Cardioplexol
Cardioplegia solution for myocardial protection during cardiac surgery
Quick Facts About Cardioplexol
Key Takeaways About Cardioplexol
- Hospital-only medication: Cardioplexol is used exclusively during cardiac surgery in operating theatres, never outside of a hospital setting
- Reversible cardiac arrest: The solution safely stops the heart so surgeons can operate, and the effect is fully reversible when the solution is washed out
- Triple mechanism: Potassium arrests the heart, magnesium stabilises the cell membrane, and procaine provides local anaesthesia
- Must be cold: The solution is typically cooled to 4-10 °C and re-administered every 20-30 minutes to maintain myocardial protection
- Proven safety record: Cardioplexol has been used for decades in cardiac surgery with a well-established safety and efficacy profile
What Is Cardioplexol and What Is It Used For?
Cardioplexol is a sterile crystalloid cardioplegia solution administered directly into the coronary arteries during open-heart surgery. It induces rapid, controlled and reversible cardiac arrest, allowing surgeons to operate on a still, bloodless heart while protecting the myocardium from ischaemic damage.
During most forms of open-heart surgery, the heart must be stopped so that surgeons can work on cardiac structures such as coronary arteries, heart valves and septal defects. Without protection, the myocardium (heart muscle) would suffer severe ischaemic injury once the blood supply is interrupted. Cardioplegia solutions like Cardioplexol address this challenge by arresting the heart in a metabolically quiescent state, dramatically reducing its oxygen demand and preserving cellular integrity.
Cardioplexol belongs to the class of crystalloid cardioplegia solutions, which use an electrolyte-based formulation without blood components. The solution contains three key active ingredients: potassium chloride (KCl), which causes myocardial cell membrane depolarisation and cardiac arrest; magnesium chloride (MgCl₂), which stabilises the cell membrane and reduces calcium influx; and procaine hydrochloride, which provides a local anaesthetic effect that further suppresses electrical activity.
The concept of cardioplegia was first introduced in the 1950s and has since become one of the cornerstones of modern cardiac surgery. Cardioplegia allows the surgeon to operate on a motionless, bloodless field while the patient's circulation is maintained by a cardiopulmonary bypass (heart-lung) machine. Without cardioplegia, the complexity and safety of cardiac surgery would be severely limited.
Cardioplexol is used in a wide range of cardiac surgical procedures, including:
- Coronary artery bypass grafting (CABG) – bypassing blocked coronary arteries to restore blood flow to the heart muscle
- Heart valve replacement or repair – replacing or repairing diseased mitral, aortic, tricuspid or pulmonary valves
- Correction of congenital heart defects – repairing structural abnormalities present from birth, such as atrial or ventricular septal defects
- Aortic root surgery – procedures on the ascending aorta and aortic root, including the Bentall procedure
- Combined procedures – operations that involve multiple cardiac interventions performed during a single session
Cardioplexol is not a medication that patients take on their own. It is administered by a specialised perfusionist and cardiac surgery team during open-heart procedures. Patients undergoing cardiac surgery do not need to request or manage this medication themselves.
What Should You Know Before Cardioplexol Is Used?
Cardioplexol is administered by highly trained cardiac surgery teams in a controlled operating theatre environment. The decision to use it is made by the surgeon and anaesthesiologist based on the surgical plan, patient physiology and pre-operative assessments.
Because Cardioplexol is used exclusively in the hospital setting during cardiac surgery, the pre-operative evaluation is comprehensive and multi-disciplinary. Before any open-heart procedure, the patient undergoes extensive assessment including cardiac imaging, blood tests, renal function tests, and electrolyte panels. These evaluations help the surgical team determine the safest approach to cardioplegia delivery.
The decision regarding which cardioplegia solution to use and how to administer it is based on multiple factors including the patient's baseline cardiac function, the expected duration of aortic cross-clamping, the specific surgical procedure, and institutional protocols. The surgeon and perfusionist work together to optimise the cardioplegia strategy for each individual patient.
