Del Nido versus warm blood cardioplegia in adult patients with a low ejection fraction

Background Del Nido cardioplegia was recently introduced to adult cardiac surgery with encouraging results. The effect of Del Nido cardioplegia in patients with low ejection fraction (EF) has not been thoroughly evaluated. The objective of this study was to assess the safety of Del Nido cardioplegia in adult patients with low EF compared to intermittent warm blood cardioplegia. Results During 2018 and 2019, 73 adult patients with an EF of ≤ 40% underwent cardiac surgery using Del Nido cardioplegia. The patients were compared to a historical cohort of consecutive patients with low EF who had intermitted warm blood cardioplegia (n = 81). Patients who had Del Nido cardioplegia had significantly lower EuroSCORE II (2.73 (1.7–4.1) vs. 4.5 (2.4–7.4), P = 0.004). There were no differences in creatinine clearance and preoperative echocardiographic data between the groups. Cardiopulmonary bypass and cross-clamp times were non-significantly lower with Del Nido cardioplegia. There were no differences in stroke and postoperative echocardiographic data between the groups. No hospital mortality was reported in both groups. Peak troponin levels were significantly higher in patients who had Del Nido cardioplegia (0.88 (0.58–1.47) vs. 0.7 (0.44–1.01) ng/dL; P = 0.01); however, after multivariable regression analysis, cardiopulmonary bypass time was the only predictor of postoperative troponin level (coefficient 0.005 (95% CI: 0.003–0.008); P < 0.001). ICU stay was significantly longer in patients who had Del Nido cardioplegia (4 (3–6) vs. 2(1–4) days, P < 0.001), while postoperative hospital stay did not differ between the groups. After multivariable regression, the use of intermittent warm blood cardioplegia was significantly associated with shorter ICU stay (coefficient − 1.80 (95% CI − 3.06 – -0.55); P = 0.01). Conclusions Prolonged ICU was reported with Del Nido cardioplegia; however, there were no differences in the duration of hospital stay and the clinical outcomes between the groups. Despite the proven efficacy of intermittent warm blood cardioplegia, the use of Del Nido cardioplegia might be safe in patients with low EF.

Effects of Del Nido and Terminal Warm Blood Cardioplegia on Myocardial Protection and Rhythm in Isolated CABG Patients

Objective: To investigate the effect of using del Nido cardioplegia+terminal hot-shot blood cardioplegia on myocardial protection and rhythm in isolated coronary bypass patients. Material and methods: A total of 122 patients were given cold (+4-8C') del Nido cardioplegia antegrade and evaluated. Del Nido+terminal warm blood cardioplegia (TWBCP) was applied to 63 patients out of 122 patients, while del Nido cardioplegia alone was applied to the other 59 patients. The preoperative and postoperative data of the patients were recorded and compared. Results: There was a significant statistical difference between the groups, in terms of volume with more cardioplegia in the del Nido+terminal warm blood cardioplegia group. Although there was no significant difference between cardiac arrest times in both groups, a statistically significant difference was found in the del Nido+terminal warm blood cardioplegia group in the starting to work time of the heart. No difference found between the groups regarding myocardial preservation. Conclusions: We can add a return to spontaneous sinus rhythm to the advantages of terminal warm blood cardioplegia and del Nido cardioplegia in literature. We think it would be a good strategy to extend the safe ischemic time limit of del Nido to 120 minutes with a terminal warm blood cardioplegia. It seems that cardioplegia techniques that will be developed by adding the successful and superior results of crystalloid cardioplegia applications, such as single dose del Nido in various open heart surgery operations and the superior myocardial return effects of terminal warm blood cardioplegia, will be used routinely in the future.

COMPARISON STUDY: INTERMITTENT ANTIGRADE WARM CARDIOPLEGIA VERSUS ANTIGRADE COLD INTERMITTENT BLOOD CARDIOPLEGIA FOR MYOCARDIAL PROTECTION DURING ELECTIVE ON PUMP CORONARY ARTERY BYPASS GRAFTING IN EARLY POST-OPERATIVE PERIOD

