ABC | Volume 115, Nº2, August 2020

Short Editorial Abdouni Myocardial Protection in Cardiac Surgery Arq Bras Cardiol. 2020; 115(2):251-252 This is an open-access article distributed under the terms of the Creative Commons Attribution License in the statistical analysis. In the analysis of variables related to the myocardium, the two solutions were shown to be equivalent, with no differences in the rates of infarction, low cardiac output, arrhythmia, inotropic use or in the levels of myocardial necrosis markers (troponin). Some studies have suggested the analysis of ventricular septal function as the best marker to determine postoperative myocardial injury, as the interventricular septum corresponds to 35-40% of the total ventricular muscle mass and is responsible for 80% of the right ventricular function. 8 Reynolds 9 reported that 40% of patients submitted to myocardial revascularization surgery and 60% of patients with valve surgery have paradoxical movement of the interventricular septum in the postoperative period, which denotes some degree of septal damage, often transient, and that is a valuable information that must be obtained by echocardiogram. Undeniably, Custodiol ® has its role in specific situations, where the use of a single dose is technically important, such as in heart transplantations, complex pediatric surgeries and in minimally invasive surgeries, where the infusion of repeated doses of the cardioplegic solution is not possible or is technically more difficult and prone to complications. Other alternative solutions are still being studied for myocardial protection. In 1995, a new cardioplegic solution was introduced for congenital heart surgery, in a study carried out at the University of Pittsburgh. 10 The solution, patented as “Del Nido’s solution”, is a mixed depolarizing blood cardioplegia and crystalloid solution that offers safe myocardial protection for up to 90 minutes with a single dose. In addition to containing potassium chloride as a depolarizing agent, the formula also contains magnesium sulphate, mannitol, sodium bicarbonate and lidocaine, and is also being used in long-term cardiac surgeries in adults with excellent results and at low cost, being an alternative to commercially available solutions. There is no best myocardial protection technique. Despite the wide variety of commercially-available cardioplegic solutions, there is no clear consensus about the ideal composition and techniques for using these solutions. In addition to choosing a solution for each patient, there is the question of the administration route (anterograde, retrograde or combined), in a single or intermittent dose, associated or not with hypothermia and other possibilities. Intermittent clamping (ischemia) without the use of cardioplegic solutions is another myocardial protection technique used by some groups with good results. The surgeons must be able to personalize their choices and choose the most adequate solution or technique for each patient according to the surgical planning, but the cost must also be a factor to be considered in our country, especially in the Public Unified Health System. More expensive solutions should be reserved for specific situations with proven benefit. 1. Miller BJ, Gibbon JH, Jr., Greco VF, Smith BA, Cohn CH, Allbritten FF Jr. The production and repair of interatrial septal defects under direct vision with the assistance of an extracorporeal pump-oxygenator circuit. J Thorac Surg. 1953;26(6):598-616. 2. Melrose DJ, Dreyer B, Bentall HH, Baker JBE. - Elective cardiac arrest: a preliminary communication. Lancet. 1955;266(6879):21-2. 3. Buckberg GD. Strategies and logic of cardioplegia delivery to prevent, avoid and reverse isquemic and reperfusion damage. J Thorac Cardiovasc Surg. 1987;93(1):127-39. 4. Oliveira MAB, Brandi AC, Santos CA, Botelho PHH, Cortez JLL, Braile DM - Modes of induced cardiac arrest: hyperkalemia and hypocalcemia - Literature review. Rev Bras Cir Cardiovasc. 2014;29(3):432-6. 5. Fallouh HB, Kentish JC, Chambers DJ. Targeting for cardioplegia: arresting agents and their safety. Curr Opin Pharmacol. 2009;9(2):220-6. 6. Bretschneider HJ. Myocardial protection. Thorac Cardiovasc Surg. 1980;28(5):295-302. 7. Gatti G, Taffarello P, Forti G, Gripari C, Gustin G, Castaldi G, et al. Custodiol®-HTK Solution vs. Cold BloodCardioplegia for IsolatedCoronary Surgery Requiring Prolonged Cross- Clamp Time: A Propensity-Matched Analysis. Arq Bras Cardiol. 2020; 115(2):241-250. 8. Nguyen T, Cao L, Movamed A. Altered Right Ventricle Contractilite Pattern after Cardiac Surgery: Monitorinf of septal function is essential. Ecocardiography. 2014;31(9):1159-65. 9. Reynolds HR, Tunick PA, Grossi EA, Dilmaniam H, Colvin SB, Kronzon I. Paradoxal septal motion after cardiac surgery: A review of 3292cases. Clin Cardiol. 2007;30(12):621-3 10. Matte GS, del Nido PJ. History and use of del Nido cardioplegia solution at Boston Children’s Hospital. J Extra Corpor Technol. 2012;44(3):98-103. References 252