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Willekes H, Parker J, Neill J, Augustin G, Fanning J, Spurlock D, Murphy E, Leung S, Boeve T, Leacche M, Willekes C, Timek T. Efficacy of del Nido cardioplegia in adult cardiac procedures with prolonged aortic crossclamp time. J Thorac Cardiovasc Surg 2024; 167:996-1007.e4. [PMID: 35660325 DOI: 10.1016/j.jtcvs.2022.02.066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 01/16/2022] [Accepted: 02/23/2022] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Equivalent myocardial protection and clinical outcomes have been shown with the use of del Nido cardioplegia (DC) compared with blood cardioplegia (BC) in adult isolated coronary artery bypass grafting and valve patients. However, its safety and efficacy in cardiac procedures with aortic crossclamp times >90 minutes is still unknown. METHODS From May 2014 to September 2019, 2506 adult patients at our center underwent cardiac surgery requiring prolonged aortic crossclamp time defined as 90 minutes or longer. Myocardial protection was achieved with BC in 1955 patients and DC in 551 patients. Two surgeons used DC exclusively and 5 used blood exclusively over the study period. BC was delivered anterograde and retrograde whereas DC was delivered anterograde only. Propensity score matching of several preoperative characteristics, including primary cardiac pathology, yielded 526 well matched pairs. Emergency and reoperative cases were included. Troponin T levels were drawn at 12 hours postoperative in all patients. Clinical data were extracted from our local Society of Thoracic Surgeons database. Subgroup analyses were performed on the basis of crossclamp time stratification. RESULTS For the propensity score-matched cohort, the median crossclamp time was longer in the BC compared with the DC group (114 [interquartile range (IQR), 100-145] minutes for DC vs 153 [IQR, 122-200] minutes for BC; P < .0001) whereas intraoperative peak glucose was higher with BC (173 [IQR, 147-200] g/dL for DC vs 197 [IQR, 171-228] g/dL for BC; P < .001). In addition, perioperative mortality (3.4% vs 3.0%; P = .7273), stroke (3.2% vs 2.1%; P = .2504), renal failure (6.5% vs 4.6%; P = .1767), atrial fibrillation (34% vs 31.4%, P = .3575), intra-aortic balloon pump use (5.3% vs 4.6%, P = .5694), and extracorporeal membrane oxygenation use (3.0% vs 2.9%, P = .8596) did not differ between DC and BC. Postoperative troponin T levels were 0.53 (IQR, 0.30-0.96) ng/mL and 0.62 (IQR, 0.38-1.07) ng/mL for DC and BC, respectively (P = .0024). Subgroup analysis revealed higher troponin T levels with DC for crossclamp times between 150 and 180 minutes. Survival rates at 1, 2, and 5 years were 93.3%, 91.1%, and 78.7% for DC and 94.5%, 91.8%, and 81.5% for BC, respectively (P = .5140). CONCLUSIONS In adult cardiac surgical procedures with aortic crossclamp times >90 minutes, comparable myocardial protection, perioperative mortality and morbidity, and distant survival were observed with the use of DC compared with BC. Higher troponin levels were seen in DC patients with crossclamp times between 150 and 180 minutes, but this was not associated with increased mortality.
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Affiliation(s)
- Holliann Willekes
- Michigan State University College of Human Medicine, Grand Rapids, Mich
| | | | - Jere Neill
- Michigan State University College of Human Medicine, Grand Rapids, Mich
| | - Gabriel Augustin
- Michigan State University College of Human Medicine, Grand Rapids, Mich
| | - Justin Fanning
- Division of Cardiothoracic Surgery, Spectrum Health, Grand Rapids, Mich
| | - David Spurlock
- Division of Cardiothoracic Surgery, Spectrum Health, Grand Rapids, Mich
| | - Edward Murphy
- Division of Cardiothoracic Surgery, Spectrum Health, Grand Rapids, Mich
| | - Stephane Leung
- Division of Cardiothoracic Surgery, Spectrum Health, Grand Rapids, Mich
| | - Theodore Boeve
- Division of Cardiothoracic Surgery, Spectrum Health, Grand Rapids, Mich
| | - Marzia Leacche
- Division of Cardiothoracic Surgery, Spectrum Health, Grand Rapids, Mich
| | - Charles Willekes
- Division of Cardiothoracic Surgery, Spectrum Health, Grand Rapids, Mich
| | - Tomasz Timek
- Division of Cardiothoracic Surgery, Spectrum Health, Grand Rapids, Mich.
