Intraoperative myocardial protection: current trends and future perspectives Gideon Cohen, MD, Michael A Borger, MD, Richard D Weisel, MD, Vivek Rao,

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Presentation transcript:

Intraoperative myocardial protection: current trends and future perspectives Gideon Cohen, MD, Michael A Borger, MD, Richard D Weisel, MD, Vivek Rao, MD, PhD The Annals of Thoracic Surgery Volume 68, Issue 5, Pages 1995-2001 (November 1999) DOI: 10.1016/S0003-4975(99)01026-7

Fig 1 Myocardial oxygen consumption (MVO2) and myocardial lactate consumption (MVL) after cross-clamp release. The MVO2 was higher in the low-flow, low hemoglobin (Hgb) group. Lactate production was not significantly different. (Reprinted with permission from Yau TM, Weisel RD, Mickle DAG, et al. Optimal delivery of blood cardioplegia. Circulation 1991;84(Suppl III):380–8.) The Annals of Thoracic Surgery 1999 68, 1995-2001DOI: (10.1016/S0003-4975(99)01026-7)

Fig 2 Relation between left ventricular stroke work index (LVSWI) and pulmonary capillary wedge pressure (PCWP) before cardiopulmonary bypass (PRE), as well as 1 hour (1 HR) and 4 hours (4 HRS) after cardiopulmonary bypass is depicted. Tepid perfusion resulted in greater LVSWI versus cold or warm at 1 hour following cardiopulmonary bypass, and versus cold at 4 hours following cardiopulmonary bypass despite similar filling pressures (PCWP). (Reprinted with permission of the Society of Thoracic Surgeons, from Hayashida N, Weisel RD, Shirai T, et al. Tepid antegrade and retrograde cardioplegia. Ann Thorac Surg 1995;59:723–9.) The Annals of Thoracic Surgery 1999 68, 1995-2001DOI: (10.1016/S0003-4975(99)01026-7)

Fig 3 Myocardial metabolism during reperfusion: myocardial oxygen extraction, lactate extraction, and acid release before aortic cross-clamping, immediately, 5, and 10 minutes after cross-clamp (XCL) removal, and 5 and 10 minutes after discontinuation of cardiopulmonary bypass (CPB). Lactate extraction recovered more quickly in the simultaneous group than in the alternate group (p = 0.03 by ANOVA), and lactate extraction was greater 10 minutes on CPB and 10 minutes after CPB. No differences in oxygen extraction or acid release were detected between groups. (Reprinted with permission from Shirai T, Rao V, Weisel RD, et al. Antegrade and retrograde cardioplegia: alternate or simultaneous? J Thorac Cardiovasc Surg 1996;112:787–96.) The Annals of Thoracic Surgery 1999 68, 1995-2001DOI: (10.1016/S0003-4975(99)01026-7)

Fig 4 Postoperative cardiac function. The relation between left ventricular stroke work index or cardiac index and pulmonary capillary wedge pressure (PCWP) is depicted. Left ventricular stroke work index decreased in both groups postoperatively (time p < 0.0001). The decrease was greater in the simultaneous group than the alternate group (p = 0.04 by analysis of covariance). Stroke work index was lower in the simultaneous group 4 hours after the operation at a higher wedge pressure. Cardiac index increased (time p = 0.017) similarly in both groups after the operation. (Reprinted with permission from Shirai T, Rao V, Weisel RD, et al. Antegrade and retrograde cardioplegia: alternate or simultaneous? J Thorac Cardiovasc Surg 1996;112:787–96.) The Annals of Thoracic Surgery 1999 68, 1995-2001DOI: (10.1016/S0003-4975(99)01026-7)

Fig 5 (Upper Panel) Myocardial lactate flux during and after cardioplegic arrest. Patients who received insulin enhanced cardioplegia displayed lactate extraction immediately after cross-clamp removal compared to persistent lactate release in the placebo group. (Lower Panel) Left ventricular function at similar filling pressures was better preserved in the insulin cardioplegia group after 2 hours of reperfusion. (LVEDP = left ventricular end diastolic pressure.) The Annals of Thoracic Surgery 1999 68, 1995-2001DOI: (10.1016/S0003-4975(99)01026-7)