Pediatrik Miyokard Korunması
Yıl 2014,
Cilt: 11 Sayı: 3, 271 - 279, 15.12.2014
Abdussemet Hazar
Mustafa Göz
Mehmet Salih Aydın
Aydemir Koçarslan
Öz
Miyokard korunmasında temel prensipler elektromekanik diastolik arrest, ventrikül dekompresyonu ve
hipoterminin amacı, kansız bir ortam sağlamak ve miyokardın iskemi süresini güvenli bir şekilde uzatmaktır.
Pediatrik kalp cerrahisinde, erişkin kalp cerrahisinde olduğu gibi myokardın yetersiz korunması önemli bir
morbidite ve mortalite nedenidir. Miyokard koruması cerrah, anestezist ve perfüzyonistin birlikte uygulanan
karmaşık bir işlemdir. Bu yazıda pediatrik kalbin özellikleri ve onun korunması tartışıldı.
Kaynakça
- 1) Hammon JW. Myocardial protection in the immature
heart. Ann Thorac Surg. 1995;60: 839–42.
2) Murphy CE, Salter DR, Morris JJ, et al. Age-related
differences in adenine nucleotide metabolism during in
vivo global ischemia. Surg Forum. 1986;37:288 –90.
3) Imura H, Caputo M, Parry A, Pawade A, Angelini GD,
Suleiman MS. Age-Dependent and Hypoxia-Related
Differences in Myocardial Protection During Pediatric
Open Heart Surgery,Circulation. 2001;103:1551-6.
4) Wittnich C, Belanger MP, Bandali KS. Newborn
hearts are at greater 'metabolic risk' during global
ischemia – advantages of continuous coronary washout
Can J Cardiol 2007;23(3):195-200.
5) Buckberg GD. Studies of hypoxemic/roxigenasyon
injury; Lincage between cardiac function and oxidant
damage. J Thorac Cardiovasc Surg 1995;110:1164-70.
6) Allen BS, Rahman SK, İlbawi M, Feinberg H, Bolling
KS, Kronon M.The detrimental effects of
cardiopulmoner bypass in cyanotic in cyanotic infants:
preventing the reoxygenasyon injury. Ann Thorac Surg
1997;64:1381-8
7) Durandy Y. Pediatric myocardial protection. Curr
Opin Cardiol. 2008 Mar;23(2):85-90.
8) Rezkalla SH, Kloner RA. No-Reflow phenomenon
Circulation 2002;105:656-62.
9) Heyndrickx GR, Millard RW, McRitchie RJ, Maroko
PR, Vatner SF. Regional myocardial functional and
electrophysiological alterations after brief coronary
artery occlusion in conscious dogs. J. Clin. Invest. 1975;
56:978-85.
10) Kloner RA, Ellis SG, Lange R, Braunwald E. Studies
of experimental coronary artery reperfusion: effectson
infarct size, myocardial function, biochemistry,
ultrastructure and microvascular damage. Circulation.
1983; 68(Suppl. I):8-15.
11) Braunwald E, Kloner RA. The stunned myocardium:
Prolonged, postischemic ventricular dysfunction.
Circulation. 1982; 66:1146-9.
12) Reimer KA, Hill ML, Jennings RB. Prolonged
depletion of theadenine nucleotide pool due to delayed
resynthesis of adenine nucleotides following reversible
myocardial ischemic injury in dogs. J. Mol. Cell. Cardiol.
1981;13:229-39.
13) Myers ML, Bolli R, Lekich RF, Hartley CJ, Roberts
R. Enhancement of recovery of myocardial function by
oxygen free-radical scavengers after reversible regional
ischemia. Circulation. 1985; 72:915-21.
14) Przyklenk K, Kloner RA. Superoxide dismutase plus
c a t a l a s e i m p r o v e c o n t r a c t i l e f u n c t i o n
inthecaninemodelofthe "stunned" myocardium. Circ.
Res.1986; 58:148-56.
