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. Initial experience and operative strategy

Eliot Rosenkranz, G. D. Buckberg, H. Laks, D. G. Mulder

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Abstract

The report reviews the initial clinical application of our experimental studies inducing cardioplegia with a warm (37°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°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 with 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 < 0.05) and intraaortic balloon support (1.2 ± 0.2 versus 3.6 ± 0.5 days, p < 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.

Original languageEnglish
Pages (from-to)507-518
Number of pages12
JournalJournal of Thoracic and Cardiovascular Surgery
Volume86
Issue number4
StatePublished - Jan 1 1983
Externally publishedYes

Fingerprint

Induced Heart Arrest
Cardiogenic Shock
Glutamic Acid
Pharmaceutical Preparations
Reperfusion
Mortality
Cardioplegic Solutions
Transplants
Constriction
Aneurysm
Survival Rate
Perfusion
Hemodynamics
Myocardial Infarction

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine
  • Surgery

Cite this

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title = "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. Initial experience and operative strategy",
abstract = "The report reviews the initial clinical application of our experimental studies inducing cardioplegia with a warm (37°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°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 with 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 < 0.05) and intraaortic balloon support (1.2 ± 0.2 versus 3.6 ± 0.5 days, p < 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.",
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