Insulin cardioplegia for elective coronary bypass surgery

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Presentation transcript:

Insulin cardioplegia for elective coronary bypass surgery Vivek Rao, MD, PhD, Michael A. Borger, MD, Richard D. Weisel, MD, Joan Ivanov, RN, George T. Christakis, MD, Gideon Cohen, MD, Terrence M. Yau, MD The Journal of Thoracic and Cardiovascular Surgery Volume 119, Issue 6, Pages 1176-1184 (June 2000) DOI: 10.1067/mtc.2000.105257 Copyright © 2000 American Association for Thoracic Surgery Terms and Conditions

Fig. 1 Arterial glucose concentrations in all 4 study groups. The differences in arterial glucose observed during cardioplegic arrest dissipated within 2 hours of arrival into the ICU. There were no overall differences in arterial glucose concentrations between groups. PRE , Prebypass; Xcl , aortic occlusion; Xcl OFF , removal of crossclamp; CPB 10 ’, 10 minutes after discontinuation of cardiopulmonary bypass; 5’, 10’, 2 HR, 4 HR, 8 HR, 24 HR , time after crossclamp removal. The Journal of Thoracic and Cardiovascular Surgery 2000 119, 1176-1184DOI: (10.1067/mtc.2000.105257) Copyright © 2000 American Association for Thoracic Surgery Terms and Conditions

Fig. 2 Intraoperative myocardial lactate flux. Cardioplegic arrest induced significant anaerobic lactate release in all patients. Over time, there were no significant effects of either glucose concentration (upper panel, P = .83) or insulin (lower panel , P = .28) on myocardial lactate flux. However, immediately after crossclamp removal, patients who received insulin cardioplegia demonstrated lactate extraction compared with persistent anaerobic lactate release in the placebo groups (P = .03 by using the Student t test). PRE , Prebypass; XCL , aortic occlusion; OFF , removal of crossclamp; LAST, final cardioplegic dose. The Journal of Thoracic and Cardiovascular Surgery 2000 119, 1176-1184DOI: (10.1067/mtc.2000.105257) Copyright © 2000 American Association for Thoracic Surgery Terms and Conditions

Fig. 3 Effects of glucose (upper panel) and insulin (lower panel) on intraoperative myocardial oxygen extraction. During the crossclamp period, there was a significant interactive effect between glucose and insulin (P = .03). During reperfusion, myocardial oxygen extraction returned to baseline in the insulin cardioplegia groups. However, there was increased oxygen extraction in the placebo groups, suggestive of repayment of an oxygen debt. There was no significant effect of glucose concentration (P = .33); however, there was a significant insulin effect over time (insulin·time effect, P = .04). PRE , Prebypass; XCL , aortic occlusion; OFF , removal of crossclamp; LAST, final cardioplegic dose. The Journal of Thoracic and Cardiovascular Surgery 2000 119, 1176-1184DOI: (10.1067/mtc.2000.105257) Copyright © 2000 American Association for Thoracic Surgery Terms and Conditions

Fig. 4 Myocardial PDH activity (nanomoles per milligrams per minute) before cardioplegic arrest (PRE) , just before aortic crossclamp removal (XCL) , and after 10 minutes of reperfusion (OFF) . PDH activity increased during cardioplegic arrest but returned to baseline values during early reperfusion (time effect, P = .009). There were no significant effects of either glucose or insulin on PDH activity (group effect, P = .48). The Journal of Thoracic and Cardiovascular Surgery 2000 119, 1176-1184DOI: (10.1067/mtc.2000.105257) Copyright © 2000 American Association for Thoracic Surgery Terms and Conditions

Fig. 5 Cardiac index (upper panel) and left ventricular stroke work index (lower panel) at 2 hours after surgery. Patients who received insulin cardioplegia demonstrated enhanced left ventricular performance compared with placebo at similar filling pressures. PCWP , Pulmonary capillary wedge pressure. Circles represent low-glucose cardioplegia, squares represent high-glucose cardioplegia, open symbols represent placebo groups, and closed symbols represent insulin groups. The Journal of Thoracic and Cardiovascular Surgery 2000 119, 1176-1184DOI: (10.1067/mtc.2000.105257) Copyright © 2000 American Association for Thoracic Surgery Terms and Conditions