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Sanetra K, Gerber W, Mazur M, Kubaszewska M, Pietrzyk E, Buszman PP, Kaźmierczak P, Bochenek A. Del Nido vs. Cold Blood Cardioplegia for High-Risk Isolated Coronary Artery Bypass Grafting in Patients with Reduced Ventricular Function. Braz J Cardiovasc Surg 2024; 39:e20220346. [PMID: 38315052 PMCID: PMC10836820 DOI: 10.21470/1678-9741-2022-0346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Accepted: 06/16/2023] [Indexed: 02/07/2024] Open
Abstract
INTRODUCTION The evidence for using del Nido cardioplegia protocol in high-risk patients with reduced ejection fraction undergoing isolated coronary surgery is insufficient. METHODS The institutional database was searched for isolated coronary bypass procedures. Patients with ejection fraction < 40% were selected. Propensity matching (age, sex, infarction, number of grafts) was used to pair del Nido (Group 1) and cold blood (Group 2) cardioplegia patients. Investigation of biomarker release, changes in ejection fraction, mortality, stroke, perioperative myocardial infarction, composite endpoint (major adverse cardiac and cerebrovascular events), and other perioperative parameters was performed. RESULTS Matching allowed the selection of 45 patient pairs. No differences were noted at baseline. After cross-clamp release, spontaneous sinus rhythm return was observed more frequently in Group 1 (80% vs. 48.9%; P=0.003). Troponin values were similar in both groups 12 and 36 hours after surgery, as well as creatine kinase at 12 hours. A trend favored Group 1 in creatine kinase release at 36 hours (median 4.9; interquartile range 3.8-9.6 ng/mL vs. 7.3; 4.5-17.5 ng/mL; P=0.085). Perioperative mortality, rates of myocardial infarction, stroke, or major adverse cardiac and cerebrovascular events were similar. No difference in postoperative ejection fraction was noted (median 35.0%; interquartile range 32.0-38.0% vs. 35.0%; 32.0-40.0%; P=0.381). There was a trend for lower atrial fibrillation rate in Group 1 (6.7% vs. 17.8%; P=0.051). CONCLUSION The findings indicate that del Nido cardioplegia provides satisfactory protection in patients with reduced ejection fraction undergoing coronary bypass surgery. Further prospective trials are required.
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Affiliation(s)
- Krzysztof Sanetra
- Division of Cardiovascular Surgery, Andrzej Frycz Modrzewski Krakow
University, Krakow, Poland
- Department of Cardiac Surgery, American Heart of Poland,
Bielsko-Biała, Poland
| | - Witold Gerber
- Department of Cardiac Surgery, American Heart of Poland,
Bielsko-Biała, Poland
- Department of Cardiac Surgery, Academy of Silesia, Katowice, Poland
| | - Marta Mazur
- Department of Cardiology, Andrzej Frycz Modrzewski Krakow
University, Krakow, Poland
| | - Marta Kubaszewska
- Department of Cardiology, Andrzej Frycz Modrzewski Krakow
University, Krakow, Poland
| | - Ewa Pietrzyk
- Department of Cardiology, Andrzej Frycz Modrzewski Krakow
University, Krakow, Poland
| | - Piotr Paweł Buszman
- Department of Cardiology, Andrzej Frycz Modrzewski Krakow
University, Krakow, Poland
- Center for Cardiovascular Research and Development, American Heart
of Poland, Katowice, Poland
- Department of Cardiology, American Heart of Poland, Bielsko-Biała,
Poland
| | | | - Andrzej Bochenek
- Department of Cardiac Surgery, American Heart of Poland,
Bielsko-Biała, Poland
- Department of Cardiac Surgery, Academy of Silesia, Katowice, Poland
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Malvindi PG, Tian DH, Bifulco O, Berretta P, Alfonsi J, Cefarelli M, Yan TD, Di Eusanio M. del Nido versus blood cardioplegia in adult cardiac surgery: a meta-analysis. J Cardiovasc Med (Hagerstown) 2023; 24:522-529. [PMID: 37409597 DOI: 10.2459/jcm.0000000000001506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/07/2023]
Abstract
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.
