Integrated myocardial management: background and initial application.

This report describes the technique of integrated myocardial management, which combines the advantages of various cardioprotective strategies to compensate for their individual shortcomings. This approach coordinates the myocardial protective techniques with the continuity of the operation so that the surgical procedure is never interrupted. This method (1) provides unimpaired vision, (2) avoids unnecessary ischemia and cardioplegic overdose, (3) allows aortic clamping as soon as cardiopulmonary bypass is started, (4) permits aortic unclamping and discontinuation of bypass shortly after the technical procedure is completed, (5) minimizes the duration of ischemia and cardiopulmonary bypass, and (6) maximizes the positive attributes of the strategies available currently. The background for this myocardial management method, which 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 1474 patients from four centers where surgeons participated in the infrastructure of this method are presented. This has led to our adoption of this approach in all adult cardiac operations.