Marketing Authorization No.: ЛП-003689
Trade name: Normacor®
Generic name: Potassium Chloride + Magnesium Sulfate + Mannitol
Dosage form: cardioplegia solutions delivery set
Clear, colorless liquid.
Pharmacotherapeutic group: cardioplegic agent
ATC code: В05ХА16
Normacor® is a set consisting of two solutions for various stages of cardioplegia: Solution No. 1 (enriched with potassium) is for achieving rapid asystole under normothermic conditions of blood cardioplegia and Solution No. 2 (low potassium) is for maintening asystole under normothermic conditions of blood cardioplegia.
Normacor® prolongs myocardium resistance to hypoxia due to the blockade of energy-intensive processes, reducing myocardial energy needs to a minimum. It provides effective protection against myocardial ischemia and reperfusion injuries under normothermia or moderate hypothermia and it does not limit duration of the surgeries.
Potassium ions are involved in the processes of transmission and transfer of nerve impulse to the innervated organs. They reduce excitability and conductivity of the myocardium and, in high doses, depress automatism.
Magnesium ions are an important intracellular cation and play a certain part in neuromuscular stimulation.
Mannitol has a decongestant, diuretic effect.
Trometamol reduces concentration of hydrogen ions and improves the blood alkaline reserve, thereby eliminating acidemia. It penetrates the cell membrane and helps eliminate intracellular acidosis.
Clinical trials of Normacor® were performed as compared to Custodiol in the bypass surgery (CABG (coronary artery bypass graft)). The study involved 90 patients randomized in two groups, at 1:1 ratio. The research results showed:
- The nature of the cardiac arrest: asystole - 97.5 % in the Normacor® group vs 82.2 % in the Custodiol group (P = 0.0322 (* P <0.05)).
- The nature of the recovery rate: 97.5 % spontaneous in the Normacor® group vs 53.3 % in the Custodiol group (P <0.0001 (*** P <0.001)).
- Use of cardiotonic therapy: 47.5 % in the Normacor® group vs 71.1 % in the Custodiol group (P = 0.0452 (* P <0.05)).
- In the Normacor® group, the average time of mechanical ventilation was less than that in the Custodiol group: 9.68 hours in the patients of the Normacor® group vs 10.72 hours in the patients of the Custodiol group (P = 0.0376 (* P <0.05)).
- Characteristics of the arterial and venous blood showed that metabolism was more physiological in the Normacor® group than in the Custodiol group.
CABG surgeries with Normacor® were performed under normothermic and moderately hypothermic cardiopulmonary bypass. Before the delivery to the heart, Normacor® was mixed with oxygenated blood of the patient from the CPB pump oxygenator. CABG surgeries in the Custodiol group were performed under hypothermia, the cardiac perfusion was performed with Custodiol. In this case, the blood from CPB pump did not enter the heart. The heart was cooled with crystalloid cardioplegic Custodiol solution at 5–8 °C.
The statistically significant result (compared with the Custodiol group) showed that the use of Normacor® during surgeries significantly improved the cardiac arrest and the restoration of cardiac activity, cardiotonics were used less frequently, and metabolism was more physiological.
No registered adverse events or serious adverse events related to the study drug were registered in the course of the clinical trials.
Pharmacokinetics of Normacor® is completely dependent on the composition of its components.
After intravenous injection, potassium and chlorine ions get involved in the common pool of body ions.
Magnesium is excreted by the kidneys (increasing the diuresis) trough filtration, renal excretion is proportional to the plasma concentration. 93–99 % of magnesium ions is subjected to reverse reabsorption in the proximal and distal renal tubules.
Mannitol is excreted by the kidneys, when 100 g is administered intravenously, 80 % is detected in the urine within 3 h.
Trometamol is excreted by the kidneys in an unmodified form, 75 % is excreted after 8 h.
Cardiac surgery: patients with preserved and reduced contractility of the heart in cases of chronic dysfunction, with severe injury of the coronary bed and myocardium, in the case of urgent or emergency surgery due to unstable angina or acute myocardial infarction, under emergency switch to cardiopulmonary bypass during surgery using a minimally invasive procedure.
Individual intolerance to the solution components.
Efficacy and safety of Normacor® in children and adolescents under the age of 18 years have not been established.
Pregnancy and lactation
Efficacy and safety of Normacor® in pregnant and breast-feeding women have not been established. The use of Normacor® is possible if the benefit to the mother outweighs the potential risk to the fetus and child.
