MYOCARDIAL PROTECTION

1) Myocardial protection during cardiac surgery goal to preserve myocardial

function while providing a bloodless and motionless operating field provide
to surgen to make surgery easier protecting mayocardium to obtained by
decreasing myocardial oxygen demand as a consequence of hypothermia
and use of electromechanical cardiac arrest induced by potassium infusion
permitting cardiac surgery to be performed on a non-beating flaccid heart.
The combination of both of these techniques has been the cornerstone in
myocardial protection during surgery allowing surgery with excellent
clinical outcome .through mayocardial protection can prevent mayocardial
injury and schemic reperfusion injury. Myocardial ischemia occurs when
blood flow to your heart is reduced, preventing the heart muscle from
receiving enough oxygen. The reduced blood flow is usually the result of a
partial or complete blockage of your heart's arteries there is some method
of mayocardial protection Hypothermic crystalliod potassium cardioplegia
in the beginning and has been diversified by pharmacological additives
blood cardioplegia, temperature modulation warm tepid, retrograde
cardioplegia controlled reperfusion, integrated cardioplegia and pre and
postconditioning this all method use for mayocardail protection.

2) METHODS use for mayocardial protection Hypothermia demonstrates,

myocardial oxygen demand decreases with temperature. Myocardial
hypothermia has therefore been used as a means of myocardial
preservation during cardiac surgery. Prior to the introduction of effective
cardioplegia solutions, systemic hypothermia was used to enable surgery
on the arrested heart, albeit with poor results. Selective myocardial
hypothermia can be very effectively achieved by administration of cold
(4°C) cardioplegia. Hypothermia has been implicated in myocardial damage
by causing myocardial edema, reducing cell membrane fluidity, and
impairing function of transmembrane receptors. temperature of
administration of blood cardioplegia, as hypothermia shifts the oxygen
 dissociation curve to the left, and means that oxygenated blood
cardioplegia is less likely to transfer the oxygen to the myocardial cells
when administered cold. Infusion of warm (37°C) blood cardioplegia before
and after cold cardioplegic arrest has been shown to preserve myocardial
ATP levels. On this basis some surgeons choose to administer a “hot-shot”
of cardioplegia prior to releasing the aortic cross-clamp and reperfusing the
myocardium. Although reducing myocardial temperature effectively
reduces myocardial oxygen demand, the additional benefit of cold blood
cardioplegia is only around 10% more than that achieved by chemically
induced arrest alone (see  In a small randomized study comparing cold,
warm, and tepid (29°C) blood cardioplegia in patients undergoing CABG
surgery, it was shown that the best clinical outcome was achieved with
tepid blood cardioplegia. Crystalloid cardioplegia, however, seems to be
most effective when administered cold. Hypothermia is to provide a degree
of organs protection and safety margin during CPB. Hypothermia exerts its
protective effect by multiple mechanisms. The most obvious mechanism is
a reduction in metabolic rate and oxygen consumption In cardiac surgery
CPB in conjunction with systemic hypothermia allows lower pump flows
better myocardial protection less blood trauma and better organ protection
than does normothermic perfusion Oxygen needs predictably fall with
lowered temperature. 

3) Cardioplegic and non cardioplegic methods use for mayocardial protection.

