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Published on: November 19, 2019
Selective Vein Graft Cold Cardioplegia and Warm Reperfusion to Enhance Early Recovery in Patients with Left Ventricle
Pasquale Totaro1, Martina Musto1, Eduardo Tulumello2
1Cardiac Surgery, IRCCS Foundation Hospital San Matteo, 27100 Pavia, Italy.
Insights
Total antegrade cardioplegia infusion and warm reperfusion (TAWR) significantly improves early cardiac recovery in patients with depressed left ventricular function undergoing multi-vessel coronary artery bypass grafting (CABG). This strategy enhances spontaneous rhythm recovery and reduces the need for inotropic support post-surgery.
Area of Science:
- Cardiovascular Surgery
- Cardiac Anesthesia
- Myocardial Protection
Background:
- Antegrade root cardioplegia is standard for myocardial protection during coronary artery bypass grafting (CABG) with cardiopulmonary bypass (CPB).
- Patients with depressed left ventricular function (EF < 40%) undergoing multi-vessel CABG often require enhanced support for left ventricular recovery post-CPB.
- Severe multi-vessel coronary stenosis exacerbates the need for improved myocardial protection strategies in these vulnerable patients.
Purpose of the Study:
- To evaluate the efficacy of a novel myocardial protection strategy, total antegrade cardioplegia infusion and warm reperfusion (TAWR), in improving early postoperative recovery.
- To compare the TAWR strategy against standard antegrade root cardioplegia with limited warm reperfusion (SAWR) in patients with depressed left ventricular function undergoing multi-vessel CABG.
- To assess key outcomes including spontaneous rhythm recovery, inotropic support requirements, and troponin release.
Main Methods:
- A prospective study involving 97 patients undergoing CABG with TAWR, with 32 patients (Group A) meeting criteria for depressed left ventricular function (EF < 40%) and multi-vessel disease requiring ≥2 vein grafts.
- Group A was compared with 32 matched patients (Group B) who underwent CABG using the standard antegrade root cardioplegia and limited warm reperfusion (SAWR) strategy.
- Outcomes analyzed included in-hospital mortality, spontaneous rhythm recovery, early and prolonged inotropic support, and postoperative troponin levels.
Main Results:
- No significant difference in in-hospital mortality between the TAWR (Group A) and SAWR (Group B) groups (3.1%).
- TAWR significantly improved spontaneous recovery of idiopathic rhythm (90% in Group A vs. 53% in Group B, p=0.001).
- TAWR reduced the need for early inotropic support (28% in Group A vs. 53% in Group B, p=0.041) and prolonged inotropic support (>48h) (25% in Group A vs. 53% in Group B, p=0.039).
Conclusions:
- The total antegrade cardioplegia infusion and warm reperfusion (TAWR) strategy significantly enhances early postoperative cardiac recovery in patients with depressed left ventricular function undergoing multi-vessel CABG.
- TAWR demonstrates superior outcomes in spontaneous rhythm recovery and reduced reliance on inotropic support compared to the standard antegrade root cardioplegia and limited warm reperfusion (SAWR) strategy.
- The TAWR strategy is recommended as the preferred approach for myocardial protection in this high-risk patient subset.
Abstract:
Background: Antegrade root cardioplegia remains the most popular strategy for myocardial protection during coronary artery bypass graft (CABG) performed with cardiopulmonary bypass (CPB) and aortic cross clamp. In patients with depressed left ventricular function, however, especially if associated with severe multiple coronary stenosis, increased pharmacological and/or mechanical support in the early post-CPB period is often required to support left ventricular recovery. In this study, we analyzed the results of a myocardial protection strategy that includes selective infusion of cardioplegia through each venous graft followed by warm reperfusion distal to each coronary anastomosis until complete removal of the aortic clamp (total antegrade cardioplegia infusion and warm reperfusion = TAWR) to improve early postoperative recovery in patients with depressed left ventricular function undergoing multi-vessel CABG. Methods: Out of 97 patients undergoing CABG using the TAWR strategy for myocardial protection, 32 patients presented with depressed left ventricle function (EF < 40%) and multi-vessel coronary diseases requiring ≥2 vein grafts and were enrolled as Group A. Combined primary outcomes and postoperative early and late left ventricle recovery (including spontaneous rhythm recovery, inotropic support and postoperative troponin release) were analyzed and compared with those of 32 matched patients operated on using standard antegrade root cardioplegia and limited warm reperfusion through LIMA graft (SAWR) enrolled as Group B. Results: Two patient died in hospital (in-hospital mortality 3.1%) with no statistical differences between the two groups. In Group A 27 patients (90%) had spontaneous recovery of idiopathic rhythm compared to 17 (53%) in group B (p = 0.001). Early inotropic support was required in nine patients (28%) of group A and seventeen patients (53%) of group B (p = 0.041). Furthermore, in eight patients (25%) of group A and seventeen (53%) of group B (p = 0.039) inotropic support was continued for >48 h. Conclusions: The TAWR strategy seems to significantly improve early postoperative cardiac recovery in patients with left ventricle depression undergoing multi-vessel CABG, when compared with SAWR strategy and could therefore be considered the strategy of choice in this subset of patients.
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