Posology and method of administration
1. Ancillary instruments
- Perfusion system for blood cardioplegia of the required length and internal diameter (not less than 4.3 mm) without heat exchanger;
- Perfusion cannulas (internal diameter of 2.5 mm to 6 mm);
- Clips for tubes;
- Cardioplegic attachment of the CPB pump with two roller pumps.
2.Cardiac tolerance to ischemia
Cardiac tolerance to ischemia is defined by the perfect perfusion from its very beginning, and by the temperature of myocardium, the temperature at the site of extracorporeal circulation, as well as by the existing heart damage.
In general, under normothermia (36 °C–37 °C) and moderate hypothermia
(30 °С–35 °С), aortic compression is well tolerated by the heart without limiting the surgery duration subject to the drug dosage regimens (see item 6 Posology).
If atrial activity during the artificial cardiac arrest is found, it should be ignored. If ventricular activity during the artificial cardiac arrest is found, perfusion of additional Normacor® should be carried out in accordance with this Guidance.
It should be remembered that achievement of long-term protection of the myocardium requires the entry of the entire volume of the injected cardioplegic mixture (Normacor® and the patient’s oxygenated blood) to the coronary bed.
3. Precautions for use
In case of impossibility of complete cross-clamping of the ascending aorta with the clip due to the significant atherosclerotic changes of the aortic root, as well as under severe aortic valve insufficiency, one should switch from antegrade to retrograde delivery of cardioplegic mixture to provide its entry into the coronary bed in accordance with this Guidance. Possible symptoms of atrial activity during the main phase of the surgeries are not a problem, and this activity should be ignored. It depends on the patient's weight and the initial level of potassium ions in the blood when the patient arrives in the operating room. Possible manifestations of the cardiac ventricular activity may require a larger volume of Normacor® to enhance the content of potassium ions in the cells of cardiomyocytes by increasing the space velocity of the cardioplegic mixture or by changing the ratio of Normacor® and the patient’s oxygenated blood from 1: 4 to 1: 2, in order to achieve a stable asystole in accordance with the scheme of administration of cardioplegic Solutions No.1 and No. 2 (see item 5 Mode of administration) without removing the aortic cross clamp.
Under both antegrade and retrograde cardioplegia during the perfusion, it is necessary to control the volume and level of potassium ions in the blood and not to add potassium ions to the perfusate. The criterion for inadequate protection of the heart at the stage of aortic cross-clamping is resumption of ventricular activity that is associated with the development of hypokalemia. The increase in the content of potassium ions and the achievement of asystole provides the remaining needs of the heart and eliminates the problem of ischemia. To this end, a separate flow of blood an cardioplegic solution should be established adhering to the original scheme of separate delivery of the cardioplegic mixture specified in Figure 3, with obligatory antegrade cardiac arrest, given the characteristics described above. At the stage of aortic cross-clamping, atrial activity should be ignored. In case of ventricular activity, one should switch to the perfusion with Solution No. 1 with blood at a ratio of 1:2 to achieve asystole (see item 6 Posology) without removing the aortic cross clamp.
4. Initial cardioplegia
After connecting the CPB pump, at the highest point of the ascending aorta, a purse-string or a U-shaped stitch (PDS 4-0) with a loop is applied to secure the perfusion cannula and drainage.
Normacor® is applied at room temperature under normothermic (36 °С–37 °С) or mild hypothermic (30 °С–35 °С) cardiopulmonary bypass.
While connecting the perfusion system to the container with cardioplegic solution, special attention should be paid to thorough ventilation of the tube system. The trap for air bubbles in the system must be filled with the solution up to overflowing to avoid formation of microbubbles due to the high air pressure.
Immediately before clamping the aorta, a puncture or an incision is made in the purse-string or between the legs of the U-shaped stitch and a cardioplegic cannula is inserted, after that the tourniquet is tightened and the cardioplegic cannula is secured on the general cardioplegic line.
5. Mode of administration
Depending on the pathology antegrade (through the aortic root), retrograde (through the coronary sinus), or mixed cardioplegia is performed. The solution is injected using the cardioplegic system. Cardioplegia is completely drawn into the system of the CPB pump.
