J Extra Corpor Technol 2024 , 56 , 207 – 210 Ó The Author ( s ), published by EDP Sciences , 2024 https :// doi . org / 10.1051 / ject / 2024027
Available online at : ject . edpsciences . org
CASE REPORT
A technique avoiding cardioplegia delivery complications : a case using systemic hyperkalemia cardiopulmonary bypass combined with circulatory arrest Tomohisa Takeichi ( CCP ) 1 ,* , Yoshihisa Morimoto ( MD ) 2 , Akitoshi Yamada ( MD ) 2 , and Takanori Tanaka ( CCP ) 1
1 Department of Clinical Engineering , Kitaharima Medical Center , 926-250 , Ichiba-cho , Ono-shi , Hyogo , 675-1392 , Japan 2 Department of Cardiovascular Surgery , Kitaharima Medical Center , 926-250 , Ichiba-cho , Ono-shi , Hyogo , 675-1392 , Japan
Received 4 April 2024 , Accepted 16 September 2024
Abstract – We conducted a high-risk redo mitral valve replacement through a right mini-thoracotomy without rib spreading ( redo-MICS MVR ) under systemic hyperkalemia combined with circulatory arrest to circumvent complications associated with cardioplegia delivery . The patient , a 75-year-old man , had a predicted mortality rate of 20 %. Initial antegrade cardioplegia successfully induced cardiac arrest , which was administered every 30 min . However , upon infusion of the second dose of cardioplegia , the aortic root pressure was approximately 20 mmHg . Despite multiple attempts to re-cross the clamp , the aortic root pressure did not improve . Consequently , retrograde cardioplegia was considered , but due to significant adhesion of the inferior vena cava , this approach was abandoned . Thus , the procedure was altered to utilize systemic hyperkalemia without aortic cross-clamping ( ACC ). Given the preoperative transesophageal echocardiography ( TEE ) diagnosis of mild aortic regurgitation , maintaining a clear surgical field was challenging , necessitating the combination of redo-MVR with circulatory arrest . This case exemplifies the successful management of cardioplegia delivery complications using systemic hyperkalemia and circulatory arrest , resulting in a favorable postoperative recovery for the patient . Key words : Cardiopulmonary bypass ( CPB ), Systemic hyperkalemia , Circulatory arrest , Cardioplegia delivery complications .
Introduction
A meta-analysis demonstrates that minimally invasive cardiac surgery ( MICS ) for redo cases is associated with a reduced incidence of in-hospital mortality , reintervention for bleeding , and acute renal failure compared to median sternotomy for redo mitral valve surgery [ 1 ]. At our institution , we actively employ totally endoscopic MICS for redo cases , aiming to mitigate risks and optimize patient outcomes . However , it is crucial to exercise caution regarding aortic crossclamping ( ACC ) due to the adhesions frequently present around the aorta in redo cases . Complications in cardioplegia delivery can be fatal . In such scenarios , beating heart ( BH ) surgery or ventricular fibrillation ( VF ) is often performed . A concern with utilizing VF is subendocardial hypoperfusion . Blood flow to the subendocardium occurs during diastole , and the compressive force exerted on the subendocardial muscle by fibrillation restricts blood flow and oxygen delivery to the myocardium during the diastolic phase [ 2 ]. Consequently , myocardial edema increases in the static diastolic state , potentially leading to
* Corresponding author : tommo . tommo @ outlook . jp cardiac dysfunction . At our institution , we employ systemic hyperkalemia cardiopulmonary bypass ( CPB ) [ 3 ]. In this case , to avoid complications in cardioplegia delivery due to incomplete ACC , we performed mitral valve replacement ( MVR ) under systemic hyperkalemia CPB . Circulatory arrest was also incorporated to address poor surgical visualization resulting from aortic regurgitation ( AR ).
This study was approved by the Institutional Review Board at Kitaharima Medical Center ( IRB-0562 ) with the waiver of informed consent .
Case report
A 75-year-old male patient ( height : 166.4 cm ; weight : 66.2 kg ), who had previously undergone percutaneous coronary intervention ( PCI ) to the left anterior descending artery ( LAD ) and coronary artery bypass grafting ( CABG ) with a saphenous vein graft to the posterior descending branch ( SVG-4PD ) combined with mitral valve replacement ( MVR ) 12 years prior , was diagnosed with severe mitral regurgitation and mild aortic regurgitation via TEE . Three-dimensional computed
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