15) Myers ML, Bolli R, Lekich RF, Hartley CJ, Roberts
R. N-2-mercaptopropionylglycine improves recovery of
myocardial function after reversible regional ischemia. J.
Am. Coll. Cardiol. 1982; 8:1161-8.
16) Bolli R, Zhu WX, Hartley CJ, Michael LH, Repine J,
Hess Ml and et al. Dimethylthiourea attenuates
dysfunction in the postischemic "stunned" myocardium.
Circulation. 1987;76:458-68.
17) Puett DW, Forman MB, Cates CU, Wilson BH, Hande
KR, Friesinger GC and et al. 1987. Oxypurinol limits.
18) Bolli R, Patel BS, Zhu WX, O'Neill PG, Charlat ML,
Roberts R. The iron chelator desferrioxamine attenuates
postischemic ventricular dysfunction. Am. J. Physiol.
1987;253:1372- 80.
19) Kern FH ,Ungerlieder RM,Raves JG,et al.The effect of
altering pump flow rate on cerebral blood flow and
metabolism in neonates,infants and children.Ann Thorac
Surg 1993;56:1366-1372
20) Kern FH, Greeley WJ. Monitoring of nasopharyngeal
and rectal temperatures is not an adequate guide of brain
cooling before deep hypotermic circulatory arrest.J
Cardiothorac Vasc Anesth 1994;8:363-365.
21) Bjork J VO, Hultquist G.Brain damage in children after
deep hypothermia. Thorax 1960;15:284
22) Wittnich C, Peniston C, Ianuzzo D, Abel JG, Salerno
TA. Relative vulnerability of neonatal and adult hearts to
ischemic injury. Circulation 1987;76(1):56-60.
23) Fisher DJ. Oxygenation and metabolism in the
developing heart. Semin Perinatol 1984;8:217-25.
24) Allen BS, Barth MJ, Ilbawi MN. Pediatric myocardial
protection: An overview. Semin Thorac Cardiovasc Surg
2001;13:56-72.
25) Parrish MD, Payne A, Fixler DE. Global myocardial
ischemia in the newborn, juvenile, and adult isolated
isovolumic rabbit heart. Agerelated differences in systolic
function, diastolic stiffness, coronary resistance,
myocardial oxygen consumption, and extracellular pH. Circ
Res 1987;61:609-15
26) Wells RJ, Friedman WF, Sobel BE. Increased
oxidative metabolism in the fetal and newborn lamb
heart. Am J Physiol 1972;222:1488-93.
27) Dawes GS, Mott JC, Shelley HJ. The importance of
cardiac glycogen for the maintenance of life in foetal
lambs and newborn animals during anoxia. J Physiol
1959;146:516-38.
28) Magovern JA, Pae WE Jr, Miller CA, Waldhausen
JA. The mature and immature heart: Response to
normothermic ischemia. J Surg Res 1989;46:366-9.
29) Yano Y, Braimbridge MV, Hearse DJ. Protection of
the pediatric myocardium. Differential susceptibility to
ischemic injury of the neonatal rat heart. J Thorac
Cardiovasc Surg 1987;94:887-96
30) Ascuitto RJ, Ross-Ascuitto NT. Substrate
metabolism in the developing heart. Semin Perinatol
1996;20:542-63
31) Kingsley PB, Sako EY, Yang MQ, et al. Ischemic
contracture begins when anaerobic glycolysis stops: A
31P-MNR study of isolated rat hearts. Am J Physiol
1991;261:469-78.
32) Vanoverschelde JL, Janier MF, Bakke JE, Marshall
DR, Bergmann SR. Rate of glycolysis during ischemia
determines extent of ischemic injury and functional
recovery after reperfusion. Am J Physiol
1994;267:1785-94
33) Tian G, Shen J, Su S, et al. Assessment of retrograde
cardioplegia with magnetic resonance imaging and
localized 31P spectroscopy in isolated pig hearts. J
Thorac Cardiovasc Surg 1997; 114:109–16.
34) Feng J, Li H, Rosenkranz ER. Pinacidil pretreatment
extends ischemia tolerance of neonatal rabbit hearts. J
Surg Res. 2000 ;90(2):131-7.
