PowerPoint Presentation (PDF) - Perfusion.com
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Myocardial Protection:<br />
Ripe For A Guideline<br />
Kenneth G. Shann, CCP<br />
Assistant Director, <strong>Perfusion</strong> Services<br />
Senior Advisor, Performance Improvement<br />
Montefiore Medical Center<br />
New York, NY
Disclosure<br />
• No Relationships to Disclose
Myocardial Protection:<br />
Ripe For A Guideline<br />
• Describe the problem and need to synthesize<br />
the evidence into guidelines<br />
• Briefly discuss the evidence related to<br />
strategies for myocardial protection<br />
• Discuss the likely challenges of<br />
operationalizing guidelines for myocardial<br />
protection
The Problem<br />
J Thorac Cardiovasc Surg 2005;129:1292-300
Ann Thorac Surg 1998;66:1323–8<br />
The Problem
The Problem<br />
• Higher severity of ischemic heart disease in<br />
current surgical population<br />
• Increased volume of older patients undergoing<br />
surgery for degenerative valve conditions<br />
• Increased volume of patients with impaired<br />
ventricular function associated with:<br />
• LVH and HF<br />
• Urgent revascularization for ACS and NSTEMI
Myocardial Protective Strategies<br />
• Temperature<br />
• Hypothermic<br />
• Normothermic<br />
• Tepid<br />
• Solutions<br />
• Blood versus crystalloid<br />
• Ratios<br />
• Arresting agent<br />
• Depolarizing<br />
• Nondepolarizing<br />
• Additives<br />
• Route of administration<br />
• Antegrade
Temperature<br />
• Hypothermic<br />
• Normothermic<br />
• Tepid<br />
J Thorac Cardiovasc Surg 1995;109:787-95)<br />
Ann Thorac Surg 1998;65:1559–65<br />
• As <strong>com</strong>pared to cold, tepid and warm techniques have been<br />
associated with:<br />
• Less biomarker release and increased rates of spontaneous return to<br />
sinus rhythm<br />
• Lower incidence of postoperative low output failure<br />
• Improved myocardial recovery and reduced need for inotropic support
Temperature<br />
Circulation 2000;102;III-339-III-345
Cardioplegia Solutions<br />
• Blood based vs. crystalloid<br />
Circulation. 2006;114[suppl I]:I-331–I-338
Cardioplegia Solutions<br />
Eur J Cardiothorac Surg. 2010 May 6. [Epub ahead of print
Cardioplegia Solutions<br />
• Blood versus crystalloid<br />
• Ratios<br />
Ann Thorac Surg 1998;65:615–21
Cardioplegia Solutions<br />
Interactive CardioVascular and Thoracic Surgery 9 (2009) 56–60
Arresting Agents & Additives<br />
• Arrest Agents<br />
• Depolarizing<br />
• Modified depolarizing<br />
• Polarizing<br />
• Additives
Route of Administration<br />
• Antegrade<br />
• Aorta<br />
• SVG<br />
• Retrograde<br />
J Thorac Cardiovasc Surg 1995;109:1116-26
Ischemic Intervals<br />
• Intervals<br />
• Continuous<br />
• Intermittent<br />
• Volumes<br />
Circulation 1995;92:341-346
Ischemic Intervals<br />
• Intervals<br />
• Continuous<br />
• Intermittent<br />
• Volumes
Conclusions<br />
• The majority of cardiac surgical deaths are attributed to heart<br />
failure<br />
• As much as 50% of those patients present with normal<br />
ejection fractions<br />
• Generation of guidelines would define the state of the<br />
evidence for myocardial protective strategies<br />
• Guidelines need to be operationalized at the local level<br />
• Tracking adherence to the guidelines through a registry would<br />
evaluate their clinical effectiveness over time
Operationalizing Guidelines For<br />
Myocardial Protection<br />
• Can it be done or are myocardial protective<br />
strategies too esoteric?<br />
• How would you utilize the guidelines at your<br />
center to effect change?<br />
• Could an international registry be helpful or do<br />
we need more RCTs?
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