Clinical Physiology of Circulation

Chief Editor

Leo A. Bockeria, MD, PhD, DSc, Professor, Academician of Russian Academy of Sciences, President of Bakoulev National Medical Research Center for Cardiovascular Surgery


Heart and lungs protection techniques in anesthetic and perfusion management of heart valves surgery

Authors: V.V. Pichugin 1, N.Yu. Mel’nikov 2, E.V. Sandalkin 2, A.P. Medvedev 1, A.B. Gamzaev 2, S.A. Zhurko 2, V.A. Chiginev 2

Company:
1 Nizhniy Novgorod State Medical Academy, Ministry of Health of the RF, ploshchad’ Minina i Pozharskogo, 10/1, Nizhniy Novgorod, 603005, Russian Federation;
2 Special Clinical Cardiac Surgery Hospital, ul. Vaneeva, 209, Nizhniy Novgorod, 603950, Russian Federation

E-mail: Сведения доступны для зарегистрированных пользователей.

Link: Clinical Physiology of Blood Circulaiton. 2014; (): -

Quote as: Pichugin V.V., Mel’nikov N.Yu., Sandalkin E.V., Medvedev A.P., Gamzaev A.B., Zhurko S.A., Chiginev V.A. Heart and lungs protection techniques in anesthetic and perfusion management of heart valves surgery. Klinicheskaya Fiziologiya Krovoobrashcheniya. 2014; 4: 50-59.

Download
Full text:  

Abstract

Objective of the study was to evaluate different heart and lungs protective techniques in heart valves surgery.
Material and methods. After ethical approval and written informed consent 100 patients undergoing valves surgery with normothermic CPB were randomized in four groups. First group (control, 22 patients) – crystalloid cardioplegia (“Consol”) and no lung ventilation/perfusion technique were used, second group (30 patients) – constant coronary perfusion in con- dition of “beating heart” and no lung ventilation/perfusion technique were used, third group (20 patients) – crystalloid car- dioplegia (“Consol”) with lung ventilation/perfusion technique were used and fourth group (28 patients) – constant coronary perfusion in condition of “beating heart” with perfusion of pulmonary artery and lungs ventilation technique were used. Clinical (types of cardiac recovery after cardioplegia; postischemic cardiac rhythm disturbances; doses of inotropes), investigation of myocardial damage markers (CK MB level), oxygenation index and lung compliance were per- formed for comparative evaluation of effectiveness of these techniques.
Results. Clinical analysis of cardiac recovery and post bypass periods revealed prevalence of spontaneous cardiac rhythm recovery, and also decrease in requirement and dosages of inotropes at the end of surgery in patients of the 2nd and 4th groups was noted that indirectly testifies to the better myocardial preservation in these patients. Changes of postoperative levels of CK MB were characterized, firstly, by its lower release in blood directly after operation and, secondly, it’s faster normalization (in 24 h after operation) in patients of the 2nd and 4th groups. Changes in functional conditions of lungs were characterized by decrease in an index of oxygenation and lungs compliance after cardiopulmonary bypass with development of an arterial hypoxemia (in 10.0–13.6% of patients) in patients from 1st and 2nd groups. Lung ventilation during bypass with pulmonary artery perfusion effectively prevented decrease in oxygenation and lungs compliance, and also development of an arterial hypoxemia after cardiopulmonary bypass in patients of 3rd and 4th groups.
Conclusion. In summary it should be noted that comparative assessment of different techniques revealed its advantages in the “improved” myocardial protection (“beating heart” and “beating heart and breathing lungs” technique) and lungs protection (“breathing lungs” and “beating heart and breathing lungs” technique).

