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The Journal of Thoracic and Cardiovascular Surgery, Vol 86, 507-518, Copyright © 1983 by The American Association for Thoracic Surgery and The Western Thoracic Surgical Association
ER Rosenkranz, GD Buckberg, H Laks and DG Mulder
This report reviews the initial clinical application of our experimental
studies inducing cardioplegia with a warm (37 degrees C) glutamate-enriched
blood solution in ischemically damaged hearts. Over 15 months, 23
consecutive coronary patients requiring preoperative intra-aortic balloon
and inotropic drug support for cardiogenic shock underwent operation for
left ventricular power failure. Twelve patients were given a warm
glutamate-enriched blood cardioplegic solution during the first 5 minutes
of aortic clamping before multidose cold (4 degrees C) glutamate blood
cardioplegia was begun; 11 patients received standard multidose cold blood
cardioplegia without glutamate. All patients had comparably depressed left
ventricular performance preoperatively despite maximal inotropic and
balloon support and showed evidence of extending myocardial infarction.
They did not differ in the number of grafts placed (3.7 +/- 0.2),
associated valve and aneurysm procedures (seven patients) or cross-clamp
time (89 +/- 6 minutes). All patients received warm blood cardioplegic
reperfusion before aortic unclamping. The perioperative mortality was 9%
(2/23); both patients who died received cold blood cardioplegia without
glutamate. In addition to lower mortality, patients receiving warm
glutamate blood cardioplegia exhibited better hemodynamics, allowing
earlier discontinuation of inotropic drug infusion (1.3 +/- 0.5 versus 2.7
+/- 0.8 days, p less than 0.05) and intraaortic balloon support (1.2 +/-
0.2 versus 3.6 +/- 0.5 days, p less than 0.05). Late mortality was 30%,
resulting in a 65% overall survival rate (2 to 15 months) for the entire
series of patients. The operative principles evolving from this early
experience include (1) warm blood cardioplegic induction, (2) glutamate
enrichment, (3) meticulous attention to cardioplegic distribution and
grafting sequence, (4) warm cardioplegic reperfusion before unclamping, and
(5) graft perfusion during construction of proximal anastomoses. Hopefully,
further application of these techniques will improve results in these
extremely high risk coronary patients requiring operation.
ARTICLES
Warm induction of cardioplegia with glutamate-enriched blood in coronary patients with cardiogenic shock who are dependent on inotropic drugs and intra-aortic balloon support
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