A Simple System to Deliver Blood Cardioplegia
Sylvio C. Provenzano, Jr, MD, MS, Robert Stacey, CCP,
David C. Newman, FRACS, MBBS, Hugh Wolfenden, FRACS, MBBS,
Con Manganas, FRACS, MBBS, and Peter W. Grant, FRACS, MBBS
Department of Cardiothoracic Surgery, Sydney Children’s Hospital, and Departments of Clinical Perfusion and Cardiothoracic
Surgery, Prince of Wales Hospital, Sydney, New South Wales, Australia
We describe a simple and inexpensive system designed
to deliver blood cardioplegia either diluted or at the
patient’s hematocrit, with controlled temperature and
additive concentration. This system can be applied to any
pump set, and suits any strategy for clinical myocardial
preservation.
(Ann Thorac Surg 2005;80:1946 –7)
© 2005 by The Society of Thoracic Surgeons
FEATURE ARTICLES
I mproved myocardial protection is one of the reasons
for the tremendous progress in cardiac surgery during
the last 3 decades. Blood cardioplegia is the most com-
mon form of clinical myocardial preservation in the
United States, according to the STS database [1]. The
purpose of this report is to present a simple, economic,
and reliable way of applying this technique, which has
been in use at our institution for the past 25 years.
This system was designed to deliver blood cardioplegia
either diluted or at the patient’s hematocrit. Temperature
control can be suited to cold, tepid, or warm cardioplegia
delivery. Furthermore, it also allows addition of different
substrates at known concentration, dispensing with the
purchase of expensive brand cardioplegia solutions and
extra devices.
Technique
The system consists of a circuit utilizing an empty 1-liter
Plasma-lyte solution bag (Baxter Health Care, Old
Toongabbie, NSW, Australia), tubing connections with a
coil for heat exchange (CardioResearch, Castle Hill,
NSW, Australia), and a roller pump (Fig 1).
Most of the tubing is 3/16 inches thick polyvinylchlo-
ride. The coil is a 3/16 inches thick polyurethane pipe,
disposed in 20 loops. It fits into two stainless steel
containers for heat exchange: one containing ice and the
other containing water, which is thermostatically con-
trolled and heated with heater elements. So, to cool or
heat the blood cardioplegia, the coil is simply moved
from one container to another. Silicone replacement
tubing is used in the roller pump.
The 1-liter Plasma-lyte solution plastic bag is used as
Accepted for publication May 4, 2004.
Address correspondence to Dr Grant, Department of Cardiothoracic
Surgery, Prince of Wales Hospital, Barker St, Randwick 2031, Sydney,
Australia; e-mail: grantpe@sesahs.nsw.gov.au.
© 2005 by The Society of Thoracic Surgeons
Published by Elsevier Inc
the cardioplegia reservoir. The total prime volume of the
cardioplegia circuit is 300 mL, allocated as 200 mL in the
bag and 100 mL in the tubing. The excess 700 mL of
solution is directed to the oxygenator, constituting the
prime.
Once cardiopulmonary bypass (CPB) is stabilized and
the patient’s temperature is 28°C, blood is derived from
the arterial (aortic) line by removing clamp B and apply-
ing clamp A (see Fig 1). When the volume in the cardio-
plegia reservoir reaches 900 mL, clamp B is reapplied to
isolate the cardioplegia from the main circuit. Substrates
are added through the pressure port three-way tap, and
the final cardioplegia solution is circulated to the desired
temperature. Delivery is achieved by applying clamps B
and C, and releasing clamp A (Fig 1).
For a typical cardioplegia induction at our institution,
we use the set described as above and a total volume of
900 mL at 10°C. The substrates used are potassium
chloride (KCl) and sodium bicarbonate (Na HCO3). We
add 20 mmol KCl to the cardioplegia blood; thus, its final
concentration will be around 23 mEq/L. We also add 10
mmol Na HCO3 to keep pH around 7.45. For warm
induction, cardioplegia is heated to 36°C, and the sub-
strates are the same as for cold induction.
Repeated doses are administered at 15- to 20-minute
intervals, with 500 mL of pure pump blood at 10°C. If
there is mechanical or electrical activity, 5 mmol KCl is
added to the cardioplegia blood. Immediately before
aortic unclamping, a last dose of warm (36°C) cardiople-
gia (“warm shot”) is administered (5 mmol KCl is added
to 1 L blood).
