Integrated myocardial management in valvular heart disease.

This report describes the technique of Integrated Myocardial Management that combines the advantages of various cardioprotective strategies to compensate for their individual shortcomings. This approach co-ordinates the myocardial protective techniques with the continuity of the operation so that the surgical continuity of the procedure is never interrupted, and there is simultaneously (a) unimpaired vision, (b) avoidance of unnecessary ischemia and cardioplegic overdose, (c) aortic clamping as soon as cardiopulmonary bypass is started, (d) aortic unclamping and discontinuation of bypass very shortly after the technical procedure is completed, while (e) minimizing the duration of ischemia and cardiopulmonary bypass and (f) maximizing the positive attributes of the strategies available currently. The background for this myocardial management method that combines antegrade/retrograde delivery, warm/cold blood cardioplegia, intermittent/continuous perfusion, blood/blood cardioplegia, and avoidance of cardioplegic overdose, hemodilution, and tangential aortic clamping is discussed. The preliminary results in 394 consecutive patients from three centers where surgeons who participated in the infra-structure of this method is presented. This has led to our adoption of this approach in all adult cardiac operations.