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Ann Thorac Surg 1992;54:449-459
© 1992 The Society of Thoracic Surgeons
Division of Cardiovascular Surgery, Department of Anaesthesia, and Clinical Epidemiology Unit, Sunnybrook Health Science Centre, University of Toronto, Toronto, Ontario, Canada
* Address reprint requests to Dr Christakis, Division of Cardiovascular Surgery, Sunnybrook Health Science Centre, 2075 Bayview Ave, H406, Toronto, Ont M4N 3M5, Canada.
The technique of warm heart surgery is defined as continuous warm blood cardioplegia and normothermic cardiopulmonary bypass. Although the systemic effects of traditional myocardial protection are well known, the effects of warm heart surgery are not. In a prospective trial, 204 patients undergoing coronary artery bypass grafting were randomized to the warm heart surgery technique (normothermic group) or traditional intermittent cold blood cardioplegia and cardiopulmonary bypass (hypothermic group). The groups had similar heparin sodium requirements, activated clotting times, urine output, hematocrit, and blood product utilization. There were no differences in hemodynamics immediately after cardiopulmonary bypass. The normothermic patients had a higher incidence of spontaneous defibrillation at cross-clamp removal (84%) than the hypothermic patients (33%) (p < 0.01). An increase in the flow rate of low K+ cardioplegia was necessary to eradicate electrical activity during aortic occlusion more often in the normothermic patients (20%) than in the hypothermic patients (3%) (p < 0.01). When low K+ cardioplegia was ineffective, high K+ cardioplegia was necessary to eradicate electrical activity in 31% of the normothermic patients compared with 10% of the hypothermic patients (p < 0.05). The total cardioplegia volume delivered to the normothermic group (4.7 ± 1.9 L) was higher than that delivered to the hypothermic group (2.6 ± 0.8 L) (p < 0.01). Although urine output was similar in both groups, the serum K+ levels were higher in the normothermic group (5.7 ± 0.8 mmol/L) than in the hypothermic group (5.3 ± 0.8 mmol/L) (p < 0.001). Low systemic vascular resistance during normothermic cardiopulmonary bypass resulted in the infusion of significantly higher volumes of crystalloid solutions (3,650 ± 800 mL) and more phenylephrine hydrochloride (1.3 ± 2.2 mg) than during hypothermic cardiopulmonary bypass (3,100 ± 700 mL and 0.4 ± 0.6 mg, respectively) (p < 0.01). Warm heart surgery should be used with caution in patients with renal failure or severe cerebrovascular disease. Serum K+ levels and fluid overload must be carefully monitored during long operations. The high incidence of low systemic vascular resistance and resulting phenylephrine infusion during normothermic cardiopulmonary bypass raises concerns about possible mammary artery or coronary artery spasm and the risk of stroke.
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I. A. Regragui, M. B. Izzat, I. Birdi, M. Lapsley, A. J. Bryan, and G. D. Angelini Cardiopulmonary bypass perfusion temperature does not influence perioperative renal function Ann. Thorac. Surg., July 1, 1995; 60(1): 160 - 164. [Abstract] [PDF]
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J. R. Van Camp, L. A. Brunsting III, K. F. Childs, and S. F. Bolling Functional recovery after ischemia: Warm versus cold cardioplegia Ann. Thorac. Surg., April 1, 1995; 59(4): 795 - 803. [Abstract] [PDF]
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A. Mezzetti, A. M. Calafiore, D. Lapenna, R. Deslauriers, G. Tian, T. A. Salerno, A. M. Verna, G. Bosco, S. D. Pierdomenico, and F. Caccurullo Intermittent antegrade warm cardioplegia reduces oxidative stress and improves metabolism of the ischemic-reperfused human myocardium J. Thorac. Cardiovasc. Surg., April 1, 1995; 109(4): 787 - 795. [Abstract] [Full Text]
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L. A. Robinson, G. D. Schwarz, D. B. Goddard, W. H. Fleming, and T. A. Galbraith Myocardial protection for acquired heart disease surgery: Results of a national survey Ann. Thorac. Surg., February 1, 1995; 59(2): 361 - 372. [Abstract] [PDF]
