Bahnson, HT

Deeb, GM

Griffith, BP

Hardesty, RL

Starzl, TE

PubMed

Name not available

Improved cardiac function using cardioplegia during procurement and transplantation

D-Scholarship@Pitt

f • r t T \ ( ~ i .,. J f , t ! t I l .; .;. I ,. I I I. t .. ' Improved Cardiac Function Using Cardioplegia During Procurement and Transplantation R. L. Hardesty, B. P. Griffith, G. M. Deeb, H. T. Bahn~onI and T. E. Starzl CARDIAC transplantation was resumed as a therapeutic procedure at the Uni-versity of Pittsburgh in June of 1980. Distant procurement and a simple preservation tech-nique can be used to preserve donor hearts for 3-4 hr with satisfactory function of the graft.! In this report. we describe a technique using cardioplegia, which improves preservation during implantation. MATERIALS AND METHODS Our use of cardioplegia during cardiectomy and implantation has vaned. In 10 instances. none was used during excision nor during implantation. in 3 it was infused only during cardiectomy, and in 16. both during excision and implantation. "'Stanford solution'" (Table 1) has been used during cardiectomy and "'Buckberg blood cardioplegia",2 (Table 2) during implantation. Heart, liver. and kidneys. all functionally satisfactory for grafting, have been obtained from 10 donors. The donor's temperature ambiently cools to 33-34°C and in situ cooling of the liver, achieved by infusing lactated Ringer's solution (4°C) into the portal vein. further cools the heart. An initial sternotomy and celiotomy provide access for a rapid cardiectomy should the hepatectom~ and nephrectomy compromise cardiac function, but this has never occurred. In situ cooling of kidneys is preferred. and the infusion is begun immediately after occlusion of the ascending aorta initiates c;:rdlectomy. The liver and kidneys are excised su bsequent to removal of the heart. Ex vivo cooling of kidneys necessitates interruption of venous return and results in hemodynamic instability. Although not preferable, it has been accomplished in order to comply with the hosting institution's wishes. The superior vena cava is stapled. the inferior cava occluded and divided, the aorta ocduded and cardioplegia infused. the pulmonary veins and pulmonary arteries transected, and lastly the aorta divided. Cardioplegia is infused into the aorta through a 12-gauge catheter at a maximal pressure of 150 mm Hg. The infusion is facili-tated by promptly transecting a pulmonary vein and eliminating return to the left atrium and ventricle. A novel technique of stapling the divided aorta of the donor heart with the Ravitch TIA 30 stapler (3.5 mm or V staples) (American Surgical Instruments. Inc.) enables cardioplegia to be infused into the donor heart during implantation (Fig. I). The 12-gauge catheter used during cardiectomy is affixed to the donor's aona with a purse-string suture at that time and left in place. During Trsnsplantsrton Proceedings, Vol. XV, No.1 (March), t983 infusion, air is evacuated by placing an IS-gauge needle into the segment of aorta between the aortic valve and staple line. The solution is infused every 20 min at a pressure of 120 mm Hg by employing a constant pressure-variable flow pump. External cooling every 20 min (4°C crystalloid solution) and internal cooling upon completion of the atrial anastomoses via the left atrial appendage was employed in every transplantation. The need for inotropic drugs (dopamine and/or dobut-amine) was ascertained retrospectively according to the number of days (>12 hr - I day) dopamine and/or dobutamine was used in excess of 10 ltg/kg/min to maintain a normal mean arterial pressure (60-80 mm Hg) and urinary output (>30 cc/hr). RESULTS When no cardioplegia (10 patients) was used during cardiectomy or implantation, dopamine and/or dobutamine were used for 2.8 days, whereas when cardioplegia was used during cardiectomy and also during implanta-tion (16 patients), these drugs were used for 0.1 days-a difference that is statistically significant (p < 0.001). The total ischemic times were not statistically different (p > 0.05) (Fig. 2). The times of transportation and implantation are detailed in Fig. 3. DISCUSSION Our initial concept was that rapid excision of the donor heart and immersion in a crystal-loid solution at 4°C was simpler and would quickly cool and arrest the heart so that the fundamental principles of preservation would be met.3 The postoperative need for inotropic support in these patients suggested that this was not correct, and subsequent laboratory From the Department of Surgery. University of Pills-burgh School of Medicine. Pittsburgh. Pa. Reprint requests should be addressed to Dr. R. L. Hardesty. Department of Surgery. University of Pitts-burgh School of Medicine. 