Comparison of Microplegia Solution and Del Nido Cardioplegia Solution in Coronary Artery Bypass Grafting Surgery: Which One is More Effective?

Background: The aim of this study is to compare the efficacy of the microplegia solution and Del Nido cardioplegia solution in coronary artery bypass surgery with clinical, biochemical, and echocardiographic data. Methods: Three hundred patients, who underwent coronary artery bypass surgery between January 2017 and January 2020, by the same surgical team were included in the study. Preoperative, operative and postoperative data (cardiac biomarker levels, cross-clamp and CPB times, echocardiographic measurements, etc.) of the patients were compared. Results: In the study, cross-clamp time was significantly shorter in the DN cardioplegia group (55.60 ± 13.49 min/75.58 ± 12.43 min, P = 0.024). No significant difference was observed between the two groups in terms of intensive care stay, extubation time, hospital stay, and cardiopulmonary bypass time. In our study, it was shown that both the left and right ventricular ejection fraction was better protected in the Del Nido cardioplegia group (5.34±3.03 vs. 3.40±2.84, P = 0.017 and 3.82±1.19 vs. 2.28±1.87, P = 0.047, respectively), and the need for inotrope support was lower in this group (28% vs. 44%, P < 0.021). There was no significant difference between the groups, in terms of blood transfusion rates, IABP requirement. Conclusion: In light of short-term results, we can say that Del Nido cardioplegia provides better myocardial protection than microplegia. In addition, Del Nido cardioplegia can be given as a single dose for 90 minutes of cross-clamp time and therefore can be preferred to increase surgical comfort and reduce cross-clamp times.

The retrospective observational study of clinical outcomes of single dose infusion of warm blood cardioplegia in patients undergoing cardiac surgery

Objective: The aim of the study was to assess the safety and efficacy of a normothermic cardioplegia solution N trademark use and obtain additional information about dosing regimens during normothermic or mild hypothermic cardiac surgery. Methods: A retrospective observational study included 150 cardio surgery patients. The primary endpoint was the intraoperative acute heart failure development. The secondary endpoints were the postoperative Troponin T concentrations, the need for catecholamine support, and the repeated infusion of a cardioplegia solution. Results: The duration of aortic cross-clamping varied from 17 to 154 minutes, median 59 [interquartile range, 46 - 73] minutes. Spontaneous sinus rhythm recovery was observed in 136 (90.7%) patients. Intraoperative acute heart failure was observed in 1 case. The Troponin T concentrations were 0.331 plus-or-minus sign 0.143 ng/mL after surgery. Mortality was 2% (3 patients). Eight patients received an additional volume of N trademark solution to maintain asystole. Among 16 patients with a cross-clamp duration greater than 90 minutes epinephrine was used in 3 (18.8%) patients in doses of more than 0.05 mcg/kg/min. Among 134 patients cross-clamp duration less than 90 minutes the catecholamine support was used in 4 (3%) patients, p=0.027. Conclusions: A primary single-dose infusion of cardioplegia solution N trademark provides myocardial protection for 59 (interquartile range, 46-73) minutes and up to 154 minutes. The catecholamine support in the group of aortic cross-clamp duration less than 90 minutes was used lesser than in the group of aortic cross-clamp duration greater than 90 minutes (3% and 18.8%, respectively). The cardioprotection during cardiopulmonary bypass surgery especially in elderly patients with concomitant disease needs to be confirmed in future investigations.

Long-Term Protective Effects of Single-Dose infusion of Warm Blood Cardioplegic Solution in a mini-pig model on the background of intraoperative anemia

Objectives: The tolerable ischemic time for many cardioplegia solutions has not been established yet. The aim of this study was to estimate the effect of a single-dose of cardioplegia solution Normacor (solution No. 1) and to establish the tolerable ischemic time in a normothermic cardiopulmonary bypass mini-pig model on the background of intraoperative anemia. Methods: Five female mini-pigs (34plus-or-minus sign3 kg, 6-month-old) were subjected to 180 min or 210 min of cardiac arrest by single-dose 400 ml Normacor cardioplegia (solution No. 1). A needle biopsy was taken from the left ventricle before the aortic cross-clamping and every 30 minutes after it. The restoration of left ventricle contractility was assessed by the clinical indicators, catecholamine support, morphological and immunohistochemical examination. Results: The morphological signs of cardiomyocytes ischemia were found after 120 minutes of aortic cross-clamping. According to the content of succinate dehydrogenase and hypoxia-inducible factor, the signs of the cardiomyocytes ischemic injury onset were detected at the same time point. During the entire period of aortic cross-clamping atrial activity was observed in all cases. The proposed single-dose ischemic time for re-dosing of cardioplegia is 120 minutes or ventricular activity onset. Conclusions: Safe and effective cardioprotection can be achieved with warm blood cardioplegia Normacor (solution No. 1) within 120 minutes for a single-dose infusion.

