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J Thorac Cardiovasc Surg 1996;111:283-284
© 1996 Mosby, Inc.

LETTERS TO THE EDITOR

Hazards of administering blood cardioplegic solution directly into the heart: Cardioplegic solutions are not equal

Gerald D. Buckberg, MD

University of California at Los Angeles
School of Medicine
Los Angeles, CA 90095-1741

To the Editor:

Recently a cardiac surgeon asked me what would happen if he injected the cardioplegic solution that my colleagues and I have described directly into the heart, rather than mixing it with blood. The answer was that I did not know, although I suspected that this procedure might severely damage the sarcolemmal membrane and produce irreversible cardiac injury. That is what occurred. Of note, this same complication occurred many years ago with the Melrose solution, and the problem has since been corrected.

This rare but potentially lethal complication leads me to the following discussion. The potential problem, even when using myocardial solutions with blood from the pump, led my colleagues and me to address this problem in the JOURNAL in 1994.Go 1

GoTable I shows the infused versus cardiovascular dose of crystalloid blood cardioplegic solution (i.e., St. Thomas' Hospital), and GoTable II shows the infused versus cardiovascular dose of blood cardioplegic solution including the crystalloid component. Please note that the solution described in GoTable I enters the heart, whereas the solution described in GoTable II must be diluted with blood to reach the heart. Delivery of the latter solution Go(Table II) to the heart without mixing it with blood will likely strip off the sarcolemmal membrane and lead to the complication that I just described.


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  		Table I. St. Thomas' Hospital solution with crystalloid component
 

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  		Table II. Blood cardioplegic solution with crystalloid component, mixed 4:1 with blood
 
For those who wish to try blood cardioplegia, they may start by adding potassium to the solution described in GoTable I to achieve a cardioplegic concentration of potassium chloride. This method will increase the concentration of potassium in the cardioplegic solution and decrease the concentration of the other components. I do not know how the heart will do, as I do not use this solution.

Conversely, never infuse the solution described in GoTable II into the heart. The need to start with a crystalloid component is not a problem with blood cardioplegia, because the heart is never ischemic when the solution is flowing both antegradely and retrogradely, as in our practice. For that reason, the delay in arrest is less problematic than when crystalloid cardioplegic solution is given. However, infusion via the coronary sinus is useful, because the amount of solution passing obstructive vessels is decreased with the heart supported by cardiopulmonary bypass, and the proximal artery is occluded.

The figures in GoTables I and GoII are simply for comparison of the different cardioplegic solutions, but they should serve to estimate the potential problems with infusing crystalloid solutions into the heart when they are meant to be mixed with a blood cardioplegic component.

I hope this brief reminder will be useful to those physicians who may wish to stop the heart with a solution that is intended to be mixed with blood in a 4:1 ratio. Clearly, the same problem would occur with any other solution that uses our formulations to stop the heart and can be used safely as the warm reperfusate.

References

  1. Buckberg GD, Ihnken K, Morita K. Use of hypocalcemic blood cardioplegia with clear extracorporeal primes containing albumin [Letter]. J THORAC CARDIOVASC SURG1994;107:941-2.



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