35) Bremer YA, Salloum F, Ockaili R, et al. Sildenafil
citrate (Viagra) induces cardioprotective effects after
ischemia/reperfusion injury in infant rabbits. Pediatr
Res 2005; 57:22–7.
36) Raja SG. Cardioprotection with sildenafil:
implications for clinical practice. Curr Med Chem 2006;
13:3155–64.
37) Köksal C, Süzer O, Bozkurt AK, Köseoğlu S.
Comparison of enoximone, amrinone or levosimendan
enriched St Thomas' hospital cardioplegic solutions
used for myocardial preservation in isolated guinea pig
hearts. Acta Medica (Hradec Kralove) 2002; 45:93–7.
38) Yamaguchi S, Watanabe G, Tomita S, Tabata S.
Lidocaine-magnesium blood cardioplegia was
equivalent to potassium blood cardioplegia in left
ventricular function of canine heart. Interact Cardio Vasc
Thorac Surg 2007; 6:172–6.
39) Jakobsen O, Muller S, Aarsaether E, et al. Adenosine
instead of supranormal potassium in cardioplegic
solution improves cardioprotection. Eur J Cardiothorac
Surg 2007; 32:493–500.
40) Sloots KL, Vinten-Johansen J, Dobson GP. Warm
nondepolarizing adenosine and lidocaine cardioplegia:
continuous versus intermittent delivery. J
ThoracCardiovasc Surg 2007; 133:1171–8.
41) Mizunati S, Al-Dadah AS, Bloch JB, et al.
Hyperkalemic cardioplegia-induced myocyte swelling
and contractile dysfunction: prevention by diazoxide.
Ann Thorac Surg 2006; 81:154–9.
42) Al-Dadah AS, Voeller RK, Schuessler RB, et al.
Maintenance of myocyte volume homeostasis during
stress by diazoxide is cardioprotective. AnnThorac Surg
2007; 84:857–62.
43) Buckberg GD. Update on current techniques of
myocardial protection. Ann Thorac Surg. 1995;60:805–
14.
44) Caputo M, Ascione R, Angelini GD, et al. The end of
the cold era: from intermittent cold to intermittent warm
blood cardioplegia. Eur J Cardiothorac Surg.
1998;14:467– 75.
45) Bull C, Cooper J, Stark J. Cardioplegic protection of
the child's heart. J Thorac Cardiovasc Surg.
1984;88:287–93.
46) Chaturvedi RR, Lincoln C, Gothard JW, et al. Left
ventricular dysfunction after repair of simple congenital
heart defects in infants and children: quantitation with
the use of conductance catheter immediately after bypass.
J Thorac Cardiovasc Surg. 1998;115:77– 83
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blood cardioplegia is not demonstrably advantageous
over cold crystalloid cardioplegia in surgery for
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48) Lofland GK, Abd-Elfattah AS, Wyse R, et al.
Myocardial adenine nucleotide metabolism in pediatric
patients during hypothermic cardioplegic arrest and
normothermic ischemia. Ann Thorac Surg. 1989;47:663–
8.
49) Buckberg GD, Brazier JR, Nelson RL, et al. Studies
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Surg 2003; 75:890–8
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53) Guru V, Omura J, Alghamdi AA, et al. Is blood
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54) Caputo M, Modi P, Imura H, et al. Cold blood versus
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55) Amark K, Berggren H, Bjo¨ rk K, et al. Myocardial
metabolism is beter preserved after blood cardioplegia in
infants. Ann Thorac Surg 2006; 82:172–8.
56) Lichtenstein SV, El dalati H, Panos A, Slutsky AS.
Long cross-clamp times with warm heart surgery. Lancet
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57) Li GC, Vasquez JA, Gallagher KP, Luchesi BR.
Myocardial protection with preconditioning. Circulation
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58) Mezzetti A, Calafiore AM, Lapenna D, et al.