1088 Scaife Hall. Pittsburgh. Pa. 15261. <i:' 1983 by Grune & Stratton. Inc. 0041-1345/83/1 501--{)302$01 .00/0 1253 1254 Table 1. Stanford Cardioplegic Solution Component Potassium Sodium Chloride Bicarbonate Dextrose Mannitol Osmolality pH (at 4° C) Concentration 30 meq!liter 25 meq/liter 30 meq/liter 25' meq/liter 50 g/Iiter 1 2.5 g/Iiter 440 mosmole/liter 8.1-8.4 Table 2. Buckberg Blood Cardioplegia Component knic calcium KC1 Osmolanty Het pH Concentration 0.6 meq/liter 30 meq/liter 355 mOsmole 20 7.7 evidence contradicted this concept. In dogs, the septal temperature decreased more rap-idly and arrest occurred sooner (Fig. 4) when cardioplegia was used during the cardiecto-my. Not compared in this report were three transplants in which cardioplegia was used during excision of the donor heart but not during implantation. The lesser need for ino-tropic support was readily evident (retrospec-tively 0.5 days of dopamine and/or dobut-amine at > 10 ~g/kg/min compared to 2.8 Fig. 1. Technique of infusing cardioplegia into the donor heart during implantation. 150 en w '; 100 z ::::;: 50 0 HARDES1Y ET AL. MYOCARDIAL PRESERVATION p>.05 ~ 151 TOTAL ISCHEMIA ~kl • CAROIOPL£GIA 3.0 2.5 en ,.. 2.0 « c 1.5 1.0 .5 p<.OOI 2.8 DOPAMINE OOBUTAMINE >1 0!'91 kq/m in Fig. 2. When no cardioplegia (10 patients) was used during cardiectomy or implantation. dopamine and I or dobutamine were used for 2.B days, whereas when cardioplegia was used during cardiectomy and also during implamation (16 patients), the.e drugs were used for 0.1 days-a difference that is statistically significant (p < 0.0011. The total ischemic times were not statistically different (p > 0.051. days without it). Concurrently, the idea of stapling the donor aorta in order to facilitate the use of cardioplegia during implantation originated and was combined with the latter. The benefits to the donor heart include main-tenance of arrest and hypothermia and washout of metabolites. The early benefit to ISCHEMIA TIMES 200 r---~-----------:K"I---I ~ NO CARDIOPLEGIA en w f-150 ::::J 100 z :::E 50 o • CARDIOPLEGIA '5' TRANSPORT IMPLANT TOTAL Fig. 3. The total ischemic times ware not statisti-cally different. The times of transportation and implan-tation are statistically significantly diffarent. I I It. I f 1 t \ l I '( I 'f • J ! \ t .'. .. IMPROVED CARDIAC FUNCTION USING CARDIOPLEGIA 1255 ADVANTAGES OF DONOR CARDIOPLEGIA 37 32 u 28 0 I W a:: ::::> l-e:::[ a:: w a.. ~ w I--.l 12 e:::[ l-n.. w (f) • NO CARDIOPLEGIA o CARDIOPLEGIA 4 0 5 10 15 TIME (MINUTES) the recipient is a lesser need for cardiotonic support postoperatively. SUMMARY More rapid cooling and early arrest of a donor heart can be achieved with the use of c:ardioplegia during cardiectomy. Stapling the divided aorta of the donor heart facilitates the infusion of cardioplegia during implantation. Combining the use of cardioplegia during 20 Fig. 4. In six dogs. the septal temperature decreased more rapidly and arrest occurred sooner when cardioplegia was used during the cardiectomy. excision and implantation lessens the need for inotropic drugs following transplantation. REFERENCES 1. Billingham ME. Baumgartner W A. Watson DC. et al: Circulation 62(Suppl I): 11. 1980 2. Follette DM. Mulder DG. Maloney JV. et a1: J Thorac Cardiovasc Surg 76:604. 1978 3. Buckberg GD: J Thorac Cardiovasc Surg 77:803. 1979 :-r II s, Ie Ln Is, ne cd tic lot on ith ~en cns 

Improved Cardiac Function Using Cardioplegia During Procurement and Transplantation.

http://d-scholarship.pitt.edu/3892/1/31735062114701.pdf

Improved Cardiac Function Using Cardioplegia During Procurement and Transplantation.

Abstract

Similar works

Full text

Available Versions

Name not available

Name not available

D-Scholarship@Pitt