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Is blood cardioplegia superior to crystalloid cardioplegia in pediatric cardiac surgery?

Department of Cardiac Surgery, Harefield Hospital, Hill End Road, Harefield, UB9 6JH, Middlesex, UK

Is blood cardioplegia superior to crystalloid cardioplegia?

The relative advantage of blood cardioplegia in relation to crystalloid cardioplegia is still the subject of debate. In spite of theoretical advantages with blood cardioplegia, the research literature is equivocal and crystalloid cardioplegia remains in use at several centres as illustrated by the BET authored by Jacob et al. [1]. Interestingly, the authors ignored the pediatric cardiac surgical population in their BET.

Congenital heart surgeons like their adult cardiac surgery colleagues are also divided with respect to their use of blood and crystalloid cardioplegic solutions. In the opinion of this author it would perhaps be useful to look at the current best available evidence to see if a more convincing and meaningful conclusion can be drawn for the pediatric population than their adult counterparts as suggested by the BET by Jacob et al. [1].

To date four randomised controlled trials (RCTs), recruiting 311 pediatric patients, have been conducted to specifically address this issue [2–5]. Of these, the trials by Modi et al. [2] and Amark et al. [3] reported different outcomes in two different publications. Whereas all the recent trials [2–4] conclude that blood cardioplegia offers superior protection, as it preserves myocardial metabolism and function more effectively than crystalloid cardioplegia in infant cardiac surgery, the trial by Young et al. [5], recruiting 138 patients, failed to demonstrate clear clinical advantage of antegrade cold blood cardioplegia over crystalloid cardioplegia during hypothermic cardioplegic arrest in pediatric cardiac surgery. However, arbitrary decisionmaking for inotropic support, subjective echocardiographic assessment of ventricular function along with the fact that the study by Young et al. [5] was performed in 1994, at a time when cardioplegic techniques were still being refined, are all important limitations which must be taken into account before accepting their conclusion.

It is extremely important to realize that although the differences in myocardial cellular and subcellular functions in neonates, the effects of cyanosis, cardiopulmonary bypass, systemic perfusion temperatures, and of reperfusion, and the varied pathologic entities involved obfuscate cardioplegic effects, evidence from RCTs is convincing enough to suggest that the benefits of blood cardioplegia are more pronounced in younger, cyanotic patients requiring longer aortic cross-clamping. On the other hand, for acyanotic patients the cardioplegic technique is not critical.

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1. Jacob S, Kallikourdis A, Sellke F, Dunning J. Is blood cardioplegia superior to crystalloid cardioplegia? Interact CardioVasc Thorac Surg 2008;7:491–499.[Abstract/Free Full Text]
2. Modi P, Suleiman MS, Reeves B, Pawade A, Parry AJ, Angelini GD, Caputo M. Myocardial metabolic changes during pediatric cardiac surgery: a randomized study of 3 cardioplegic techniques. J Thorac Cardiovasc Surg 2004;128:67–75.[Abstract/Free Full Text]
3. Amark K, Berggren H, Björk K, Ekroth A, Ekroth R, Nilsson K, Sunnegårdh J. Blood cardioplegia provides superior protection in infant cardiac surgery. Ann Thorac Surg 2005;80:989–994.[Abstract/Free Full Text]
4. Caputo M, Modi P, Imura H, Pawade A, Parry AJ, Suleiman MS, Angelini GD. Cold blood versus cold crystalloid cardioplegia for repair of ventricular septal defects in pediatric heart surgery: a randomized controlled trial. Ann Thorac Surg 2002;74:530–534.[Abstract/Free Full Text]
5. Young JN, Choy IO, Silva NK, Obayashi DY, Barkan HE. Antegrade cold blood cardioplegia is not demonstrably advantageous over cold crystalloid cardioplegia in surgery for congenital heart disease. J Thorac Cardiovasc Surg 1997;114:1002–1008.[Abstract/Free Full Text]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Shahzad G. Raja Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Raja, S. G. Search for Related Content PubMed Articles by Raja, S. G. Related Collections Related Article