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R. M. Becker, A. A. Rich, and J. R. Reed Normothermic cardiopulmonary bypass Ann. Thorac. Surg., February 1, 1995; 59(2): 546 - 547. [PDF]
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U. Hvass and J.-P. Depoix Clinical study of normothermic cardiopulmonary bypass in 100 patients with coronary artery disease Ann. Thorac. Surg., January 1, 1995; 59(1): 46 - 51. [Abstract] [PDF]
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M. Tonz, T. Mihaljevic, L. K. von Segesser, E. R. Schmid, H. I. Doller-Jemelka, P. Pei, and M. I. Turina Normothermia versus hypothermia during cardiopulmonary bypass: A randomized, controlled trial Ann. Thorac. Surg., January 1, 1995; 59(1): 137 - 143. [Abstract] [PDF]
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P. J. Hendry, R. G. Masters, and A. Haspect Is there a place for cold crystalloid cardioplegia in the 1990s? Ann. Thorac. Surg., December 1, 1994; 58(6): 1690 - 1694. [Abstract] [PDF]
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B. L. Bufkin, R. J. Mellitt, J. P. Gott, A. H. Huang, Pan-Chih, and R. A. Guyton Aerobic blood cardioplegia for revascularization of acute infarct: Effects of delivery temperature Ann. Thorac. Surg., October 1, 1994; 58(4): 953 - 960. [Abstract] [PDF]
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B. Frering, I. Philip, M. Dehoux, C. Rolland, J. M. Langlois, and J. M. Desmonts Circulating cytokines in patients undergoing normothermic cardiopulmonary bypass J. Thorac. Cardiovasc. Surg., October 1, 1994; 108(4): 636 - 641. [Abstract] [Full Text]
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G. T. Christakis, S. E. Fremes, J.-P. Koch, S. Harwood, S. Juhasz, E. Sharpe, K. A. Deemar, C. Hamilton, E. Chen, V. Rao, et al. Determinants of low systemic vascular resistance during cardiopulmonary bypass Ann. Thorac. Surg., October 1, 1994; 58(4): 1040 - 1049. [Abstract] [PDF]
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L. C. Pelletier, M. Carrier, Y. Leclerc, R. Cartier, E. Wesolowska, and B. C. Solymoss Intermittent antegrade warm versus cold blood cardioplegia: A prospective, randomized study Ann. Thorac. Surg., July 1, 1994; 58(1): 41 - 49. [Abstract] [PDF]
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S. A. Mills Warm retrograde blood cardioplegia: A prospective trial Ann. Thorac. Surg., February 1, 1994; 57(2): 281 - 282. [PDF]
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T. D. Martin, J. M. Craver, J. P. Gott, W. S. Weintraub, J. Ramsay, C. T. Mora, and R. A. Guyton Prospective, randomized trial of retrograde warm blood cardioplegia: Myocardial benefit and neurologic threat Ann. Thorac. Surg., February 1, 1994; 57(2): 298 - 304. [Abstract] [PDF]
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P. Menasche, S. Haydar, J. Peynet, C. D. Buit, R. Merval, G. Bloch, A. Piwnica, and A. Tedgui A potential mechanism of vasodilation after warm heart surgery: The temperature-dependent release of cytokines J. Thorac. Cardiovasc. Surg., January 1, 1994; 107(1): 293 - 299. [Abstract] [Full Text]
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G. Lisi, G. Sani, M. Maccherini, B. Biagioli, and M. Toscano Platelet function and hypothermic cardiopulmonary bypass Ann. Thorac. Surg., December 1, 1993; 56(6): 000349759390724V - 349759390724V. [PDF]
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P. Menasche, J.-P. Fleury, L. Veyssie, O. Le Dref, B. Touchot, A. H. Piwnica, and B. Gerard Limitation of vasodilation associated with warm heart operation by a "mini-cardioplegia" delivery technique Ann. Thorac. Surg., November 1, 1993; 56(5): 1148 - 1153. [Abstract] [PDF]
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A. L Panos, R. Deslauriers, P. L Birnbaum, and T. A Salerno Review article : Perspectives on myocardial protection: warm heart surgery Perfusion, July 1, 1993; 8(4): 287 - 291. [Abstract] [PDF]
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U. Hvass and J.-P. Depoix Normothermic cardiopulmonary bypass Ann. Thorac. Surg., July 1, 1993; 56(1): 202 - 202. [PDF]
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R. A. Guyton Warm blood cardioplegia: Benefits and risks Ann. Thorac. Surg., May 1, 1993; 55(5): 1071 - 1072. [Abstract] [PDF]
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