Influence of Two Different Types of Cardioplegia on Hemodilution During and After Cardiopulmonary Bypass , Postoperative Chest-Drainage Bleeding and Consumption of Donor Blood Products

The aim of this study is to compare the effects of colloidal cardioplegia and blood cardioplegia in patients who underwent cardiac surgical procedures with cardiopulmonary bypass, and to evaluate their influence on hemodilution, bleeding and consumption of donor blood products in a retrospective clinical study.  male patients who underwent cardiac surgical procedure were divided into two groups:  patients were administered intermittent normotherm or mild hypotherm (°C) Calafiore blood cardioplegia with potassium chloride , ;  patients were administered one initial doses of cold Kirsch solution followed from intermittent cold colloidal cardioplegia using hydroxyethyl starch (HES /,). Hemoglobin values after the first dose of cardioplegia were significantly lower in the HES-group than in the Calafioregroup). After the first dose of cardioplegia platelets count was lower in the HES-group than in the Calafiore-group. Hemoglobin and hematocrit values h postoperative were lower in the HES-group than in the Calafiore-group. There was no difference in chest-drainage bleeding h and h postoperative between the groups. The consumption of donor erythrocyte concentrate and fresh frozen plasma was significantly higher in the HES-than in the Calafioregroup. The choice of either colloidal or blood cardioplegia does not influence the postoperative chest-drainage bleeding. The results suggest that high molecular colloidal cardioplegia with HES-solution is associated with higher hemodilution during and after cardiopulmonary bypass and significantly increases the consumption of donor blood products.


Introduction
Myocardial state and need for the blood which circulating through coronary artery depend of the functional condition of the heart.As a sub-discipline of cardiac surgery, myocardial protection involves skillful application of techniques designed to protect the operated heart from injury.There are a variety of strategies for myocardial protection.Frequently used and well established strategy is the pharmacologically induced, reversible, electromechanical, diastolic cardiac arrest achieved by direct infusion of cardioplegic crystalline solutions or blood cardioplegia in the coronary circulation.Different possibilities to induce and receive cardiac arrest are warm or cold, antegrade or retrograde, continuous or intermittent application of a cardioplegic solution.Cardioplegia offers selective perfusion to the heart and avoids ischemic injury primarily in that it reduces oxygen demand to less than  of that of the working heart ().Cardioplegic solutions vary greatly concerning their temperature at which they will be infused, their composition, pH-values and osmolality.The frequency of application, the amount of the solution and the style of application are also under discussion.It is common, for all cardioplegic solutions that they change the extra-cellular milieu for electrolytes and the attributes of myocardial cell membranes, either by electrically stabilizing the membranes or sealing up the permeability of myocardial cell membranes for ions.An electromechanical block with distinct decrease in energy-using actions on myocardial cell membranes and in the contractile apparatus is the aim ().The advantages of every strategic application of cardioplegic technique should be compared against known disadvantages of that technique and a balance should be achieved, which enhances the safety of every cardiac operation as it is harmonized with the patient's specific physiological needs ().In our retrospective study we examined a crystalline -colloidal cardioplegia and a blood cardioplegia concerning their systemic influence on hemodilution during and after CPB, postoperative chest-drainage bleeding and the consumption of donor blood products.The transfusion of donor blood or plasma decreases the patient's safety because of potential risk of infection or allergic reactions and raises the costs of the procedure, which is increasingly important as the clinics are requested to focus on cost effectiveness.

Materials and Methods
All the patients included in the study were male and underwent either a coronary artery bypass grafting (CABG), a mitral-or aortal valve replacement or a combination of these procedures.The differences in patients' age, weight and height and their body surface area (BSA) were not statistically significant (Table ).After median sternotomy, systemic heparinization ( U/kg) and cannulation of the ascending aorta and cavoatrial cannulation or cannulation of superior and inferior vena cava was conducted.Cardiopulmonary bypass was started with a hollow fibre membrane oxygenator ("Monolyth" Sorin Group), a non coated table and machine tubing set with arterial filter (Sorin Group) and a roller pump head (Stöckert).The volume of the priming solution in all patients amounted to  ml ( ml NaCl ,  and  ml Ringer/Lactate) with . I.U.Heparin.In all patients cardioplegia was administered through a cannulation in the aortic root, except in the patients who underwent an aortic valve procedure when the ascending aorta was opened and the cardioplegia directly administered in both coronary orifices by special cardioplegic cannulas ( or  French DLP).

