Document Type : Original Article
Authors
1 Department of anesthesia , ICU &pain management ,Faculty of Medicine for girl Al-Azhar University ,Cairo, Egypt
2 Department of Cardiothoracic Surgery, Faculty of Medicine for Girls, Al-Azhar University, Cairo, Egypt. M.D
Abstract
Keywords
INTRODUCTION
Cardiac surgery is always accompanied by a certain degree of myocardial damage which is multifactorial, ischemia-reperfusion injury is the major factor inducing intraoperative myocardial damage. Cardioplegia is a method of myocardial protection where the heart is perfused with a solution to cause electromechanical arrest which reduces myocardial oxygen consumption.1,2. Cardioplegia can be crystalloid (cold) or blood-based (warm or cold); it can be given continuously or intermittently via antegrade or retrograde routes. Cold crystalloid cardioplegic solutions are divided into two type groups: the primary one is the extracellular group as
(St Thomas’ solution and its modifications) its content like the extracellular fluid and contains a high concentration of sodium, calcium, and magnesium, the secondary one is the intracellular group as custodiol (HTK) [histidine - tryptophan -ketoglutarate] its content like the intracellular fluid and consists of a low concentration of sodium and calcium. Both types have a high concentration of potassium.3,4 Custodiol is believed to be convenient, simple to deliver, less time consuming, and induced cardiac arrest in diastole by hyperpolarization mimics a natural resting state of the heart, minimizes metabolic demand, and decreasing ATP depletion thus improving the conditions of the heart at the end of surgery. On contrary cold cardioplegic solutions had economic cost and satisfactory clinical result and efficacy in a different group of patients and induced cardiac arrest by membrane depolarization but disadvantages compared with another cardioplegia it is known as poorly supplies oxygen, it also increases the percent of hemodilution which is already high after the priming volume and it also decreases the oncotic pressure.5 Therefore we have done this study to compare the effects of custodiol and st.thomas cardioplegia on the myocardial protection during mitral valve replacement surgeries.
PATIENT AND METHODS
A prospective, randomized, comparative, double‑ controlled study was conducted on 50 adult patients in the Cardiothoracic Department in Al-Zahraa University Hospital, Al-Azhar University, Cairo from December 2016 to December 2019. All adult patients aged between 25 - 65 years, belonging to American Society of Anesthesiologists (ASA) classes II-III and undergoing mitral valve replacement surgery after taking approval of the local institutional ethical committee and informed consent obtained using computer-generated randomization (Random Allocation Software, M. Saghaei, Isfahan, Iran).
Patients were randomly assigned into two groups contains 25 patients (HTK group) received custodiol cardioplegia and (CCC group ) received cold crystalloid cardioplegia. Patients with a history of heart failure, severe cases of pulmonary hypertension, neurological manifestation, renal problems, hepatic insufficiency, and also patients suffering from pulmonary diseases, patients with redo cardiac surgery. Urgent or emergent operations and patients with ejection fraction (EF) presented to us with less than 40% were excluded from the study.
Anesthesia Technique:
Pre-anesthetic check-up was done in all the patients one day before surgery and patients were assessed and required investigations were done including liver, and renal function tests, complete blood count, coagulation profile including prothrombin time, partial thromboplastin time and international normalizing ratio (INR ) and prothrombin concentration and arterial blood gases were performed.
On arrival at the operating theatre, the peripheral intravenous line was inserted and all patients were premedicated with intravenous midazolam 0.01- 0.1mg / kg and were monitored by pulse oximetry for assessment of (SpO2), electrocardiogram ( ECG ), leads were put on the patient all over the time of procedures and noninvasive blood pressure ( NIBP). Lastly, patients connected to invasive blood pressure monitor (Infinity® Kappa – Drager ) after induction of anesthesia, all patients were induced with thiopentone thiopental in a dose of 0.5-2 mg/kg, IV fentanyl 3-5 μg/kg, and rocuronium bromide (0.6–1.2 mg/kg), as a muscle relaxant to facilitate intubation. Maintenance of anesthesia was achieved with a mixture of oxygen and air (1: 1), isoflurane at 1–2 % minimum alveolar concentration (MAC), rocuronium with infusion as (5-10 µg/kg/min) and using fentanyl with a dosage of 0.05 μg / kg /min. Ventilation was adjusted to maintain an end‑tidal carbon dioxide value between 30 and 35 mmHg. Good monitoring of arterial blood pressure was obtained with the radial artery line as an invasive blood pressure monitoring. Also, it helps us for good monitoring of blood gases sampling all over the operation. A central venous catheter (central venous line) was placed under complete aseptic conditions with good sterilization; urine output was monitor by insertion of a urinary catheter during operation. Also, core body temperature was assessed and monitored through the nasopharynx with its specific probe.
