Recently we had a patient undergoing coronary artery bypass surgery with cardiopulmonary bypass. The heart was still beating despite giving more than 300 mEq potassium in cardioplegia solution through retrograde and antegrade route. Adding adenosine was not successful too. Have you faced similar challenges? How did you manage it?
check the expiry date , amount of potassium , concentration and temperature. low dose potassium does not arrest the heart.
well, in such an occasion i ask the perfusionist to check for the circulating potassium value. if it is low, cardiac arrest delays.
The vials were not outdated. Serum potassium was more than 6 mEq/L. We checked it several times.
Maybe it is better to give cardioplegia frequently like every 10 min and or continouse retrograde with coronnary artery shunt to keep myocardial temperature low to decrease oxygen demand.
Could be collateral coronaries being fed from somewhere other than the aorta. Could consider systemically cooling, fibrillating or systemic potassium load (will require a hemoconcentrator and extra time to remove the potassium at the end)
Cooling and systemic potassium load were two options we chose. time interval between cardioplegia doses were as short as 10-15 minutes and the patient received continuous cardioplegia through grafts. However, the heart was still beating though weaning from CPB was not prolonged and rather straight forward.
Severely hypertrophied hearts are often resistant to cardioplegic arrest and need significantly larger dose and frequent repetition (every 10-15 min). Poor response to cardioplegia can also be secondary to very sever coronary artery disease associated with good collaterals causing poor distribution and rapid washout of cardioplegia. Continuous retrograde cardioplegia, systemic cooling and frequent repetition can help.
Review the echocardiogram for a dilated coronary sinus ...with left superior vena cava....which is one important cause
Check also the right ventricule drainage because sometime you can have a backflow from the right ventricule to the coronary veins providing "normal blood"to the heart with a low concentration of potassium
If heart did not arrest despite perfusing through the Grafts intermittently, its definitely a problem with the solution.
Changing the batch of CP had helped us at times in our institute.
Either: crossclamp not placed properly/ Plaque avoiding propper clamp closure or cardioplegia itself has a Problem OR non-coronary collaterals.
I would cool the patient down, Place a vent and induce fibrillation or Open The clamp and do the cabg beeting heart.
Vascular malformations connecting coronary artery to bronchial or systemic circulation may also cause unsuccessful cardioplegic arrest. I had such a patient.
we had the same situation and we tried all the conventional antegrade,retrograde and direct thru coronaries but the heart would not accept and LV was responding sluggish while RV had no response and atria contracting.
potassium 7meq
LSVC or collateral coronaries being fed from somewhere other than the aorta were the only options that we can think of
total LAD,total non dominant RCA and ectatic circ with distal critical disease was the presentation
agree with cross clamp fibrillation or beating heart be it on or off pump ,but it all depends upon the operators experience
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