del Nido cardioplegia: ready for prime time in adult cardiac surgery?

Comparison of Del Nido (a different application) and crystalloid blood cardioplegia on arrhythmia and early results

BACKGROUND

The results of the use of del-Nido(DN) solution using a different method or crystalloid blood cardioplegia in coronary bypass patients were compared. We aimed to investigate the effects on intraoperative and postoperative arrhythmias, arrhythmia durations and early results.

METHODS

The study included 175 patients using crystalloid blood cardioplegia (Group 1) and 150 patients using DN solution(Group 2). In the DN group, 75% of the calculated plegia dose was given first. the remaining part was applied by giving from grafts. Intraoperative/postoperative data were compared.

RESULTS

There was no significant difference between the groups in terms of demographic characteristics. Preop troponin level was similar.(p = 0.190) However, there was a statistical difference between the postoperative 6th hour.(p = 0.001) There was no difference in troponin values at the postoperative 24th hour. (p = 0.631) Spontaneous rhythm occurred at the cardiopulmonary by pass (CPB) weaning stage in most of the patients in Group 2 (95.3%). Although the need for temporary pacing was less in Group 2, it was not significant.(p = 0.282) No patient required permanent pacing. CPB duration, cross clamp times and intraoperative glucose levels, intensive care follow-up times and hospitalization times were found to be shorter in Group 2. Although the postoperative atrial fibrillation frequency was similar (p = 0.261), the time to return to sinus was lower in Group 2.(p = 0.001).

CONCLUSION

The use of DN cardioplegia solution provides significant positive contributions to avoid arrhythmias compared to crystalloid blood cardioplegia. DN solution applied with this method may contribute to reducing the anxieties associated with its use in isolated coronary artery bypass surgery.

Del Nido cardioplegia versus blood cardioplegia in coronary artery bypass grafting

Purpose

The del Nido cardioplegia (DC) has been extensively used in congenital heart surgery for over two decades and is becoming popular in adult cardiac surgery. We evaluated the efficacy and safety of DC, compared to conventional blood cardioplegia (BC), in adult patients undergoing isolated coronary artery bypass grafting (CABG).

Methods

This metachronous study included a total of 2330 consecutive patients who underwent isolated CABG. The study population was divided into two groups: BC group, consisting of 1165 patients (May 2012 through December 2015); and DC (del Nido) cardioplegia group consisting of 1165 patients (January 2016 through June 2018). Propensity matching yielded 735 well-matched pairs. The propensity-matched cohorts of BC and DC were compared in terms of myocardial function outcomes and other clinical outcomes to determine the efficacy and safety of both the cardioplegic solutions.

Results

There was no difference in 30-day mortality [odds ratio (OR), 0.74; 95% confidence interval (CI), 0.16-3.35, p = 0.70]. There was a significant decrease in the DC group in the postoperative events, including re-exploration rates [OR, 0.25; 95% CI, 0.118-0.568, p < 0.001], myocardial infarction [OR, 0.282; 95% CI, 0.133-0.596, p < 0.001], left ventricular dysfunction [OR, 0.60; 95% CI, 0.396-0.916, p = 0.018], and acute kidney injury (AKI) [OR, 0.255; 95% CI, 0.156-0.418, p < 0.001]. The rate of spontaneous return to sinus rhythm was significantly higher in the DC group [OR, 5.162; 95% CI, 3.701-7.198, p < 0.001]. Cardiopulmonary bypass time (95.2 ± 29.1 min vs. 82.1 ± 28.8 min, p < 0.001) and aortic cross-clamp (ACC) time (57.3 ± 19 min vs. 48.7 ± 19.0 min, p < 0.001) were higher in the DC group, but the absolute difference in ACC time was only 8 min. There was no difference in AKI requiring renal replacement therapy [OR, 0.62; 95% CI, 0.203-1.912, p = 0.40], postoperative cerebrovascular accidents [OR, 0.398; 95% CI, 0.077-2.059, p = 0.073], and postoperative ventricular arrhythmias [OR, 0.80; 95% CI, 0.456-1.916, p = 0.47].

Conclusion

This study revealed comparable clinical outcomes and effective myocardial protection with DC, compared to BC in patients undergoing isolated CABG. In addition, DC demonstrated the ease of administration with the feasibility of single-dose administration.

