Continuous monitoring of myocardial acid-base status during intermittent warm blood cardioplegia.
OBJECTIVE
Intermittent warm blood cardioplegia (IWBC) is a well-established technique for myocardial protection during cardiac operations. According to standardized protocols, IWBC administration is currently performed every 15-20 min regardless of any individual variable and in the absence of any instrumental monitoring. We devised a new system for continuous measurement of the acid-base status of coronary sinus blood for on-line evaluation of myocardial oxygenation during IWBC.


METHODS
In 19 patients undergoing cardiac surgery for coronary artery bypass graft and/or valve surgery and receiving IWBC (34-37 degrees C) by antegrade induction (3 min) and retrograde or antegrade maintenance (2 min) every 15 min, continuous monitoring of myocardial oxygenation and acid/base status was performed by means of a multiparameter PO(2), PCO(2), pH, and temperature sensor (Paratrend7 (R), Philips Medical System) inserted into the coronary sinus.


RESULTS
Mean cross-clamping time was 76+/-26 min; ischemic time was 13+/-0.2 min. pH decline was not linear, showing an initial fast decline, a point of flexus, and a progressive slow decline. After every ischemic period, the pH adaptation curve showed a complex pattern reaching step-by-step lower minimum levels (7.28+/-0.14 during the first ischemic period, to 7.16+/-0.19 during the third ischemic period - P=0.003). PO(2) decreased rapidly at 90% in 5.0+/-1.2 min after every reperfusion. During ischemia, PCO(2) increased steadily at 1.6+/-0.1 mmHg per minute, with progressively incomplete removal after successive reperfusion, and progressive increase of maximal level (42+/-12 mmHg during the first ischemic period, to 53+/-23 mmHg during the third ischemic period - P=0.05).


CONCLUSIONS
Myocardial oxygen, carbon dioxide, and pH show marked changes after repeated IWBC. Myocardial ischemia is not completely reversed by standardized reperfusions, as reflected by steady deterioration of PCO(2) and pH after each reperfusion. Progressive increase of reperfusion durations or direct monitoring of myocardial oxygenation could be advisable in cases of prolonged cross-clamping time.
Graffigna
A C L
AC
Cardiac Surgery Unit, S. Chiara Hospital, Largo Medaglie d'Oro, 38100 Trento, Italy. graffigna@tn.aziendasanitaria.trentino.it
Nollo
G
G
Pederzolli
C
C
Ferrari
P
P
Widesott
L
L
Antolini
R
R
D000136:Acid-Base Equilibrium; D000368:Aged; D001769:Blood; D002245:Carbon Dioxide / Q000097:blood; D006348:Cardiac Surgical Procedures; D002315:Cardiopulmonary Bypass; D003331:Coronary Vessels; D005260:Female; D006324:Heart Arrest, Induced / Q000379:methods; D006801:Humans; D006863:Hydrogen-Ion Concentration; D008297:Male; D008875:Middle Aged; D016343:Monitoring, Intraoperative; D009206:Myocardium / Q000378:metabolism*; D010100:Oxygen / Q000097:blood
D002245:Carbon Dioxide; D010100:Oxygen