Myocardial Protection in Cardiac Surgery: Physiological Principles and Contemporary Cardioplegia Strategies
Myocardial Protection and Cardioplegia
DOI:
https://doi.org/10.71350/ajaic.12Keywords:
Myocardial protection, Cardioplegia, Cardiac surgery, Cardiopulmonary bypass, Ischemia–reperfusion injuryAbstract
Myocardial protection is a key determinant of outcomes in cardiac surgery and plays a critical role in minimizing ischemia- and reperfusion-related myocardial injury. Since the clinical introduction of cardiopulmonary bypass, cardioplegia has become the cornerstone strategy for achieving controlled cardiac arrest, enabling complex intracardiac procedures to be performed under safe and optimal conditions. However, ongoing advances in surgical techniques and perfusion technology, together with the increasing prevalence of elderly patients with multiple comorbidities, have necessitated continuous re-evaluation of myocardial protection strategies.
Contemporary cardioplegia approaches differ with respect to temperature management, solution composition, and modes of application, each aiming to balance effective myocardial metabolic suppression with surgical feasibility. Likewise, variations in delivery routes and application patterns have been developed to accommodate diverse anatomical and procedural scenarios. The evolution of cardioplegic solutions reflects an effort to address fundamental physiological requirements, including buffering acidosis, limiting ionic overload, and supporting myocardial energy metabolism during cardiac arrest and subsequent reperfusion.
Despite the availability of numerous cardioplegia techniques and solutions, no single approach has been demonstrated to be universally superior for all patient populations and surgical procedures. Consequently, optimal myocardial protection requires a physiology-based and individualized strategy that considers the interplay between myocardial physiology, patient-specific vulnerability, and the complexity of the surgical intervention. A thorough understanding of the mechanisms underlying myocardial protection remains essential for minimizing myocardial injury and achieving optimal clinical outcomes in modern cardiac surgery.
References
1. Padak M, Dikme R. Chapter 3. In: Academic Studies in Health Sciences VII. Ankara: Artıkel Akademi; 2023. p. 35–42.
2. Tire Y. History of myocardial protection. In: Myocardial Protection and Current Approaches in Cardiac Surgery. Arsan S, editor. Ankara: Türkiye Klinikleri; 2025. p. 1–5.
3. Herting JR, Berg AM, Hadova K, Heinick A, König S, Kuhlmann M, et al. Myocardial overexpression of protein phosphatase 2A-B56α improves resistance against ischemia–reperfusion injury. J Mol Cell Cardiol Plus. 2023;3:100030.
4. Wang Q, Zuurbier CJ, Huhn R, Torregroza C, Hollmann MW, Preckel B, et al. Pharmacological cardioprotection against ischemia–reperfusion injury—the search for a clinically effective therapy. Cells. 2023;12(10):1432.
5. Tveita T, Sieck GC. Physiological impact of hypothermia: the good, the bad, and the ugly. Physiology. 2022;37(2):69–87.
6. Oberman R, Shumway KR, Bhardwaj A. Physiology, cardiac. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023.
7. Joukar S. A comparative review on heart ion channels, action potentials and electrocardiogram in rodents and human: extrapolation of experimental insights to clinic. Lab Anim Res. 2021;37(1):25.
8. Bradić J, Andjić M, Novaković J, Jeremić N, Jakovljević V. Cardioplegia in open heart surgery: age matters. J Clin Med. 2023;12(4):1698.
9. Francica A, Tonelli F, Rossetti C, Tropea I, Luciani GB, Faggian G, et al. Cardioplegia between evolution and revolution: from depolarized to polarized cardiac arrest in adult cardiac surgery. J Clin Med. 2021;10(19):4485.
10. Dobson GP, Faggian G, Onorati F, Vinten-Johansen J. Hyperkalemic cardioplegia for adult and pediatric surgery: end of an era? Front Physiol. 2013;4:228.
11. Nishina D, Chambers DJ. Efficacy of esmolol cardioplegia during hypothermic ischaemia. Eur J Cardiothorac Surg. 2018;53(2):392–399.
12. Carvajal C, Goyal A, Tadi P. Cardioplegia. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023.
13. Lopes JB, Santos CCM. Coronary perfusion pressure during antegrade cardioplegia in on-pump CABG patients. Braz J Cardiovasc Surg. 2017;32:171–176.
14. Kamassai JD, Lowery DR. Retrograde cardioplegia. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023.
15. Ahmed AA, Mahboobi SK. Warm blood cardioplegia. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023.
16. Mukharyamov M, Schneider U, Kirov H, Caldonazo T, Doenst T. Myocardial protection in cardiac surgery—hindsight from the 2020s. Eur J Cardiothorac Surg. 2023;64(6):ezad424.
17. Singh SSA, De SD, Spadaccio C, Berry C, Al-Attar N. An overview of different methods of myocardial protection currently employed peri-transplantation. Vessel Plus. 2017;1:213–229.
18. Sanetra K, Pawlak I, Cisowski M. Del Nido cardioplegia—what is the current evidence? Kardiochir Torakochirurgia Pol (Polish Journal of Thoracic and Cardiovascular Surgery). 2018;15(2):114–118.
19. El-Morsy GZ, Abdullah HM, Abo-Haded HM, Elgamal MAF, El-Deep AM. Does type of cardioplegia affect myocardial and cerebral outcome in pediatric open cardiac surgeries? Ain Shams J Anesthesiol. 2014;7(2).
20. Chen Y, Shi J, Xia TC, Xu R, He X, Xia Y. Preservation solutions for kidney transplantation: history, advances and mechanisms. Cell Transplant. 2019;28(12):1472–1489.
21. Ad N, Holmes SD, Massimiano PS, Rongione AJ, Fornaresio LM, Fitzgerald D. The use of del Nido cardioplegia in adult cardiac surgery: a prospective randomized trial. J Thorac Cardiovasc Surg. 2018;155(3):1011–1018.
22. Ghiragosian C, Harpa M, Stoica A, Sânziana FO, Bălău R, Hussein HA, et al. Theoretical and practical aspects in the use of Bretschneider cardioplegia. J Cardiovasc Dev Dis. 2022;9(6):178.
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Copyright (c) 2026 Hicret Kumalar Gişi, Nail Kahraman, Deniz Demir, Gültekin Coşkun, Nöfel Ahmet Biniçier, Mehmet Coşkun
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