Surgical results of only antegrade del Nido cardioplegia infusion in conventional coronary artery bypass grafting: a retrospective study

BACKGROUND

Additional retrograde cardioplegia infusion in conventional coronary artery bypass grafting (CABG) was introduced to address the concern of inappropriate cardioplegia delivery through the stenotic coronary artery. However, this method is complex and requires repeated infusions. Therefore, we investigated the surgical outcomes of only antegrade cardioplegia infusion in conventional CABG.

METHODS

We included 224 patients who underwent isolated CABG between 2017 and 2019. The patients were divided into two groups according to the cardioplegia infusion method: antegrade cardioplegia infusion with del Nido solution (n=111, group I) and antegrade+retrograde cardioplegia infusion with blood cardioplegia solution (n=113, group II).

RESULTS

The sinus recovery time after release of the aorta cross-clamp was shorter in group I (3.8±7.1 minutes, n=98) than in group II (5.8±4.1 minutes, n=73) (p=0.033). The total cardioplegia infusion volume was lower in group I (1,998.6±668.6 mL) than in group II (7,321.0±2,865.3 mL) (p<0.001). Creatine kinase-MB levels were significantly lower in group I than in group II (p=0.039). Newly developed regional wall motion abnormalities on follow-up echocardiography were detected in two patients (1.8%) in group I and five patients (4.4%) in group II (p=0.233). There was no significant difference in ejection fraction improvement between the two groups (3.3%±9.3% in group I and 3.3%±8.7% in group II, p=0.990).

CONCLUSION

The only antegrade cardioplegia infusion strategy in conventional CABG is safe and has no harmful effects.

Non-selective Del Nido and St Thomas cardioplegia in adults: analysis of early clinical experience using propensity matching

BACKGROUND

Del Nido cardioplegia (DNC) is a single-dose, high potassium, low-volume cardioplegia solution that has grown in favor recently. However, the use of DNC in the Asian population may be associated with certain challenges.

METHODS

Between January 2017 and April 2022, DNC was used for myocardial protection in this single-center retrospective study. In total, 5731 patients underwent open heart surgeries, where 310 patients received DNC for single or multiple procedures. A total of 307 pair of propensity-matched patients from DNC and cold blood St. Thomas cardioplegia (STC) were compared.

RESULTS

In total, 5085 patients with STC and 310 patients with DNC from the cohort were matched, reflecting the initial group sizes before propensity matching. About 307 patient pairs were included in the final analysis after propensity matching with the interest variables. In the STC group, the requirement for an immediate postoperative intra-aortic balloon pump (IABP) was significantly higher [18 (5.9%) in DNC versus 28 (9.1%) in STC, p = 0.021]. A 30-day mortality was comparable between the DNC and STC groups (2.9% versus 3.3%, p = 1.00). Major adverse cardiac events (MACE) (2.6% versus 3.6%, p = 0.648) showed no difference between the groups. In both single and multiple procedure subgroups, there were no statistically significant differences in 30-day mortality and MACE incidences when comparing STC and DNC.

CONCLUSION

The use of DNC in adults is acceptable and adaptable. Comparable clinical outcomes between STC patients and DNC were revealed by our investigation. There were no appreciable differences in 30-day mortality or MACE despite the STC group having a much higher need for immediate postoperative IABP.

Comparison of del Nido Cardioplegia vs blood cardioplegia in adult aortic surgery is the single-dose cardioplegia technique really advantageous?

BACKGROUND

/objective: The aim of the present study was to compare the operative and early postoperative results of the use of del Nido Cardioplegia solution (dNCS) with traditional blood cardioplegia (BC) in adult aortic surgery.

METHODS

A retrospective single-center study was performed on 118 patients who underwent aortic surgery with cardiopulmonary bypass (CPB) between January 2016 and June 2020. Patients were divided in to two groups according to the type of cardioplegia solution used. Cardiac arrest was achieved in Group 1 (n = 65) with traditional BC and in Group 2 (n = 53) with dNCS. Operative and postoperative outcomes of the patients were compared between the two groups.

