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Mitral Valve Surgery Under Perfused Ventricular Fibrillation with Moderate Hypothermia

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Mitral Valve Surgery Under Perfused Ventricular Fibrillation with Moderate Hypothermia Circ J 2002; 66: 450–452 Mitral Valve Surgery Under Perfused Ventricular Fibrillation With Moderate Hypothermia Kazuhito Imanaka, MD; Shunei Kyo, MD; Masanori Ogiwara, MD; Hiroaki Tanabe, MD; Hiroshi Ohuchi, MD; Haruhiko Asano, MD; Yuji Yokote, MD; Satoshi Gojo, MD; Masaaki Kato, MD The safety and myocardial protective effect of perfused ventricular fibrillation (VF) under moderate hypothermia were investigated. Through a midline sternotomy and opening the left atrium from the right side, isolated mitral valve surgery was performed under aortic cross-clamping (ACC) and cardioplegic arrest using Bretschneider HTK solution in 96 patients, and under perfused VF in 20 patients (VF Group). Patient characteristics, clinical outcomes, and perioperative variables were compared. A satisfactory surgical view was obtained in all VF Group patients. Patient characteristics in the 2 groups were similar, and both groups had comparable results for mortality and morbidity, operation time, cardiopulmonary bypass time, peak levels of creatine kinase (CK) and its myocardial fraction, hours of mechanical ventilation, intensive care unit stay, and postoperative left ventricu- lar ejection fraction. Even in VF Group patients with preoperative critical hemodynamic compromise, inotropes could be discontinued within 3 days. Thus, no detrimental effect of perfused VF was observed. On the other hand, in patients who underwent ACC and cardioplegic arrest of 120min or longer, peak levels of CK and its myocardial fraction were significantly higher than those of the rest of C group patients and VF Group patients. Perfused VF under moderate hypothermia can be a good alternative myocardial protection strategy during mitral valve surgery, particularly in patients in whom ACC is unsuitable or the duration of ACC is expected to be long. (Circ J 2002; 66: 450–452) Key Words: Mitral valve; Myocardial protection; Perfused ventricular fibrillation urrently, the most common method of myocardial because of the presence of critical hemodynamic compro- protection during mitral valve surgery is induction mise in 4, severely atherosclerotic ascending aorta in 7, C of electromechanical arrest by aortic cross-clamp- functioning previous coronary artery bypass graft in 3, ing (ACC) and infusion of cardioplegic solution. However, dense adhesion in 3, and for miscellaneous reasons in 3. VF this method is unsuitable in some cases, especially in poor- was usually induced just by systemic cooling. risk patients, and we have used an alternative strategy, In C Group patients, 2,000ml of Bretschneider HTK namely, ventricular fibrillation (VF) without ACC. In this solution at 4°C was infused through the aortic root at a rate study, the safety and efficacy of perfused VF under moder- of around 250 ml/min. When the duration of ACC ex- ate hypothermia were investigated. ceeded 90–120min,1–3 700–1,000ml of high-potassium (20 mmol/L) blood cardioplegic solution, comprising CPB perfusate and additional potassium chloride, was infused Methods every 30min. Patient characteristics, clinical outcomes, and From February 1997 until September 2000, 116 patients variables during and after surgery were compared between underwent isolated mitral valve surgery through a midline the 2 groups. sternotomy and opening of the left atrium from the right side. Patients who required concomitant aortic valve proce- Statistical Analyses dures or coronary artery bypass surgery were excluded. Data are expressed as mean±standard deviation. Student’s Surgery was performed under ACC and cardioplegic arrest t-test or chi-squared test were used to compare the groups. in 96 patients (C Group), or under VF either without ACC Correlation was analyzed with Pearson’s method. Differ- or with a very short duration of ACC in 20 patients (VF ences were regarded as statistically significant at p<0.05. Group). Cardiopulmonary bypass (CPB) flow was main- tained above 2.4L·min–1·m–2 and the rectal temperature was lowered to 28–30°C. Results In VF Group patients, perfused VF was employed Patient characteristics are summarized in Table1. The 2 groups were comparable in many aspects. The majority of (Received November 26, 2001; revised manuscript received January patients had suffered severe cardiac symptoms. Four VF 9, 2002; accepted January 22, 2002) Group patients (acute myocardial infarction and papillary Department of Cardiovascular Surgery, Saitama Medical School, muscle rupture, 1 case; acute massive mitral regurgitation Saitama, Japan Mailing address: Kazuhito Imanaka, MD, Department of Cardiovas- caused by infectious endocarditis (IE), 3) were in a severely cular Surgery, Saitama Medical School, 38 Morohongo, Moroyama- impaired