Cardioplegia in pediatric cardiac surgery: do we believe in magic?

Cardioplegia has become the gold standard of myocardial protection for practically every type of heart surgery during which the ascending aorta must be clamped. Although there is little doubt about the efficacy of cardioplegia in the adult heart, there are few studies on the pediatric heart and their results are contradictory. The physiology of pediatric heart muscle differs considerably from that of the adult myocardium. The pediatric heart distinguishes itself from that of the adult most impressively in its greater tolerance for ischemia. This ischemia tolerance is enhanced by the use of hypothermia. Considering that hypothermia is a powerful tool to prolong ischemia tolerance and that most pediatric cardiac surgeons report similar results using different types of cardioplegia, some surgeons are tempted to suspect that the contribution of the cardioplegia composition to protecting the pediatric heart may be overestimated. This provocative statement is critically discussed in this article. We examine the protective potential of cardioplegia (in various compositions), or of hypothermia, or of both in pediatric cardiac surgery. We pay special attention to several key differences between the physiologies of the pediatric myocardium and the adult myocardium and attempt to relate them to the available surgical methods of myocardial protection. We conclude that the composition of cardioplegia indeed is an important component of successful operative management in pediatric heart surgery. We provide evidence that the benefit of cardioplegia over hypothermia alone is minor at low temperatures (below 15°C), but becomes substantial when the temperature increases.