Comparative Effects of Single-Dose Cardioplegic Solutions Especially in Repeated Doses During Minimally Invasive Aortic Valve Surgery

Objective This study aims to compare del Nido cardioplegia (DNC) and histidine–tryptophan–ketoglutarate (HTK) cardioplegic solutions in minimally invasive aortic valve replacement (mini-AVR) surgery to discuss the safety level of myocardial protection and rationale for redosing intervals. Methods During the period from January 2017 to June 2019, 200 patients undergoing mini-AVR (solely or with concomitant procedures) were prospectively randomized to DNC ( n = 100) and HTK ( n = 100), both up to 90 minutes ischemic time. Patients with ischemic time over 90 minutes, needing a redosing, were further analyzed in 2 subgroups with DNC-R ( n = 30) and HTK-R ( n = 36). Sensitive biomarkers, in addition to routine biochemistry, were also documented at baseline (T1), after cessation of cardiopulmonary bypass (T2), and on the first postoperative day (T3). Transmural myocardial biopsies were sampled for staining. Results No statistical differences could be demonstrated in DNC and HTK groups with up to 90 minutes cross-clamp times in routine biochemical measurements and basic perioperative clinical outcomes. DNC-R showed significantly more arrhythmia/AV block incidence resulting in more extended intensive care unit (ICU) stay. Interleukin-6 and syndecan-1 in DNC and DNC-R groups were substantially higher at T2. Aquaporin-4 levels were significantly lower in the DNC-R group, demonstrating unsatisfactory response of cells to an excessive volume at T2. Conclusions DNC and HTK provided acceptable myocardial protection as single-dose applications. DNC-R had significantly unbalanced levels of biomarkers, and more arrhythmia/AV block incidence resulting in more extended ICU stay. For patients who may need redosing HTK may be preferable to DNC.

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Safety of Single-Dose Histidine-Tryptophan-Ketoglutarate Cardioplegia during Minimally Invasive Mitral Valve Surgery

Innovations Technology and Techniques in Cardiothoracic and Vascular Surgery ◽

10.1177/155698451400900604 ◽

2014 ◽

Vol 9 (6) ◽

pp. 416-420 ◽

Cited By ~ 3

Author(s):

Carlo Savini ◽

Giacomo Murana ◽

Marco Di Eusanio ◽

Sofia Martin Suarez ◽

Giuliano Jafrancesco ◽

...

Keyword(s):

Single Dose ◽

Mitral Valve ◽

Minimally Invasive ◽

Myocardial Protection ◽

Mitral Valve Surgery ◽

Valve Surgery ◽

Aortic Cross Clamp Time ◽

Htk Solution ◽

Cardioplegic Solutions ◽

Creatine Kinase Isoenzyme Mb

Objective Minimally invasive mitral valve surgery may require a prolonged period of myocardial ischemia. Cardioplegic solutions that necessitate a single dose for adequate myocardial protection are evoked to simplify surgery and result to be appealing in this setting. The aim of this study was to assess early outcomes after minimally invasive mitral valve surgery using one single dose of histidine-tryptophanketoglutarate solution (HTK; Custodiol) for myocardial protection. Methods Between February 2003 and October 2012, a total of 49 consecutive patients underwent minimally invasive mitral valve surgery using a single dose of HTK solution for myocardial protection. The patients’ mean (SD) age was 57 (14) years; the preoperative ejection fraction was normal in all cases. The mean (SD) CPB time and aortic cross-clamp time were 148 (45) minutes and 97 (45) minutes, respectively. Results The heart spontaneously restarted after cross-clamp removal in 37 patients (75.5%). Five patients (10.2%) required prolonged inotropic drug support. Postoperatively, no significant increase in myocardial cytonecrosis enzymes was found [mean (SD) creatine kinase isoenzyme MB, 77.14 (53.67) μg/L at 3 hours, 71.2 (55.67) μg/L at 12 hours, and 42.53 (38.38) μg/L at 24 hours)], and no ischemic electrocardiogram modifications were observed before discharge. Conclusions During minimally invasive mitral valve surgery, HTK solution provided excellent myocardial protection even after prolonged periods of cardioplegic arrest. The avoidance of repetitive infusions may reduce the risk for coronary malperfusion due to dislodgement of the endoaortic clamp (if used) and increase the surgeon's comfort during the procedure.

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Myocardial Protection and Financial Considerations of Custodiol Cardioplegia in Minimally Invasive and Open Valve Surgery

Innovations Technology and Techniques in Cardiothoracic and Vascular Surgery ◽

10.1097/imi.0000000000000314 ◽

2016 ◽

Vol 11 (6) ◽

pp. 420-424 ◽

Cited By ~ 11

Author(s):

Brian W. Hummel ◽

Randall W. Buss ◽

Paul L. DiGiorgi ◽

Brittany N. Laviano ◽

Nalani A. Yaeger ◽

...

