New strategies in myocardial preservation

Myocardial protection seems to be evolving toward simplified techniques, among which the use of minimally diluted tepid blood cardioplegia delivered retrograde or in a combined fashion is gaining wider clinical acceptance. In the future, agents that can duplicate the cardioprotective effects of ischemic preconditioning, prevent the cell-damaging calcium overload by inhibition of the sodium-hydrogen exchanger, and preserve endothelial function hold the greatest promises. The concept of hyperpolarized arrest (as opposed to the conventional potassium-induced depolarized arrest) also might be a breakthrough if it becomes clinically feasible. Finally, beating-heart (coronary) surgery without aortic cross-clamping possibly could be the ultimate form of myocardial protection, in particular if the inflammatory effects of cardiopulmonary bypass that adversely affect cardiac function can be mitigated by new developments in biomaterials and appropriate drug therapies.