RESULTS

Patient demographic characteristics were similar between the two groups. dNCS group showed significantly lower aortic cross-clamp (ACC) time (73.3 vs. 87.5 min, P = 0.001), cardioplegia volume (1323.9 ± 368.5 vs. 2773.8 ± 453.8 ml, P< 0.001), defibrillation rate (44.4%vs. 69.2%, P = 0.006), drainage amount (412 ± 73.2 vs. 446.9 ± 95.1 ml, P = 0.026) and inotropic support need (37% vs. 55.3%, P = 0.046). Also dNCS group had significantly lower high sensitive troponin I (hsTnI) levels at 6th (203.5 ± 68.6 vs. 275.7 ± 76.2 ng/L, P< 0.001) and 24th (253.1 ± 101 vs. 293.4 ± 80.1 ng/L, P = 0.017) postoperative hours. And dNCS group showed significantly higher hematocrit levels at 6th (25.1 ± 3.2 vs. 22.5 ± 2.5%, P< 0.001) and 24th (25.8 ± 2.7 vs. 24.6 ± 2.8%, P = 0.024) postoperative hours. Times of intensive care unit stay, durations of intuabation and hospital stay times were similar in both groups. There was no significant difference in terms of postoperative ejection fraction values (P = 0.714).

CONCLUSION

Compared with conventional BC, dNCS provided significantly shorter ACC times, reduced the need for intraoperative defibrillation, lowered postoperative hsTnI levels with comparable early clinical outcomes for adult patients undergoing aortic surgery. dNCS is a safe and efficient alternative to the traditional BC solution in adult aortic cardiac surgery.

Del Nido Cardioplegia in Coronary Artery Bypass Grafting Surgery: A safe, efficacious and economic alternative to St. Thomas solution; an experience from a developing nation

INTRODUCTION

del Nido cardioplegia is a newer solution getting popular worldwide, whereas in Nepal, St. Thomas cardioplegia solution is conventionally used. There is no national recommendation on cardioplegia solutions supported by evidences from Nepalese studies. This study aimed to evaluate and compare the efficacy of these solutions in Nepalese patients undergoing coronary artery bypass grafting.

METHODS

Patients undergoing coronary revascularization, from May 2018 to December 2019, were randomized into St. Thomas and del Nido groups based on the cardioplegia administered, with 45 patients in each group. Preoperative, intraoperative, and postoperative parameters and cost of cardioplegia preparation in the two groups were compared.

RESULTS

The cardiopulmonary bypass time (106.13 ± 24.65 minutes vs 107.62 ± 18.69 minutes, p = 0.02), aortic cross clamp time (66.22 ± 15.40 minutes vs 72.07 ± 12.23 minutes, p = 0.04), volume (1059.22 ± 100.30 ml vs 1526.67 ± 271.81 ml, p < 0.001) and number of cardioplegia doses (1.00 ± 0.00 vs 2.51 ± 0.66, p < 0.001) were significantly lower with del Nido cardioplegia. A lower CPK-MB at second post-operative (59.91 ± 31.62 vs 73.82 ± 37.25, p = 0.03) and a higher left ventricle ejection fraction at discharge (56.33 ± 8.94% vs 50.45 ± 8.55%, p < 0.001) was observed in del Nido group. There was one death in St. Thomas group. ICU and hospital stay were similar in both groups. St. Thomas solution was found to be costlier than del Nido solution (USD 5.40 ± 0.96 vs USD 3.50 ± 0.34, p < 0.001).

CONCLUSION

The del Nido cardioplegia was found to be efficacious, safe and more economical alternative to St. Thomas solution.

Use of del Nido Cardioplegia for Adult Heart Surgery: How Long Is Not Too Long?

The most apparent practical advantage of del Nido cardioplegia (DNC) is that it allows the surgeon a longer arrest period before a subsequent dose is needed, as opposed to the conventional St. Thomas' cardioplegia solution where the recommended ischemic time is ∼15-20 minutes. In this study, we explored the incidence of arrhythmia after cross-clamp removal as a surrogate for a safe myocardial ischemic time with the use of DNC in adult heart surgery. A total of 113 patients who had undergone heart valve repair and/or replacement surgery at the National University Hospital, Singapore, were investigated. This single-center retrospective study was conducted on a population where DNC had been used for myocardial protection between January 2017 and April 2019. Cardioplegia ischemic time interval groups were not significant predictors of postoperative arrhythmia, defibrillation, and intraoperative intra-aortic balloon pump usage. Crude comparison of postoperative outcomes showed no significant differences in any other postoperative variables, including mortality and total hospital stay. From the results of the present study, it appears that there is no optimal ischemic time interval for the administration of DNC within a 120-minute time period. It is likely that DNC has a redosing interval of, and may provide adequate myocardial protection, for up to 120 minutes.