The surgical approach was done through a median sternotomy. The cardiopulmonary bypass (CPB) was established by an arterial cannula in the ascending aorta/aortic arch. Venous drainage was achieved through a two-stage cannula inserted in the right atrium or bicaval cannulation via the superior and inferior vena cava.
Before cannulation, a heparinization protocol of an initial bolus dose of 200-300 U per kilogram was given to maintain activated clotting time (ACT) between 400-450 sec) while we are placing the aortic purse-string sutures, CPB will be started following cannulation of the ascending aorta, superior vena cava, and inferior vena cava. We maintained all patients' body temperature at (28°-32°C) with good cooling. After aortic cross-clamping, the cardioplegia was administered in a short time to achieve the diastolic cardiac arrest. The solution was infused antegrade manner through aortic root cannula which inserted in the ascending aorta proximal to the cross-clamp, Topical cooling by ice slush was used in many patients to reach moderate hypothermia.
In Custodiol group (Bretschneider HTK , Bensheim, Germany at 2 - 8°C) patients were given 25- 30mL/Kg in a single dose over 5–7 min, under an initial hydrostatic pressure of 80–100 mmHg. (maximum pressure 120 mmHg) another half dose was administered after three hours of cross-clamping or in case of any electrical or mechanical activity. In Cold crystalloid cardioplegia group (St. Thomas’ solution at 4 - 8°C) patients were given 20 mL/kg in the first dose and followed by 10 mL/Kg administered every 25–30 min at a pressure of 250-300 mmHg. Weaning from CPB started when the patients were rewarmed to 35-37°C followed by the removal of venous cannula and filtration. After that, protamine sulfate (1-1.5mg / kg) was given to reverse the effects of heparinization and regain normal ACT just before cross-clamp removal and at the end of the CPB. Packed red blood cell transfusion and fresh frozen plasma were used when hematocrit levels were less than 22% during the intraoperative period. The operative parameters: Cardiopulmonary bypass time (CPB), Aortic cross-clamp time (ACC), the volume of cardioplegia, spontaneous rhythm restoration post x clamp, use of inotropic support during surgery, temporary pacemaker and duration of surgery.
Laboratory parameters: Serum CK-MB (MB fraction of creatine phosphokinase ) & troponin I and serum sodium.
N.B Criteria for diagnosing a myocardial infarction: by at least two of the following:
Cardiac enzyme elevation (CK-MB > 30 U/l or
troponin I > 10 ng/ml).
The appearance of a new Q wave after suegery on the electrocardiogram of more than 0.03 second at least two serial electrocardiograms (ECG changes may be blurred by new-onset conduction disturbances, which common in the early postoperative period).
A new hypokinetic or akinetic area in the left or right ventricle by echocardiography.
Postoperative Parameters: Duration of mechanically ventilation, duration of inotropic support, ICU stay, and hospital stay.
Postoperative Complications: Sepsis, CVA (cerebrovascular accident), the incidence of renal dysfunction (elevated serum creatinine >2 mg/ dl or increase the baseline preoperative value by twice ), respiratory failure, and mortality within 30 days.
The primary outcome: To detect the number of patients' needs for inotropic support and its duration. The secondary outcomes: Assessment of the serum level of CK-MB or troponin I, I.C.U stay postoperatively and postoperative complications in the HTK group versus CCC group.
Sample size justification :
A sample size calculation was performed depend on MedCalc® version 12.3.0.0 program "Ostend, Belgium", and calculation of statistical calculator based on 95% confidence interval and power of the study 80% with α error 5%, According to a previous study, showed that the inotropic support need in group A (100%), group B (65%) vs. group C (90%), was a statistically significant difference. So it can depend on this assumption of study 7.the sample size was calculated according to these values used a minimal sample size of 57 patients was enough to find such a difference. Assuming a drop-out ratio of 5%, the sample size will be 50 patients; 25 patients in each group to produce cardiac arrest.