Initial experience with del Nido cardioplegia solution at a Pediatric and Congenital Cardiac Surgery Program in Brazil

Objective: The aim of this study was to evaluate outcome measures between our standard multidose cardioplegia protocol and a del Nido cardioplegia protocol in congenital heart surgery patients. Methods: Retrospective single-center study including 250 consecutive patients that received del Nido cardioplegia (DN group) with a mandatory reperfusion period of 30% of cross clamp time and 250 patients that received a modified St. Thomas’ solution (ST group). Groups were matched by age, weight, gender, and Risk Adjustment for Congenital Heart Surgery (RACHS-1) scores. Preoperative hematocrit and oxygen saturation were also recorded. Outcomes analyzed were the vasoactive inotropic score (VIS), lactate, ventilation time, ventricular dysfunction with low cardiac output syndrome (LCOS), intensive care unit (ICU) length of stay (LOS), hospital LOS, bypass and aortic cross-clamp times, and in-hospital mortality. Results: Both groups were comparable demographically. Statistically significant differences (p ⩽ 0.05) were noted for cardiac dysfunction with LCOS, hematocrit at end of surgery (p = 0.0038), VIS on ICU admission and at end of surgery (p = 0.0111), and ICU LOS (p = 0.00118) with patients in the DN group having more desirable values for those parameters. Other outcome measures did not reach statistical significance. Conclusion: In our congenital cardiac surgery population, del Nido cardioplegia strategy was associated with less ventricular dysfunction with LCOS, a lower VIS and decreased ICU LOS compared with patients that received our standard myocardial protection using a modified St. Thomas’ solution. Despite the limitation of this study, including its retrospective nature and cohort size, these data supported our transition to incorporate del Nido cardioplegia solution with a mandatory reperfusion period as the preferred myocardial protection method in our program.

A proposed redosing interval of del Nido cardioplegia solution in adult cardiac surgery: a propensity-matched study

Background: Recently, del Nido cardioplegia solution (DN) has been utilized in adult cardiac surgery. However, adequate interval of maintenance dose(s) is still unclear. The purpose of this study was to assess the safety and efficacy of our DN protocol by comparing with conventional cold whole blood cardioplegia (CWB). Methods: A total of 1003 consecutive patients (DN group, N = 350 vs. CWB group, N = 653) underwent cardiovascular surgery between July 2013 and September 2018 were included in this study. The DN protocol was to administer 1000 to 1200 ml as an initial dose and to add maintenance dose(s) (500 ml each) every 60 minutes when the estimated cross-clamp time was over 90 minutes. CWB was given every 20 minutes, regardless of cross-clamp time. Propensity matching identified 254 matched pairs for analysis. The preoperative and postoperative data were reviewed. Results: Cross-clamp time was significantly shorter in the DN group compared with the CWB group (107 ± 56 minutes vs. 116 ± 49 minutes, p = 0.0458). A retrograde cannula was used in 124 (48.8%) patients in the DN group and 181 (71.3%) patients in the CWB group (p < 0.0001). There were no significant differences in requiring postoperative cardiac supports (inotropes, mechanical circulatory supports) and major complications. In-hospital mortality was similar between two groups (DN group: 3.2% vs. CWB group: 2.4%, p = 0.5872). Conclusions: Short-term clinical outcomes in the patients underwent cardiovascular surgery with the DN protocol including the redosing interval strategy were acceptable. Also, DN protocol was associated with shortened cross-clamp time and less usage of the retrograde cannula.

Use of del Nido cardioplegia in acute aortic dissection surgery

Objective: Del Nido cardioplegia solution provides a depolarized hyperkalemic arrest lasting up to 60 minutes. Single-dose del Nido cardioplegia solution may offer an alternative myocardial protection strategy to conventional whole blood cardioplegia following acute aortic dissection surgery. Methods: We retrospectively reviewed 122 consecutive patients with acute aortic dissection undergoing arch reconstruction surgery procedure with cardioplegia arrest from January 2017 to December 2019. Patients exclusively received with whole blood cardioplegia (n = 60, January 2017–December 2018) or del Nido cardioplegia (n = 62, January 2018–December 2019). Preoperative and postoperative data were retrospectively reviewed. Results: No significant difference between two groups in mortality (4/60 vs 3/62, p = 0.964), cardiopulmonary bypass time (168.0 ± 10.5 minute vs 165.0 ± 12.5 minute, p = 0.154), aortic cross-clamp time (91.8 ± 9.0 minute vs 93.2 ± 9.5 minute, p = 0.405), selective antegrade cerebral perfusion time (21.8 ± 5.0 minute vs 22.4 ± 4.7 minute, p = 0.496) and postoperative vasoactive inotropic score (34.8 ± 1.9 vs 35.2 ± 2.1, p = 0.272), neurological complications rate (8/60 vs 12/62, p = 0.523), renal insufficiency rate (5/60 vs 7/62, p = 0.807) and the troponin T level (304.8 ± 111.3 vs 315.0 ± 94.9, p = 0.588), respectively. Mean volume of crystalloid was significantly higher in the del Nido group compared to the whole blood cardioplegia group (1010.2 ± 20.3 mL vs 300.0 ± 19.6 mL, p < 0.001). Patients requiring defibrillation was 7/62 vs 28/60 (p < 0.001), with statistical difference in both groups. Conclusion: Short-term outcomes in acute aortic dissection surgery using del Nido cardioplegia solution were acceptable and comparable to conventional multi-dose whole blood cardioplegia. Del Nido cardioplegia technique is associated with lower defibrillations rate and requires a reduced frequency of infusions that results in longer durations between infusions and may be a feasible alternative to conventional whole blood cardioplegia solution in acute aortic dissection surgery.