CARDIOPLEGIA is used on CPB to induce an arrest of the heart. Components
of cardioplegia solution are varied in different institutions but
include potassium to achieve diastolic arrest A cross clamp is applied to
the ascending aorta and the cardioplegia is administered into the aortic
root in an antegrade fashion via the coronary ostia. Retrograde cardioplegia is
used routinely in many institutions by infusion into the coronary sinus with
backward filling of the cardiac veins. Most commonly, cold cardioplegia at 4°
C is administered intermittently in 15- to 20 minute intervals. temperature of
administration of blood cardioplegia, as hypothermia shifts the oxygen
dissociation curve to the left, and means that oxygenated blood cardioplegia
is less likely to transfer the oxygen to the myocardial cells when administered
cold. Infusion of warm (37°C) blood cardioplegia before and after cold
cardioplegic arrest has been shown to preserve myocardial ATP levels. On this
basis some surgeons choose to administer a “hot-shot” of cardioplegia prior
to releasing the aortic cross-clamp and reperfusing the myocardium. Although
reducing myocardial temperature effectively reduces myocardial oxygen
demand, the additional benefit of cold blood cardioplegia is only around 10%
more than that achieved by chemically induced arrest alone (see  In a small
randomized study comparing cold, warm, and tepid (29°C) blood cardioplegia
in patients undergoing CABG surgery, it was shown that the best clinical
outcome was achieved with tepid blood cardioplegia. Crystalloid cardioplegia,
however, seems to be most effective when administered cold. Non
cardioplegic method use in CABG with CPB using non-cardioplegic methods
proved very safe, with low mortality and morbidity These methods are simple
and expeditious and remain as very useful alternative techniques of
myocardial preservation coold the heart tempreture reduce the oxygen
consumption and also use ice splash for protection mayocardium.
Pharmalogical support also can provide mayocaridal protection uses
bradycardia drugs wich decrease heart rate during cpb. In active coronary
perfusion during an OPCAB procedure offers superior myocardial protection
over passive or no coronary perfusion. When passive perfusion involving a
cannula with a multidelivery manifold is used, flow is directly proportional to
the prevailing arterial pressure, the quantity of grafts being perfused, and the
relative vascular resistance of each of the coronary beds connected to the
manifold. The net result is that under situations of hypotension and multiple
grafts, the net perfusion to each graft may be less than 20 mL/min. The
mechanism behind superior quantity and distribution of assisted flow relates
to the simple use of an in-line pump rather than pressure-dependent passive
flow. When systemic pressures fall during mechanical manipulation of the
heart as in grafting the `posterior wall, coronary blood flow can be maintained
at or above systemic levels. By maintaining adequate coronary flow, the
negative feedback cycle of decreased systemic pressure causing decreased
 coronary perfusion pressure and further myocardial dysfunction is
interrupted.

4) hypothermic
5) crystalloid potassium cardioplegia in the beginning and has
6) been diversified by pharmacological additives
7) hypothermic
8) crystalloid potassium cardioplegia in the beginning and has
9) been diversified by pharmacological additives
10) hypothermic
11) crystalloid potassium cardioplegia in the beginning and has
12) been diversified by pharmacological additive
4) In cardiac surgery CPB in conjunction with systemic hypothermia allows
lower pump flows, better myocardial protection, less blood trauma, and
better organ protection than does normothermic perfusion Hypothermia is
used as a protective strategy for the brain and vital organs during CPB the
cerebral metabolic rate of oxygen consumption (CMRO2) decreases
approximately 7 percent per degree Celsius reduction in temperature. Mild
hypothermia (approximately 34°C) is typically selected for CABG surgery.
Moderate hypothermic temperatures may be selected for cardiac valve repair
or replacement surgery due to the length and complexity of these procedure.
Moderate reductions in temperature confer the same neuroprotective
benefits as deeper levels of hypothermia during focal ischemia.Deep
Hypothermic Circulatory Arrest cardiopulmonary arrest is induced to allow
surgery on major blood vessels which cannot be bypassed intraoperatively
and therefore upon which surgery would normally cause disruption to distal
blood flow and profound haemorrhage in the surgical field. Hypothermia
causes a depression of the metabolic rate and cellular metabolism, protecting
the central nervous system (CNS) from ischemia. Hypothermia is defined as
mild between 32 to 35°C, moderate between 28 and 32°C and deep less than
28°C. 1 This represents profound suppression of cerebral metabolic activity
and confers the neuroprotection of Deep hypothermia the use of
hypothermic circulatory arrest is limited by the duration of the circulatory
 arrest that can safely be tolerated before significant neurological and
multisystem side effects occur 1 this represents profound suppression of
cerebral metabolic activity and confers the neuroprotection of Deep
hypothermia the use of hypothermic circulatory arrest is limited by the
duration of the circulatory arrest that can safely be tolerated before
significant neurological and multisystem side effects occur. Cooling and arrest
Once CPB is established at full pump flow rate cooling will begin to the chosen
temperature. The temperature gradient between the venous inflow to the
CPB circuit and the arterial outflow is kept at less than 10°c. 3 Many centres
pack the head in ice or use a head cooling device to prevent passive
rewarming.

Referances:
my all four assignment refrances( gravely+manual) I forgate to Mention
refrances in (adequacy of perfusion) and (inflammatory response on cpb)