ABSTRACT Background: Postoperative blood hyperlactaemia is an indicator of organ anaerobic metabolism and is associated with morbidity after cardiac surgery. This prospective study aims to explore the source, triggers and clinical implications for hyperlactaemia in patients undergoing mitral valve surgery using Custodiol cardioplegia. Methods: Twenty consecutive elective patients undergoing open-heart surgery for mitral valve repair/replacement using Custodiol (based on Bretschneider’s HTK-solution) cardioplegia were recruited. A serial measurement of arterial blood lactate was performed. Pre-, intra-and post-operative clinical data were obtained and cardiac injury was determined by serial plasma measurement of postoperative release of CK-MB. Results: There were no in-hospital deaths. Most of the patients (n=16) needed intraoperative direct current cardioversion to treat ventricular arrhythmias or post-operative vasopressors (n=13) to treat vasoplegia. There was significant cardiac injury as determined by the marked increase of serum CK-MB (p<0.05). A significant (p<0.05) increase in blood lactate was found to follow a biphasic profile. The first peak (from 0.54±0.03 to 1.3±0.07mM) was observed immediately following the release of the aortic cross-clamp and remained high for 1 hour. This was followed by a second peak at 12 hours post-operatively (1.9±0.2mM). The second rise in lactate was seen only in patients that required post-operative vasopressors (1.3 ±0.2 vs 2.2±0.3mM, p<0.05), in whom a significant late decrease in CVP was also observed (12.2 ±1.0 to 7.7± 1.0 for 1 and 12 hours postoperative, respectively). Hyperlactaemia did not correlate with any other variables including CK-MB levels, cross-clamp or cardiopulmonary bypass time. Conclusions: In patients undergoing mitral valve surgery with Custodiol cardioplegia there is marked cardiac injury and a biphasic release of blood lactate. The initial peak in lactate occurs immediately following unclamping the aorta and is likely to be of organ (e.g. heart and lungs) origin. A second peak is only seen in patients requiring postoperative vasopressors to treat vasoplegia. Hyperlactaemia following mitral valve surgery with Custodiol cardioplegia does not seem to be related to myocardial injury as expressed by CK-MB release.
Cite this paper
R. Ascione, A. Venturini, E. Polesel, D. Mangino, C. Zanchettin, G. Zoffoli, G. Angelini and M. Suleiman, "Source, Triggers and Clinical Implications of Hyperlactemia in Patients Undergoing Mitral Valve Surgery Using Custodiol Cardioplegia," World Journal of Cardiovascular Surgery, Vol. 3 No. 5, 2013, pp. 131-138. doi: 10.4236/wjcs.2013.35027.
 M.-S. Suleiman, K. Zacharowski and G. D. Angelini, “Inflammatory Response and Cardioprotection during Open-Heart Surgery: The Importance of Anaesthetics,” British Journal of Pharmacology, Vol. 153, No. 1, 2008, pp. 21-33.
 R. Ascione, M.-S. Suleiman and G. D. Angelini, “Retrograde Hot-Shot Cardioplegia in Patients with Left Ventricular Hypertrophy Undergoing Aortic Valve Replacement,” The Annals of Thoracic Surgery, Vol. 85, No. 2, 2008, pp. 454-458. doi:10.1016/j.athoracsur.2007.08.039
 H. Imura, M. Caputo, K. Lim, M. Ochi, M.-S. Suleiman, K. Shimizu and G. D. Angelini, “Pulmonary Injury after Cardiopulmonary Bypass: Beneficial Effects of Low-Frequency Mechanical Ventilation,” The Journal of Thoracic and Cardiovascular Surgery, Vol. 137, No. 6, 2009, pp. 1530-1537.
 A. Uusaro, E. Ruokonen and J. Takala, “Splanchnic Oxygen Transport after Cardiac Surgery: Evidence for Inadequate Tissue Perfusion after Stabilization of Hemodynamics,” Intensive Care Medicine, Vol. 22, No. 1, 1996, pp. 26-33. doi:10.1007/BF01728327
 R. Ascione, S. Talpahewa, C. Rajakaruna, B. C. Reeves, A. T. Lovell, A. Cohen and G. D. Angelini, “Splanchnic Organ Injury during Coronary Surgery with or without Cardiopulmonary Bypass: A Randomized, Controlled Trial,” The Annals of Thoracic Surgery, Vol. 81, No. 1, 2006, pp. 97-103. doi:10.1016/j.athoracsur.2005.06.038
 D. W. Landow and J. A. Oliver, “Splanchnic Lactate Production in Cardiac Surgery Patients,” Critical Care Medicine, Vol. 21, Supplement 2, 1993, pp. S84-S91.
 J. Mandak, et al., “Impact of Cardiopulmonary Bypass on Peripheral Tissue Metabolism and Microvascular Blood Flow,” Perfusion, Vol. 23, No. 6, 2008, pp. 339-346.
 J. Mand’ak, et al., “Changes in Metabolism and Blood Flow in Peripheral Tissue (Skeletal Muscle) during Cardiac Surgery with Cardiopulmonary Bypass: The Biochemical Microdialysis Study,” Perfusion, Vol. 19, No. 1, 2004, pp. 53-63. doi:10.1191/0267659104pf704oa
 Y. A. Louagie, et al., “Continuous Cold Blood Cardioplegia Improves Myocardial Protection: A Prospective Randomized Study,” The Annals of Thoracic Surgery, Vol. 77, No. 2, 2004, pp. 664-671.