Intermittent antegrade warm cardioplegia reduces
oxidative stress and improves metabolism of the ischemic
reperfused human myocardium. J Thorac Cardiovasc
Surg 1995; 109:787–95.
59) Jacquet LM, Noirhomme PH, Van Dyck MJ, et al.
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61) Kohman LJ, Veit LJ. Single dose versus multidose
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62) Modi P, Suleiman SM, Reeves BC, et al. Changes in
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63) Najm HK, Wallen WJ, Belanger MP, et al. Does the
degree of cyanosis affect myocardial adenosine
triphosphate levels and function in children undergoing
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64) Catinella FP, Cunningham JN Jr, Spencer FC.
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methylprednisolone in patients undergoing cardiac surgery.
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Hypertonic–hyperoncotic solutions improve cardiac
function in children after open-heart surgery. Pediatrics
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normothermic blood cardioplegic arrest and
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83) Hoffman TM, Wernovsky G, Atz AM, et al. Efficacy and
safety of milrinone in preventing low cardiac output
syndrome in infants and children after corrective surgery for
congenital heart disease. Circulation 2003; 107: 996–1002.
84) Hayashi Y, Sawa Y, Nishimura M, Ichikawa H, Kagisaki
K, Ohtake S, Matsuda H.Clinical evaluation of leukocytedepleted blood cardioplegia for pediatric open heart
operation. . Ann Thorac Surg. 2000 ;69(6):1914-9.
85) Lazar HL. Enhanced Preservation of Acutely Ischemic
Myocardium and Improved Clinical Outcomes Using
Glucose-Insulin-Potassium (GIK) Solutions. Am. J. Cardial
1997; 80(3): 90-3.
Pediatric Miyocardial Protection
Yıl 2014,
Cilt: 11 Sayı: 3, 271 - 279, 15.12.2014
Abdussemet Hazar
Mustafa Göz
Mehmet Salih Aydın
Aydemir Koçarslan
Öz
The basic principles of the protection of myocardium with diastolic electromechanical arrest, ventricular
decompression and hypothermia purpose of providing an environment bloodless and safely extend the
duration of myocardial ischemia. Pediatric cardiac surgery as well as Adult cardiac surgery, inadequate
protection of the myocardium is an important cause of morbidity and mortality. Myocardial protection is a
complex procedure and applied with surgeon, the anesthesiologist, and perfusionist. Features of pediatric
heart and its preservation are discussed in this article.
Kaynakça
- 1) Hammon JW. Myocardial protection in the immature
heart. Ann Thorac Surg. 1995;60: 839–42.
2) Murphy CE, Salter DR, Morris JJ, et al. Age-related
differences in adenine nucleotide metabolism during in
vivo global ischemia. Surg Forum. 1986;37:288 –90.
3) Imura H, Caputo M, Parry A, Pawade A, Angelini GD,
Suleiman MS. Age-Dependent and Hypoxia-Related
Differences in Myocardial Protection During Pediatric
Open Heart Surgery,Circulation. 2001;103:1551-6.
4) Wittnich C, Belanger MP, Bandali KS. Newborn
hearts are at greater 'metabolic risk' during global
ischemia – advantages of continuous coronary washout
Can J Cardiol 2007;23(3):195-200.
5) Buckberg GD. Studies of hypoxemic/roxigenasyon
injury; Lincage between cardiac function and oxidant
damage. J Thorac Cardiovasc Surg 1995;110:1164-70.
6) Allen BS, Rahman SK, İlbawi M, Feinberg H, Bolling
KS, Kronon M.The detrimental effects of
cardiopulmoner bypass in cyanotic in cyanotic infants:
preventing the reoxygenasyon injury. Ann Thorac Surg
1997;64:1381-8
7) Durandy Y. Pediatric myocardial protection. Curr
Opin Cardiol. 2008 Mar;23(2):85-90.
8) Rezkalla SH, Kloner RA. No-Reflow phenomenon
Circulation 2002;105:656-62.
