Reply to Condello

We wish to thank Dr Condello for the comments on our review in which we summarize the principles of myocardial protection and illustrate areas in need of further research [1]. Dr Condello addresses several technical aspects in his letter, starting with post-conditioning and then moving to the impact of aortic regurgitation on cardioplegia delivery, differences between delivery routes and finally the cardioplegia volume to cardiac mass relationship [2]. We fully agree that all these considerations are important and may impact outcomes on a case-by-case basis. There are even more points in this context, for instance the timing of repeated cardioplegia delivery, the temperature of cardioplegia or even the temperature of the patient. From the perspective of our review, it is important to realize that none of these individual factors have ever been shown to make ‘the’ (important) difference. We mentioned this in the text for instance when we describe the role of the different modes of cardioplegia delivery and when all efforts failed to demonstrate differences worth mentioning. This statement is further supported by the fact that not even commonly used end-points to assess protection (such as biomarker release) unequivocally indicate irreversible myocardial damage [3]. However, we believe that engaging in this type of discussion is valuable for operating surgeons, because it allows them to adapt or potentially even deviate from their local myocardial protection standard more comfortably in times of need. Given the huge heterogeneity regarding myocardial protection and cardioplegia strategies in cardiac surgery worldwide, we always arrive at the same conclusion, which may flippantly be summarized as follows: ‘the special quality of a special kind of myocardial protection is more related to the special surgeon with his or her special attention to avoiding myocardial damage rather than one special aspect of many to consider’. Practice shows that dealing with antegrade or retrograde cardioplegia or the degree of aortic regurgitation varies too much as to be ‘the’ decisive factor. Understanding these connections is in our opinion already an important step towards providing optimal myocardial protection case by case. We therefore thank Dr Condello for this valuable discussion.

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