Contraindications
There are few absolute contraindications specific to Cardioplexol itself, since it is one of several cardioplegia options available. However, the surgical team considers the following factors:
- Known hypersensitivity to procaine or other ester-type local anaesthetics – in such cases, alternative cardioplegia formulations without procaine may be used
- Severe pre-existing hyperkalaemia – since Cardioplexol contains high potassium concentrations, additional potassium loading must be carefully managed in patients with already elevated serum potassium levels
- Significant renal impairment – impaired potassium excretion may prolong the effects of high-potassium cardioplegia and delay cardiac recovery
Warnings and Precautions
Several precautions are observed by the surgical team when using Cardioplexol:
- Electrolyte monitoring: Serum potassium levels must be closely monitored throughout the procedure, as the potassium load from repeated cardioplegia doses can cause systemic hyperkalaemia
- Temperature control: The solution should be administered at the correct temperature (typically 4-10 °C for cold cardioplegia) to ensure adequate myocardial cooling
- Re-dosing intervals: Cardioplegia must be re-administered at regular intervals (usually every 20-30 minutes) to maintain cardiac arrest and myocardial protection
- Aortic regurgitation: In patients with significant aortic valve insufficiency, antegrade delivery of cardioplegia may be ineffective, requiring retrograde delivery through the coronary sinus
- Coronary artery disease: Severe coronary stenoses may impair the distribution of cardioplegia to all regions of the myocardium, potentially leaving some areas inadequately protected
Pregnancy and Breastfeeding
Cardiac surgery during pregnancy is extremely rare and is only performed when the mother's life is at immediate risk and no alternative treatments are available. In such exceptional circumstances, the use of Cardioplexol as part of the surgical procedure would be considered within the overall risk-benefit assessment. The decision involves a multidisciplinary team including obstetricians, cardiac surgeons, anaesthesiologists and neonatologists.
Breastfeeding is not relevant during the acute surgical period, but mothers who have undergone cardiac surgery can typically resume breastfeeding once they have recovered sufficiently and are no longer receiving medications that are contraindicated during lactation. Cardioplexol itself is cleared from the body rapidly after surgery and does not pose a risk to breastfeeding.
How Does Cardioplexol Interact with Other Drugs?
Because Cardioplexol is used during cardiac surgery in conjunction with general anaesthesia and cardiopulmonary bypass, its interactions are managed by the anaesthesiology and perfusion teams. The most clinically significant interactions involve drugs that affect potassium levels, cardiac conduction or neuromuscular function.
Drug interactions with Cardioplexol are primarily pharmacodynamic rather than pharmacokinetic, meaning they relate to additive or opposing effects on cardiac physiology rather than changes in drug metabolism. The perioperative team manages these interactions through careful monitoring, dose adjustments and timing of medication administration.
Understanding these interactions is crucial for the surgical team because the transition from cardiac arrest back to a normal rhythm depends on restoring the appropriate electrolyte balance and removing the cardioplegia solution. Any medications that affect potassium handling, cardiac conduction or the autonomic nervous system can influence this recovery period.
Major Interactions
| Drug / Class | Interaction | Clinical Significance |
|---|---|---|
| Beta-blockers (e.g. metoprolol, atenolol) | May prolong cardiac arrest and delay resumption of sinus rhythm after cross-clamp removal | Timing of pre-operative beta-blocker doses is carefully planned |
| Calcium channel blockers (e.g. verapamil, diltiazem) | Additive negative inotropic and chronotropic effects may impair cardiac recovery | Often held on the morning of surgery |
| Potassium-sparing diuretics (e.g. spironolactone) | Increase risk of systemic hyperkalaemia when combined with potassium-rich cardioplegia | Serum potassium closely monitored; may be held pre-operatively |
| ACE inhibitors / ARBs | Can potentiate hyperkalaemia and may cause refractory vasoplegia post-bypass | Typically discontinued 24-48 hours before surgery |
| Digoxin | Hyperkalaemia from cardioplegia potentiates digoxin toxicity; combined effect on cardiac conduction | Digoxin levels checked pre-operatively; dose may be adjusted |
Minor Interactions
| Drug / Class | Interaction | Management |
|---|---|---|
| Non-depolarising neuromuscular blockers (e.g. rocuronium) | Magnesium in Cardioplexol may potentiate neuromuscular blockade | Monitored via train-of-four stimulation |
| Insulin | Insulin drives potassium intracellularly, potentially reducing cardioplegia efficacy | Glucose-insulin management protocols adjusted during bypass |
| Aminoglycoside antibiotics | Additive effect with magnesium on neuromuscular blockade | Routine perioperative monitoring |
What Is the Correct Dosage of Cardioplexol?