9) Heyndrickx GR, Millard RW, McRitchie RJ, Maroko
PR, Vatner SF. Regional myocardial functional and
electrophysiological alterations after brief coronary
artery occlusion in conscious dogs. J. Clin. Invest. 1975;
56:978-85.
10) Kloner RA, Ellis SG, Lange R, Braunwald E. Studies
of experimental coronary artery reperfusion: effectson
infarct size, myocardial function, biochemistry,
ultrastructure and microvascular damage. Circulation.
1983; 68(Suppl. I):8-15.
11) Braunwald E, Kloner RA. The stunned myocardium:
Prolonged, postischemic ventricular dysfunction.
Circulation. 1982; 66:1146-9.
12) Reimer KA, Hill ML, Jennings RB. Prolonged
depletion of theadenine nucleotide pool due to delayed
resynthesis of adenine nucleotides following reversible
myocardial ischemic injury in dogs. J. Mol. Cell. Cardiol.
1981;13:229-39.
13) Myers ML, Bolli R, Lekich RF, Hartley CJ, Roberts
R. Enhancement of recovery of myocardial function by
oxygen free-radical scavengers after reversible regional
ischemia. Circulation. 1985; 72:915-21.
14) Przyklenk K, Kloner RA. Superoxide dismutase plus
c a t a l a s e i m p r o v e c o n t r a c t i l e f u n c t i o n
inthecaninemodelofthe "stunned" myocardium. Circ.
Res.1986; 58:148-56.
15) Myers ML, Bolli R, Lekich RF, Hartley CJ, Roberts
R. N-2-mercaptopropionylglycine improves recovery of
myocardial function after reversible regional ischemia. J.
Am. Coll. Cardiol. 1982; 8:1161-8.
16) Bolli R, Zhu WX, Hartley CJ, Michael LH, Repine J,
Hess Ml and et al. Dimethylthiourea attenuates
dysfunction in the postischemic "stunned" myocardium.
Circulation. 1987;76:458-68.
17) Puett DW, Forman MB, Cates CU, Wilson BH, Hande
KR, Friesinger GC and et al. 1987. Oxypurinol limits.
18) Bolli R, Patel BS, Zhu WX, O'Neill PG, Charlat ML,
Roberts R. The iron chelator desferrioxamine attenuates
postischemic ventricular dysfunction. Am. J. Physiol.
1987;253:1372- 80.
19) Kern FH ,Ungerlieder RM,Raves JG,et al.The effect of
altering pump flow rate on cerebral blood flow and
metabolism in neonates,infants and children.Ann Thorac
Surg 1993;56:1366-1372
20) Kern FH, Greeley WJ. Monitoring of nasopharyngeal
and rectal temperatures is not an adequate guide of brain
cooling before deep hypotermic circulatory arrest.J
Cardiothorac Vasc Anesth 1994;8:363-365.
21) Bjork J VO, Hultquist G.Brain damage in children after
deep hypothermia. Thorax 1960;15:284
22) Wittnich C, Peniston C, Ianuzzo D, Abel JG, Salerno
TA. Relative vulnerability of neonatal and adult hearts to
ischemic injury. Circulation 1987;76(1):56-60.
23) Fisher DJ. Oxygenation and metabolism in the
developing heart. Semin Perinatol 1984;8:217-25.
24) Allen BS, Barth MJ, Ilbawi MN. Pediatric myocardial
protection: An overview. Semin Thorac Cardiovasc Surg
2001;13:56-72.
25) Parrish MD, Payne A, Fixler DE. Global myocardial
ischemia in the newborn, juvenile, and adult isolated
isovolumic rabbit heart. Agerelated differences in systolic
function, diastolic stiffness, coronary resistance,
myocardial oxygen consumption, and extracellular pH. Circ
Res 1987;61:609-15
26) Wells RJ, Friedman WF, Sobel BE. Increased
oxidative metabolism in the fetal and newborn lamb
heart. Am J Physiol 1972;222:1488-93.
27) Dawes GS, Mott JC, Shelley HJ. The importance of
cardiac glycogen for the maintenance of life in foetal
lambs and newborn animals during anoxia. J Physiol
1959;146:516-38.
