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Ann Thorac Surg 1983;36:664-674
© 1983 The Society of Thoracic Surgeons

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Articles

Improved Myocardial Protection during a Prolonged Cross-Clamp Period

From the Divisions of Cardiovascular Surgery, Cardiology, and Clinical Biochemistry, the Toronto General Hospital and the University of Toronto, Toronto, Ont, Canada

^* Address reprint requests to Dr. Weisel, Division of Cardiovascular Surgery, Toronto General Hospital, EN 13–224, 200 Elizabeth St, Toronto, Ont, Canada M5G 1L7

Severe coronary stenoses limit delivery of cardioplegic solution to ischemic regions in patients undergoing bypass operations. A prospective randomized trial was undertaken to determine whether the construction of proximal as well as distal anastomoses during a prolonged cross-clamp period would provide more uniform cardiac cooling and better myocardial protection. Ninety-one consecutive patients undergoing elective coronary bypass operations were randomized into two groups. The long cross-clamp technique was used in 46 patients (Group 1), and a proximal anastomosis was constructed after each distal anastomosis. The short cross-clamp technique was employed in 45 patients (Group 2), and distal anastomoses were constructed during aortic occlusion. Cardiopulmonary bypass time was identical, but the cross-clamp period was longer in Group 1 (59 ± 15 minutes versus 46 ± 17 minutes in Group 2; p < 0.001). The mean temperature in the most ischemic region was colder with the long cross-clamp technique (12.5 ± 3.1°C in Group 1 versus 14.8 ± 3.2°C in Group 2; p < 0.01). The total amount of the myocardial isoenzyme of serum creatine kinase released was greater in Group 2 than in Group 1 (332 ± 34 IU/L per hour in Group 1 versus 469 ± 45 IU/L per hour in Group 2). Thirty-six patients had coronary sinus catheters inserted (18 patients in each group). Myocardial lactate extraction returned to normal sooner in the patients who had a long cross-clamp period; time to a normal lactate extraction was 0.8 ± 0.8 hours in Group 1 versus 2.2 ± 2.1 hours in Group 2 (p < 0.001). Volume loading and atrial pacing 2 to 4 hours postoperatively produced a similar hemodynamic response in the two groups, but myocardial lactate extraction increased in Group 1 and decreased in Group 2 (p < 0.05). The construction of proximal as well as distal anastomoses during a prolonged cross-clamp period produced more uniform cooling and improved myocardial protection.

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