not long ago a new technique for myocardial protection that does not rely in succession hypothermia has been reported.

not long ago a new technique for myocardial protection that does not rely in succession hypothermia has been reported. in this process the heart is continuously perfused with normothermic hyperkalemic life-current cardioplegia during the cross-clamp period. Cardiae arrest is achieved and maintained using high flats of potassium. Hypothermia is not part of this technique; thus, the danger of hypothermia can be avoided in the patient with frosty agglutinin disease without compromising myocardial protection. This communication reports our experience using retrograde continuous normothermic vital current cardioplegia in one patient with efficacious cold agglutinins and severe coronary artery occlusive disease. This patient experienced an commonplace operative and postoperative course and remains asymptomatic, now more than couple years after operation. (Chest 1993; 104:1627-29)

chiefly current techniques of myocardial protection rely upon moderate systemic hypothermia (22 [degrees] to 30 [degrees] C) and vivid cardiac hypothermia (15 [degrees] to 20 [degrees] C)[1] These temperatures are well below the critical temperature and within the range of thermal amplitudes exhibited on most cold hemagglutinins. Patients with nipping agglutinin disease are therefore at risk for acute vascular thrombosis and hemolysis using standard techniques of myocardial protection. Alternative processs usually involving some compromise of myocardial protection, have been tried in the past for these patients.[2-6] This condition is unusual enough that there is in addition no consensus for the optimum convoy of bypass and myocardial protection.

The question of the necessity of hypothermia for myocardial protection has been raised lately and the successful use of continuous normothermic hyperkalemic life-blood cardioplegia, a new technique based forward this concept, has been reported.[7-10] Theoretically, this technique has several attractive aspects, including the avoidance of chilled injury to blood elements and avoidance of periods of myocardial ischemia. As reported initially, cardioplegia was administered in an antegrade fashion. We have make use ofed a modification of this technique with the retrograde administration of continuous normothermic life-blood cardioplegia since April 1990. When neared with a patient with efficacious cold agglutinins, we thought this technique would be ideal to provide appropriate myocardial protection.

Case Report

A 76-year-old man was referr to our practice for myocardial revascularization. He has been known to have idiopathic chill hemagglutinin disease since 1975 if it were not that was in generally good health. At the time of hospital admission, he was noted to have a mild anemia (hemoglobin, 91 g/dl; hematocrit, 263 percent) The biting agglutinin titer was 1:8,192 and the critical temperature of his biting reactive autoantibodies was 28 [degrees] to 30 [degrees] C Serum protein electrophoresis showed an abnormal protein (paraprotein) band measuring 06 g/dl To avoid chilly stress, the patient had mov to southern Mexico more than 10 years ago.

The patient expanded exertional angina in 1983, and was prosperously treated medically until 1990. Coronary angiography was performed in October 1990 and revealed significant left main disease, strict triple-vessel disease, and normal left ventricular function. The patient was seen at sum of two units hospitals in southern California with tertiary cardiac surgery programs, nevertheless was turned down for operation because of the high thermal amplitude and severity of his cutting hemagglutinin disease. He was subsequently referr to our service and underwent operation forward November 8, 1990.

Surgical Technique and Intraoperative Course

After the induction of general anesthesia, standard median sternotomy was performed. The arterial cannula was inserted in the ascending aorta. Venous reply was through a single, two-stage cannula placed in the right atrial appendage and directed to the inferior vena cava. A retrograde coronary sinus cannula was inserted blindly from the right atrium. The position of this cannula was checked at palpation. With crystalloid prime, cardiopulmonary bypass was initiated at normothermia. Normothermia was maintained from end to end the procedure. The ascending aorta was cross- clamped and normothermic progeny cardioplegia with a final potassium concentration of 20 mEq using a 4:1 kin cardioplegic delivery system was given in an antegrade fashion at 300 ml/min. total cardiac arrest was achieved without ventricular fibrillation within 2 min. Maintenance normothermic life-blood cardioplegia, identical to the induction vital fluid cardioplegia except for a final potassium concentration of 6 mEq/L was then delivered continuously via the retrograde catheter in every part the remainder of the cross-clamp period at a rate of 100 ml/min. The hematocrit forward bypass was never lower than 19 percent Coronary sinus crushing was monitored and maintained at a mean of 30 mm Hg Catheter position was intermittently confirmed by dint of observation of the middle cardiac vein. Electrical and mechanical arrest was maintained from top to toe the cross-clamp period.

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