Statistical Analysis:
The statistical analysis was performed using a standard SPSS software package, IBM SPSS Statistics for Windows, Version 23.0. Armonk, New York: IBM Corp). Data were presented in the form of ( n. ) and (%) for qualitative data and compared by using the chi-square test. The quantitative data were presented as mean values ± SD, numbers, and compared between two independent groups by using Independent t-test. The confidence interval was set to 95% and the margin of error accepted was set to 5%.
RESULTS
There was no statistically significant difference between the CCC group and HTK group as regards demographic variables (age, sex, ASA, weight, height ) (table 2).
The duration of CPB, aortic cross-clamping time (ACC), and the surgical duration, (P-value > 0.05) were comparable between both groups with no significant difference. But there was a statistically significant difference between the two groups as regarding the incidence of spontaneous rhythm restoration (56%) in HTK group compared to (28%) in CCC group and also in the use of inotropic support with the highest percentage (92%) in group CCC and lowest percentage (64%)in group HTK . The mean volume of transfusions for patients was highly significantly reduced in the HTK group versus the CCC group (1412.1 ± 108.7 vs. 1782.9 ± 214.7). Temporary pacing was used in (three patients) of the CCC group in comparison to (one patient) in the HTK group which was not statistically significant between both groups
(table 3).
There were no statistical differences between the two groups regarding CK-MB and troponin (I) preoperative or at 24 h or 48h postoperatively, but there was a higher increase in their release at 24 h and 48h postoperative in CCC group in comparison to HTK group.
There was no statistical difference regarding serum sodium between both groups preoperative or postoperatively but showed a significant reduction in serum sodium significantly after clamping in the HTK group (table 4).
Duration of inotropic support significantly higher in CCC compared with HTK but other postoperativeparameters were comparable in both groups (duration of ventilator stay, ICU stay, and hospital stay) ( figure 1).
The incidence of complications after surgery was comparable in both groups (table 5).
|
Components |
St. Thomas cardioplegia (cold crystalloid cardioplegia) |
Custodiol cardioplegia (HTK) |
|
Na+ (mmol/L) |
144 |
15 |
|
K+ (mmol/L) |
20 |
9 |
|
Mg++ (mmol/L) |
16 - 32 |
4 |
|
Ca++ (mmol/L) |
2.2 - 4.8 |
0.015 |
|
Histidine (mmol/L) |
— |
180 |
|
Tryptophan (mmol/L) |
— |
2 |
|
Ketoglutarate (mmol/L) |
— |
1 |
|
Mannitol (mmol/L) |
— |
30 |
|
Dextrose (g/L) |
10 |
— |
|
NaHCO3 (mmol/L) |
22.5 |
— |
|
Osmolality (mosm/L) |
300 - 320 |
300 |
|
PH → |
5.5 |
7.02-7.20 |
Table 1: Composition of the cardioplegic solution [Viana et al. (7)].
|
Parameter |
CCC group |
HTK group |
Test value |
P value |
Sig. |
|
Age (yr) |
38.06 ± 6.22 |
39. 03 ± 9.61 |
0.424● |
0.674 |
NS |
|
Sex Male |
11 (44.0%) |
12 (48.0%) |
0.081* |
0.776 |
NS |
|
ASA class II III
|
13 (52.0%) 12 (48.0%) |
14 (56.0%) 11 (44.0%) |
0.081* |
0.776 |
NS |
|
Weight(kg) |
72.11±5.51 |
70.50±6.47 |
-0.947● |
0.348 |
NS |
|
Height(cm) |
165.65±6.57 |
166.86±7.12 |
0.624● |
0.535 |
NS |
Table 2: Demographic data of both groups.
