Strategies to improve myocardial protection during extracorporeal circulation

A recent survey of outcomes in 8,641 patients who underwent coronary artery bypass grafting (CABG) operations in northern New England indicates an overall mortality of 4.48%. (1) Importantly, 65% of all deaths could be directly attributed to postoperative heart failure. These data indicate that in spite of the dramatic improvements in myocardial protection that have been accomplished over the past decades, there is still room for improvement, in particular in high-risk patients who may poorly tolerate superimposition of perioperative ischemic damage on their underlying critical hemodynamic status. This paper reviews the major techniques in current clinical use with more emphasis on recent advances and possible perspectives. From a practical standpoint, a distinction can be made between strategies directly targeted at the myocardium and strategies that can indirectly enhance cardioprotection by attenuating the systemic inflammatory effects of cardiopulmonary bypass (CPB). These different approaches will thus be reviewed consecutively.