28) Magovern JA, Pae WE Jr, Miller CA, Waldhausen
JA. The mature and immature heart: Response to
normothermic ischemia. J Surg Res 1989;46:366-9.
29) Yano Y, Braimbridge MV, Hearse DJ. Protection of
the pediatric myocardium. Differential susceptibility to
ischemic injury of the neonatal rat heart. J Thorac
Cardiovasc Surg 1987;94:887-96
30) Ascuitto RJ, Ross-Ascuitto NT. Substrate
metabolism in the developing heart. Semin Perinatol
1996;20:542-63
31) Kingsley PB, Sako EY, Yang MQ, et al. Ischemic
contracture begins when anaerobic glycolysis stops: A
31P-MNR study of isolated rat hearts. Am J Physiol
1991;261:469-78.
32) Vanoverschelde JL, Janier MF, Bakke JE, Marshall
DR, Bergmann SR. Rate of glycolysis during ischemia
determines extent of ischemic injury and functional
recovery after reperfusion. Am J Physiol
1994;267:1785-94
33) Tian G, Shen J, Su S, et al. Assessment of retrograde
cardioplegia with magnetic resonance imaging and
localized 31P spectroscopy in isolated pig hearts. J
Thorac Cardiovasc Surg 1997; 114:109–16.
34) Feng J, Li H, Rosenkranz ER. Pinacidil pretreatment
extends ischemia tolerance of neonatal rabbit hearts. J
Surg Res. 2000 ;90(2):131-7.
35) Bremer YA, Salloum F, Ockaili R, et al. Sildenafil
citrate (Viagra) induces cardioprotective effects after
ischemia/reperfusion injury in infant rabbits. Pediatr
Res 2005; 57:22–7.
36) Raja SG. Cardioprotection with sildenafil:
implications for clinical practice. Curr Med Chem 2006;
13:3155–64.
37) Köksal C, Süzer O, Bozkurt AK, Köseoğlu S.
Comparison of enoximone, amrinone or levosimendan
enriched St Thomas' hospital cardioplegic solutions
used for myocardial preservation in isolated guinea pig
hearts. Acta Medica (Hradec Kralove) 2002; 45:93–7.
38) Yamaguchi S, Watanabe G, Tomita S, Tabata S.
Lidocaine-magnesium blood cardioplegia was
equivalent to potassium blood cardioplegia in left
ventricular function of canine heart. Interact Cardio Vasc
Thorac Surg 2007; 6:172–6.
39) Jakobsen O, Muller S, Aarsaether E, et al. Adenosine
instead of supranormal potassium in cardioplegic
solution improves cardioprotection. Eur J Cardiothorac
Surg 2007; 32:493–500.
40) Sloots KL, Vinten-Johansen J, Dobson GP. Warm
nondepolarizing adenosine and lidocaine cardioplegia:
continuous versus intermittent delivery. J
ThoracCardiovasc Surg 2007; 133:1171–8.
41) Mizunati S, Al-Dadah AS, Bloch JB, et al.
Hyperkalemic cardioplegia-induced myocyte swelling
and contractile dysfunction: prevention by diazoxide.
Ann Thorac Surg 2006; 81:154–9.
42) Al-Dadah AS, Voeller RK, Schuessler RB, et al.
Maintenance of myocyte volume homeostasis during
stress by diazoxide is cardioprotective. AnnThorac Surg
2007; 84:857–62.
43) Buckberg GD. Update on current techniques of
myocardial protection. Ann Thorac Surg. 1995;60:805–
14.
44) Caputo M, Ascione R, Angelini GD, et al. The end of
the cold era: from intermittent cold to intermittent warm
blood cardioplegia. Eur J Cardiothorac Surg.
1998;14:467– 75.
45) Bull C, Cooper J, Stark J. Cardioplegic protection of
the child's heart. J Thorac Cardiovasc Surg.
1984;88:287–93.
46) Chaturvedi RR, Lincoln C, Gothard JW, et al. Left
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