Single- versus multidose cardioplegia in adult cardiac surgery patients: A meta-analysis

OBJECTIVE

To compare outcomes of single (intervention group: del Nido [DN], and histamine-tryptophan-ketoglutarate) versus multidose (control group) cardioplegia in the adult cardiac surgery patients.

METHODS

Medical search engines were interrogated to identify relevant randomized controlled trials and propensity-score matched cohorts. Meta-analysis was conducted for primary (in-hospital/30-day mortality) and secondary (ischemic and cardiopulmonary bypass [CPB] times, reperfusion fibrillation, peak of cardiac enzymes, myocardial infarction) endpoints. Subgroup analyses were conducted for study design and type of intervention, and meta-regression for primary outcome included type of surgery and left ventricular ejection fraction as moderators.

RESULTS

Ten randomized controlled trials and 13 propensity-score matched cohorts were included, reporting on 5516 patients. Estimates are expressed as (parameter value [OR, odds ratio; MD, mean difference; SMD, standardized mean difference]/unit of measure [95% confidence interval], P value). DN reduced ischemic time (MD, -7.18 minutes [-12.52 to -1.84], P < .01), CPB time (MD, -10.44 minutes [-18.99 to -1.88], P .01), reperfusion fibrillation (OR, 0.16 [0.05-0.54], P < .01), and cardiac enzymes (SMD -0.17 [-0.29, 0.05], P < .01) compared with multidose cardioplegia. None of these beneficial effects were reproduced by histamine-tryptophan-ketoglutarate, which instead increased CPB time (MD, 2.04 minutes [0.73-3.37], P < .01) and reperfusion fibrillation (OR, 1.80 [1.20-2.70], P < .01). There was no difference in mortality and myocardial infarction between single and multidose, independently of type of surgery or left ventricular ejection fraction.

CONCLUSIONS

DN decreases operative times, reperfusion fibrillation, and surge of cardiac enzymes compared with multidose cardioplegia.

del Nido cardioplegia in adult cardiac surgery: beyond single-valve surgery

OBJECTIVES

In recent years, the use of del Nido (DN) cardioplegia has been reported in single-valve surgery or isolated coronary artery bypass surgery with acceptable outcomes. The reports of its use in more complex adult cardiac procedures, however, have been scarce.

METHODS

We enrolled a total of 149 adult patients who underwent heart valve surgery with the use of DN cardioplegia between May 2014 and December 2016. For a benchmark comparison, 892 patients who underwent cardiac valve surgery with blood cardioplegia during the same period served as controls. To reduce selection bias, propensity score matching was used; the inverse probability of treatment weighting method was performed for further validations.

RESULTS

Overall, 57.7% of patients in the DN group underwent multiple or complex cardiac procedures. Early mortality rates were 0.7% and 2.4% in the DN and blood groups, respectively (P = 0.31). Propensity score matching yielded 111 pairs of patients who were well balanced for all 23 measured baseline covariates. In the matched cohort, the postoperative peak troponin I levels (P = 0.004) and the aortic clamping times (P < 0.001) were significantly lower and shorter compared with those in the blood group. There were no significant differences in early mortality rates (1.9% vs 0%, P > 0.99), low cardiac output (P = 0.57) and neurological events (P = 0.21). The quantities of postoperative transfusions (P = 0.008) and fluid supplements (P < 0.001) were significantly lower in the matched DN group compared with the blood group.

CONCLUSIONS

The use of DN in adult valve surgery including complex procedures may confer acceptable outcomes comparable to or even superior to those obtained with the use of blood cardioplegia.

Comparison of del Nido Cardioplegia with Blood Cardioplegia in Coronary Artery Bypass Grafting Combined with Mitral Valve Replacement

OBJECTIVE

To compare del Nido cardioplegia (DNC) with blood cardioplegia (BC) in coronary artery bypass grafting (CABG) combined with mitral valve replacement.

