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.

Keywords: Cold crystalloid cardioplegia (CCC); aortic valve replacement; myocardial protection; warm blood cardioplegia (WBC).

Figure 1

Postoperatively (at time 0, 24, 48 hours) release of creatine-phospho-kinase (CPK) expressed as U/L, and peak value. WBC, warm blood cardioplegia; CCC, cold crystalloid cardioplegia.

Figure 2

Postoperatively (at time 0, 24, 48 hours) release of creatine-kinase-MB (CK-MB) expressed as ng/mL, and peak value. WBC, warm blood cardioplegia; CCC, cold crystalloid cardioplegia; CPK, creatine-phospho-kinase.

Figure 3

Postoperatively (at time 0, 24, 48 hours) release of cardiac troponin I (cTnI) expressed as ng/mL, and peak value. WBC, warm blood cardioplegia; CCC, cold crystalloid cardioplegia.

Figure 4

Postoperatively (at time 0, 24, 48 hours) release of aspartate aminotransferase (AST) expressed as ng/mL, and peak value. WBC, warm blood cardioplegia; CCC, cold crystalloid cardioplegia.

Figure 5

Mean value (%) of the ratio greater than 10% between creatine kinase MB (CK-MB) and total creatine-phospho-kinase (CPK) postoperatively measured (at time 0, 24 and 48 hours). WBC, warm blood cardioplegia; CCC, cold crystalloid cardioplegia.