Cardioplegia delivery is based mainly on pressure:
flow is adjusted to keep the cardioplegia line pressure of
150 mm Hg, which corresponds to approximately 80 mm
Hg in the aortic root.
For myocardial revascularization, we normally do the
distal anastomoses first and the proximals with a side
clamp. We use the Multiple Delivery Cardioplegia Set
(Medtronic, Minneapolis, MN), which allows for vein
grafts to be perfused either with cardioplegia (as soon as
the distal anastomose is performed), or warm blood
(when the aortic clamp is released). When retrograde
cardioplegia is applied, the pressure is measured directly
from the cannula, and kept between 30 mm Hg and 40
mm Hg, so that flow varies accordingly.
The system configuration for pediatric cases is the
same, but it differs in size: the tubing is 3/16 inches thick
with a prime volume of 100 mL; the cardioplegia reser-
0003-4975/05/$30.00
doi:10.1016/j.athoracsur.2004.05.005
Ann Thorac Surg
2005;80:1946 –7
voir is a 500-mL Plasma-lyte solution plastic bag; and
there is a one-way valve at the end of the cardioplegia
line (just before connection to the cardioplegia cannula)
to avoid air entering the system. The KCl concentration is
the same as for adults. The cardioplegia doses for chil-
dren less than 30 kg are 20 mL/kg and 10 mL/kg for
induction and repeated doses, respectively.
Comment
The concept and initial experience with blood cardiople-
gia were highlighted by the Buckberg group [2] in the late
1970s. The system described above was adapted by one of
us (R.S.) 25 years ago and has been in use ever since in
adult and pediatric cases, for any operation, regardless of
complexity.
From January 1996 to December 2003, 5,828 adults with
median age of 67.75 years (range, 18 to 92) were operated
on with the use of cardiopulmonary bypass (coronary
artery disease or valve disease, or both, comprising 5,479
cases [94.1%], and others, 349 [5.9%]). Reoperations ac-
counted for 9.1% (521) of the procedures. Overall mortal-
ity was 2.26% and the use of intraoperative and postop-
erative intraaortic balloon counterpulsation for low-
output syndrome was 1.3%. Median cross-clamp and
CPB times were 52 and 87 minutes, respectively. Seventy-
six percent of the hearts resumed spontaneous sinus
rhythm after aortic cross-clamp removal.
This cardioplegia circuit proved to be reliable, with
good and reproducible results. It is quite simple to
handle: it needs only one roller set from the main pump
and two tubing clamps to operate. This system also suits
any perfusion technique and surgical preference: the way
of delivery can be antegrade or retrograde, including
perfusion of vein grafts and coronary ostia; temperature
HOW TO DO IT PROVENZANO ET AL 1947
BLOOD CARDIOPLEGIA SYSTEM
Fig 1. The system to deliver blood cardioplegia is
depicted as recirculation mode. A, B, and C indi-
cate where clamps are applied to operate the sys-
tem. Arrows indicate flow direction.
FEATURE ARTICLES
is easily set to warm, cold, or tepid. It allows continuous
or intermittent delivery with controlled perfusion pres-
sure. The cardioplegia hematocrit can be high (patient’s
hematocrit) or low (diluted). In relation to cardioplegia
additives, we solely use potassium chloride and sodium
bicarbonate, but it is possible to add any other substrate
such as magnesium sulfate, glutamate, aspartate, citrate,
Tham, and so forth, with known concentrations.
Regarding expenses, this system costs only 25% of
other brand cardioplegia systems in our market (Au$ 50,
against Au$ 200 for the most expensive; cardioplegia
solution and additives not included). Total savings per
year are significant, even in a moderately busy unit. If
commercially available cardioplegia solutions or special
perfusion pumps and their maintenance were to be
included, the difference in cost would be even greater.
In conclusion, this system to deliver blood cardioplegia
is suitable for any clinical myocardial protection strategy.
Moreover, it is cost effective, simple, and has proved to be
reliable for more than 25 years.
The authors acknowledge the expertise of Mr Andrew Lahanas
for editing the illustration and Mr Daminda Weerasinghe for
data review.
References
1. STS U.S. cardiac surgery database. 1997 CAB only patients—
univariate analysis: intraoperative variables. Available at:
http://www.sts.org/doc/4722. Accessed March 31, 2003.
2. Follete DM, Mulder DG, Maloney JV, Buckberg GD. Advan-
tages of blood cardioplegia over continuous coronary perfu-
sion or intermittent ischemia: experimental and clinical study.
J Thorac Cardiovasc Surg 1978;76:604 –19.