Standardization of myocardial protection: comment on "Cardiac surgery 2023 reviewed".

There have been few recent innovations since the introduction of cardioplegia more than 50 years ago. Surprisingly, cardioplegia as one of the most essential steps in terms of heart muscle protection during a surgical procedure requiring cardiac arrest has never been really standardized. As a consequence, a considerable variety of cardioplegic solutions and applications have developed: cold versus warm, crystalloid versus blood cardioplegia, antegrade versus retrograde or both, as well as different time schedules for repeated administration. A new cardioplegia solution, called CardioplexolTM, has recently received CE-market approval as a drug - following two phase III studies. CardioplexolTM shows several advantages: the administration follows a very simple protocol, minimizing the risk of errors in manipulation, diastolic arrest occurs immediately, thus allowing immediate begin of the cardiac work once the aorta has been cross clamped. The very low volume of crystalloid solution (e.g. 100 ml as induction and a second application of 100 ml following 45-60 minutes of ischemia), avoids hemodilution and therefore the need for filtration during surgery. In addition, the injection through the aortic root canula eliminates the need for an additional cardioplegia pump and its disposable tubing system. This simplified cardioplegia that is not inferior to Buckberg solution has the potential for standardization of myocardial protection protocols.