What is the preferred route of cardioplegia in patients with mitral stenosis, mitral regurgitation, coronary artery disease, aortic stenosis (AS), and aortic regurgitation (AR)?

From the Guidelines

For patients with mitral stenosis, mitral regurgitation, coronary artery block, and aortic stenosis or regurgitation, a combined antegrade and retrograde approach to cardioplegia is recommended to ensure optimal myocardial protection. This approach is supported by the study published in 2016 in the journal Innovation 1, which suggests that a combined approach can mirror the surgical team's customary approach and comfort level during conventional sternotomy approaches to mitral valve surgery.

When using cardioplegia, the surgical team should preoperatively plan an antegrade approach alone or a combined antegrade and retrograde approach, considering the patient's specific pathology. For example:

• In mitral stenosis, antegrade cardioplegia may be preferred as retrograde delivery may be inadequate due to the stenotic valve impeding flow.
• In mitral regurgitation, either antegrade or retrograde cardioplegia can be used, though retrograde may be more effective as antegrade delivery can be washed out through the incompetent valve.
• For coronary artery disease, a combined approach is optimal - initial antegrade delivery followed by retrograde maintenance, ensuring myocardial protection despite coronary obstructions.
• In aortic stenosis, retrograde cardioplegia is preferred initially as the stenotic valve may prevent adequate antegrade distribution.
• For aortic regurgitation, retrograde cardioplegia is recommended since antegrade delivery would regurgitate back into the left ventricle, compromising myocardial protection.

The choice of cardioplegia route should be individualized based on specific pathology, with the goal of achieving uniform myocardial cooling and protection, as suggested by the study 1. Combined antegrade-retrograde techniques often provide the most comprehensive myocardial protection in complex valve and coronary disease.

Some key considerations for the approach include:

• Effective aortic occlusion
• Operative field encroachment and venous drainage impairment
• Use in redo operations
• Mitral valve exposure
• Risk of aortic injury
• Other cardiac structure injury
• De-airing and stroke
• Surgeon learning curve
• Cost

These factors should be taken into account when deciding on the optimal approach for cardioplegia delivery in patients with complex cardiac pathology, as discussed in the study 1.

From the Research

Cardioplegia Route in Mitral Stenosis and Mitral Regurgitation

• The route of cardioplegia in patients with mitral stenosis and mitral regurgitation, as well as coronary artery blockage and aortic stenosis (AS) or aortic regurgitation (AR), is not directly addressed in the provided studies 2, 3.
• However, the studies discuss the mechanisms and pathophysiology of mitral regurgitation, including its etiologies, mechanisms, and natural progression 2.
• The treatment strategy for mitral regurgitation, including the decision to perform concurrent mitral valve repair or replacement during coronary artery bypass grafting or aortic valve replacement surgery, is also discussed 3.
• The studies suggest that the treatment approach may vary depending on the severity of mitral regurgitation and the presence of other cardiac conditions, such as coronary artery disease or aortic valve disease 3.
• In terms of cardioplegia, the route of administration may depend on the specific surgical procedure being performed and the individual patient's anatomy and physiology.
• Further research is needed to determine the optimal route of cardioplegia in patients with complex cardiac conditions, such as mitral stenosis and mitral regurgitation, coronary artery blockage, and AS or AR.