Efficacy of Histidine–Tryptophan–Ketoglutarate Solution Versus Blood Cardioplegia in Cardiac Surgical Procedures: A Randomized Controlled | Parallel Group Study
DOI:
https://doi.org/10.1532/hsf.3495Keywords:
Blood cardioplegia, cardiac procedures , HTK solution, CustodiolAbstract
Background: In cardiac surgery, myocardial protection is required during cross-clamping followed by reperfusion. The use of cardioplegic solutions helps preserve myocardial energy stores, hindering electrolyte disturbances and acidosis during periods of myocardial ischaemia. This study aimed to compare the efficacy and safety between the histidine–tryptophan–ketoglutarate (HTK) solution and blood cardioplegia in various cardiac surgeries.
Methods: Three-hundred-twenty patients aged 30-70 years old undergoing various cardiac surgeries were randomized into the HTK group and the blood cardioplegia group. The ventilation time, total bypass time, cross-clamp time, length of intensive care unit (ICU) or hospital stay, and postoperative complications were analyzed.
Results: The total bypass time and cross-clamp time were significantly shorter in the HTK group than in the blood cardioplegia group (P < 0.001). Segmental wall motion abnormalities (SWMA) at postoperative echocardiography were significantly higher in in the blood cardioplegia group (P = 0.008). The number of patients requiring DC Shock was significantly higher in the HTK group (P < 0.001). The number of patients requiring inotropic support was significantly higher in the blood cardioplegia group (P < 0.001). The length of ICU, hospital stay, and ventilation time were significantly longer in the blood cardioplegia group than in the HTK group (P = 0.004, P < 0.001, P < 0.001, respectively). The number of patients requiring prolonged ventilation was significantly higher in the blood cardioplegia group compared with the HTK group (P = 0.022). There was no significant difference between the study groups regarding electrocardiographic changes, 30-day mortality, and 30-day readmission.
Conclusion: The use of HTK cardioplegia was associated with significantly shorter cross-clamp time, bypass time, duration of mechanical ventilation, length of ICU stay, and length of hospital stay. It is associated with less incidence of postoperative segmental wall abnormalities and less need for inotropic support than blood cardioplegia. Custodiol cardioplegia is a safe and feasible option that can be used as an effective substitute for blood cardioplegia to enhance myocardial protection.
References
Ali AS, Ataa SA, Moftahb HM, El Ghanamb MA, Eldin Moustafab MG. 2019. A comparative study between custodiol and warm blood cardioplegia in coronary artery bypass graft operation with poor left ventricular function. J Med Sci Res. 2:132-6.
Bojan M, Peperstraete H, Lilot M, Tourneur L, Vouhé P, Pouard P. 2013. Cold histidine-tryptophan-ketoglutarate solution and repeated oxygenated warm blood cardioplegia in neonates with arterial switch operation. Ann Thorac Surg. 95:1390-6.
Braathen B, Jeppsson A, Scherstén H, et al. 2011. One single dose of histidine-tryptophan-ketoglutarate solution gives equally good myocardial protection in elective mitral valve surgery as repetitive cold blood cardioplegia: a prospective randomized study. J Thorac Cardiovasc Surg. 141:995-1001.
Careaga G, Salazar D, Téllez S, Sánchez O, Borrayo G, Argüero R. 2001. Clinical impact of histidine-ketoglutarate-tryptophan (HTK) cardioplegic solution on the perioperative period in open heart surgery patients. Arch Med Res. 32:296-9.
Fannelop T, Dahle GO, Salminen PR, et al. 2009. Multidose cold oxygenated blood is superior to a single dose of Bretschneider HTK-cardioplegia in the pig. Ann Thorac Surg. 87(4):1205-1213.
Hachida M, Nonomyama M, Bonkohara Y, Hanayama N, Saitou S, Maeda T. 1997. Clinical Assessment of Prolonged Myocardial Preservation for Patients with a Severely Dilated Heart. Ann Thorac Surg. Jul;64(1):59-63.