METHODS

A 3-year single-center retrospective cohort study was carried out. Subjects who underwent CABG (up to triple bypass) combined with mitral valve replacement were divided into DNC and BC groups. Each group had thirty subjects.

RESULTS

Both groups demonstrated similar baseline characteristics, including age, gender, cardiac/non-cardiac comorbidity, and preoperative echocardiographic parameters. Compared with the BC group, the DNC group demonstrated significantly lower cardioplegia volume (BC = 1130.00±194.1 mL, DNC = 884.33±156.8 mL, P=0.001), cardiopulmonary bypass time (DNC = 110.90±12.52 min, BC = 121.70±13.57 min, P=0.002), aortic clamp time (DNC = 91.37±11.58 min, BC = 101.37±13.87 min, P=0.004), and need for intraoperative defibrillation (DNC = 6 events, BC = 21 events, P=0.001). Postoperative creatine kinase-MB levels and troponin levels were significantly lower in the DNC group than in the BC group. Postoperative haemoglobin and haematocrit levels were significantly higher in the DNC group than in the BC group. The intubation period (hours) in intensive care unit (ICU) was significantly small in the BC group (DNC = 8.13±12.21, BC = 6.82±1.57, P=0.037); however, ICU stay, total hospital stay, and postoperative complication rates were not significantly different between them. At pre-discharge echocardiography, the DNC group demonstrated significantly higher ejection fraction rates than the BC group (47.79±5.50 and 45.72±5.86, respectively, P=0.005).

CONCLUSION

DNC presented better intraoperative and postoperative parameters and it is an effective and safe alternative to BC for CABG combined with mitral valve replacement.

Modified whole blood microplegia in high-risk patients

BACKGROUND

Numerous studies have documented the safety of whole blood cardioplegia on clinical outcomes after cardiac surgery. However, there is a paucity of studies investigating the outcomes of whole blood microplegia after cardiac surgery. Our protocol of whole blood microplegia includes removal of the crystalloid portion and utilizing the Quest Myocardial Protection System, for delivery of del Nido cardioplegia additives in whole blood. This study sought to evaluate the effects of whole blood microplegia on clinical outcomes, following cardiac surgery, in high-risk cardiac surgery patients.

METHODS

Between February 2016 and December 2017, 131 high-risk patients underwent cardiac surgery operations, utilizing whole blood microplegia and were compared with a contemporaneous control group of 236 low-risk patients. High-risk patients included those who underwent combined coronary artery bypass grafting (CABG) and valve repair or replacement, double-valve surgery, triple-valve repair or replacement, and patients with ejection fraction < 40%. Multivariable logistic regression analysis was performed to identify independent risk factors of mortality after cardiac surgery.

RESULTS

Operative mortality was 7% for high-risk and 0% for low-risk patients (P < 0.001). Of those patients, five had isolated CABG (two had emergent CABG), two had double-valve surgery, two had combined valve/CABG. In multivariate analysis, high-risk classification (odds ratio = 3.66, 95% confidence intervals = 1.04-12.9, P = 0.04), emerged as an independent predictor of operative mortality.

CONCLUSIONS

Whole blood microplegia, is a novel myocardial protection strategy that can be applied in high-risk cardiac surgery patients and prolonged operations, requiring cardioplegic arrest with acceptable early clinical outcomes.

The Use of del Nido Cardioplegia for Myocardial Protection in Isolated Coronary Artery Bypass Surgery

BACKGROUND

The del Nido (DN) cardioplegia solution has been widely used in paediatric open-heart surgery for years; however, its application in adult open-heart surgery has not yet gained sufficient popularity. We investigated the safety and efficiency of the DN cardioplegia solution versus the traditional crystalloid cardioplegia solution [St. Thomas' Hospital (STH) cardioplegia solution] in adult patients undergoing coronary artery bypass grafting (CABG).

METHODS

A retrospective comparative analysis of 200 consecutive patients undergoing isolated on-pump CABG between April 2016 and September 2017 was performed. Patients were divided into two groups: DN group (n = 100) and STH group (n = 100). Groups were compared with regard to perioperative clinical outcomes, and the safety and efficiency of the DN cardioplegia solution in CABG surgery were evaluated.