Data were presented in the form of mean±SD or numbers and (percentages)
● Independent t-test; *: Chi-square test
Histidine Tryptophan Ketoglutarate (HTK); Cold Crystalloid Cardioplegia (CCC)
|
Parameter |
CCC group (n=25) |
HTK group (n=25) |
Test value |
P-value |
Sig. |
|
Aortic cross clamp time (min) |
85.4 ± 30.2 |
80.2 ± 37.0 |
-0.544● |
0.589 |
NS |
|
Cardiopulmonary by pass time (min) |
175.3 ± 28.3 |
170.5 ± 33.3 |
-0.549● |
0.585 |
NS |
|
Volume of cardioplegia (ml) |
1782.9±214.7 |
1412.1±108.7 |
-7.704● |
0.000 |
HS |
|
Spontaneous rhythm restoration post clamp removal (no.) |
7 (28.0%) |
14 (56.0%) |
4.023* |
0.045 |
S |
|
Use Inotropic Support during surgery (no.) |
23 (92.0%) |
16 (64.0%) |
5.711* |
0.017 |
S |
|
Temporary pacemaker (no.) |
3 (12.0%) |
1 (4.0%) |
1.087 |
0.297 |
NS |
|
Duration of surgery (min) |
250.3 ± 20.0 |
245.5 ± 23.0 |
-0.787● |
0.435 |
NS |
Table 3: Intraoperative data of both groups.
Data were presented in the form of mean±SD or numbers and (percentages)
● Independent t-test; *: Chi-square test
HTK: Histidine-Tryptophan-Ketoglutarate; CCC: Cold Crystalloid Cardioplegia.
|
|
CCP group (n=25) |
HTK group (n=25) |
Test value● |
P-value |
Sig. |
|
CK-MB (ng/mL ) CK-MB before operation |
1.45 ± 1.31 |
1.26 ± 0.99 |
-0.579 |
0.566 |
NS |
|
CK-MB 24 hr postoperative |
15.6 ± 3.3 |
14.3 ± 2.15 |
1.650 |
0.105 |
NS |
|
CK-MB 48 hr postoperative |
7.48 ± 30.1 |
6.36±20.7 |
-0.153 |
0.879 |
NS |
|
Troponin I (cTnI) (ng/mL) Troponin I before operation |
0.09 ± 0.68 |
0.03 ± 0.29 |
-0.406 |
0.687 |
NS |
|
Troponin I 24 hr postoperative |
7.20 ± 1.15 |
6.81 ± 0.48 |
-1.565 |
0.124 |
NS |
|
Troponin I 48 hr postoperative |
3.81 ± 1.26 |
3.35 ± 0.57 |
-1.663 |
0.103 |
NS |
|
Serum Na (mmol/L) Serum Na (mmol/L) preoperative |
136.0 ± 3.3 |
135.6 ±2.8 |
-0.462 |
0.646 |
NS |
|
Serum Na (mmol/L) after clamping |
131.0 ± 5.4 |
128.0 ±1.15 |
-2.717 |
0.009 |
HS |
|
Serum Na (mmol/L) after CPB |
129.5 ± 4.9 |
127.6 ± 5.7 |
1.264 |
0.212 |
NS |
Table 4: Laboratory parameters.
Data were presented in the form of mean±SD
● Independent t-test
CK-MB= MB fraction of creatine phosphokinase, cTnI = cardiac Troponin I
Postoperative Complications |
CCC group (n=25) |
HTK group (n=25) |
Test value* |
P-value |
Sig. |
|
Sepsis |
1 (4.0%) |
1 (4.0%) |
0.000 |
1.000 |
NS |
|
Cerebrovascular accident |
1 (4.0%) |
(0%) |
1.020 |
0.313 |
NS |
|
Acute kidney injury |
(0%) |
(0%) |
NA |
NA |
NA |
|
Respiratory failure |
1 (4.0%) |
(0%) |
1.020 |
0.313 |
NS |
|
Mortality |
(0%) |
(0%) |
NA |
NA |
NA |
Table 5: Postoperative Complications.
Data were presented as numbers and percentages
*: Chi-square test.
Figure 1: Comparison between both groups regarding postoperative data.
DISCUSSION
The present study demonstrated that the external granular layer of 2 weeks old rat, born to controlled mothers, was formed of many layers of small cells that were packed together with deeply stained nuclei. At the age of 4 weeks, the external granular layer was seen forming a rim on the outer surface of the folium. This may be explained by the migration of the cells from the external granular layer towards the internal granular layer through the molecular and the Purkinje layers.11
The present work revealed that prenatal exposure to pregabalin markedly affected the postnatal structure and morphology of the cerebellar cortex of offspring. In the present study, the toxicity of pregabalin was mostly manifested in the Purkinje cell layer; which in turn was reflected on the morphological structure of all layers of the cerebellar cortex. These findings were in agreement with Yadav et al.4 who found that prenatal administration of pregabalin disrupted the architecture and the linear arrangement of the cells in the Purkinje layer.