Cardioplexol dosing is determined by the cardiac surgeon and perfusionist based on the patient's body weight, cardiac anatomy, procedure type and duration of aortic cross-clamping. An initial (induction) dose is given to arrest the heart, followed by maintenance doses every 20-30 minutes.
The dosage of cardioplegia is not standardised in the same way as oral medications. Instead, volumes are tailored to each patient and procedure. The goal is to deliver sufficient solution to arrest all regions of the myocardium rapidly and uniformly, then to maintain arrest and myocardial protection throughout the cross-clamp period. The perfusionist monitors myocardial temperature and electrical activity to guide re-dosing.
Induction Dose (Initial Arrest)
Adults
The typical induction dose of cold crystalloid cardioplegia is approximately 10-20 mL/kg body weight, infused into the aortic root (antegrade delivery) or coronary sinus (retrograde delivery) over 2-4 minutes at a temperature of 4-10 °C. For a 70 kg adult, this equates to approximately 700-1,400 mL. The infusion is continued until electrical silence is achieved on the electrocardiogram and the myocardial temperature falls below 15 °C.
Children and Infants
Paediatric cardioplegia dosing follows similar weight-based principles but requires careful attention to the smaller blood volume and the increased vulnerability of the immature myocardium. Typical induction volumes range from 20-30 mL/kg in neonates and infants. The perfusionist adjusts volumes based on the child's size, the type of congenital defect being repaired and institutional protocols. Some centres modify the electrolyte composition for paediatric patients.
Maintenance Doses
Re-dosing Protocol
After the initial induction dose, maintenance doses are administered every 20-30 minutes or whenever the myocardial temperature rises above the target range or electrical activity is detected. Maintenance doses are typically half the volume of the induction dose (approximately 5-10 mL/kg in adults). The frequency may be increased if the myocardial temperature rises due to blood warming from collateral circulation or surgical manipulation.
Delivery Routes
Cardioplexol can be delivered through two primary routes:
- Antegrade delivery: Infused into the aortic root after the aortic cross-clamp is applied, distributing through the coronary arteries in their normal direction of flow. This is the most common approach but may be less effective in patients with severe coronary artery disease.
- Retrograde delivery: Infused through a catheter placed in the coronary sinus, flowing backwards through the venous system to reach the myocardium. This is particularly useful when coronary artery disease limits antegrade distribution, or during aortic valve surgery.
- Combined antegrade-retrograde delivery: Some surgical teams use both routes simultaneously or alternately to ensure optimal distribution, especially during complex or prolonged procedures.
Overdose
Because Cardioplexol is used in a controlled surgical environment with continuous monitoring, overdose in the traditional sense is rare. However, excessive volumes of potassium-rich cardioplegia can lead to systemic hyperkalaemia, which may cause cardiac rhythm disturbances during the weaning phase from cardiopulmonary bypass. The perfusionist and anaesthesiologist manage this by monitoring serum potassium levels, using modified ultrafiltration, and administering potassium-lowering treatments (such as insulin with glucose, calcium chloride, or sodium bicarbonate) as needed.
Cardioplexol must never be administered outside of a cardiac surgical setting with cardiopulmonary bypass capability. Intravenous administration of a high-potassium solution without cardiac bypass would cause fatal cardiac arrest. This medication is handled exclusively by trained perfusionists and cardiac surgery teams.
What Are the Side Effects of Cardioplexol?
Side effects of Cardioplexol relate primarily to the systemic effects of its potassium and magnesium content, as well as rare allergic reactions to procaine. Most effects are transient and managed by the perioperative team during and immediately after surgery.
It is important to understand that the "side effects" of cardioplegia solutions are different from those of conventional medications. Because Cardioplexol is used during major surgery under general anaesthesia with full cardiopulmonary bypass support, its effects are closely monitored and actively managed. The distinction between side effects of the cardioplegia solution and the effects of the surgical procedure itself can be difficult to separate clinically.
The following frequency estimates are based on published literature on crystalloid cardioplegia solutions used in cardiac surgery. The frequencies refer to events attributable to the cardioplegia solution rather than to the surgery or cardiopulmonary bypass itself.
