Cardiomyocyte apoptosis after antegrade and retrograde cardioplegia during aortic valve surgery
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Published on: October 27, 2020
Tommi Vähäsilta1, Markus Malmberg, Antti Saraste
1Department of Surgery, Turku University Hospital, University of Turku, Turku, Finland.
Insights
Retrograde cardioplegia increased cardiomyocyte apoptosis and impaired heart function after aortic valve replacement compared to antegrade delivery, indicating inadequate myocardial protection.
Area of Science:
- Cardiovascular Surgery
- Cardiac Surgery
- Myocardial Protection
Background:
- Retrograde cardioplegia delivery may lead to uneven heart perfusion.
- The impact of retrograde versus antegrade cardioplegia on cardiomyocyte apoptosis and cardiac function is not well understood.
Purpose of the Study:
- To compare the effects of antegrade and retrograde cardioplegia on cardiomyocyte apoptosis and left ventricular function in patients undergoing aortic valve replacement.
Main Methods:
- A randomized clinical trial compared antegrade (n=10) and retrograde (n=10) cardioplegia during aortic valve replacement.
- Apoptosis was assessed using terminal transferase-mediated dUTP nick end labeling and caspase activation.
- Cardiac function was evaluated using echocardiography and MRI, alongside cardiac enzyme measurements.
Main Results:
- Retrograde cardioplegia significantly increased cardiomyocyte apoptosis in the left ventricle post-surgery (p=0.01).
- Immediate postoperative systolic function, assessed by mitral annulus movement, was reduced in the retrograde group.
- Left ventricle mass index showed a long-term reduction in the antegrade group from pre- to 9 months post-operation.
Conclusions:
- Retrograde cardioplegia is linked to increased cardiomyocyte apoptosis and impaired immediate systolic function post-aortic valve replacement.
- Unlike antegrade cardioplegia, retrograde delivery did not show favorable long-term left ventricle remodeling.
- These findings suggest that retrograde cardioplegia may offer inadequate myocardial protection compared to antegrade delivery.
Background:
Retrograde delivery is associated with inadequate perfusion of cardioplegia to all regions of the heart, but the effects on cardiomyocyte death and functional outcome remain unknown. We compared antegrade and retrograde cardioplegia in a randomized clinical trial to see whether it has effect on cardiomyocyte apoptosis and left ventricular function.
Methods:
Patients underwent elective aortic valve replacement surgery due to aortic valve stenosis. They were randomly allocated to receive antegrade (n = 10) or retrograde (n = 10) cardioplegia. Apoptotic cardiomyocytes (terminal transferase-mediated dUTP nick end labeling, caspase activation) and RNA levels of apoptosis-regulating proteins were studied in transmyocardial biopsies obtained before and after the operation. Magnetic resonance imaging and transesophageal echocardiography were performed, and cardiac enzymes were measured.
Results:
Clinical outcome and cardiac enzyme release were comparable between the groups. Cardiomyocyte apoptosis was significantly increased (terminal transferase-mediated dUTP nick end labeling) in the left ventricle after the operation in the retrograde, but not in the antegrade group (respectively, 0.00% [0.039%] versus 0.092% [0.205%], p = 0.01; and 0.00% [0.00%] versus 0.023% [0.054%], p = 0.14). Expression of apoptosis-regulating proteins BAX, BAD, and BCL-2 were comparable between groups. By transesophageal echocardiography, the systolic mitral annulus movement was decreased immediately after the operation in the retrograde group. By magnetic resonance imaging, the left ventricle mass index was reduced preoperatively to 9 months postoperatively in the antegrade group.
Conclusions:
In contrast to antegrade cardioplegia, retrograde cardioplegia is associated with increased cardiomyocyte apoptosis, impaired immediate postoperative systolic function, and lack of long-term favorable left ventricle remodeling after aortic valve replacement, suggesting inadequate myocardial protection.
