Del Nido Cardioplegia in Ascending Aortic Surgery

Del Nido versus conventional blood cardioplegia in patients with combined aortic root surgery: A retrospective study

OBJECTIVE

This study aimed to compare the safety and efficacy of Del Nido cardioplegia (DNC) and conventional blood cardioplegia (CBC) in combined aortic surgery.

METHODS

This retrospective study involved elective patients who underwent combined aortic root surgery between September 2017 and July 2023. Patients were divided into two groups: the DNC and the CBC group. The primary outcome was high-sensitivity cardiac troponin I and creatine kinase-MB levels at the 0, 1, 2, and three postoperative days. The secondary outcomes contained postoperative left ventricular ejection fraction, return to spontaneous rhythm after aortic de-clamping, postoperative myocardial infarction, new-onset atrial fibrillation, postoperative mechanical circulatory support, mechanical ventilation duration, intensive care unit stay, postoperative hospital stay, and the reduction of left ventricle end-diastolic diameter at 3 months after surgery.

RESULTS

223 patients were included and divided into the CBC (n = 111) and the DNC group (n = 112). There was no statistical difference in patients' demographics and preoperative parameters between the two groups. No in-hospital mortality. The total cardioplegia volume [35.25 (30.30,43.65) ml/kg versus 21.43 (18.42,25.62) ml/kg, p < 0.001] and infusion times [2 (2,3) times versus 1 (1,2) times, p < 0.001] were less and the incidence of return to spontaneous rhythm after de-clamping was higher in the DNC group [59.5% versus 83%, p < 0.001]. Postoperative high-sensitivity cardiac troponin I and creatine kinase-MB levels were comparable between the two groups. DNC is related to a shorter duration of mechanical ventilation, intensive care unit stay, and hospital stay than CBC. The rate of return to spontaneous rhythm after aortic de-clamping seemed to decrease with the prolongation of aortic cross-clamping (ACC) duration, and there was no difference between the two groups when the time exceeded 120 min.

CONCLUSIONS

The safety and efficacy of using DNC were comparable to CBC in combined aortic surgery. The rate of return to spontaneous rhythm after aortic de-clamping seemed to decrease with the prolongation of ACC time. Further studies may be needed to fully elucidate the advantages of DNC in postoperative recovery and its long-term effects on patient outcomes.

del Nido versus blood cardioplegia in adult cardiac surgery: a meta-analysis

AIMS

Initially developed for myocardial protection in immature cardiomyocytes, del Nido cardioplegia has been increasingly used over the past decade in adult patients. Our aim is to analyse the results from randomized controlled trials and observational studies comparing early mortality and postoperative troponin release in patients who underwent cardiac surgery using del Nido solution and blood cardioplegia.

METHODS

A literature search was performed through three online databases between January 2010 and August 2022. Clinical studies providing early mortality and/or postoperative troponin evaluation were included. A random-effects meta-analysis with a generalized linear mixed model, incorporating random study effects, was implemented to compare the two groups.

RESULTS

Forty-two articles were included in the final analysis for a total of 11 832 patients, 5926 of whom received del Nido solution and 5906 received blood cardioplegia. del Nido and blood cardioplegia populations had comparable age, gender distribution, history of hypertension and diabetes mellitus. There was no difference in early mortality between the two groups. There was a trend towards lower 24 h [mean difference -0.20; 95% confidence interval (CI) -0.40 to 0.00; I2 = 89%; P = 0.056] and lower peak postoperative troponin levels (mean difference -0.10; 95% CI -0.21 to 0.01; I2 = 0.87; P = 0.087) in the del Nido group.

CONCLUSION

del Nido cardioplegia can be safely used in adult cardiac surgery. The use of del Nido solution was associated with similar results in terms of early mortality and postoperative troponin release when compared with blood cardioplegia myocardial protection.

A novel dosing strategy of del Nido cardioplegia in aortic surgery

Objective

While del Nido (DN) cardioplegia is increasingly used in cardiac surgery, knowledge is limited in its safety profile for operations with prolonged crossclamp time (CCT). We have introduced a unique redosing strategy for aortic surgery: all operations use DN with a 1000-mL initiation dose (750 mL antegrade, 250 mL retrograde) composed of 1:4 blood:DN crystalloid. At 90 minutes CCT and every 30 minutes thereafter, a 250-mL dose was introduced retrograde in a 4:1 (“reverse”) ratio. Additionally, at 90 minutes CCT and every 90 minutes thereafter, a reverse ratio dose of approximately 100 to 400 mL was introduced via the right coronary artery. Here, we analyze the outcomes of our unique redosing strategy used.

Methods

In total, 440 patients underwent aortic surgery between January 2015 and March 2021 under a single surgeon and received DN. Our primary end points were change in left ventricular ejection fraction (LVEF) and right ventricular systolic function based on echocardiography. Multivariable linear regression was used to analyze the relationship between CCT and outcomes.

Results

The median was 61 years old (interquartile range, 51-69), and 23% were female. Indication was aneurysm in 65% and dissection in 24%. Median preoperative LVEF was 60% (55%-62%). Median CCT and cardiopulmonary bypass times were 135 minutes (93-165 minutes) and 181 minutes (142-218 minutes), respectively. In-hospital mortality occurred in 3%. Multivariable linear regression showed CCT was not associated with change in LVEF or change in right ventricular systolic function.

Conclusions

Our unique method of redosing DN cardioplegia appears to provide safe and effective myocardial protection for aortic surgery.