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Lack of cardioplegia uniformity in clinical myocardial preservation
T L Demmy1, S P Haggerty, T M Boley
1Division of Cardiothoracic Surgery, University of Missouri, Columbia 65212.
Insights
This study reveals significant variability in cardioplegia solutions used during open heart surgery in Missouri. Many untested, customized cardioplegic admixtures are used, highlighting a need for further research, especially for high-risk patients.
Area of Science:
- Cardiology
- Cardiac Surgery
- Pharmacology
Background:
- Myocardial preservation advances improve survival after open heart surgery.
- Limited data exists on national/regional cardioplegia use patterns.
- Understanding current practices is crucial for optimizing cardiac surgical outcomes.
Purpose of the Study:
- To investigate regional patterns of cardioplegia solution use in open heart surgery.
- To characterize the composition of commonly used crystalloid and blood-based cardioplegic solutions.
- To identify variations from established formulations and potential areas for standardization.
Main Methods:
- A survey of all open heart surgery programs in Missouri was conducted.
- Data collected on cardioplegic solutions administered over a 1-year period.
- Analysis of solution composition, including crystalloid and blood-based types and their additives.
Main Results:
- 8,382 patients received cardioplegia from 61 surgeons across 26 hospitals.
- All cardioplegic solutions were hospital-produced, with significant diversity in formulations.
- Most crystalloid (69%) and blood-based (89%) solutions differed substantially from reported standards.
- Common additives included bicarbonate, glucose, and magnesium, but no calcium channel blockers or high-energy phosphates were reported.
Conclusions:
- Numerous untested, customized cardioplegic admixtures are in routine clinical use.
- The effectiveness of induced cardiac arrest and hypothermia may mask suboptimal solution efficacy.
- Further investigation into customized cardioplegia is warranted, particularly for high-risk patient populations.
Abstract:
Advances in myocardial preservation have led to improved patient survival after open heart operations. However, few studies have detailed the nature of national or regional patterns of cardioplegia use. To determine the regional pattern, all open heart surgery programs in Missouri were surveyed. During 1 year, it was found that cardioplegia was administered to 8,382 patients by 61 cardiothoracic surgeons at ten academic affiliated hospitals and 16 nonteaching hospitals. All cardioplegic solutions were hospital produced. Of 13 crystalloid solutions, 11 differed from one another and eight were intracellular formulations. Of 28 multidose blood-based cardioplegic solutions, there were 23 different mixtures. Most crystalloid (69%) and blood-based (89%) solutions differed substantially from commonly reported formulations. The incidences of the various additives to crystalloid solutions were as follows: bicarbonate, 92%; glucose, 69%; lidocaine, 54%; mannitol, 46%; magnesium, 31%; calcium, 23%; methylprednisolone, 15%; heparin, 8%; and acetate, 8%. Of the common blood-based cardioplegic solution additives, the following incidences were observed: glucose, 79%; bicarbonate, 43%; trishydroxyaminomethane, 36%; acetate, 29%; magnesium, 29%; procaine (or lidocaine), 25%; citrate-phosphate-dextrose, 18%; mannitol/albumin, 14%; nitroglycerin, 11%; glutamate/aspartate, 11%; calcium, 7%; insulin, 3%; and methylprednisolone, 3%. No calcium channel blocker or high-energy phosphate additives were reported. We conclude that many different cardioplegic admixtures that have not been tested experimentally are used routinely in clinical practice, presumably with acceptable results. Because the salutary effects of induced cardiac arrest and hypothermia may mask suboptimal solutions, further study of customized cardioplegia should be considered, particularly with regard to high-risk patients.