Is there a rationale for short cardioplegia re-dosing intervals?

Abstract

While cardioplegia has been used on millions of patients during the last decades, the debate over the best technique is still going on. Cardioplegia is not only meant to provide a non-contracting heart and a field without blood, thus avoiding the risk of gas emboli, but also used for myocardial protection. Its electromechanical effect is easily confirmed through direct vision of the heart and continuous electrocardiogram monitoring, but there is no consensus on the best way to assess the quality of myocardial protection. The optimal approach is thus far from clear and the considerable amount of literature on the subject fails to provide a definite answer. Cardioplegia composition (crystalloid vs blood, with or without various substrate enhancement), temperature and site(s) of injection have been extensively researched. While less frequently studied, re-dosing interval is also an important factor. A common and intuitive idea is that shorter re-dosing intervals lead to improved myocardial protection. A vast majority of surgeons use re-dosing intervals of 20-30 min, or even less, during coronary artery bypass graft and multidose cardioplegia has been the “gold standard” for decades. However, one-shot cardioplegia is becoming more commonly used and is likely to be a valuable alternative. Some surgeons prefer the comfort of single-shot cardioplegia while others feel more confident with shorter re-dosing intervals. There is no guarantee that a single strategy can be safely applied to all patients, irrespective of their age, comorbidities or cardiopathy. The goal of this review is to discuss the rationale for short re-dosing intervals.

Keywords: Myocardial protection; Del Nido cardioplegia; Continuous cardioplegia; Intermittent cardioplegia; Single-shot cardioplegia; Multidose cardioplegia; Crystalloid cardioplegia; Blood cardioplegia; Custodiol^®; Histidine-ketoglutarate-tryptophan

Core tip: During myocardial ischemia, cardioplegia is the preferred method of myocardial protection. However, decades after its implementation, there is still no consensus on the optimal re-dosing interval. Shorter re-dosing (15-30 min) has been preferred to longer intervals (45-60 min), but the choice of one approach over another relies more on the surgeon’s preference than on clear advantages. As the interest for one-shot cardioplegia has been increasing recently, we intend to discuss the rationale, if any, for short cardioplegia re-dosing interval.