infants undergoing extracorporeal membrane oxygena-tion. J Thorac Cardiovasc Surg 1991; 101: 607–11.
- Hirschl R, Heiss K, Bartlett R. Severe myocardial dysfunction during extracorporeal membrane oxygena-tion. J Pediatr Surg 1992; 27: 48–53.
- Joachimsson P, Sjoberg F, Forsman M et al. Adverse effects of hyperoxemia during cardiopulmonary bypass. J Thorac Cardiovasc Surg 1996; 112: 812–19.
- Gu YJ, de Vries AJ, Boonstra PW, van Oeveren W. Leukocyte depletion results in improved lung function and reduced inflammatory response after cardiac surgery. J Thorac Cardiovasc Surg 1996; 112: 494–500.
- Morioka K, Muraoka R, Chiba Y et al. Leukocyte and platelet depletion with a blood cell separator: effects on lung injury after cardiac surgery with cardiopulmonary bypass. J Thorac Cardiovasc Surg 1996; 111: 45–54.
- Chiba Y, Morioka K, Muraoka R et al. Effects of depletion of leukocytes and platelets on cardiac dysfunction after cardiopulmonary bypass. Ann Thorac Surg 1998; 65: 107–13.
- Mizuno BR, Buckberg GD, Young HH. Hypocalcemia in piglets reduces cardiac and pulmonary vascular disturbance after hypoxemia and reoxygenation during cardiopulmonary bypass. J Thorac Cardiovasc Surg 1999; 47: 302–10.
- Sharikabad MN, Ostbye KM, Brors O. Increased [Mg2+]O reduces Ca2+ influx and disruption of mito-chondrial membrane potential during reoxygenation. Am J Physiol Heart Circ Physiol 2001; 281: H2113–23.
- Boland R, Martonosi A, Tillack TW. Developmental changes in the composition and function of sarcoplas-mic reticulum. J Biol Chem 1974; 249: 612–23.
- Corno AF, Bethancourt DM, Laks H et al. Myocardial protection in the neonatal heart; a comparison of topical hypothermia and crystalloid and blood cardioplegia solutions. J Thorac Cardiovasc Surg 1987; 93: 163–72.
- Fujiwara T, Heinle J, Britton L, Mayer Jr. Myocardial preservation in neonatal lambs: comparison of hypothermia with crystalloid and blood cardioplegia. J Thorac Cardiovasc Surg 1991; 101: 703–12.
- Pearl JM, Laks H, Drinkwater DC et al. Normocalcemic blood or crystalloid cardioplegia provides better neonatal myocardial protection than does low-calcium car-dioplegia. J Thorac Cardiovasc Surg 1993; 105: 201–6.
- Rosenkranz ER, Okamoto F, Buckberg GD et al. Safety of prolonged aortic clamping with blood cardioplegia III. Aspartate enrichment of glutamate-blood cardio-plegia in energy depleted hearts after ischemic and reperfusion injury. J Thorac Cardiovasc Surg 1986; 91: 428–35.
- Jarmakani JM, Nagatomo T, Langer GA. The effect of calcium and high phosphate compounds on myocardial contracture in the newborn and adult rabbit. J Mol Cell Cardiol 1978; 10: 1017–23.
- Tsukube T, McCully JD, Federman M, Krukenkamp IB, Levitsky S. Developmental differences in cytosolic calcium accumulation associated with surgically induced global ischemia. Optimization of cardioplegic protection and mechanism of action. J Thorac Cardiovasc Surg 1996; 112: 175–84.
- Aoki M, Nomura F, Kawata H, Mayer JE Jr. Effect of calcium and preischemic hypothermia on recovery of myocardial function after cardioplegic ischemia in neonatal lambs. J Thorac Cardiovasc Surg 1993; 105: 207–13.
- Allen BS, Okamoto F, Buckberg GD, Bugyi HI, Leaf J. Studies of controlled reperfusion after ischemia IX. Reperfusate composition: benefits of marked hypocal-cemia and diltiazem on regional recovery. J Thorac Cardiovasc Surg 1986; 92 (Suppl): 564–72.
- Kronon M, Bolling KS, Allen BS et al. The relationship between calcium and magnesium in pediatric myocar-dial protection. J Thorac Cardiovasc Surg 1997; 114: 1010–19.
- McCully JD, Levitsky S. Mechanisms of in vitro car-dioprotective action of magnesium on the aging myocardium. Magnesium Res 1997; 10: 157–68.
- Lareau S, Boyle AJ, Stewart LC et al. The role of magnesium in myocardial preservation. Magnesium Res 1995; 8: 85–97.
- Sha Kerinia T, Ali IM, Sullivan JA. Magnesium in car-dioplegia: is it necessary? Can J Surg 1996; 39: 397–400.
