- Instruct perfusionist as to quantity of cardioplegia to be administered - If antegrade alone is used, a good rule of thumb is 1200 cc - If retrograde is added, a good rule of thumb is 1000 cc antegrade, 500 cc retrograde - Antegrade cardioplegia goes in - Avoid manipulation of the heart that might make aortic valve incompetent, causing ventricular distention and impairing protection - Note quantity of cardioplegia when both electrical and mechanical asystole is achieved, add 100-200 cc's to this and it can be used as a target dose for future maintenance antegrade cardioplegia. If retrograde alone is used for the particular maintenance dose, aim for double. - If electromechanical silence is difficult to achieve, check application of cross clamp, and if it is properly positioned, give additional cardioplegia, and consider lowering body temperature further to assist myocardial protection. - As antegrade goes in, check root pressure with finger, check pressure above cross clamp with finger, and check LV distention on TEE and with the back of hand on the anterior surface - Apply topical slush to RV, avoid any slush falling between LV and left lateral pericardium - Perform [[Preparation for Proximals]] - Begin [[Preparation for In Situ Arterial Grafts]] - If retrograde cardioplegia is used - Perfusionist announces end of antegrade dose - Switch to retrograde[^a] - Request desired dose from perfusionist - Heart can be manipulated as necessary during retro to allow initial inspection of vessels - Lift up apex to make sure sinus is filled with pink blood during retrograde infusion [^a]:Switching to retrograde involves the manual turn of a stopcock on the field, but it also involves turning the root vent hooked up to the cardioplegia Y connector on. This can be done by the untrusting surgeon using integral clips on the circuit, but I recommend leaving these clips untouched and reliance on the perfusionist to control this instead. I believe this improves the interactivity between surgeon and perfusionist. I also recommend inspection of the aortic root at appropriate intervals to make sure this confidence is well-placed. As the great man said, "trust, but verify."