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J Thorac Cardiovasc Surg 2005;129:372-381
© 2005 The American Association for Thoracic Surgery

Cardiopulmonary Support and Physiology

Intraoperative regional myocardial acidosis and reduction in long-term survival after cardiac surgery

^a Surgical Service, VA Boston Healthcare System, Boston, Mass
^b Harvard Medical School, Boston, Mass
^c Brigham and Women's Hospital, Boston, Mass
^d Massachusetts Veterans Epidemiology Research and Information Center, Boston, Mass
^e Colorado Health Outcomes Group, Denver, Colo

Received for publication February 11, 2004; revisions received March 22, 2004; accepted for publication May 20, 2004.

^* Address for reprints: Shukri F. Khuri, MD, Chief, Surgical Service (112), VA Boston Healthcare System, 1400 VFW Pkwy, West Roxbury, MA 02132 (E-mail: shukri.khuri{at}med.va.gov).

BACKGROUND: Regional myocardial acidosis, as measured with tissue pH electrodes during cardiac surgery, has been shown to be reflective of regional myocardial ischemia. This study examined the relationship between intraoperative regional myocardial acidosis and long-term survival of patients undergoing cardiac surgery with cardiopulmonary bypass.

METHODS: A total of 496 adult patients who underwent valve replacement, coronary artery revascularization, or both with intraoperative myocardial pH monitoring in the anterior and posterior left ventricular walls were followed up for 3 to 17 years (average 10.2 ± 4.9 years) for all cause mortality. Regional myocardial acidosis in each patient was defined by the lower of the anterior and posterior wall pH values.

RESULTS: A bivariate automatic interaction detection analysis identified three significant regional myocardial acidosis thresholds that affected long-term mortality: pH_37C less than 6.63 before aortic crossclamping, integrated mean pH_37C less than 6.34 during the period of aortic crossclamping, and pH_37C less than 6.73 at discontinuation of cardiopulmonary bypass. Cox proportional hazard regression analysis identified each of these thresholds to be independently determinant of survival, with pH_37C during aortic crossclamping having the highest risk ratio (risk ratio 2.15, 95% confidence interval 1.37-3.37). Raising pH_37C from lower than threshold before aortic crossclamping to higher than threshold during clamping increased the median survival by 40.2%.

CONCLUSION: In adult patients undergoing cardiac surgery with cardiopulmonary bypass, regional myocardial ischemic acidosis before aortic crossclamping, during aortic crossclamping, and at discontinuation of cardiopulmonary bypass are independently associated with reduced long-term postoperative survival. Reversing or avoiding myocardial acidosis during cardiac surgery improves long-term patient survival.

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