The ultrastructural changes of Purkinje cells of offspring born to pregabalin treated mothers in the current study confirmed the histological changes noticed by the light microscopic examination; in the form of nuclear changes, irregular cell membranes. These nuclear changes of the Purkinje cells were further accompanied by abnormalities in the cytoplasm, which displayed dilatation of the endoplasmic reticulum, vacuolations, and loss of cytoplasmic organelles. Sobaniec,12 explained that the dark appearance of Purkinje cells was probably due to the apoptosis process because these cells displayed markedly condensed karyoplasm and cytoplasm. Also, Chavez-Valdez et al.13 postulated that the dilation of the endoplasmic reticulum is possible during necrosis.
The present study revealed marked degeneration of the axons, which displayed vacuolations with loss of neurofilaments, and organelles and this might be due to toxic effects caused by pregabalin on the cerebellum. This was in agreement with Lehning et al.14 who found that the injured neurons were not able to maintain their distal processes, so they suggested that the degeneration of axons might be a phase of the dying back process of the neuronal injury. Shalaby and Sarhan,15 attributed the loss of myelin sheath to the damage in the cellular contents such as lipids, DNA, and proteins.
The current study estimated the immunohistochemical expression of GFAP at different postnatal ages and detected statistically significant, strong positive immune reactivity in offspring born to pregabalin treated mothers.
After any injury in the central nervous system, either because of a disease chemical insult, trauma, or genetic disorders, the astrocytes become in a reactive state and responds to this injury by a process called astrogliosis. In the process of astrogliosis, GFAP is rapidly synthesized by astrocyte, so this process can be detected by immunostaining with the GFAP antibody.16 so, in this study, the astrogliosis could be a result of the toxic effect of pregabalin on neurons of the cerebellum.
Evidence in support of pregabalin induced astrocyte activation has been proposed by Gottfried et al.17 who declared that astrocytes become reactive during valproic acid treatment being characterized by up-regulation of GFAP and showed a higher number of processes than the control ones. Moreover, Lee et al.18 reported an increase in glial fibrillary acidic protein because of prenatal antiepileptic drug exposure.
Pregabalin teratogenicity could be explained by the increase in fetal oxidative stress, as the fetal brain in the rat is more susceptible to increased oxidative stress in comparison to other fetal organs.19, 20 Kamel,21 reported that pregabalin caused oxidative DNA damage and elevation in some serum biochemical parameters related to the liver and produced oxidative stress in the albino rat.
In this study, the administration of folic acid was effective in decreasing the toxic effect of pregabalin on the cerebellar cortex. This observation was in agreement Yadav et al.4 who found that combined administration of folic acid and pregabalin to pregnant mice led to an amelioration of the deleterious effects of pregabalin on the cerebellar cortex of their offspring. Myocardiaprotection techniques are important during cardiac surgery as the myocardial injury is caused by many factors such as ischemia-reperfusion injury, inflammatory response, and hemodilution during cardiopulmonary bypass. The cardioplegic solution is one of the important protective measures designed to attenuate ischemic injury. 8,9
Cardioplegic solutions make the heart tolerable for long ischemic and reperfusion events and cause myocardial arrest by providing an additional buffer.
This study designed to differentiate between the efficacy of a single dose of (custodiol) versus multiple doses of cold crystalloid cardioplegia on myocardial protection of patients with mitral valve replacement surgeries.
Few studies compared myocardial protection between HTK and St. Thomas cardioplegia .10,11,7
In agreement with the current studywho compare HTK with St. Thomas cardioplegia for myocardial protection and found no significant differences observed between both groups in aortic cross-clamp or CPB times. The volume of transfusions was significantly reduced in the HTK group versus the CCC group (772.1±88.7 vs. 1352.9±214.7 ml) The rates of spontaneous defibrillation in the HTK group were significantly higher than of CCC group (92.9 vs. 72.2%). The changes in serum sodium observed in the HTK group decreased significantly after clamping. But the duration of ICU stay and postoperative hospitalization was significantly shorter in HTK than the CCC group (10.5±1.4 vs. 20.1±4.4 days) also mortality in the HTK group was significantly lower than that of the CCC group (2.8 vs. 22.2%).10
Similarly to our result studyperformed on three groups of pediatric patients were assigned into (group A: receive HTK solution ), (group B: Blood cardioplegia) and (group C: Thomas cardioplegia), three groups were comparable as regarding aortic cross-clamping, duration of CPB and the surgical duration without significant difference, Their results were different from the current study in a higher percentage of patients needed inotropic drugs to support after CPB were reported in HTK solution group then Thomas cardioplegia group and lowest one was in the blood cardioplegia group ). On the other hand, the time of mechanical ventilation, length of ICU stay were highly significant in blood cardioplegia group7.