Hamed MA, Abdelghaffar RA. 2018. Comparative study between three solutions for cardioplegia in pediatric cardiac surgery: histidine-tryptophan-ketoglutarate (HTK) solution, blood cardioplegia and crystalloid (St. Thomas) cardioplegia. J Anesth Clin Res. 9:818.
Huang JB, Liu YL, Yu CT, et al. 2011. Lung biopsy findings in previously inoperable patients with severe pulmonary arterial hypertension associated with congenital heart disease. Int J Cardiol. 151:76-83.
Ishikawa S, Ueda K, Neya K, et al. 2010. Effects of original crystalloid cardioplegia followed by additional blood cardioplegia: treatments for prolonged cardiac arrest. Ann Thorac Cardiovasc Surg. 16: 335-9.
Korun O, Özkan M, Terzi A, Aşkın G, Sezgin A, Aşlamacı S. 2013. The comparison of the effects of Bretschneider's histidine-tryptophan ketoglutarate and conventional crystalloid cardioplegia on pediatric myocardium at tissue level. Artif Organs. 37:76-81.
Liu J, Feng Z, Zhao J, Li B, Long C. 2008. The myocardial protection of HTK cardioplegic solution on the long-term ischemic period in pediatric heart surgery. ASAIO J. 54:470-3.
Mahrous R, Abo El-Ela A, Mukhtar A, et al. 2016. A comparative study for the efficacy of blood cardioplegia versus histidine-tryptophan-ketoglutarate (HTK) cardioplegia in pediatric patients undergoing total corrective cardiac surgery. Med J Cairo Univ. r:389-95.
Nardi P, Vacirca SR, Russo M, et al. 2018. Cold crystalloid versus warm blood cardioplegia in patients undergoing aortic valve replacement. J Thorac Dis. 10:1490-9.
Pizano A, Montes FR, Carreno M, Echeverri D, Umana JP. 2018. Histidine- Triptophan, Ketoglutalate solution versus blood cardioplegia in cardiac surgery: A propensity- score matched analysis. The Heart Surgery Forum. 21(3): 158-164.
Prathanee S, Kuptanond C, Intanoo W, Wongbhudha C, Karunasumaeta C. 2015. Custodiol-HTK solution for myocardial protection in CABG patients. J Med Assoc Thai. 98:164-7.
Preusse CJ, Gebhard MM, Bretschneider HJ. 1981. Myocardial “equilibration processes” and myocardial energy turnover during initiation of artificial cardiac arrest with cardioplegic solution - reasons for a sufficiently long cardioplegic perfusion. Thorac Cardiovasc Surg. 29:71-6.
Saitoh Y, Hashimoto M, Ku K, et al. 2000. Heart preservation in HTK solution: role of coronary vasculature in recovery of cardiac function. Ann Thorac Surg. 69:107-12.
Sakata J, Morishita K, Ito T, Koshino T, Kazui T, Abe T. 1998. Comparison of clinical outcome between histidine-tryptophan-ketoglutarate solution and cold blood cardioplegic solution in mitral valve replacement. J Card Surg. 13:43-7.
Takeuchi K, Akimoto H, Maida K, Munakata M, Fukui K, Daitoku K, Takaya S, Suzuki S, Tabayashi K, Tanaka S. 2002. Myocardial Protection of the Pressure Overload Hypertrophied Heart in Human Cardiac Surgery by Acceleration of Anaerobic Glycolysis. J Cardiovasc surg (Torino). Feb;43(1):37-41.
Viana FF, Shi WY, Hayward PA, Larobina ME, Liskaser F, Matalanis G. 2013. Custodiol versus blood cardioplegia in complex cardiac operations: an Australian experience. Eur J Cardiothorac Surg. 43:526-31.
Von Oppell UO, Pfeiffer S, Preiss P, Dunne T, Zilla P, Reichart B. 1990. Endothelial cell toxicity of solid-organ preservation solutions. Ann Thorac Surg. 50(6):902-910.
Weisel RD. 2013. Blood or crystalloid cardioplegia: which is better? Eur J Cardiothorac Surg. 43:532-3.
