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ORIGINAL ARTICLE

Normotermic continuous blood cardioplegy

Domingo M Braile; Roberto V Ardito; Marcos Zaiantchick; José L. Verde Santos; Marcelo José F Soares

DOI: 10.1590/S0102-76381989000200001

ABSTRACT

The authors discuss the use of cardioplegic solution as well as its composition. The immediate stop of the heart beats can be obtained with cardioplegic solutions whether they are crystalloid or blood-cardioplegia, oxygen-enriched or not, either in association or alone; hypotermia also can be used or not. The agents to stop the heart can be potassium, magnesium, procaine or calcium blockers. Caution is needed in regard to hypotermia since low temperature itself is not enough to protect myocardium for long periods. Substrates like glucose and oxygen must be supplied during the aortic clamping period, to provide some aerobic metabolism. The addition of other substrates like aspartate, glutamate and lactate as well as ATP and/or phosphate creatine, Krebs cicle intermediates can improve the myocardium salvage. The cell membrane, with all its structural, selective and secretory functions, is the most sensible region to ischemic injure. The retrograde cardioplegy allows a better difusion of the solutions. We believe that it should be part of any cardiac surgery, although we must be aware of its limitations. Perfusion is the most important step of the myocardium salvage when the delivery of free radicals occurs, so the use of scavengers can improve the results of reperfusion. The normotermic blood oxygenated cardioplegy in enriched with substrates was used initially in extremely severe cases of muscle dysfunction, in severe myocardium ischemia or for lack of adequate protection during ischemia and/or reperfusion, and now has been extended to all cases. It is advisable to have the heart chambers always drained, avoiding any increase of tension on the walls which would lead to a higher oxygen consumption. The authors describe the technique and the solution for cardioplegy used in the Cardiac Service of IMC and the results achieved with its use. They conclude that the use of blood modified normotermic cardioplegy aminoacid-enriched and asystolic reperfusion are satisfactory in myocardium salvage and for reverting the ischemic injures.

RESUMO

Os autores discutem o emprego da cardioplegia, bem como sua composição. A parada imediata dos batimentos pode ser conseguida com soluções cardioplégicas cristalóides ou sangüíneas, oxigenadas ou não. O agente que leva o coração à parada pode ser potássio, magnésio, procaína ou, mesmo, quelantes e bloqueadores de cálcio associados entre si ou não, contando com a edição da hipotermia ou não. Deve-se ficar atento para a falsa sensação de proteção a que a baixa temperatura possa nos induzir, uma vez que o frio, por si só, não é suficiente para manter o miocárdio viável por longos períodos. Substratos, como glicose e oxigênio, devem ser fornecidos durante o período de clampeamento aórtico, para garantir algum metabolismo aeróbio, nesse período. A adição de outros substratos, como glutamato, aspartato e lactato, assim como ATP ou creatina fosfato, precursores de intermediários do ciclo de Krebs, podem melhorar muito a proteção miocárdica. A infusão de cardioplegia sangüínea normotérmica de forma contínua mantém as necessidades metabólicas básicas para a sobrevivência das células. A membrana celular, com todas as suas funções estruturais e secretoras, é o ponto mais sensível à injúria isquêmica. Os removedores de radicais livres (scavengers) são protetores indiretos da membrana celular. A cardioplegia retrógrada permite melhorar a distribuição das soluções na árvore coronariana, sendo muito útil nas reoperações. Ela deve fazer parte da tática cirúrgica, sem esquecermos suas limitações. O momento da reperfusão é o mais importante da proteção miocárdica; é nesse período que ocorre a liberação de radicais livres. O uso de removedores (scavengers) pode melhorar as condições e o resultado da reperfusão. A cardioplegia sangüínea oxigenada e normotérmica enriquecida com substratos, antes usada em casos extremamente graves, por disfunção muscular em isquemia miocárdica severa, ou por ausência de proteção adequada, durante a fase de isquemia e/ou reperfusão, foi expandida para todos os casos. É recomendado que o coração tenha, sempre, suas câmaras drenadas, evitando-se qualquer aumento na tensão da parede, o que levaria a maior consumo de oxigênio. Os autores descrevem a técnica e as soluções cardioplégicas aplicadas no Serviço de Cirurgia Cardíaca do IMC e os resultados obtidos com o uso das mesmas. Concluem ser satisfatório o uso de cardioplegia normotérmica modificada e reperfusão assistólica, enriquecidas por aminoácidos, na preservação da função miocárdica e na reversão dos danos isquêmicos.
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