Topic 11B Flashcards
Two Main Goals of Cardioplegia
- Prevent myocardial ischemic damage (induction/maintenance)
- Prevent/minimize injury (reperfusion)
limit detrimental changes such as (7)
- rapid cellular conversion from aerobic (O2) to anaerobic metabolism (no O2)
- high-energy phosphate (e.g. ATP) depletion
- intracellular acidosis
- calcium influx
- cell membrane disruption
- Intracellular Ca++ accumulation
- Cellular edema (inability to consume oxygen)
Cardioplegia Setups include:
crystalloid
blood
MPS
Crystalloid=
Single pass system
Blood cardioplegia setup=
- Fixed ratio (Bridged or Non-bridged)
2. Variable/controlled ratio
MPS=
microcardioplegia
3 Phases of Cardioplegia include
Induction of arrest
Maintenance of arrest
Reperfusion
Cold Induction Solutions (Crystalloid and Blood)= (4)
- ECF cardioplegia solution
- Potassium depolarization arrest
- Depolarizes the cardiac myocyte with hyperkalemia
- Ca++ ATPase and Na+/K+ATPase still operative and need energy
Pure Crystalloid Cardioplegia Induction:
Advantages (4)
History of use
Ease
Cheap
Low viscosity
Pure Crystalloid Cardioplegia Induction:
Disadvantages (6)
Cellular edema Low O2 capacity Left shift oxy-Hgb curve Activates platelets, leukocytes, and complement Impaired membrane stabilization Hemodilution
Generic Crystalloid Solutions: Lactated Ringer’s 1000 mL KCL= MgCl= Mannitol= NaHCO2=
KCL 20 mEq
MgCl 32 mEq
Mannitol 12.5 g
NaHCO2 6.5 mEq
Lactated Ringer’s 1000 mL: What do you add prior to use?
Procaine 10% 2.7 mL
Generic Crystalloid Solutions: Normosol 1000 mL NaHCO2= KCL= Mannitol=
NaHCO2 35 mEq
KCL 35 mEq
Mannitol 25% 12.5 g
Normosol 1000 mL: What do you give prior to use? (3)
Lidocaine 75 mg
Ntg 500 mcg
Albumin 25% 12.5 g
Cold Blood Cardioplegia Induction
Advantages (4)
O2 carrying capacity
Reduced hemodilution
Buffering/oncotic effects
O2 radical scavengers present
Cold Blood Cardioplegia Induction
Disadvantages (3)
Sludging
Oxy-Hgb curve disruption
Possible red cell damage
Warm Blood Cardioplegia Induction
Advantages (3)
Improved aerobic metabolism
Improved LV function
Improves compromised hearts
Warm Blood Cardioplegia Induction
Disadvantages
Expensive due to additives
Low Potassium Maintenance= (3)
- Usually every 15 to 20 minutes
- Cold blood cardioplegia or crystalloid
- Restores arrest post wash-out
Preparation for Reperfusion= (6)
Substrate-enhanced warm cardioplegia Limit calcium Limit PO2 Controlled reperfusion De-air adequately Avoid ventricular distension
Know the SV per tubing size
look at lab notes from last quarter
Controlled reperfusion=
The endothelium is damaged during ischemia–damage can increase through unregulated reperfusion
•Upon XC Removal: MAP → 40 mmHg for 1-2 minutes then MAP→ 70 mmHg after 2 minutes
Hot Shot=
- Just prior to removal of the aortic cross clamp
- In addition to cross clamp drugs
Cross clamp drugs (4)
Aspartate Glutamate Tham Dextrose CPD --Due to cost: warm blood may be substituted
Custodial Cardioplegia =(HTK)
Histidine Tryptophan Ketoglutarate
Custodial Cardioplegia (HTK): Intracellular cardioplegia solution (4)
Low sodium concentration
Histidine
Tryptophan
Mannitol
Benefits of HTK Cardioplegia: Initial use
organ protection
Benefits of HTK Cardioplegia: Now used in cardiac surgery because (3)
Longer safe time of ischemia
During valve surgery
Minimally invasive procedures
Del Nido Solution (4:1)=
Plasmalyte base which is similar to ECF
Warm Continuous Retrograde Blood Cardioplegia:
Lichtenstein (1991) suggested that the heart
could be maintained at
37ºC throughout the cross clamp period to enhance perioperative myocardial function
Warm Continuous Retrograde Blood Cardioplegia:
“Warm Heart Trial” (1994): Studied nearly 2000 patients randomized to normothermic or hypothermic cardioplegia– they found that…
Normothermic patients experienced a lower incidence
of post-operative low output syndrome with no differences in mortality or myocardial infarction
Warm retrograde cardioplegia flow must be
> 100 mL/min to minimize myocardial lactate production
Cross clamp drugs right after cross clamp removal
lidocaine
mannitol
Single Clamp Technique=
One clamp episode
One unclamp episode
Distals and proximals done during one ischemic time
Single Clamp Technique is used with
Used with calcified stiff aortas
Side Biting Clamp Technique=
Two clamp episodes
Two unclamping episodes
Distals done during first ischemic time
Proximals done during second ischemic time
Side Biting Clamp Technique has shorter
cross clamp times
Side Biting Clamp Technique= Ischemic time is
only with fully clamped aorta
Intermittent Crossclamp=
Increased risk of stroke
Not commonly used
Intermittent Crossclamp: clamp time is
the sum of all fully ischemic times
Fibrillatory Arrest=
Creates a nearly motionless heart by placing an
alternating current generator in contact with the left
ventricle
Fibrillatory Arrest: Left side of heart can be
opened without the fear of ejecting air into the aorta.