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Affiliation(s)
- Pietro Giorgio Malvindi
- Cardiac Surgery Unit, Lancisi Cardiovascular Center, Ospedali Riuniti delle Marche, Polytechnic University of Marche, Ancona, Italy
| | - David H Tian
- Department of Anaesthesia and Perioperative Medicine, Westmead Hospital
- Critical Care Division, The George Institute for Global Health, Sydney
- Department of Surgery, University of Melbourne, Melbourne, Australia
| | - Olimpia Bifulco
- Cardiac Surgery Unit, Lancisi Cardiovascular Center, Ospedali Riuniti delle Marche, Polytechnic University of Marche, Ancona, Italy
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padova, Italy
| | - Paolo Berretta
- Cardiac Surgery Unit, Lancisi Cardiovascular Center, Ospedali Riuniti delle Marche, Polytechnic University of Marche, Ancona, Italy
| | - Jacopo Alfonsi
- Cardiac Surgery Unit, Lancisi Cardiovascular Center, Ospedali Riuniti delle Marche, Polytechnic University of Marche, Ancona, Italy
| | - Mariano Cefarelli
- Cardiac Surgery Unit, Lancisi Cardiovascular Center, Ospedali Riuniti delle Marche, Polytechnic University of Marche, Ancona, Italy
| | - Tristan D Yan
- Department of Cardiothoracic Surgery, Royal Prince Alfred Hospital
- Sydney Medical School, Sydney University, Sydney, Australia
| | - Marco Di Eusanio
- Cardiac Surgery Unit, Lancisi Cardiovascular Center, Ospedali Riuniti delle Marche, Polytechnic University of Marche, Ancona, Italy
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Huang Y, Yan S, Song Y, Wang X, Yang K, Zhang L, Gui W, Wang J, Yang Y, Xie Y, Wang D, Li X. Del nido versus conventional blood cardioplegia in patients with obstructive hypertrophic cardiomyopathy. Perfusion 2023:2676591231163270. [PMID: 36921566 DOI: 10.1177/02676591231163270] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/17/2023]
Abstract
BACKGROUND Myocardial protection is essential in cardiac surgery with cardiopulmonary bypass The Del Nido cardioplegia which was initially used in pediatric cardiac surgery, has been increasingly used in adult cardiac surgery recently. However, no literature has reported the efficacy of DNC in hypertrophic obstructive cardiomyopathy. METHODS This retrospective study involved elective patients who underwent extended surgical myectomy with or without concomitant cardiac surgical procedures between September 2017 and June 2022. Patients were distributed into two groups, the DNC and the CBC group. The primary outcome was high-sensitivity cardiac troponin I (hs-TnI) and creatine kinase-MB (CK-MB) levels at the 0, 1, and 2 postoperative days. The secondary outcomes contained: intraoperative LVEF, return to spontaneous rhythm; postoperative myocardial infarction, worsening or deteriorating of EF, mechanical circulatory support; new-onset atrial fibrillation; mechanical ventilation duration; intensive care unit hours; in-hospital days. RESULTS Fifty-nine patients were included and divided into the CBC (n = 15) and the DNC group (n = 44). There was no statistical difference in patients' demographics and preoperative parameters between the two groups. No in-hospital mortality. The total cardioplegia volume [21.93(18.36,26.07) vs. 25.68(23.17,37.12), p = 0.012] and infusion times [1(1,1) vs. 2(2,3), p = 0.000] were less and the incidence of return to spontaneous rhythm after declamping was higher in the DNC group [97.7% vs. 73.3%, p = 0.013]. Postoperative hs-TnI and CK-MB levels were comparable between the two groups. A longer DNC infusion interval was associated with higher levels of CK-MB on postoperative day 1 and day 2 (p = 0.009 and p = 0.011, respectively). CONCLUSIONS The use of DNC in extended surgical myectomy procedure was as safe and effective as CBC. However, DNC infusion interval over 60 minutes was associated with increased postoperative CK-MB levels.