- Caspi J, Rudis E, Bar I, Safadi T, Saute M. Effects of magnesium on myocardial function after coronary artery bypass grafting. Ann Thorac Surg 1995; 59: 942–7.
- Hearse DJ, Stewart DA, Braimbridge MV. Myocardial protection during ischemic cardiac arrestathe importance of magnesium in cardioplegic infusates. J Thorac Cardiovasc Surg 1978; 75: 877–85.
- Kronon MT, Allen BS, Halldorsson A et al. Delivery of a nonpotassium modified maintenance solution to enhance myocardial protection in stressed neonatal hearts: a new approach. J Thorac Cardiovasc Surg 2001; 23: 119–29.
- Kronon M, Allen BS, Hernan J et al. Superiority of magnesium cardioplegia in neonatal myocardial protection. Ann Thorac Surg 1999; 68: 2285–95.
- Hanafy HM, Allen BS, Winkelmann BS et al. Warm blood cardioplegic induction: an underused modality. Ann Thorac Surg 1994; 58: 1589–94.
- Allen BS, Rosenkrantz ER, Buckberg GD et al. Studies of prolonged regional ischemia. VI. Myocardial infraction with left ventricular power failure: a medical/surgical emergency requiring urgent revascularization with maximal protection of remote muscle. J Thorac Cardiovasc Surg 1989; 98: 691–703.
- Kirklin J, Barratt-Boyes B. Myocardial management during cardiac surgery with cardiopulmonary bypass. In: J Kirklin, B Barrett-Boyes, eds. Cardiac Surgery, 2nd edn. New York: Churchill Livingstone, 1993: 129–66.
- Julia P, Kofsky ER, Buckberg GD, Young HH, Bugyi HI. Studies of myocardial protection in the immature heart. I. Enhanced tolerance of immature versus adult myocardium to global ischemia with reference to metabolic differences. J Thorac Cardiovasc Surg 1990; 100: 879–87.
- Kronon M, Allen BS, Bolling KS et al. The role of cardio-plegic induction temperature and amino acid enrichment in neonatal myocardial protection. Ann Thorac Surg 2000; 70: 756–64.
- Kofsky E, Julia P, Buckberg GD, Young H, Tixier D. Studies of myocardial protection in the immature heart. V. Safety of prolonged aortic clamping with hypocal-cemic glutamate/aspartate blood cardioplegia. J Thorac Cardiovasc Surg 1991; 101: 33–43.
- Jones RN, Peyton RB, Sabine RL. Transmural gradient in high-energy phosphate content in patients with coronary artery disease. Ann Thorac Surg 1981; 32: 546–53.
- Reed M, Barak C, Malloy C, Maniscalco S, Jessen M. Effects of glutamate and aspartate on myocardial substrate oxidation during potassium arrest. J Thorac Cardiovasc Surg 1996; 112: 1651–60.
- Landymore RW, Marvle AE, MacAulay MA, Li QY, Fris J. Oxygenated cardioplegia ameliorates the adverse effects of small amplitude electrical recording of activity on myocardial, metabolic and functional recovery. Eur J Cardiothorac Surg 1991; 5: 37–40.
- Lucchese B. Myocardial ischemia, reperfusion and free radical injury. Am J Cardiol 1990; 65: 14I–23I.
- Kronon MT, Allen BS, Rahman SK et al. Reducing postischemic reperfusion damage in neonates using a terminal warm substrate enriched blood cardioplegic reperfusate. Ann Thorac Surg 2000; 70: 765–70.
- Verrier ED, Boyle EMJ. Endothelial cell injury in cardiovascular surgery. Ann Thorac Surg 1996; 62: 915–22.
- Boyle, EM Jr, Pohlman TH, Cornejo CJ, Verrier ED. Ischemia-reperfusion injury. Ann Thorac Surg 1997; 64: S24-30.
- Follette D, Fey K, Buckberg GD et al. Reducing postis-chemic damage by temporary modification of reper-fusate calcium, potassium, pH, and osmolarity. J Thorac Cardiovasc Surg 1981; 82: 221–38.
- Teoh KH, Christakis GT, Weisel RD et al. Accelerated myocardial metabolic recovery with terminal warm blood cardioplegia. J Thorac Cardiovasc Surg 1986; 91: 888–95.
- Taggart D, Hadjinikolas L, Hooper J et al. Effects of age and ischemic times on biochemical evidence of myocar-dial injury after pediatric cardiac operations. J Thorac Cardiovasc Surg 1997; 113: 728–35.
- Chaturvedi R, Lincoln C, Gothard J et al. Left ventricular dysfunction after open repair of simple congenital heart defects in infants and children: quantitation with the use of a conductance catheter immediately after bypass. J Thorac Cardiovasc Surg 1998; 115: 77–83.
