Comparative Analysis of the Effectiveness of Different Options for the Administration of Cardioplegic Solution during Surgical Correction of an Aortic Aneurysm Combined with Coronary Artery Lesions

Keywords: acute dissecting aortic aneurysm, coronary artery bypass grafting, ischemic heart disease, myocardial protection, Custodiol, antegrade/retrograde cardioplegia, coronary artery mesh dissection, coronary artery mesh plasty

Abstract

The aim. To determine the effectiveness of myocardial protection in various variants of administration of cardioplegic solution in patients with aortic aneurysms combined with coronary artery lesions.

Materials and methods. We analyzed 111 operations for aortic aneurysms combined with lesions of the coronary arteries, which were performed from 2011 to 2020 at the National Amosov Institute of Cardiovascular Surgery of the National Academy of Medical Sciences of Ukraine. The subjects were divided into four groups: group 1 where all three methods of cardioplegic solution administration (antegradely, retrogradely and into alloshunts) were used (60 [54.1%] patients), group 2 with administration of cardioplegic solution retrogradely and into alloshunts (48 [43.2%] patients), group 3 with antegrade and retrograde administration (2 [1.8%] patients), and group 4 with only retrograde administration of cardioplegic solution (1 [0.9%] patient). Of these operations, 19 (17.1%) were performed for acute type A aortic dissection, 4 (53.6%) for chronic type A aortic dissection, 88 (79.3%) for aortic aneurysm without dissection. The most common surgical interventions performed were: Robicsek procedure (41 [36.9%] interventions), Bentall – de Bono procedure (40 [36.0%] interventions), supracoronary ascending aortic replacement (22 [19.8%] operations), Wheat procedure (7 [6.3%] interventions).

Results. According to our results, the aortic cross-clamp time was longer in group 2 (p < 0.05). The average time of extubation in groups 1 and 2 did not differ significantly (p > 0.05). At the same time, the average time of stay of patients in the intensive care unit differed significantly (p < 0.05) in patients of groups 1 (168.92 ± 121.54 h) and 2 (199.35 ± 214.42 h), which indicates faster recovery of patients of group 1. We diagnosed a total of 34 (30.6%) complications in 111 operated patients. A significant number of complications, namely 20 (33.3%) cases, were observed in group 1. The most frequent complications in this group were atrial fibrillation which occurred in 4 (6.7%) cases and hemorrhagic complications which were observed in 3 (5.0%) cases; of these, 1 (1.7%) case was with hemothorax and hemopericardium (this patient underwent rethoracotomy), 1 (1.7%) with hemopericardium and tamponade, and 1 (1.7%) with hemothorax. Of the 111 operations analyzed, 5 (4.5%) cases turned out to be fatal.

Conclusions. The most effective method of introducing a cardioplegic solution in surgical interventions for aortic aneurysms combined with coronary artery lesions is the administration of cardioplegic solution antegradely, retrogradely and into alloshunts, after anastomosing thereof. This technique allows for the most effective protection of the myocardium by reducing the period of ischemia.

In other cases, when it is impossible to introduce a cardioplegic solution antegradely (due to dissection of coronary arteries) or retrogradely (due to the presence of a persistent left superior vena cava), it is advisable to use all available alternative methods of protection and, if possible, to reduce the aortic cross-clamp time.