 J. Poling, et al., “Evaluation of Myocardial Metabolism with Microdialysis during Bypass Surgery with Cold Blood-or Calafiore Cardioplegia,” European Journal Cardio-Thoracic Surgery, Vol. 30, No. 4, 2006, pp. 597-603.
 E. Solligard, et al., “Rectal Lactate Levels in Endoluminal Microdialysate during Routine Coronary Surgery,” Anaesthesia, Vol. 62, No. 3, 2007, pp. 250-258.
 H. Lin and M. S. Suleiman, “Cariporide Enhances Lactate Clearance upon Reperfusion but Does Not Alter Lactate Accumulation during Global Ischaemia,” Pflügers Archiv, Vol. 447, No. 1, 2003, pp. 8-13.
 J. Takala, E. Ruokonen and J. Takala, “Lactate Metabolism and Regional Lactate Exchange after Cardiac Surgery,” New Horizons, Vol. 4, No. 4, 1996, pp. 483-492.
 S. Inoue, M. Kuro and H. Furuya, “What Factors Are Associated with Hyperlactatemia after Cardiac Surgery Characterized by Well-Maintained Oxygen Delivery and a Normal Postoperative Course? A Retrospective Study,” European Journal of Anaesthesiology, Vol. 18, No. 9, 2001, pp. 576-584.
 M. Ranucci, et al., “Hyperlactatemia during Cardiopulmonary Bypass: Determinants and Impact on Postoperative Outcome,” Critical Care, Vol. 10, No. 6, 2006, p. R167. doi:10.1186/cc5113
 F. Toraman, et al., “Lactic Acidosis after Cardiac Surgery Is Associated with Adverse Outcome,” Heart Surgery Forum, Vol. 7, No. 2, 2004, pp. E155-E159.
 A. Morishita, “Efficacy of Terminal Warm Blood Cardioplegia in Combination with Bretschneider-HTK Solution for Myocardial Protection,” Kyobu Geka, Vol. 52, No. 10, 1999, pp. 831-835.
 J. Ackemann, W. Gross, M. Mory, M. Schaefer and M. M. Gebhard, “Celsior versus Custodiol: Early Postischemic Recovery after Cardioplegia and Ischemia at 5 Degrees C,” The Annals of Thoracic Surgery, Vol. 74, No. 2, 2002, pp. 522-529. doi:10.1016/S0003-4975(02)03675-5
 N. Greenson, et al., “Usefulness of Cardiac Troponin I in Patients Undergoing Open Heart Surgery,” American Heart Journal, Vol. 141, 2001, No. 3, pp. 447-455.
 M. Pojar, “Peripheral Tissue Metabolism during Off-Pump versus On-Pump Coronary Artery Bypass Graft Surgery: The Microdialysis Study,” European Journal Cardio-Thoracic Surgery, Vol. 33, No. 5, 2008, pp. 899-905.
 M. Licker, A. Schweizer and F. E. Ralley, “Thermoregulatory and Metabolic Responses Following Cardiac Surgery,” European Journal of Anaesthesiology, Vol. 13, No. 5, 1996, pp. 502-510.
 A. Thoren, M. Elam and S. E. Ricksten, “Jejunal Mucosal Perfusion Is Well Maintained during Mild Hypothermic Cardiopulmonary Bypass in Humans,” Anesthesia & Analgesia, Vol. 92, No. 1, 2001, pp. 5-11.
 M. Heringlake, “The Metabolic and Renal Effects of Adrenaline and Milrinone in Patients with Myocardial Dysfunction after Coronary Artery Bypass Grafting,” Critical Care, Vol. 11, No. 2, 2007, p. R51.
 M. A. Levin, et al., “Early On-Cardiopulmonary Bypass Hypotension and Other Factors Associated with Vasoplegic Syndrome,” Circulation, Vol. 120, No. 17, 2009, pp. 1664-1671. doi:10.1161/CIRCULATIONAHA.108.814533
 D. W. Landry and J. A. Oliver, “The Pathogenesis of Va- sodilatory Shock,” The New England Journal of Medicine, Vol. 345, No. 8, 2001, pp. 588-589.
 H. Janssen, P. H. E. Janssen and C. E. Broelsch, “UW Is Superior to Celsior and HTK in the Protection of Human Liver Endothelial Cells against Preservation Injury,” Liver Transplantation, Vol. 10, No. 12, 2004, pp. 1514-1523. doi:10.1002/lt.20309
 G. Puhl, et al., “24-h Storage of Pig Livers in UW, HTK, Hydroxyethyl Starch, and Saline Solution: Is Microdialysis an Appropriate Method for the Continuous Graft Monitoring during Preservation?” Transplant International, Vol. 19, No. 4, 2006, pp. 303-309.
 P. Panzera, “Solutions for Organ Perfusion and Storage: Haemorheologic Aspects,” Transplantation Proceedings, Vol. 37, No. 6, 2005, pp. 2456-2458.