Keyword(s):

Single Dose ◽

Minimally Invasive ◽

Myocardial Protection ◽

Gulf Coast ◽

Medical Center ◽

Valve Surgery ◽

Hospital Charges ◽

Retrospective Case ◽

Equal Distribution ◽

Blood Cardioplegia

Objective Single-dose antegrade crystalloid cardioplegia with Custodiol-HTK (histidine-tryptophan-ketoglutarate) has been used for many years. Its safety and efficacy were established in experimental and clinical studies. It is beneficial in complex valve surgery because it provides a long period of myocardial protection with a single dose. Thus, valve procedures (minimally invasive or open) can be performed with limited interruption. The aim of this study is to compare the use of Custodiol-HTK cardioplegia with traditional blood cardioplegia in patients undergoing minimally invasive and open valve surgery. Methods A single-institution, retrospective case-control review was performed on patients who underwent valve surgery in Lee Memorial Health System at either HealthPark Medical Center or Gulf Coast Medical Center from July 1, 2011, through March 7, 2015. A total of 181 valve cases (aortic or mitral) performed using Custodiol-HTK cardioplegia were compared with 181 cases performed with traditional blood cardioplegia. Each group had an equal distribution of minimally invasive and open valve cases. Right chest thoracotomy or partial sternotomy was performed on minimally invasive valve cases. Demographics, perioperative data, clinical outcomes, and financial data were collected and analyzed. Results Patient outcomes were superior in the Custodiol-HTK cardioplegia group for blood transfusion, stroke, and hospital readmission within 30 days (P < 0.05). No statistical differences were observed in the other outcomes categories. Hospital charges were reduced on average by $3013 per patient when using Custodiol-HTK cardioplegia. Conclusions Use of Custodiol-HTK cardioplegia is safe and cost-effective when compared with traditional repetitive blood cardioplegia in patients undergoing minimally invasive and open valve surgery.

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Single-dose del Nido Cardioplegia in Minimally Invasive Aortic Valve Surgery

Seminars in Thoracic and Cardiovascular Surgery ◽

10.1053/j.semtcvs.2017.10.001 ◽

2017 ◽

Vol 29 (4) ◽

pp. 471-476 ◽

Cited By ~ 6

Author(s):

Daniel Ziazadeh ◽

Regina Mater ◽

Ben Himelhoch ◽

Andrew Borgman ◽

Jessica L. Parker ◽

...

Keyword(s):

Single Dose ◽

Aortic Valve ◽

Minimally Invasive ◽

Valve Surgery ◽

Aortic Valve Surgery

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Improved myocardial protection in minimally invasive aortic valve surgery with the assistance of port-access technology

Journal of Thoracic and Cardiovascular Surgery ◽

10.1016/s0022-5223(98)00442-5 ◽

1998 ◽

Vol 116 (5) ◽

pp. 874-875 ◽

Cited By ~ 11

Author(s):

Shubjeet Kaur ◽

Jorge Balaguer ◽

Thomas J. Vander Salm

Keyword(s):

Aortic Valve ◽

Minimally Invasive ◽

Myocardial Protection ◽

Valve Surgery ◽

Aortic Valve Surgery ◽

Access Technology ◽

Port Access

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Myocardial Protection During Minimally Invasive Aortic Valve Replacement

Journal of Cardiothoracic and Vascular Anesthesia ◽

10.1053/j.jvca.2017.02.022 ◽

2017 ◽

Vol 31 (6) ◽

pp. e94-e95

Author(s):

Michael Essandoh

Keyword(s):

Aortic Valve ◽

Aortic Valve Replacement ◽

Minimally Invasive ◽

Valve Replacement ◽

Myocardial Protection

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Comparative study between the use of St. Thomas' II cardioplegia and del Nido cardioplegia in patients who underwent open-heart surgery

Nepalese Heart Journal ◽

10.3126/njh.v17i1.28802 ◽

2020 ◽

Vol 17 (1) ◽

pp. 23-27

Author(s):

Satish Vaidya ◽

Asit Baran Adhikari ◽

Robin Karmacharya ◽

Karan Rai

Keyword(s):

