Retrograde hot-shot cardioplegia in patients with left ventricular hypertrophy undergoing aortic valve replacement.
BACKGROUND
Intermittent antegrade cold-blood cardioplegia followed by terminal warm-blood cardioplegic reperfusion or hot-shot is reported to reduce myocardial injury in the setting of coronary surgery. The efficacy of this cardioplegic technique in patients with left ventricular hypertrophy secondary to aortic stenosis remains uncertain.


METHODS
Thirty-six patients with left ventricular hypertrophy undergoing aortic valve replacement were prospectively randomized to cold-blood cardioplegia either alone (cold-blood cardioplegia group) or with retrograde hot-shot (hot-shot group). Reperfusion injury was assessed by measuring myocardial levels of adenosine triphosphate and lactate in left and right ventricular biopsies taken 5 minutes after institution of cardiopulmonary bypass and 20 minutes after removal of cross-clamp using high-performance liquid chromatography and enzymatic techniques. Myocardial injury was assessed by serial release of troponin I up to 48 hours postoperatively. Overall clinical outcome was prospectively collected.


RESULTS
Baseline and intraoperative characteristics were similar between groups. In the hot-shot group, there were no significant changes in the myocardial concentration of adenosine triphosphate and lactate in both left and right ventricular biopsies after reperfusion. In the cold-blood cardioplegia group, there was a trend to a fall in adenosine triphosphate levels in the left and right ventricular biopsies after reperfusion, but this reached statistical significance only in the right ventricle. Troponin I release was raised in both groups at 4 and 12 hours after surgery (p < 0.05), but did not reach levels of myocardial infarction.


CONCLUSIONS
The terminal retrograde hot-shot reperfusion does not add any extra benefit to antegrade cold-blood cardioplegia in preventing myocardial injury in patients with left ventricular hypertrophy undergoing aortic valve replacement. Nevertheless, it appears to reduce ischemic stress in the right ventricle. There was no difference in clinical outcome between groups.
Ascione
Raimondo
R
Bristol Heart Institute, University of Bristol, Bristol, United Kingdom. r.ascionen@bristol.ac.uk
Suleiman
Saadeh M
SM
Angelini
Gianni D
GD
D000368:Aged; D001024:Aortic Valve Stenosis / Q000000981:diagnostic imaging / Q000601:surgery*; D002314:Cardioplegic Solutions; D002315:Cardiopulmonary Bypass / Q000379:methods; D003080:Cold Temperature; D017548:Echocardiography, Transesophageal; D017558:Elective Surgical Procedures; D005260:Female; D005500:Follow-Up Studies; D006324:Heart Arrest, Induced / Q000009:adverse effects / Q000379:methods*; D006350:Heart Valve Prosthesis; D019918:Heart Valve Prosthesis Implantation / Q000379:methods*; D006358:Hot Temperature; D006801:Humans; D017379:Hypertrophy, Left Ventricular / Q000150:complications*; D008297:Male; D008875:Middle Aged; D015428:Myocardial Reperfusion Injury / Q000209:etiology / Q000503:physiopathology*; D011446:Prospective Studies; D018570:Risk Assessment; D012680:Sensitivity and Specificity; D015996:Survival Rate; D016896:Treatment Outcome
D002314:Cardioplegic Solutions