Myocardial protection by pressure- and volume-controlled continuous hypothermic coronary perfusion (PVC-CONTHY-CAP) in combination with ultra-short beta-blockade and nitroglycerine.
The aim of the study was to validate clinically a new technique of myocardial protection developed for intra- and extra-cardiac surgery on the beating heart. The concept combines the principle of continuous pressure- and volume-controlled coronary artery perfusion (PVC-CONTHY-CAP) with the specific myocardioprotective effects of hypothermia and nitrates and, on the other hand, with the beta-blocker-mediated reduction of chronotropy and inotropy necessary for convenient surgery. Under standard ECC conditions after cross-clamping the aorta coronary perfusion with oxygenated blood enriched with nitroglycerine (10 micrograms/kg/h) and esmolol (0.05 mg/ml flow/min) is started via an additional perfusion cannula placed in the aortic root. The temperature of the perfusate is maintained at 32 degrees C, the intraaortic pressure at 40-70 mmHg and the perfusion flow in the range 0.8-1.0 ml/g heart muscle/min. In CABG procedures an additional perfusion catheter is used for perfusion of distal coronary artery segments. Using this technique 100 consecutive patients, adults and children, were operated on between 2/96 and 8/96. In 84 adult patients (age: 45-82 yrs), 78 CABG procedures (54 elective, 13 urgent, 11 acute) with a mean bypass count of 3.7 (range 1-7), 69 ITA grafts, 72 grafts to CX, and 3 MVRec/MVRpl, and 6 pure MVRec/MVRpl procedures (1 urgent, 1 emergency) were performed. The mean coronary perfusion time was 48 min (range 21-88 min). In 5 patients perioperative infarction (CABG; 1 emergency after PTCA, 4 elective) with significant increase of CK-MB values (57-98 U/L) occurred. In the 4 elective patients (3 with diabetes mellitus) re-intervention was not possible due to small-vessel disease. In one patient with preoperative infarction IABP was necessary. No patient died. There were 16 children (age: 4weeks-16 yrs): VSD, n = 6, AV-C, n = 2, TOF, n = 1, MVRec, n = 1, DORV (Rastelli), n = 2, SV (TCPC), n = 3, and PV obstruction, n = 1. The mean coronary perfusion time was 97 min (range: 27-260 min). The mean ICU stay 3.9 d (range: 1-10 d). One child died (TCPC) on the 10th postoperative day due to multi-organ failure. In conclusion, PVC-CONTHY-CAP is designed especially for emergency and urgent procedures, i.e. patients with PTCA-related complications, patients with severely depressed LV function, and patients with complex congenital cyanotic heart defects. Using PVC-CONTHY-CAP, coronary artery bypass grafting as well as intracardiac procedures for congenital and acquired heart defects can be performed safely and conveniently, the system is easy to handle for both the cardiac surgeon and perfusionist. Due to its pharmacological properties continuous intracoronary application of nitrates in combination with hypothermia seems to be essential as a preventive treatment modality for the ischemic state.
Borowski
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Department of Cardiovascular Surgery, University of Cologne, Germany.
Korb
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H
D000293:Adolescent; D000319:Adrenergic beta-Antagonists / Q000627:therapeutic use*; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002315:Cardiopulmonary Bypass / Q000379:methods*; D002648:Child; D002675:Child, Preschool; D003131:Combined Modality Therapy; D001026:Coronary Artery Bypass / Q000379:methods*; D004630:Emergencies; D006330:Heart Defects, Congenital / Q000601:surgery*; D006801:Humans; D007036:Hypothermia, Induced / Q000379:methods*; D007223:Infant; D007231:Infant, Newborn; D007902:Length of Stay; D008875:Middle Aged; D005996:Nitroglycerin / Q000627:therapeutic use*; D011412:Propanolamines / Q000627:therapeutic use*; D015203:Reproducibility of Results; D013997:Time Factors; D014665:Vasodilator Agents / Q000627:therapeutic use*
D000319:Adrenergic beta-Antagonists; D011412:Propanolamines; D014665:Vasodilator Agents; D005996:Nitroglycerin; C036604:esmolol