Figure 1 - Diagram of antegrade delivery of the cardioplegic mixture of Normacor® and oxygenated blood
A - general cardioplegic line;
1 - clip on the aorta; 2 - standard Y-shaped cardioplegic cannula;
3 - aortic root; 4 - clip on the line for the drainage of the left ventricle;
5 - clip on the antegrade cardioplegic line; 6 - Luer connector.
On the general cardioplegic line (A), after the clamping of the ascending aorta (1), the cardiac arrest is conducted antegradely (see Figure 1). Cardioplegic mixture enters the aortic root (3) through the standard Y-shaped cardioplegic cannula (2). The line for the drainage of the left ventricle through the aortic root must be simultaneously clamped with a clip (4). If it is necessary to unload the left heart, the delivery of the cardioplegic mixture must be stopped, the antegrade cardioplegia line (5) must be clipped after removing the clip from the line for the drainage of the left ventricle. The tightness of the connection is provided by Luer connectors (6) included in the standard package for cardioplegia delivering cardioplegic mixture through the general cardioplegic line.
In addition to the antegrade method, according to the indications, one can use the mixed mode of administration for cardioplegia - antegrade and retrograde - through the coronary sinus (see Figure 2).
Figure 2 - Mixed (antegrade and retrograde) delivery of the cardioplegic mixture of Normacor® and oxygenated blood
A - general cardioplegic line;
1 - clip on the aorta; 2 - standard Y-shaped cardioplegic cannula;
3 - aortic root; 4 - clip on the line for the drainage of the left ventricle;
5 - clip on antegrade cardioplegic line; 6 - Luer connector;
7 - coronary sinus; 8 - standard catheter for retrograde cardioplegia;
9 - clip on the catheter line for retrograde cardioplegia.
On the general cardioplegic line (A), after the clamping of the ascending aorta (1), the cardiac arrest is conducted antegradely (see Figure 1). Cardioplegic mixture enters the aortic root (3) through the standard Y-shaped cardioplegic cannula (2). The line for the drainage of the left ventricle through the aortic root must be simultaneously clamped with a clip (4). If it is necessary to unload the left heart, the delivery of the cardioplegic mixture must be stopped, the antegrade cardioplegia line (5) must be clipped after removing the clip from the line for the drainage of the left ventricle. The tightness of the connection is provided by Luer connectors (6) included in the standard package for cardioplegia delivering cardioplegic mixture through the general cardioplegic line. After antegrade cardiac arrest, according to the indications, retrograde delivery of the cardioplegic feed mixture through the coronary sinus (7) can be started using a standard retrograde cardioplegia catheter (8). The antegrade cardioplegic line must be clamped and the total cardioplegic line must be connected to the standard catheter for retrograde cardioplegia using the Luer connector. The line for drainage of the left ventricle is unclamped simultaneously, and so the left heart is unloaded through the aortic root. If it is necessary to restart antegrade cardioplegia, the catheter for retrograde cardioplegia must be clamped (9) and antegrade cardioplegia must be performed according to the standard procedure described above.
The solution is injected using the cardioplegic system (see Figure 3).
Figure 3 - Scheme of injection of cardioplegic mixture of Normacor®
(Solution No. 1 or Solution No. 2) and oxygenated blood
1 - arterial pump; 2 - fitting for arterial perfusion, 3 - oxygenator; 4 - fitting for coronary perfusion; 5 - line for coronary perfusion; 6, 9 - roller pumps of the cardioplegic attachment of the CPB pump; 7 - T-piece which connects the blood and Normacor®; 8 - vial with Solution No. 1 or Solution No. 2; 10 - line for coronary perfusion of Normacor®; A - general cardioplegic line.
Through the arterial pump (1) of the CPB pump, blood (from the oxygenator fitting for arterial perfusion (2) enters the patient’s aorta via the standard cardiopulmonary bypass circuit. Oxygenator (3) has a special fitting for coronary perfusion (4) through which the blood in the line (5) via the pump (6) of cardioplegic attachment of the CPB pump enters the coronary bed of the patient, mixing in the T-piece (7) with Normacor® from the vial (8). Normacor® enters the patient's coronary bed via another pump (9) of the cardioplegic attachment of the CPB pump and the T-piece, but via the line of the cardioplegic system (10). Separate injection of Normacor® and oxygenated blood through the pumps of the cardioplegic attachment of the CPB pump enables changing the ratio of 1:2 to 1:4 and back without removing the aortic cross clamp, as well as adjusting the volume of the administered cardioplegic solution entering the general cardioplegic line (A).