Yang Q, Zhang RZ, Yim AP, He GW. 2004. Histidine-tryptophan-ketoglutarate solution maximally preserves endothelium-derived hyperpolarization factor mediated function during heart preservation: comparison with University of Wisconsin solution. J Heart Lung Transpl. 26:352-9
Published
How to Cite
Issue
Section
Author Disclosure & Copyright Transfer Agreement
In order to publish the original work of another person(s), The Heart Surgery Forum® must receive an acknowledgment of the Author Agreement and Copyright Transfer Statement transferring to Forum Multimedia Publishing, L.L.C., a subsidiary of Carden Jennings Publishing Co., Ltd. the exclusive rights to print and distribute the author(s) work in all media forms. Failure to check Copyright Transfer agreement box below will delay publication of the manuscript.
A current form follows:
The author(s) hereby transfer(s), assign(s), or otherwise convey(s) all copyright ownership of the manuscript submitted to Forum Multimedia Publishing, LLC (Publisher). The copyright transfer covers the exclusive rights to reproduce and distribute the article and the material contained therein throughout the world in all languages and in all media of expression now known or later developed, including but not limited to reprints, photographic reproduction, microfilm, electronic data processing (including programming, storage, and transmission to other electronic data record(s), or any other reproductions of similar nature), and translations.
However, Publisher grants back to the author(s) the following:
- The right to make and distribute copies of all or part of this work for use of the author(s) in teaching;
- The right to use, after publication in The Heart Surgery Forum, all or part of the material from this work in a book by the author(s), or in a collection of work by the author(s);
- The royalty-free right to make copies of this work for internal distribution within the institution/company that employs the author(s) subject to the provisions below for a work-made-for-hire;
- The right to use figures and tables from this work, and up to 250 words of text, for any purpose;
- The right to make oral presentations of material from this work.
Publisher reserves the right to grant or refuse permission to third parties to republish all or part of the article or translations thereof. To republish, such third parties must obtain written permission from the Publisher. (This is in accordance with the Copyright Statute, United States Code, Title 17. Exception: If all authors were bona fide officers or employees of the U.S. Government at the time the paper was prepared, the work is a “work of the US Government” (prepared by an officer or employee of the US Government as part of official duties), and therefore is not subject to US copyright; such exception should be indicated on signature lines. If this work was prepared under US Government contract or grant, the US Government may reproduce, royalty-free, all or portions of this work and may authorize others to do so, for official US Government purposes only, if the US Government contract or grant so requires.
I have participated in the conception and design of this work and in the writing of the manuscript and take public responsibility for it. Neither this manuscript nor one with substantially similar content under my authorship has been published, has been submitted for publication elsewhere, or will be submitted for publication elsewhere while under consideration by The Heart Surgery Forum, except as described in an attachment. I have reviewed this manuscript (original version) and approve its submission. If I am listed above as corresponding author, I will provide all authors with information regarding this manuscript and will obtain their approval before submitting any revision. I attest to the validity, accuracy, and legitimacy of the content of the manuscript and understand that Publisher assumes no responsibility for the validity, accuracy, and legitimacy of its content. I warrant that this manuscript is original with me and that I have full power to make this Agreement. I warrant that it contains no matter that is libelous or otherwise unlawful or that invades individual privacy or infringes any copyright or other proprietary right. I agree to indemnify and hold Publisher harmless of and from any claim made against Publisher that relates to or arises out of the publication of the manuscript and agree that this indemnification shall include payment of all costs and expenses relating to the defense of any such claim, including all reasonable attorney’s fees.
I warrant that I have no financial interest in the drugs, devices, or procedures described in the manuscript (except as disclosed in the attached statement).
I state that the institutional Human Subjects Committee and/or the Ethics Committee approved the clinical protocol reported in this manuscript for the use of experimental techniques, drugs, or devices in human subjects and appropriate informed consent documents were utilized.
Furthermore, I state that any and all animals used for experimental purposes received humane care in USDA registered facilities in compliance with the “Principles of Laboratory Animal Care” formulated by the National Society for Medical Research and the “Guide for the Care and Use of Laboratory Animals” prepared by the Institute of Laboratory Animal Resources and published by the National Institutes of Health (NIH Publication No. 85-23, revised 1985).