Fibrillatory Arrest: Should be used in conjunction with
hypothermia
Fibrillatory Arrest: Advantages
Avoid cross clamp
Quiescent heart with coronary perfusion
Fibrillatory Arrest: Disadvantages
Higher energy requirement than arrested heart
Spontaneous ejection will result in air emboli
Fibrillatory Arrest: Keep ____ elevated
MAP
Additional Strategies to Enhance Protection (7)
Anesthetic agents (↑ preconditioning) Acute normovolemic hemodilution (↓ A fib) Neutrophil depletion (↓ V fib) Erythropoietin (↓ myocardial injury) N-acetylcysteine (↓ oxidative stress) Deferoxamine (↓lipid peroxidation) Statins (↑NO release)
Anesthetic agents does what?
(↑ preconditioning)
Acute normovolemic hemodilution does what?
(↓ A fib)
Neutrophil depletion does what?
(↓ V fib)
Erythropoietin does what?
(↓ myocardial injury)
N-acetylcysteine does what?
(↓ oxidative stress)
Deferoxamine does what?
(↓lipid peroxidation)
Statins does what?
(↑NO release)
Monitoring Effectiveness for the Perfusionist
•GOAL:
optimize uniformity and effectiveness of delivery (especially retrograde) •Temperature •pH •Electrical Activity
Monitoring-Temperature: Thermo coupled needle usually inserted
septal muscle
myocardial temp probe
Monitoring-Temperature: Ensure delivery of
adequate dose (is it going where it belongs?)
Monitoring-Temperature: See efficacy of delivery
•Antegrade-
•Retrograde-
- Antegrade-cases of aortic insufficiency
* Retrograde-cannula position ( in RA?)
Monitoring-Temperature: Determine when
next dose needed
timers
What can the perfusionist do if arrest is not occurring as
expected?
is aortic valve competent/insufficient
did it go the the LV
change from antegrade to retrograde
is the aortic clamp not on all the way (dilutes cardioplegia)
low K instead of high K?
bridge open or closed?
hypertrophied LV walls require a higher pressure
Temperatures effect on pH and partial pressure assuming O2 content is constant: Increase temp=
Shift curve to the right Decrease HOH Increase H+ Increase OH- Decrease pH
Temperatures effect on pH and partial pressure assuming O2 content is constant: Decrease temp=
Shift curve to the left Increase HOH Decrease H+ Decrease OH- Increase pH
Failure to arrest can be due to
Aortic insufficiency Cross-clamp or cardioplegia needle malpositioned Inadequate solution (low potassium) Low flow? Low pressure? Temperature?
Myocardial Protection for Off-Pump Procedures:
Regional ischemia unavoidable- May become…
global problem when multiple vessels grafted
Myocardial Protection for Off-Pump Procedures:
Use of suction-based stabilizers has reduced the problem of
working on a moving target
•Provide good exposure without excess compression of
ventricle
Myocardial Protection for Off-Pump Procedures:
Ischemic preconditioning=
Brief period of vessel occlusion before occluding for
construction of the anastomosis
Myocardial Protection for Off-Pump Procedures:
Keep normal to high…
systemic blood pressure
•May increase flow through collaterals
vessels
Myocardial Protection for Off-Pump Procedures:
Attach proximal end of graft before
attaching distal
•Immediate re-establishment of flow to ischemic area
Myocardial Protection for Off-Pump Procedures:
Use of _______ shunt
intracoronary
Myocardial Protection for Off-Pump Procedures:
Perfusion-assisted…
direct coronary artery bypass (PADCAB)
•Perfuse completed grafts
Ingredients to know (7)
K+ Na+ Ca++ NaHCO3 THAM Glucose Mannitol
Actions of K+
electromechanical arrest
Actions of Na+
↓ edema/intracelluar Ca++ buildup
Actions of Ca++
Membrane stabilization
Actions of NaHCO3
↑ pH
Actions of THAM
↑ pH
Actions of Glucose
Substrate, ↑ Osmolarity, ↓ edema
Actions of Mannitol
↑ Osmolarity
Solution Concentrations: KCl
High K
Low K
High K= 100 mmol/L
Low K= 40 mmol/L
Solution Concentrations: THAM
High K
Low K
High K= 12 mmol/L
Low K= 12 mmol/L
Solution Concentrations: MgSO4
High K
Low K
High K= 9 mmol/L
Low K= 9 mmol/L
Solution Concentrations: Dextrose
High K
Low K
High K= 250 mmol/L
Low K= 250 mmol/L
Solution Concentrations: CPD
High K
Low K
High K= 20 ml
Low K= 20 ml