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Celsior® Cardioplegic Solution in Orthotopic Cardiac Transplantation. A Comparative Study with Buckberg Solution.Crespo, F.M.; Rodríguez Delgadillo, M.A.; Paladini, G.; Juffé Stein, A.
Servicio de Cirugía Cardíaca. Hospital Juan Canalejo.
La Coruña. España
Material and Methods
Introduction: Nowadays, cardiac transplantation seems to be the only treatment for end-stage heart failure, pathology that appears to be more and more frequent. Due to organ shortage to satisfy waiting lists requirements, alternative strategies appeared, generally not as definitive solutions but as palliative procedures(as cardiomyoplasty and aortomyoplasty). Donor election and management is the gold standard, if there is a good donor , results will be satisfactory.
One of the main causes of graft failure in cardiac transplantation, is functional alteration of the graft, that is shown since re-oxigenation of the transplanted organ is performed, and is usually ligated to the ischaemic time between cardiectomy and reimplantation. Depressed ventricular contraction is frequent in the postoperative period, mainly with marginal donors or long-distance ablation procedures, with more than 4 hours of ischaemic time, being this the limit in which injuries became irreversible.
Cardiac transplantation goes through different steps:
In each of these steps there are cellular and functional injuries, so it is our aim to avoid these alterations.
In order to minimize the risk, several authors have described the use of protective solutions either for cardiectomy perfusion, cold preservation or reimplantation reperfusion. This technical improves oin myocardial protection, permit us the use of "suboptimal" donors which probably, would have been rejected in the past.
Celsior® formulation joins the fundamental precepts of organ preservation and with those specific of myocardial metabolism. This formulation permits the use of Celsior® for all the steps of cardiac transplantation: initial cardioplegia, storage, ischaemia and reperfusion.
The objectives of the formulation are the following:
* Prevention of edema achieved by impermeants present in
the solution (Mannitol y Lactobionate).
* Prevention of oxidative damage caused by free radicals :
# Reduced Glutathione (GSH),strong antioxidant that inactivates oxygen, preserving its activity against free radicals.
# Mannitol which associates its osmotic effect with a hydroxile radical inactivator effect.
# Histidine, initially used for its low temperature buffer effect, it is also used as a free radical inactivator.
* Prevention of calcium overload:
# It is an apropiate ionic formulatio (low Calcium, moderate potassium, high levels of Sodium and Magnessium)
# Slight acidosis (correct pH levels are achieved by usig hitidine).
# An energy sustrate, Glutamate, that allows anaerobic production of high energy components, what leads to reduce the ATP component of calcium contraction (ionic modifications, as acidosis,acts over the calcium-dependient components of the contraction).
In our hospital, since the donor heart arrives, we use continuous normothermic blood cardioplegic solution, in a controlled perfusion, in order to heal potential hypothermic cellular damage (dema, ionic calcium redistribution, an increase in coronary vascular resistances, inactivation of active mechanism as Na/K bomb).
We performed a comparative study in myocardial protection with intermitent cold blood cardioplegia(Buckberg´s technique) against continuous normothermic Celsior® cardioplegia.
Material and Methods: A total of 109 patient that underwent cardiac transplantation were divided in two groups: in group A(n=59) those who received myocardial protection with continuous normothermic Celsior® cardioplegia, and group B(n=50) the ones that received intermitent cold blood cardioplegia(Buckberg´s technique). In group A, 78% were male and 22% females. Preoperative diagnosis was: idiopathic dilated cardiomyopathy 46,78%, ischaemic 35,68%, valvular 12,65%, and others 4,89%. In group B, 86% were male and 14% females, diagnosis was: idiopathic dilated cardiomyopathy 59.68%, ischaemic 38.71%, and others 1,6% ( no valvular pathology).
Results: In group A, 14,71% of donors had previous cardic arrest; mean CPB ( cardio pulmonary bypass) time was 112 min.; spontaneous synus rhythm was present in 86.33%; pacemaker was needed in 4,81%; only Isoproterenol was used for CPB weaning in 79.32%; stable synus rhythm was present in 85.70% of the patients.
In group B, 16.07% of donors had previous cardic arrest; mean CPB time was 120 min.; spontaneous synus rhythm was present in 75.65%; pacemaker was needed in 17.24%; only Isoproterenol was used for CPB weaning in 71.93%; stable synus rhythm was present in 74.19% of the patients
Conclusions: Our experience show that myocardial protection with Celsior® solution, is the choice procedure in cardiac transplantation due to a better CPB recovery and a decrease in graft reperfusion damage.
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