general and hemodynamic condition (evident machi, Iruma-gun, Saitama 350-0495, Japan. E-mail: imanaka@ lung edema with hypotension (<80mmHg) and oliguria). saitama-med.ac.jp Mitral valve repair was undertaken in 41% of C Group Circulation Journal Vol.66, May 2002 Mitral Valve Surgery Under VF 451 Table 1 Patient Characteristics VF Group (n=20) C Group (n=96) p value MS:MR 4:16 27:69 NS M:F 12:8 43:53 NS Age (years) 55.4±15.2 57.4±12.5 NS BSA (m2) 1.55±0.25 1.51±0.20 NS NYHA II:III:IV 2:9:9 12:56:28 NS Sternal re-entry 7 19 NS MICS 2 18 NS IE 4 8 NS Ejection fraction (%) 68.8±12.9 71.0±12.1 NS Left atrial diameter (mm) 49.8±10.6 52.7±11.3 NS MVP:MVR 9:11 38:58 NS Associated procedure TAP 1 17 NS Miscellaneous 2 7 NS MS, mitral stenosis; MR, mitral regurgitation; BSA, body surface area; NYHA, New York Heart Association functional class; MICS, minimally invasive cardiac surgery; IE, infective endocarditis; MVP, mitral valvuloplasty; MVR, mitral valve replacement; TAP, tricuspid annuloplasty. Table 2 Clinical Results VF Group (n=20) C Group (n=96) p value Operation time 267±49 259±65 NS CPB time 144±22 129±40 NS ACC time 1.2±3.6 82.6±29.0 <0.05 Rectal temperature 28.4±1.3 29.5±2.9 NS Peak CK (IU/L) 1,008±640 1,238±977 NS Peak CKMB (IU/L) 94±57 87±46 NS Mechanical ventilation time (h) 11.0±12.7 10.7±11.6 NS Intensive care unit stay (days) 2.0±1.3 2.4±1.1 NS Postoperative ejection fraction (%) 62.7±18.8 62.5±13.2 NS Hospital death 2 3 NS Low output syndrome 0 1 NS Cerebral infarction 1 3 NS CPB, cardiopulmonary bypass; ACC, aortic cross clamp; CK, creatine kinase; CKMB, myocardial fraction of CK. patients and 45% of VF Group patients. required large doses of inotropes just after surgery. Peri- Clinical results are shown in Table2. Satisfactory expo- operative stroke occurred in 1 VF Group patient and 3 C sure of the mitral apparatus was obtained in all VF Group Group patients. The 2 groups had a comparable duration of patients by somewhat extending the atriotomy. During mechanical ventilation and intensive care unit stay, and treatment in the vicinity of the antero-lateral commissure, the left ventricular ejection fraction (LVEF) at hospital traction caused aortic regurgitation and ACC was temporar- discharge was almost the same. The New York Heart Asso- ily necessary in 3 patients. Operation and CPB times were ciation functional class of all survivors was I or II. almost the same in the 2 groups. ACC time was signifi- cantly shorter in the VF Group. Peak levels of serum creatine kinase (CK) and its myo- Discussion cardial fraction (CKMB) in the 2 groups were almost the Intraoperative myocardial protection is a major concern. same. The VF time of VF Group patients was 104±26min Induction of cardioplegic arrest with ACC is a widely (range, 52–146). VF time did not show a significant corre- accepted solution for lessening myocardial damage, but it lation with peak CK or CKMB. On the other hand, peak has several potential drawbacks; namely, time limitation, CK was 1,858±1,651 and CKMB was 139±49 in 9 patients reperfusion injury, myocardial edema and diastolic dys- with ACC and cardioplegic arrest longer than 120 min, function.4–7 Moreover, ACC is undesirable in the presence both significantly higher than those of the rest of C Group of atherosclerotic aorta,8 previous coronary bypass grafts9–11 patients and VF Group patients. and so forth. Two VF Group patients died, one of stroke and the other Mitral valve surgery under VF and intermittent ACC has of uncontrollable IE. Three deaths occurred in the C Group: been recognized a suboptimal strategy and was almost low output syndrome in 1 case, rupture of an abdominal abandoned after the undesirable physiology of perfused VF mycotic aneurysm in 1, and uncontrollable IE in 1. Hospi- and poor postoperative hemodynamic results were re- tal mortality of any cause and of cardiac cause was, re- ported,12–14 although these drawbacks could be reduced.15,16 spectively, 10% and 5% in VF Group and 3.1% and 2.1% In the present study, the clinical results of both groups in C Group. In the VF Group, severe postoperative low were comparable, although perfused VF was used in output syndrome was not observed and prolonged (4 days patients whose clinical condition was more complicated. or longer) infusion of inotropic agent was unnecessary, The levels of CK and CKMB were almost the same, which although patients with preoperative circulatory collapse suggested that perfused VF was not an inappropriate myo- Circulation Journal Vol.66, May 2002 452 IMANAKA K et al. cardial protection strategy. Thus, we believe that VF under ACC or none at all was used in a selected group of patients. moderate hypothermia without ACC or with ACC of short The clinical results were comparable with those of the duration is a safe and good alternative during mitral valve control group patients, which proved the safety and satis- surgery.
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