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Ann Thorac Surg 1989;47:663-668
© 1989 The Society of Thoracic Surgeons

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Articles

Myocardial adenine nucleotide metabolism in pediatric patients during hypothermic cardioplegic arrest and normothermic ischemia

^a Cardiothoracic Unit, The Hospital for Sick Children, London, England
^b Institute of Child Health, University of London, London, England
^c Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA

^_* Address reprint requests to Dr Lofland, Division of Cardiovascular Surgery, Medical College of Virginia, Box 68 MCV Station, Richmond, VA 23298-0068.

Quantitative assessment of high-energy phosphate levels, including degradation or utilization during ischemia, has not previously been performed in infants and children. Animal experiments suggest that high-energy phosphate metabolism varies with maturation. To help answer these questions, 24 patients aged 2 months to 8 years underwent myocardial biopsy immediately after the institution of cardiopulmonary bypass (16 to 20 °C). Additional samples were obtained at 16 and 45 minutes after aortic cross-clamping and administration of cardioplegia (St. Thomas's solution) (in vivo ischemia). Seven patients also underwent major myocardial resection. Resected specimens were placed in a 37 °C bath and divided into equal-sized samples that were removed at ten-minute intervals (in vitro ischemia). All samples were immersed in liquid nitrogen and analyzed for adenine nucleotide pool metabolites using high-performance liquid chromatography. Levels of adenosine triphosphate were high before cross-clamping but diminished during the period of protected ischemia. Adenosine triphosphate loss was much more pronounced in patients less than 18 months old (p < 0.05) and was associated with accumulation of adenosine monophosphate and inosine, a finding not seen in patients more than 18 months old (p < 0.05). The same trends documented during in vivo ischemia were noted during in vitro ischemia. Immaturity of 5'-nucleotidase results in accumulation of adenosine monophosphate during ischemia. It is known that 5'-nucleotidase is present in neonatal myocardial cell membranes and absent from the cytosol. Our findings suggest that a relative deficiency of cytosolic 5'-nucleotidase exists beyond the neonatal period and also that the myocardium of patients less than 18 months of age is not adequately protected by both hypothermia and the cardioplegic solution used in this study.

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