Background: Defending the heart against potential damage during cross-clamping is the most important and vital step to ensuring a successful surgical outcome(1). The creation of cardioplegia solutions was one of the major advances in cardiac surgery that allowed surgeons to conduct complicated surgical procedures to avoid myocardial injury (14). Treating cardioplegia at a cool temperature would be a significant factor in lowering myocardial metabolism. However, the reduction in myocardial metabolism due to hypothermia, compared with that achieved by diastolic arrest, is usually very negligible. Since Normothermias enzymatic and cellular processes work better (7). Owing to the propensity of the heart to resume electrical operation during normothermia, however, this must be administered consistently or only with short interruptions (4). Terminal warm blood cardioplegia (hot shot) is normally done just before the elimination of the aortic cross-clamp since it has been demonstrated that myocardial metabolism is increasing (23). Methods: A prospective controlled randomised study (200 hundred patients aged 40 to 65 years of both sexes underwent elective CABG pump surgery) will be included. They will be divided into three groups of patients: Group I:includes 100 Patients who received intermittent cold blood cardioplegia. Group II:includes 100 Patients who received intermittent warm blood cardioplegia with controlled reperfusion for 3 minutes before aortic unclamping. Study made from January, 2019 to August, 2020, at National Heart Institute.All patients were thoroughly evaluated preoperatively, intraoperatively, and postoperatively. Results: We hypothesized that in our patient cohort, warm blood cardioplegia could be as successful as or even better than the conventional antegrade cold blood cardioplegia. Patients were randomised into two similar blocks, each of which consisted of 100 patients, each of whom obtained one of the two cardioplegic solutions. Our analysis did not indicate a statistically important difference in the post-operative release of myocardial biomarkers (Troponin I) & CK in both classes. This finding did not significantly reflect the clinical outcome of our patient, which may indicate similar myocardial protection in primary low-risk CABG patients for both cold and warm blood cardioplegia. Conclusion: During the time of cardiac arrest, both methods tend to enable an equal and adequate approach for myocardial defence. To attain improved myocardial defence, warm blood cardioplegia needs a shorter administration interval. Therefore, the choice between one type of cardioplegia and the other remains at the discretion of the surgeon. The statistically minor variation found in the release of myocardial enzymes did not translate into distinct clinical results.

Antegrade Intermittent Cold Cardioplegia in Comparison to Antegrade Intermittent Warm Cardioplegia in Heart Valve Surgery

Background: The cardioplegic arrest is essential for motionless and bloodless heart valve surgery. The objective of this work was to compare antegrade cold versus warm blood cardioplegia during valve surgery. Methods: This randomized controlled study included 100 patients who had mitral valve surgery. Patients were randomly assigned into two groups; the warm cardioplegic group (n= 50) and the cold cardioplegic group (n= 50). Study endpoints were creatine kinase myocardial band, lactate dehydrogenase, and troponin levels. Results: There was no significant difference in age and sex between groups (p= 0.51 and 0.56, respectively). Cardiopulmonary bypass was significantly longer in the cold group (85.66 ± 22.9 vs. 72.34 ± 25.09 minutes; P= 0.01); however, there was no difference in ischemic time (p= 0.32). The number of DC shocks given for each patient is less in the warm group with a median of 1.5 (range 1-3 times), while in the cold group, the median was 2 (range 2-4 times); p= 0.02. The amount of blood loss was significantly lower among the warm group (645.4 ± 464.93 ml vs. 404 ± 252.7 P< 0.01). warm group had significantly lower postoperative CK (532.78 ± 249.08 vs. 638.14 ± 344.01 IU/L; P< 0.01), CK-MB (78.64 ± 34.58 vs. 103.18 ± 82.11; P< 0.0.01), LDH level (805.3 ± 322.71 vs. 1060.88 ± 500.94 mg/dl; P< 0.01) and (0.4148 ± 0.226 vs. 0.6404 ± 0.411 ng/ml; P< 0.01). Conclusion: Antegrade warm blood cardioplegia may provide better myocardial protection during valve surgery compared to the cold cardioplegia. A larger study is recommended.

Warm Blood Cardioplegia for Myocardial Protection: Concepts and Controversies

Warm blood cardioplegia has been an established cardioplegic method since the 1990s, yet it remains controversial in regard to myocardial protection. This review will describe the physiologic and technical concepts behind warm blood cardioplegia, as well as outline the current basic and clinical research that evaluates its usefulness. Controversies regarding this technique will also be reviewed. A long history of experimental data indicates that warm blood cardioplegia is safe and effective and thus suitable myocardial protection during cardiopulmonary bypass surgeries.

Intermittent Antegrade Warm Blood Cardioplegia: What Is Next?

The introduction of warm heart surgery was a radical change in the concept of myocardial protection. In 1992, we applied a protocol for intermittent antegrade warm blood cardioplegia (CPL), which acquired some popularity for its simplicity and effectiveness. The possibility to deliver the warm blood CPL intermittently using the antegrade route attracted the attention of the scientific world, as the surgical procedure was less complicated. In this report, our aim is to focus on the changes that the protocol underwent over time and the reasons why these changes were made.