Kirsch -Solution
The cardioplegic effect of this solution established by Kirsch, Rodewald and Kalmar in  () result from the substances procaine hydrochloride and magnesium aspartate in sorbitol solution with a greatly reduced concentration of sodium and calcium.Magnesium inhibits calcium receptors in the cell membrane.Procaine has a membrane stabilizing effect which blocks sodium flow into the cell.Decreased concentrations of sodium and calcium avoid action potential.Increased concentration of magnesium in the Kirsch -solution leads to a rapid diastolic cardiac arrest.In contrast to other cardioplegic methods, Kirsch-solution is administered as a single cold injection immedi- ately after aortic clamping. - ml is injected in the aortic root or directly in the coronary orifices with soft manual pressure over  - seconds (Table ).

HES -Solution (Bleese)
The cardioplegicaly active components of this so-called "Hamburger" solution are magnesium, procaine and a reduced sodium concentration.The solution contains glucose as a substrate.Myocardial metabolism is decreased by inhibition of membrane -ATP.In order to avoid myocardial edema, the solution contains colloidosmoticaly active hydroxyethylstarch (HES) with molecular weight of .Dalton, which maintains colloid osmotic pressure of the solution at , mmHg (,). mg prednisolone was added into  ml of HES -solution as a steroid which decreases capillary permeability and stabilizes lysosomal membrane during ischemia.Also,  ml sodium hydrogencarbonate was added to reach a pH-value of , at °C.Application of cold HES solution followed directly after a single injection of Kirsch -solution -as described in Table  using roller pump pressure and volume control until myocardial temperature of approximately  -°C was reached.
The coronary perfusion pressure should not exceed  - mmHg.The total amount of given HES -solution varied from  - ml with a mean of  ml.

Calafiore Blood Cardioplegia
Comparing with crystalline cardioplegic solutions blood cardioplegia have serious advantages like higher oxygen transport capacity, higher oncotic pressure, physiological rheology and an antioxidant effect.Blood cardioplegia contains oxygen radical scavengers and natural buffer substances such as proteins of histidine and imidazole -groups (,).Calafiore introduced an intermittent warm blood cardioplegia where a perfuser syringe with  mmol/l potassium chloride is connected in line with oxygenated blood via ¼" -¼" LL connector ().The blood and potassium is administered using a roller pump and bubble trap following the application protocol described in Table .After an initial infusion, additional infusions follow respectively when a distal coronary anastomosis is finished or every  minutes ().

STATISTICAL ANALYSIS
Statistical analysis of differences within and between groups was performed with multiple analysis of variance followed by application of Student t-test.Differences were considered significant when p<,.All data are expressed as mean ± SD.

Results
Following the first dose of cardioplegia hemoglobin values were significantly lower (p<,) in the HES-group (, ± , g/dl ) than in the Calafiore group ( , ± , g/dl ); (

Conclusion
The use of colloidal or blood cardioplegia does not influence the postoperative chest-drainage bleeding.The results show that high molecular colloidal cardioplegia with HES-solution is associated with greater hemodilution during CPB which remains almost h postoperative.Consequence is a significantly increased consumption of donor blood and plasma products intra-and postoperative.Blood cardioplegia may have advantages in this sense.Toreiterate , the goal of the operation is not to deliver cardioplegia, but to treat the patient as well as possible.

Discussion
We examined two different types of cardioplegia to study the consequences of a volume invasive cardioplegia concerning hemodilution and the effects on the circulatory system during and after cardiac surgical procedures with cardiopulmonary bypass.Hemodilution affects the pharmacokinetic and pharmacodynamic properties of drugs, predominantly by changing the protein binding by dilution of all plasma proteins ().Large amounts of colloid cardioplegia dilute circulating catecholamine ().HES-solution is known to interfere with blood coagulation according to inhibition of thrombocyte aggregation.Although we did not notice significant difference in postoperative blood loss in our patients between the two cardioplegia forms, longer bleeding time may be a potential risk.Large molecules of the HES-solution (.Dalton) increase blood viscosity and may, in hypothermia, have negative influence on microcirculation ().Higher colloid osmotic pressure resulting from the size of molecules may decrease urine output because glomerular filtration rate developed proportional to the difference between perfusion pressure and colloid osmotic pressure ().
MIRSAD KACILA ET AL.: INFLUENCE OF TWO DIFFERENT TYPES OF CARDIOPLEGIA ON HEMODILUTION DURING AND AFTER CARDIOPULMONARY BYPASS, POSTOPERATIVE CHEST-DRAINAGE BLEEDING AND CONSUMPTION OF DONOR BLOOD PRODUCTS

Table  ,
Chart ).Also, hematocrit values h after the surgery were lower in the HES-group (, ± ,) MIRSAD KACILA ET AL.: INFLUENCE OF TWO DIFFERENT TYPES OF CARDIOPLEGIA ON HEMODILUTION DURING AND AFTER CARDIOPULMONARY BYPASS, POSTOPERATIVE CHEST-DRAINAGE BLEEDING AND CONSUMPTION OF DONOR BLOOD PRODUCTS