References

1. Wan S., DeSmet J.M., Barvais L., Goldstein M., Vincent J.L., LeClerc J.L. Myocardium is a major source of proinflammato- ry cytokines in patients undergoing cardiopulmonary bypass. J. Thorac. Cardiovasc. Surg. 1996; 112 (3): 806–11.
2. Murphy G.J., Angelini G.D. Side effects of cardiopulmonary bypass: what’s the reality? J. Card. Surg. 2004; 19: 481–8.
3. Ng C.S., Wan S., Yim A.P., Arifi A.A. Pulmonary dysfunction after cardiac surgery. Chest. 2002; 121: 1269–77.
4. Schlensak C., Doenst T., Preusser S., Wunderlich M., Kleinschmidt M., Beyersdorf F. Bronchial artery perfusion during cardiopulmonary bypass does not prevent ischemia of the lung in piglets: assessment of bronchial artery blood flow with fluorescent microspheres. Eur. J. Cardiothorac. Surg. 2001; 19 (3): 326–31; discussion 331–2.
5. Massoudy P., Zahler S., Becker B.F., Braun S.L., Barankay A., Meisner H. Evidence for inflammatory responses of the lungs during coronary artery bypass grafting with cardiopulmonary bypass. Chest. 2001; 119 (1): 31–6.
6. Siepe M., Goebel U., Mecklenburg A., Doenst T., Benk C., Stein P. et al. Pulsatile pulmonary perfusion during cardio- pulmonary bypass reduces the pulmonary inflammatory response. Ann. Thorac. Surg. 2008; 86 (1): 115–22. doi: 10.1016/j.athoracsur.2008.03.062
7. Salerno T.A., Houck J.P., Barrozo C.A., Panos A., Christa- kis G.T., Abel J.G., Lichtenstein S.V. Retrograde continuous warm blood cardioplegia: a new concept in myocardial protec- tion. Ann. Thorac. Surg. 1991; 51 (2): 245–7.
8. Salerno T.A. Warm heart surgery. 1st ed. London: Edward Arnold; 1995.
9. Magnusson L., Zemgulis V., Tehling A., Wernlund J., Tydén H., Thelin S., Hedenstierna G. Use of a vital capacity maneuver to prevent atelectasis after cardiopulmonary bypass. Anesthe- siology. 1998; 88 (1): 134–42.
10. Friedman M., Sellke F.W., Wang S.Y., Weintraub R.M., Johnson R.G. Parameters of pulmonary injury after total or partial cardiopulmonary bypass. Circulation. 1994; 90 (5; Pt 2): II262–8.
11. Gabriel E.A., Salerno T.A. Principles of pulmonary protection in heart surgery. Springer-Verlag London Limited; 2010.
12. Pichugin V., Scopin I., Kahktsyan P., Medvedev A., Chiginev V.,
Gamzaev A. et al. Beating heart valve surgery for patients with severe left ventricular dysfunction. In: 17 Biennial Congress Association of Thoracic and Cardiovascular Surgeons of Asia. Manila, Philippines; 2005: 298.
13. Pichugin V., Scopin I. , Chiginev V., Kahktsyan P., Gamzaev A., Medvedev A. et al. Advanced perfusion technique for patients with severe left ventricular dysfunction. In: A Multidisciplinary Congress in Cardio-Thoracic Healthcare. 16 World Congress of the World Society of Cardio-Thoracic Surgeons. Ottawa, Canada; 2006: 216–7.
14. Matsumoto Y., Watanabe G., Endo M., Sasaki H., Kasashi- ma F., Kosugi I. Efficacy and safety of on-pump beating heart surgery for valvular disease. Ann. Thorac. Surg. 2002; 74 (3): 678–83.
15. Katircioglu S.F., Cicekcioglu F., Tutun U., Parlar A.I., Babaroglu S., Mungan U., Aksoyek A. On-pump beating heart mitral valve surgery without cross-clamping the aorta. J. Card. Surg. 2008; 23 (4): 307–11. doi: 10.1111/j.1540-8191.2008. 00648.x
16. Ihnken K., Morita K., Buckberg G.D., Aharon A., Laks H., Panos A.L. et al. The safety of simultaneous arterial and coronary sinus perfusion: experimental background and initial clinical results. J. Card. Surg. 1994; 9 (1): 15–25.
17. Ihnken K., Morita K., Buckberg G.D., Aharon A., Laks H., Beyersdorf F., Salerno T.A. Simultaneous arterial and coronary sinus cardioplegic perfusion: an experimental and clinical study. Thorac. Cardiovasc. Surg. 1994; 42 (3): 141–7.
18. Wang J., Liu H., Xiang B., Li G., Gruwel M., Jackson M. et al. Keeping heart empty and beating improves preservation of hypertrophied hearts for valve surgery. J. Thorac. Cardiovasc. Surg. 2006; 132 (6): 1314–20. Erratum in: J. Thorac. Cardiovasc. Surg. 2011; 141 (6): 1556.
19. Mehlhorn U., Allen S.J., Adams D.L., Davis K.L., Gogo- la G.R., de Vivie E.R., Laine G.A. Normothermic continuous antegrade blood cardioplegia does not prevent myocardial edema and cardiac dysfunction. Circulation. 1995; 92 (7): 1940–6.
20. Ricci M., Macedo F.I., Suarez M.R., Brown M., Alba J., Salerno T.A. Multiple valve surgery with beating heart tech- nique. Ann. Thorac. Surg. 2009; 87 (2): 527–31. doi: 10.1016/j.athoracsur.2008.10.030
21. Macedo F.I., Carvalho E.M., Hassan M., Ricci M., Gologorsky E., Salerno T.A. Beating heart valve surgery in patients with low left ventricular ejection fraction. J. Card. Surg. 2010; 25 (3): 267–71.
22. Macedo F.I., Carvalho E.M., Gologorsky E., Salerno T. Lung ventilation/perfusion may reduce pulmonary injury during cardiopulmonary bypass. J. Thorac. Cardiovasc. Surg. 2010; 139 (1): 234–6.
23. Macedo F.I., Carvalho E.M., Gologorsky E., Salerno T. Gas Exchange during lung perfusion/ventilation during cardiopul- monary bypass: preliminary results of a pilot study. Open J. Cardiovasc. Surg. 2010; 3: 1–7.

 If you found mistakes, select text and press Alt+A