References

  1. Bush LR, Romson JL, Ash JL, Lucchesi BR. Effect of Diltiazem on Extent of Ultimate Myocardial Injury Resulting from Temporary Coronary Artery Occlusion in Dogs. J Cardiovasc Pharmacol. 1982;4(2):285-96. https://doi.org/10.1097/00005344-198203000-00018
  2. du Toit EF, Opie LH. Modulation of severity of reperfusion stunning in the isolated rat heart by agents altering calcium flux at onset of reperfusion. Circ Res. 1992;70(5):960-7. https://doi.org/10.1161/01.res.70.5.960
  3. Krause S, Hess ML. Characterization of cardiac sarcoplasmic reticulum dysfunction during short-term, normothermic, global ischemia. Circ Res. 1984;55(2):176-84. https://doi.org/10.1161/01.res.55.2.176
  4. Kaplan P, Hendrikx M, Mattheussen M, Mubagwa K, Flameng W. Effect of ischemia and reperfusion on sarcoplasmic reticulum calcium uptake. Circ Res. 1992;71(5):1123-30. https://doi.org/10.1161/01.res.71.5.1123
  5. Kusuoka H, Porterfield JK, Weisman HF, Weisfeldt ML, Marban E. Pathophysiology and pathogenesis of stunned myocardium. Depressed Ca2+ activation of contraction as a consequence of reperfusion-induced cellular calcium overload in ferret hearts. J Clin Invest. 1987;79(3):950-61. https://doi.org/10.1172/JCI112906
  6. Nayler WG. The role of calcium in the ischemic myocardium. Am J Pathol. 1981;102(2):262-70.
  7. Nakai M, Shimamoto M, Yamasaki F, Fujita S, Masumoto H, Yamada T, et al. Surgical treatment of thoracic aortic aneurysm in patients with concomitant coronary artery disease. Jpn J Thorac Cardiovasc Surg. 2005;53(2):84-7. https://doi.org/10.1007/s11748-005-0006-x
  8. Lu S, Zhao Y, Song K, Yao W, Kang L, Li J, et al. Long-Term Outcomes of Surgical Treatment for Acute Type-A Aortic Dissection with Coronary Artery Involvement. Int Heart J. 2021;62(5):1069-75. https://doi.org/10.1536/ihj.20-821
  9. Zhang K, Dong SB, Pan XD, Lin Y, Zhu K, Zheng J, et al. Concomitant coronary artery bypass grafting during surgical repair of acute type A aortic dissection affects operative mortality rather than midterm mortality. Asian J Surg. 2021;44(7):945-51. https://doi.org/10.1016/j.asjsur.2021.01.031
  10. Yalcin M, Tayfur KD, Urkmez M. Should patients undergo ascending aortic replacement with concomitant cardiac surgery? Cardiovasc J Afr. 2016;27(6):338-44. https://doi.org/10.5830/CVJA-2016-026
  11. Fujiyoshi T, Koizumi N, Nishibe T, Sugiyama K, Ogino H. Direct Repair of Localized Aortic Dissection with Critical Malperfusion of the Left Main Trunk. Ann Thorac Cardiovasc Surg. 2018;24(6):320-3. https://doi.org/10.5761/atcs.cr.17-00140
  12. Chen H, Wang L, Wan L, Xiao L, Chen X. Use of del Nido cardioplegia in acute aortic dissection surgery. Perfusion. 2021;36(3):233-8. https://doi.org/10.1177/0267659120938528
  13. Prathanee S, Kuptanond C, Intanoo W, Wongbhudha C, Karunasumaeta C. Custodial-HTK Solution for Myocardial Protection in CABG Patients. J Med Assoc Thai. 2015;98 (Suppl 7):S164-7.
  14. Sales Mda C, Frota Filho JD, Aguzzoli C, Souza LD, Rösler ÁM, Lucio EA, et al. Aortic Center: specialized care improves outcomes and decreases mortality. Rev Bras Cir Cardiovasc. 2014;29(4):494-504. https://doi.org/10.5935/1678-9741.20140122
  15. Chen YF, Chien TM, Yu CP, Ho KJ, Wen H, Li WY, et al. Acute aortic dissection type A with acute coronary involvement: A novel classification. Int J Cardiol. 2013;168(4):4063-9. https://doi.org/10.1016/j.ijcard.2013.07.031
  16. Okada K, Omura A, Kano H, Ohara T, Shirasaka T, Yamanaka K, et al. Short and Midterm Outcomes of Elective Total Aortic Arch Replacement Combined With Coronary Artery Bypass Grafting. Ann Thorac Surg. 2012;94(2):530-6. https://doi.org/10.1016/j.athoracsur.2012.04.034
  17. Neri E, Toscano T, Papalia U, Frati G, Massetti M, Capannini G, et al. Proximal aortic dissection with coronary malperfusion: presentation, management, and outcome. J Thorac Cardiovasc Surg. 2001;121(3):552-60. https://doi.org/10.1067/mtc.2001.112534
Published
2023-03-27
How to Cite
Zhekov, I. I., Sarhosh, O. I., Grytsiuk, A. V., Perepeliuk, A. I., & Rudenko, A. V. (2023). Comparative Analysis of the Effectiveness of Different Options for the Administration of Cardioplegic Solution during Surgical Correction of an Aortic Aneurysm Combined with Coronary Artery Lesions. Ukrainian Journal of Cardiovascular Surgery, 31(1), 45-52. https://doi.org/10.30702/ujcvs/23.31(01)/ZhS014-4552