Achievement of asystole
Before clamping the aorta, the cardioplegic system is filled with a mixture of cardioplegic solution No. 1 and oxygenated blood. Immediately after the aortic clamping, antegrade perfusion of cardioplegic mixture of Solution No. 1 and oxygenated blood at a ratio of 1:2 is performed. The rate of the antegrade delivery of the mixture until the asystole is achieved is 300 ml/min. As a rule, asystole occurs within 1 - 2 minutes. After reaching asystole, the drug remaining in the vial should be injected to bring its total volume to 400 ml by decreasing the delivery rate of the mixture with blood to 250 mL/min. If asystole does not occur within 3 minutes, the delivery rate of the mixture should be increased to 350 ml/min. If necessary an additional vial of Solution No. 1 should be used. If asystole does not occur within 5 minutes, retrograde delivery of the cardioplegic mixture of Solution No 1 and oxygenated blood at a ratio of 1: 2 through the coronary sinus without removing the aortic cross clamp should be used (see item 5 Mode of administration) at 100 ml/min and the pressure not exceeding 50 mm Hg.
After reaching the stable asystole, antegrade perfusion using Solution No 2 and oxygenated blood at a ratio of 1:4 at the rate of 150 ml/min is started. The pressure during injection of the solution is not more than 100 mm Hg in the aorta root. A mixed (see item 5 Mode of administration) delivery of the cardioplegic mixture (antegrade and retrograde) at the rate of 100 ml/min is possible. Under retrograde injection, the pressure should be less than 50 mm Hg. If it is necessary to ensure a dry surgical field, the flow of the cardioplegic mixture of Solution No. 2 and oxygenated blood should be stopped for a period of 1 to 20 minutes at one time, with subsequent renewal in accordance with the above parameters of perfusion, or the flow of cardioplegic mixture should be stopped repeatedly for a period of 1 to 15 minutes, followed by renewal for 2-3 minutes between the intervals, in accordance with the above perfusion parameters.
2. Termination of cardioplegia
Before removing the clip from the aorta, perfusion of cardioplegic mixture of Normacor® and oxygenated blood is stopped.
Allergic reactions to components of the drug are possible. No adverse or allergic reactions were identified during the clinical study of the drug.
The consequence of Normacor® overdose can be hyperkalemia. Under administration of Normacor®, potassium is the main element responsible for the arrest and protection of the heart at the main stage of the surgery. Hyperkalemia manifests itself by the lengthening of the interval of the self-recovery of the heart rate after removal of the clamp from the aorta. Elimination of the effects of overdose (hyperkalemia) occurs by itself, as a result of potassium washing out due to the effect of one of the components of Normacor®, osmotic diuretic - mannitol.
Additional treatment is not required.
No drug interaction was found. The drugs can be excreted faster due to the presence of mannitol in Normacor®.
Normacor® is not used for any types of injections or infusions.
Cardioplegia solutions delivery set (250 ml vials, 450 bottles) 200, 400 ml.
Solution No. 1. 200 ml or 400 ml of the product in 250 ml or 450 ml glass bottles respectively, sealed with rubber stoppers and crimped with aluminum caps.
Solution No. 2. 200 ml or 400 ml of the product in 250 ml or 450 ml glass bottles respectively, sealed with rubber stoppers and crimped with aluminum caps.
Cardioplegia solutions delivery set: Solution No. 1 and No. 2, 250 ml bottles, 14 pcs of each; or Solution No. 1 and No. 2, 450 ml bottles, 7 pcs of each, along with the package insert are placed in a cardboard box.
In a dark place at a temperature of less than 25 °C. Keep out of the reach of children.
2 years. Do not use after the expiry date.
For hospitals only.
Marketing Authorization Holder/Send claims to: OOO KardioSistemFarma, Russia (OOO “KSF”, Russia)
2a-1, Rabochaya St. Khimki, Moscow Region, 141400 Russia
Tel.: +7 (495) 925-30-74, Fax: +7 (495) 626-97-80, www.normacor.ru
Manufacturer (full cycle): MosFarm OOO, Russia
3, Moskovskoye shosse, Sergiyev Posad, Moscow Region, 141300 Russia
63, Bogorodskoe Village, Bogorodskoe Settlement, Sergiyevo-Posadsky Municipal District, Moscow Region, 141342 Russia