Very Common (affects more than 1 in 10 patients)
- Transient hyperkalaemia (elevated serum potassium after cardioplegia doses)
- Myocardial oedema (mild swelling of heart muscle due to crystalloid fluid load)
- Transient reduction in myocardial contractility during the immediate post-bypass period
Common (affects 1 in 10 to 1 in 100 patients)
- Need for temporary cardiac pacing due to transient conduction disturbances after weaning from bypass
- Requirement for inotropic support (medications to strengthen heart contractions) during the early post-operative period
- Haemodilution (dilution of the blood) from the volume of crystalloid cardioplegia solution
Uncommon (affects 1 in 100 to 1 in 1,000 patients)
- Persistent cardiac rhythm disturbances requiring prolonged pacing or antiarrhythmic therapy
- Localised myocardial injury in areas with inadequate cardioplegia distribution
- Hyponatraemia (low sodium) due to dilutional effects of the crystalloid solution
Rare (affects fewer than 1 in 1,000 patients)
- Allergic reaction to procaine (ester-type local anaesthetic hypersensitivity)
- Severe persistent myocardial stunning unresponsive to standard management
- Paradoxical coronary spasm during cardioplegia delivery
Adverse events during cardiac surgery are documented as part of routine surgical and anaesthetic records. If you or a family member have concerns about events that occurred during or after cardiac surgery, discuss them with your cardiac surgeon or anaesthesiologist at your post-operative follow-up appointment.
How Should Cardioplexol Be Stored?
Cardioplexol is stored and handled by hospital pharmacy and perfusion departments according to strict pharmaceutical protocols. Patients never need to store or handle this medication.
As a hospital-only medication, Cardioplexol is subject to institutional storage protocols that ensure its safety, sterility and efficacy at the time of use. The following guidelines apply to healthcare professionals responsible for its storage and preparation:
- Storage temperature: Store at room temperature (15-25 °C) or as specified by the manufacturer until preparation for use. Do not freeze the solution.
- Light protection: Protect from direct sunlight and store in the original packaging until use.
- Sterility: The solution must remain sterile. Do not use if the container is damaged, the seal is broken, or the solution appears cloudy or contains particulate matter.
- Shelf life: Use before the expiry date printed on the packaging. Once opened or prepared, the solution should be used promptly and any unused portion discarded according to hospital waste protocols.
- Pre-surgical preparation: Before administration, the solution is typically cooled to 4-10 °C using a specialised cardioplegia delivery system that includes a heat exchanger. The perfusionist prepares the solution as part of the standard cardiopulmonary bypass setup.
As with all medications, Cardioplexol should be kept out of the reach of unauthorised personnel. It is classified as a prescription-only, hospital-use medication and is stored in designated areas within the pharmacy or perfusion department.
What Does Cardioplexol Contain?
Cardioplexol is a crystalloid cardioplegia solution containing three active ingredients – potassium chloride, magnesium chloride and procaine hydrochloride – in a balanced electrolyte vehicle designed for direct coronary perfusion.
Active Ingredients
Each of the three active ingredients in Cardioplexol serves a specific pharmacological purpose in achieving and maintaining cardiac arrest:
| Ingredient | Role | Mechanism |
|---|---|---|
| Potassium chloride (KCl) | Primary arresting agent | Depolarises the myocardial cell membrane by elevating extracellular potassium, preventing repolarisation and halting electrical conduction. The heart stops in diastole (relaxed state). |
| Magnesium chloride (MgCl₂) | Membrane stabiliser | Stabilises the cell membrane, acts as a natural calcium antagonist, reduces calcium influx into myocardial cells, and helps prevent reperfusion injury. |
| Procaine hydrochloride | Local anaesthetic | Blocks sodium channels, reducing action potential propagation and electrical excitability. Provides additional myocardial protection against spontaneous depolarisation. |
Solution Vehicle
The active ingredients are dissolved in a carefully balanced aqueous vehicle that is designed to be physiologically compatible with the myocardium. The vehicle typically includes sodium chloride and water for injection, with the osmolality and pH adjusted to minimise cellular damage during coronary perfusion. The exact composition may vary by manufacturer and formulation.
How the Ingredients Work Together
The three active ingredients in Cardioplexol work synergistically to provide comprehensive myocardial protection:
- Rapid arrest: Potassium chloride quickly depolarises the myocardial cells, stopping the heart within seconds of coronary perfusion. This arrest in diastole reduces myocardial oxygen consumption by approximately 90%.
- Membrane protection: Magnesium chloride stabilises the cell membrane and acts as a calcium antagonist, preventing the calcium overload that would otherwise lead to cellular damage during ischaemia and reperfusion.