- Kronon MT, Allen BS, Halldorsson A et al. L-arginine, prostaglandin, and white cell filtration equally improve myocardial protection in stressed neonatal hearts. J Thorac Cardiovasc Surg 1999; 118: 665–73.
- Pearl JM, Drinkwater DC, Laks H. Leukocyte depleted reperfusion of transplanted human hearts: a randomized, double-blind clinical trial. J Heart Lung Transpl 1992; 11: 1082–92.
- Sawa Y, Matsuda H. Myocardial protection with leukocyte depletion in cardiac surgery. Semin Thorac Cardiovasc Surg 2001; 13: 73–81.
- Hayashi Y, Sawa Y, Nishimura M et al. Clinical evaluation of leukocyte-depleted blood cardioplegia for pedi-atric open heart operation. Ann Thorac Surg 2000; 69: 1914–19.
- Jewett PH, Kissmeyer-Nielsen P, Wolff B, Qvist N. Randomized comparison of leukocyte-depleted versus buffy-coat-poor blood transfusion and complications after colorectal surgery. Lancet 1996; 348: 841–5.
- Sawa Y, Taniguchi K, Kadoba K et al. Leukocyte depletion attenuates reperfusion injury in patients with left ventricular hypertrophy. Circulation 1996; 93: 1640–6.
- Allen BS, Winkelmann JW, Hanafy HM et al. Retrograde cardioplegia does not perfuse the right ventricle. J Thorac Cardiovasc Surg 1995; 109: 1116–26.
- Allen BS, Evans-Murcia D, Hartz RS. Integrated cardio-plegia allows complex valve repairs in all patients. Ann Thorac Surg 1996; 62: 23–30.
- Gates RN, Laks HL, Drinkwater DC et al. The microvas-cular distribution of cardioplegia solution in the piglet heart. J Thorac Cardiovasc Surg 1993; 105: 845–53.
- Buckberg GD, Beyersdorf F, Kato NS. Technical considerations and logic of antegrade and retrograde blood cardioplegic delivery. Sem Thorac Cardiovasc Surg 1993; 5: 125–33.
- Sawatari K, Kadoba K, Bergner B, Mayer JE Jr. Influence of initial reperfusion pressure after hypothermic cardio-plegic ischemia on endothelial modulation of coronary tone in neonatal lambs. J Thorac Cardiovasc Surg 1991; 101: 777–82.
- Kronon MT, Bolling KS, Allen BS et al. The importance of monitoring cardioplegia infusion pressure in neonatal myocardial protection. Ann Thorac Surg 1998; 66: 1358–64.
-
Buckberg GD,
Allen BS,
Beyersdorf F.
Blood cardio-plegic strategies during adult cardiac operations.
In:
HM Piper,
CJ Preusse, eds.
Ischemia-Reperfusion in Cardiac Surgery.
Kluwer Academic: Norwell, Mass,
1993:
181–227.
10.1007/978-94-011-1713-5_7 Google Scholar
- Buckberg GD, Beyersdorf F, Allen BS, Robertson JR. Integrated myocardial management. Background and initial application. J Cardiac Surg 1995; 10: 68–89.
- Fujiwara T, Kurtts T, Anderson W, Heinke J, Mayer JE Jr. Myocardial protection in cyanotic neonatal lambs. J Thorac Cardiovasc Surg 1988; 96: 700–10.
- Rebeyka I, Hanan SA, Borges MR et al. Rapid cooling contracture of the myocardium. J Thorac Cardiovasc Surg 1990; 100: 240–9.
- Gates RN, Laks H, Drinkwater DC et al. The microvas-cular distribution of cardioplegia solution in the piglet heart-retrograde vs. antegrade delivery. J Thorac Cardiovasc Surg 1993; 105: 845–53.
- Partington MT, Acar C, Buckberg G et al. Studies of retrograde cardioplegia II. Nutritive blood flow distribution in normal and jeopardized myocardium. J Thorac Surg 1989; 97: 613.
- Buckberg GD, Coghlan HC, Hoffman JIE, Torent-Quasp F. The structure and function of the helical heart and its buttress wrapping. VII. Critical importance of the septum for right ventricular function. Semin Thorac Cardiovasc Surg 2001; 13: 402–16.
- Jarmakani JM, Graham TP, Canent RV, Jewett PH. Left heart function in children with tetralogy of Fallot before and after palliative or corrective surgery. Circulation 1972; 46: 478–90.
- Rocchini AP, Keane JF, Cantaneda AR, Nadas AS. Left ventricular function following attempted surgical repair of tetralogy of Fallot. Circulation 1978; 57: 798–802.