RESULTS

In the DN group, mean aortic cross-clamp, cardiopulmonary bypass, and total operation times were significantly shorter than in the STH group. After the release of the aortic cross-clamp, the requirement for intraoperative defibrillation was significantly less in the DN group. There were no significant differences between the groups in terms of the levels of perioperative cardiac biomarkers (including creatine kinase-myocardial band and troponin I), major postoperative adverse events, and in-hospital mortality.

CONCLUSIONS

This study revealed that the use of the DN cardioplegia solution in adult patients undergoing isolated CABG provides significantly shorter aortic cross-clamp, cardiopulmonary bypass, and total operation times compared with the traditional cardioplegias solution. The DN solution could be used as a safe and efficient alternative to the traditional cardioplegia solutions in CABG surgery.

Utilization of Del Nido Cardioplegia in Adult Coronary Artery Bypass Grafting - A Retrospective Analysis

BACKGROUND

Studies assessing the safety and effectiveness of Del Nido cardioplegia for adult cardiac surgery remain limited. We investigated early outcomes after coronary artery bypass grafting (CABG) using single-dose Del Nido cardioplegia vs. conventional multi-dose blood cardioplegia. Methods and Results: The 81 consecutive patients underwent isolated CABG performed by a single surgeon. The initial 27 patients received anterograde blood cardioplegia, while the subsequent 54 patients received anterograde Del Nido cardioplegia. There were no differences in the baseline characteristics of each group nor any differences in the 30-day incidences of myocardial infarction, all-cause death, and readmission following surgery. The use of Del Nido cardioplegia was associated with shorter cardiopulmonary bypass time (98 vs. 115 min, P=0.011), shorter cross-clamp time (74 vs. 87 min, P=0.006), and decreased need for intraoperative defibrillation (13.0% vs. 33.3%, P=0.030) compared with blood cardioplegia. To control for the difference in cross-clamp time, we performed propensity score matching with a logistical treatment model and confirmed that Del Nido cardioplegia provided similar outcomes as blood cardioplegia and also reduced the need for defibrillation independent of cross-clamp time.

CONCLUSIONS

Compared with conventional blood cardioplegia, Del Nido cardioplegia provided excellent myocardial protection with reduced need for intraoperative defibrillation, shorter bypass and cross-clamp times, and comparable early clinical outcomes for adult patients undergoing CABG.

Del Nido cardioplegia in low risk adults undergoing first time coronary artery bypass surgery

OBJECTIVES

Single-dose del Nido cardioplegia has been used in the pediatric population for many years. Only a small amount of data exists about its use in adult cardiac surgery. We sought to compare the outcomes of all patients undergoing coronary artery bypass, using our 4:1 blood cardioplegia versus single-dose 1:4 del Nido cardioplegia, at our institution.

METHODS

Data were retrospectively reviewed from all patients during 2 consecutive years (2013-2014). We switched our cardioplegia protocol from 4:1 blood cardioplegia to exclusively 1:4 single-dose del Nido cardioplegia in early 2014. A total of 408 patients were evaluated. Two hundred and forty-nine consecutive patients underwent coronary artery bypass using blood cardioplegia and 159 using del Nido Cardioplegia.

RESULTS

Cardiopulmonary bypass time, cross-clamp time, in-hospital mortality and length of stay were similar (p>0.05): 63 ± 23 vs. 65 ± 21 min, 50 ± 20 vs. 52 ± 20 min, 0.8% vs. 0.6% and 6.4 ± 3 vs. 5.8 ± 3 days, respectively. For secondary outcomes: patients requiring defibrillation was 105/249 (42%) vs. 13/159 (8%) (p<0.0001), blood transfusion was required in 96/249 (38%) vs. 48/159 (30%) (p<0.085), total volume administered was 1139mL vs. 813 mL per case (p<0.0001), hematocrit change was 11.6% vs. 10.9% (p<0.04) and the mean cost per dose was $157.54 vs $5.74.

CONCLUSIONS

Single-dose del Nido cardioplegia is an effective and economic cardioplegia and can be used with good outcomes in coronary surgery. Most patients have spontaneous return of sinus rhythm and there is a trend towards decreased transfusion rate.