- Electrical silence: Procaine hydrochloride provides an additional layer of protection by blocking sodium channels, ensuring that spontaneous electrical activity does not restart the heart prematurely and cause uncoordinated contractions that would increase oxygen demand.
This triple mechanism – depolarisation arrest, membrane stabilisation and local anaesthesia – provides robust myocardial protection that allows extended periods of cardiac arrest (typically 60-120 minutes, sometimes longer) during complex cardiac surgical procedures. When the surgical repair is complete and the cardioplegia is washed out, the heart typically resumes a normal rhythm spontaneously or with minimal electrical stimulation.
How Does Cardioplegia Work? Understanding Myocardial Protection
Cardioplegia works by exploiting the heart's dependence on precisely regulated electrolyte gradients. By disrupting the normal potassium gradient across the myocardial cell membrane, the solution prevents the electrical impulses that drive cardiac contraction, stopping the heart in a relaxed state that minimises energy consumption.
To understand how Cardioplexol works, it helps to understand the normal physiology of cardiac contraction. The heart beats because of carefully orchestrated electrical impulses that originate in the sinoatrial (SA) node and propagate through the cardiac conduction system. These impulses cause changes in the electrical potential across the myocardial cell membrane – a process called depolarisation – which triggers the release of calcium ions inside the cell, leading to muscle contraction.
Under normal conditions, the resting membrane potential of a cardiac myocyte is approximately −90 millivolts. This negative potential is maintained by the sodium-potassium pump (Na+/K+-ATPase), which keeps potassium concentration high inside the cell and low outside. When an electrical impulse arrives, sodium channels open, the membrane depolarises, and the cell contracts.
Cardioplexol disrupts this process by flooding the extracellular space with a high concentration of potassium. This reduces the potassium gradient across the membrane, raising the resting membrane potential to approximately −50 millivolts. At this level, the sodium channels remain inactivated and cannot respond to electrical stimuli, so the cell cannot depolarise or contract. The result is depolarisation arrest – the heart stops in diastole (the relaxed phase), which is the state of lowest oxygen consumption.
The addition of hypothermia (cooling the myocardium to 4-10 °C) further reduces metabolic demand. For every 10 °C drop in temperature, the metabolic rate falls by approximately 50%. Together, cardiac arrest and hypothermia reduce myocardial oxygen consumption by more than 97% compared to a normally beating, warm heart. This dramatic reduction in metabolic demand is what allows the heart to tolerate prolonged periods without coronary blood flow.
Magnesium plays a critical supporting role by blocking L-type calcium channels, reducing calcium influx into the myocardial cells. Excessive intracellular calcium during ischaemia and reperfusion is a major cause of cellular injury (so-called calcium paradox). By limiting calcium entry, magnesium helps preserve cellular integrity and reduces the risk of reperfusion injury – the paradoxical damage that can occur when blood flow is restored to ischaemic tissue.
Procaine acts on sodium channels, further suppressing electrical excitability and preventing spontaneous depolarisation. This is particularly important because surgical manipulation of the heart, temperature changes and electrolyte shifts can occasionally trigger unwanted electrical activity that could cause the heart to fibrillate (quiver ineffectively) rather than remain still.
What Are the Different Types of Cardioplegia?
Cardioplegia solutions are broadly classified as crystalloid (like Cardioplexol) or blood-based. Each type has advantages and disadvantages, and the choice depends on surgical preference, procedure complexity and patient factors. Both provide effective myocardial protection.
The field of myocardial protection has evolved significantly since cardioplegia was first introduced. Today, cardiac surgeons have several options for protecting the heart during surgery. Understanding the differences helps contextualise where Cardioplexol fits in modern practice.
Crystalloid Cardioplegia
Crystalloid solutions like Cardioplexol use an electrolyte-based formulation without any blood components. Key advantages include:
- Simple preparation and immediate availability
- Consistent, standardised composition
- Clear solution allows better visualisation of the surgical field
- No risk of transfusion-related complications
- Lower cost compared to blood cardioplegia setups
Potential disadvantages include the lack of oxygen-carrying capacity, haemodilution from large volumes of crystalloid, and the risk of myocardial oedema from repeated administration.
