Background: Optimal myocardial protection during cardiac surgery with ischemic arrest is predicated forward among other variables.

Background: Optimal myocardial protection during cardiac surgery with ischemic arrest is predicated forward among other variables, homogeneous cardioplegia distribution. Contrast echocardiography has been shown to provide information regarding the intramyocardial distribution of cardioplegia solution. To trial the hypothesis that information regarding cardioplegia distribution derived from contrast echocardiography may be associated with immediate clinical consequence after cardiac surgery, data from 21 patients were examined retrospectively.

Methods: Contrast-enhanced cardioplegia distribution patterns of the left ventricle short axis view obtained with transesophageal echocardiography were examined off-line by the agency of four observers blinded to clinical issue Contrast effect was scored for eight equally divided myocardial parts (0 = no contrast, 1 = nonuniform contrast, 2 = uniform contrast, 3 = excessive contrast). The scores were then averaged between portions and between observers to generate an antegrade, a retrograde, and a combined global contrast score for each patient.

Results: Seventeen patients were separated from bypass without difficulty (group A) and 4 patients required sustained inotropic therapy or an intra-aortic balloon interrogate to facilitate separation from bypass (group B) As would be anticipateed group A patients had a higher average preoperative ejection fraction than did dispose B patients (60 percent [+ or -] 14 v 31 percent [+ or -] 7 p < 001) In dispose A, however, for 4 of 17 patients (23 percent) subdued preoperative ejection fraction was not predictive of postoperative exogenous circulatory support requirements. clump A patients also had significantly higher antegrade (16 v 12 p < 002) retrograde (17 v 11 p < 002) and combined global contrast scores (17 v 11 p < 001) than did assign places to B patients. All patients with subdued preoperative ejection fraction and grave intraoperative contrast scores required exogenous support to separate from cardiopulmonary bypass.

Conclusion: Contrast echocardiography makes possible an evaluation of the intensity and distribution of contrast-enhanced cardioplegia delivery and we believe the efficacy of intraoperative myocardial protection. Although reasonable preoperative ejection fraction is a known predictor of poor immediate postoperative issue following cardiac surgery, not all patients with soft preoperative ejection fractions require inotropic support postoperatively. Our eventuates suggest that monitoring cardioplegia distribution with contrast echocardiography may propound insight for better patient stratification based forward intraoperative myocardial protection in patients with soft ejection fraction. We believe a more extensive evaluation of this relationship should be pursu in a prospective manner.

(Chest 1994; 106:38-45)

CPB = cardiopulmonary bypass;

TEE = transesophageal echocardiography

Contrast echocardiography was first described during cardiac surgery according to Goldman and Mindich,(1) who reported myocardial enhancement in regions receiving cardioplegia solutions during antegrade delivery. In novel years, improvements in ultrasound technology and in ultrasound contrast agents have l to prosperous studies in which cardioplegia distribution,(2) coronary collateral flow(3) and the succes of bypass grafting(4) have been evaluated intraoperatively. To our knowledge, however, no application of mind has determined whether the quality of perfusion demonstrated by dint of intraoperative contrast echo correlates with clinical issue This question is important because elective cardiac surgery conclusions in death in 1 to 5 percent of patients and in perioperative myocardial infarction in 4 to 21 percent of patients.(5)(6)(7)

The relationship between soft ejection fraction preoperatively and the ne for inotropic support postoperatively has been established.(8)(9)(10(11) However, not all patients with cheap preoperative ejection fractions require postoperative exogenous circulatory support. The efficiency of myocardial protection plays an important part in preserving the remaining compromised state of myocardial function in these patients. However, general techniques used to monitor the adequacy of myocardial protection are solely retrospectively sensitive to the general intents of poor myocardial protection, so as global left ventricular dysfunction and segmental wall motion abnormalities.(12)(13) Furthermore, intraoperative techniques designed to assess the on-line efficiency of cardioplegia delivery, so as quiescence of the ECG or myocardial temperature recordings, provide an incomplete evaluation of cardioplegia delivery to the entire myocardium.(14) Intraoperative contrast echocardiography, however, allows direct, on-line assessment of regional cardioplegia delivery(2)(15) and myocardial perfusion(4)(16)(17) and thus has the potential to assess myocardial protection by means of cardioplegia and to predict ischemic perioperative consequence We retrospectively tested the hypothesis that clinical issue immediately after cardiac surgery is influenced from homogeneous cardioplegia distribution regardless of preoperative global ventricular function and that contrastenhanced cardioplegia distribution together with preoperative global ventricular function could be used to predict which patients will require postoperative inotropic support.

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