Single Dose ◽

Myocardial Protection ◽

Heart Surgery ◽

Open Heart Surgery ◽

Left Ventricular ◽

Left Ventricular Ejection ◽

Open Heart ◽

Cardioplegic Solution ◽

Aortic Cross Clamp ◽

Ischemic Time

Background and Aims: Cardioplegia is used to arrest the heart after the application of an aortic cross-clamp that interrupts the coronary circulation. Commonly used St. Thomas’II cardioplegic solution has to be repeated at short intervals, which may cause additional myocardial injury. So, this study is done to determine whether del Nido (DN) cardioplegia, which has a longer duration of arrest with a single dose, provides equivalent or better myocardial protection as compared to St. Thomas’ II Cardioplegia. Methods: A prospective observational study was done among 100 patients who underwent open-heart surgery with myocardial protection, between September 2016 to August 2018 in Bangabandhu Sheikh Mujib Medical University, Bangladesh. Patients were divided into two groups, group A (n=50) for del Nido cardioplegic and group B (n=50) for St. Thomas’ II cardioplegia. We compared the amount of cardioplegic solution, Aortic cross-clamp time, cardiopulmonary bypass (CPB) time, ischemic time, arrhythmia, spontaneous sinus rhythm after declamping, intraoperative DC shock requirement, postoperative left ventricular ejection fraction, serum potassium level, low cardiac output, cardiac Troponin level I and CK-MB release after 12 hours and 24 hours, presence of myocardial infarction and death. Results: The per-operative variable suggested spontaneous activity during a cardiac arrest was 2% in del Nido and 14% in St. Thomas’ II group (p=0.044). Similarly, during intraoperative phase spontaneous restoration of cardiac activity after the procedure in del Nido was 2.90 ± 1.16 minutes and in St. Thomas’ II was 1.8 ± 0.615 minutes (p=0.001). However total bypass time and ischemic time were not significant. During the postoperative period, Troponin I and CKMB were measured at 12 hours and 24 hours which were not statistically different in two groups. Postoperatively, low output syndrome was seen among 3 patients in del Nido Group and 4 patients in St. Thomas’ II group (p-value=0.341). Conclusion: This study showed with the use of del Nido cardioplegia provides equivalent myocardial protection to St. Thomas’ II cardioplegia, with the use of only single-dose cardioplegia.

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In search of optimal cardioplegia for minimally invasive valve surgery

Perfusion ◽

10.1177/02676591211012554 ◽

2021 ◽

pp. 026765912110125

Author(s):

Sion Russell ◽

Salman Butt ◽

Hunaid A Vohra

Keyword(s):

Cardiac Arrest ◽

Minimally Invasive ◽

Myocardial Protection ◽

Myocardial Damage ◽

Valve Surgery ◽

Cardioplegic Solution ◽

Comprehensive Literature Review ◽

Pros And Cons ◽

Minimally Invasive Valve Surgery ◽

Cardioplegic Solutions

Cardioplegic solutions are used in cardiac surgery to achieve controlled cardiac arrest during operations, making surgery safer. Cardioplegia can either be blood or crystalloid based, with perceived pros and cons of each type. Whilst it is known that cardioplegia causes cardiac arrest, there is debate over which cardioplegic solution provides the highest degree of myocardial protection during arrest. Myocardial damage is measured post-operatively by biomarkers such as serum TnT, TnI or CK-MB. It is known that the outcomes of minimally invasive valve surgery are comparable to full sternotomy valve operations. Despite there being a wide diversity in use of different cardioplegic solutions across the world, this comprehensive literature review found no superiority of one cardioplegic solution over the other for myocardial protection during minimally invasive valve procedures.

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Myocardial Protection During Aortic Valve Replacement:Comparison Between Sanguineous and Asanguineous Cardioplegic Solutions

Scandinavian Journal of Thoracic and Cardiovascular Surgery ◽

10.3109/14017438109101038 ◽

1981 ◽

Vol 15 (2) ◽

pp. 135-139 ◽

Cited By ~ 10

Author(s):

Vollmer Bomfim ◽

Lennart Kaijser ◽

Rutger Bendz ◽

Christer Sylvén ◽

Christian Olin

Keyword(s):

Aortic Valve ◽

Myocardial Protection ◽

Cardioplegic Solutions

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Del Nido cardioplegia in the setting of minimally invasive aortic valve surgery

Perfusion ◽

10.1177/0267659116662701 ◽

2016 ◽

Vol 32 (2) ◽

pp. 112-117 ◽

Cited By ~ 16

Author(s):

Nicola Vistarini ◽

Eric Laliberté ◽

Philippe Beauchamp ◽

Ismail Bouhout ◽

Yoan Lamarche ◽

...

Keyword(s):

Aortic Valve ◽

Minimally Invasive ◽

Myocardial Protection ◽

Valve Surgery ◽

Myocardial Infarctions ◽

Aortic Valve Surgery ◽

Intravenous Insulin ◽

Group 12 ◽

Group 2 ◽

Group 1

The purpose of this study is to report our experience with del Nido cardioplegia (DNC) in the setting of minimally invasive aortic valve surgery. Forty-six consecutive patients underwent minimally invasive aortic valve replacement (AVR) through a “J” ministernotomy: twenty-five patients received the DNC (Group 1) and 21 patients received standard blood cardioplegia (SBC) (Group 2). The rate of ventricular fibrillation at unclamping was significantly lower in the DNC group (12% vs 52%, p=0.004), as well as postoperative creatinine kinase-MB (CK-MB) values (11.4±5.2 vs 17.7±6.9 µg/L, p=0.004). There were no deaths, myocardial infarctions or major complications in either group. Less postoperative use of intravenous insulin (28% vs 81%, p<0.001) was registered in the DNC group. In conclusion, the DNC is easy to use and safe during minimally invasive AVR, providing a myocardial protection at least equivalent to our SBC, improved surgical efficiency, minimal cost and less blood glucose perturbations.

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