Blood Cardioplegia
Blood cardioplegia mixes a concentrated cardioplegic solution with the patient's own oxygenated blood, typically in a 1:4 or 1:8 ratio. This approach offers:
- Oxygen delivery to the arrested myocardium via haemoglobin
- Natural buffering capacity to maintain pH homeostasis
- Oncotic pressure that reduces myocardial oedema
- Free radical scavengers that may reduce reperfusion injury
Other Variations
Additional cardioplegia strategies that have been developed include:
- Del Nido cardioplegia: A crystalloid-blood mixture originally developed for paediatric surgery, now increasingly used in adults. It allows a single dose to protect the heart for up to 90 minutes without re-dosing.
- Warm vs. cold cardioplegia: While cold cardioplegia (like Cardioplexol) is more traditional, some centres use warm (37 °C) blood cardioplegia, particularly for the terminal ("hot shot") dose before removing the aortic cross-clamp.
- Custodiol (HTK solution): A histidine-tryptophan-ketoglutarate solution that provides long-lasting protection with a single dose, used particularly in transplant surgery and complex cases requiring extended cross-clamp times.
Frequently Asked Questions About Cardioplexol
Cardioplexol is a cardioplegia solution used during open-heart surgery to induce controlled, reversible cardiac arrest. This allows surgeons to operate on a still, bloodless heart while protecting the heart muscle from ischaemic damage. It is used in procedures such as coronary artery bypass grafting (CABG), heart valve replacement or repair, and correction of congenital heart defects.
Cardioplexol contains a high concentration of potassium chloride, which depolarises the heart muscle cell membranes and prevents the electrical impulses that cause the heart to beat. Magnesium chloride stabilises the membrane, and procaine hydrochloride provides a local anaesthetic effect. Together, these components induce a rapid, controlled and fully reversible cardiac arrest.
Yes, completely. Once the surgery is finished and the Cardioplexol is washed out of the coronary circulation, the heart typically resumes a normal rhythm spontaneously or with brief electrical stimulation (defibrillation). The effect of the cardioplegia solution is entirely reversible, and the heart returns to its normal electrical and mechanical function.
No, absolutely not. Cardioplexol is exclusively a hospital medication used during cardiac surgery while the patient is connected to a cardiopulmonary bypass (heart-lung) machine. It requires specialised equipment, trained perfusionists, and a full cardiac surgical team. It is never prescribed for outpatient or home use, and administering it outside of a properly equipped operating theatre would be fatal.
While the heart is stopped with Cardioplexol, the patient's blood circulation and oxygen supply are maintained by a cardiopulmonary bypass (heart-lung) machine. This machine takes over the function of both the heart and the lungs, pumping blood through the body and oxygenating it. The patient is under general anaesthesia throughout the procedure and is unaware of the cardiac arrest. Once the surgery is complete, the heart is restarted and the patient is weaned off the bypass machine.
With regular re-dosing every 20-30 minutes and adequate myocardial cooling, the heart can safely remain arrested for several hours. However, longer cross-clamp times are associated with an incrementally higher risk of myocardial injury, so surgeons aim to minimise the duration of cardiac arrest. Most routine cardiac procedures require cross-clamp times of 45-120 minutes.
References
This article is based on the following peer-reviewed sources, international guidelines and authoritative medical references:
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- European Association for Cardio-Thoracic Surgery (EACTS) / European Society of Cardiology (ESC). Guidelines on myocardial revascularization. European Heart Journal. 2024;45(35):2831-2907.
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- World Health Organization. WHO Model List of Essential Medicines. 23rd edition, 2023. Geneva: WHO.
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- Ovrum E, Tangen G, Tollofsrud S, et al. Cold blood versus cold crystalloid cardioplegia: a prospective randomised study of 345 aortic valve patients. European Journal of Cardio-Thoracic Surgery. 2010;38(6):745-749.
- American Heart Association / American College of Cardiology. AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease. Circulation. 2021;143(5):e72-e227.
About the Medical Editorial Team
This article has been written and reviewed by the iMedic Medical Editorial Team, comprising licensed specialist physicians in cardiac surgery, cardiology and anaesthesiology. Our editorial process follows the GRADE evidence framework and adheres to international guidelines from the ESC, EACTS, AHA and WHO.
Content authored by medical professionals with expertise in cardiac surgery and pharmacology, following evidence-based guidelines.
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Evidence Level 1A: Based on systematic reviews and meta-analyses of randomised controlled trials.
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