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Myocardial protection in diabetics with left main stem disease: which is the best strategy?
F Onorati1, M De Feo, F Cerasuolo
1Department of Cardiothoracic and Respiratory Sciences, Second University of Naples, Naples, Italy.
Insights
For diabetic patients with left main stem disease (LMSD), a combined antegrade and retrograde cardioplegia route offers better biochemical and perioperative outcomes compared to antegrade-only delivery. This strategy improves myocardial protection during surgery.
Area of Science:
- Cardiology
- Cardiac Surgery
- Diabetology
Background:
- Diabetes mellitus is a significant risk factor for extensive coronary artery disease.
- Optimal cardioplegia administration in diabetic patients with severe ischemic heart disease, particularly left main stem disease (LMSD), remains debated.
- Myocardial protection strategies are crucial for managing these high-risk patients.
Purpose of the Study:
- To compare two distinct myocardial protection strategies in diabetic patients with LMSD undergoing coronary artery bypass grafting.
- To evaluate the efficacy of antegrade versus combined antegrade-retrograde cardioplegia delivery in this specific patient population.
Main Methods:
- A prospective study involving 90 diabetic patients with LMSD undergoing isolated myocardial revascularization between 2000 and 2003.
- Patients were randomized into two groups: antegrade cardioplegia (Group A, n=45) and antegrade followed by intermittent retrograde cardioplegia (Group B, n=45).
- Postoperative monitoring included ECG, cardiac biomarkers (Troponin I, MB-CPK), and echocardiography to assess myocardial injury and function.
Main Results:
- While major in-hospital outcomes like mortality and myocardial infarction were similar, Group B showed a shorter hospital stay (p=0.002).
- Group A had a higher incidence of postoperative atrial fibrillation (p<0.001) and required more inotropic support (p=0.006).
- Significantly lower Troponin I levels were observed in Group B from 12 to 72 hours postoperatively (p<0.0001), indicating less myocardial damage.
Conclusions:
- The combined antegrade and intermittent retrograde cardioplegia route demonstrates superior biochemical and perioperative results in diabetic patients with LMSD.
- This strategy offers enhanced myocardial protection, leading to better clinical outcomes despite similar major adverse events.
- Further research may refine cardioplegia delivery techniques for diabetic patients with complex coronary artery disease.
Aim:
Diabetes mellitus is a well known risk factor for extensive coronary disease. The optimal route for cardioplegia administration in patients with severe ischaemic heart disease undergone surgery, especially with left main stem disease (LMSD) is still under debate. Aim of the study is to compare 2 different strategies of myocardial protection in diabetics with LMSD.
Methods:
Between January 2000 and June 2003 90 consecutive patients with type II diabetes mellitus and LMSD undergoing isolated myocardial revascularization were divided into 2 groups according to the route of cardioplegia delivery: antegrade in 45 patients (group A), antegrade followed by intermittent retrograde in 45 (group B). ECG, Troponin I, MB-CPK, MB-CPK mass were performed at 12, 24, 48, and 72 hours postoperatively. Echocardiography was performed preoperatively and before hospital discharge.
Results:
Groups were homogeneous in preoperative and intraoperative variables, apart from higher incidence of unstable angina and longer cardiopulmonary bypass time in Group B and hypertension in Group A. Hospital deaths, in intensive care units (ITU) stay, perioperative acute myocardial infarction, intra-aortic balloon pump support, postoperative recovery of left ventricle ejection fraction and wall motion score index were similar in both groups. In hospital stay proved shorter in group B (p=0.002), whereas postoperative atrial fibrillation was higher in group A (p<0.001), as postoperative inotropic support (p=0.006). Troponin I proved significantly higher in group A from the 12 degrees to the 72 degrees postoperative hour (p<0.0001).
Conclusions:
Despite major in hospital end-points did not differ with strategy of cardioplegia administration, combined route of intermittent blood cardioplegia allows better biochemical and perioperative results in diabetics with LMSD.
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