Against the present finding, the study compared custodiol versus modified cold cardioplegia in coronary artery bypass grafting and found there were significant longer cross-clamp and cardiopulmonary bypass times in the custodiol compared versus St. Thomas cardioplegia (49.1±19.0 vs. 41.0±12.9 minutes) and (82.2±23.7 vs. 74.5±18.5 minutes) respectively while spontaneous rhythm recovery rate was similar in both groups. the amount of cardioplegia was significantly larger in the custodiol vs. st.thomas group (1667 vs. 1306 ml respectively), but this study similar to our result in inotropic support (9.0% vs. 12.0%) and postoperative. complications that were comparable between two groups but ICU and hospital stay were less frequent in the custodiol group, with no statistical significance(14.8% vs. 24.0%, p=0.348) and (7.4% vs. 12.0% respectively).11 Some of their results were different from ours maybe because of the differences in the type of surgery and a relatively high number of patients (104 patients ) have been included in their study.
similar to the current study but used cold blood cardioplegia study who studied HTK versus cold blood cardioplegia in pediatric surgery. The inotropic dose needed and duration of its usage were significantly high in cold blood cardioplegia compared with HTK and spontaneous recovery of the heart was higher in the HTK group but CPB duration was insignificant between (custodiol group) and ( cold blood cardioplegia group).12
Also, study whocompared custodiol with cold blood cardioplegia, There was no significant difference in aortic cross-clamp time between the cold cardioplegia and HTK group (73 ± 3 vs 75 ± 3 minutes; P = 0. 81). And also no difference in inotropic support but there was a significant difference as regarding spontaneous fibrillation (71%) in patients receiving custodiol resumed cardiac activity compared to (13%) of patients in the group receiving cold blood cardioplegia.13
In agreement with our study, literature measured serum sodium and osmolality after HTK cardioplegia at different Intra- and postoperative time-points, patients showed a significant reduction in serum sodium in HTK compared with other cardioplegia solution significantly after clamping. However, there was not any significant alteration in osmolality thus suggesting isotonic hyponatremia 14,15,10. But in our study, we not measured serum osmolality.
The present study observed that custodiol group and the cold crystalloid group as regarding CK-MB and troponin I post-surgery, there was no statistically significant difference between both groups. Supporting our result, the studycompared HES with St. Thomas cardioplegia during coronary artery bypass surgery to evaluate myocardial protection of both groups and found that there was no significant difference in the values of troponin I and CK-MB post-surgery. The peak values of all enzymes were 6h after surgery.11
Similarly, a meta-analysis performed by16 (who studied the effects of blood cardioplegia versus crystalloid cardioplegia during cardiac surgery of pediatric) reported that cardiac troponin I level postoperatively was not significantly different between two groups with no evidence of improvement in myocardial injury for either group.Also study comparing three groups (custodiol group, st.thomas cardioplegia group, and blood cardioplegia solution) during pediatric cardiac surgery and evaluate protective effects of three groups on the myocardial of the heart and found that CK-MB and no statistically significantly different of troponin t levels among the three groups with no superiority for HTK 7
Also, study who reported that there was nosignificant data with a difference between custodiol and crystalloid cardioplegia as regarding CK-MB levels and troponin I .17
Against our result who observed that creatine kinase-MB isoenzyme and troponin t levels were significantly higher in group HTK compared with cold blood cardioplegia, the highest levels were found 6h postoperatively.12 Their results were different from ourstudy may be due to the use of cold blood cardioplegia not cold cardioplegia. The main limitations of the study, it was done in a single institution, the operations were performed by different surgeons and therefore, lack standardization. We didn't analyze postoperative ejection fraction and didn't use of transesophageal echocardiography.
CONCLUSION
HTK cardioplegia offers better myocardial protection compared to cold crystalloid cardioplegia detected by less need to inotropic support, low level of CK-MB and troponin-I postoperatively, less hospital, I.C.U stays and other parameters which may suggest that its benefits could be ascertained in a larger study.
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