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Affiliation(s)
- Yingshan Huang
- Department of Cardiopulmonary Bypass, Yunnan Fuwai Cardiovascular Hospital, Kunming, China
| | - Shujie Yan
- Department of Cardiopulmonary Bypass, State key laboratory of Cardiovascular Medicine, Fuwai Hospital, National center for Cardiovascular disease, Chinese Academy of Medical science and Peking Union Medical College, Beijing, China
| | - Yi Song
- Department of Cardiopulmonary Bypass, Yunnan Fuwai Cardiovascular Hospital, Kunming, China
| | - Xiaoqi Wang
- Department of Cardiac Surgery, Yunnan Fuwai Cardiovascular Hospital, Kunming, China
| | - Ke Yang
- Department of Anesthesiology, Yunnan Fuwai Cardiovascular Hospital, Kunming, China
| | - Ling Zhang
- Department of Cardiopulmonary Bypass, Yunnan Fuwai Cardiovascular Hospital, Kunming, China
| | - Wenting Gui
- Department of Cardiopulmonary Bypass, Yunnan Fuwai Cardiovascular Hospital, Kunming, China
| | - Jiao Wang
- Department of Cardiopulmonary Bypass, Yunnan Fuwai Cardiovascular Hospital, Kunming, China
| | - Yunling Yang
- Department of Cardiopulmonary Bypass, Yunnan Fuwai Cardiovascular Hospital, Kunming, China
| | - Yan Xie
- Department of Cardiopulmonary Bypass, Yunnan Fuwai Cardiovascular Hospital, Kunming, China
| | - Dongmei Wang
- Department of Cardiopulmonary Bypass, Yunnan Fuwai Cardiovascular Hospital, Kunming, China
| | - Xinyue Li
- Department of Cardiopulmonary Bypass, Yunnan Fuwai Cardiovascular Hospital, Kunming, China
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Zhai K, Cheng X, Zhang P, Wei S, Huang J, Wu X, Gao B, Li Y. Del Nido cardioplegia for myocardial protection in adult cardiac surgery: a systematic review and update meta-analysis. Perfusion 2023; 38:6-17. [PMID: 34263684 DOI: 10.1177/02676591211031095] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
OBJECTIVE Although the application of del Nido cardioplegia solution (DNC) in adult cardiac surgery is accumulating, the feasibility and safety of this myocardial protection strategy in adults remains controversial. We aimed to update our previous meta-analysis to determine the myocardial protective effect of DNC versus conventional cardioplegia (CC) in adult cardiac surgery. METHODS A comprehensive literature search was performed using PubMed, EMBASE, the Cochrane Library, and International Clinical Trials Registry Platform databases through November 2020. RESULTS Thirty-seven observational studies and four randomized controlled trials (RCTs) including 21,779 patients were identified. The DNC group was associated with decreased postoperative cardiac enzymes [troponin T (cTnT) and creatine kinase-MB (CK-MB)] [standardized mean differences (SMD): -0.59, 95% confidence interval (CI): -0.99 to -0.19, p = 0.004], cardiopulmonary bypass (CPB) time (MD: -9.31, 95% CI: -13.10 to -5.51, p < 0.00001), aortic cross-clamp (ACC) time (MD: -7.20, 95% CI: -10.31 to -4.09, p < 0.00001), and cardioplegia volume (SMD: -1.95, 95% CI: -2.46 to -1.44, p < 0.00001). Intraoperative defibrillation requirement was less in the DNC group [relative risk (RR): 0.50, 95% CI: 0.33 to 0.75, p = 0.0007]. The pooled analysis revealed no significant difference in operative mortality among the patients assigned to DNC and those undergoing CC. CONCLUSION In adult cardiac surgery, compared to CC, myocardial protection used with DNC yield similar or better short-term clinical outcomes. More high-quality trials and RCTs reflecting long-term follow-up morbidity and mortality are required in the future to confirm these findings.
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Affiliation(s)
- Kerong Zhai
- Department of Cardiac Surgery, Lanzhou University Second Hospital, Lanzhou University, Lanzhou, China
- Laboratory of Extracorporeal Life Support, Lanzhou University Second Hospital, Lanzhou University, Lanzhou, China
| | - Xingdong Cheng
- Department of Cardiac Surgery, Lanzhou University Second Hospital, Lanzhou University, Lanzhou, China
- Laboratory of Extracorporeal Life Support, Lanzhou University Second Hospital, Lanzhou University, Lanzhou, China
| | - Pengbin Zhang
- Department of Cardiac Surgery, Lanzhou University Second Hospital, Lanzhou University, Lanzhou, China
- Laboratory of Extracorporeal Life Support, Lanzhou University Second Hospital, Lanzhou University, Lanzhou, China
| | - Shilin Wei
- Department of Cardiac Surgery, Lanzhou University Second Hospital, Lanzhou University, Lanzhou, China
- Laboratory of Extracorporeal Life Support, Lanzhou University Second Hospital, Lanzhou University, Lanzhou, China
| | - Jian Huang
- Department of Cardiac Surgery, Lanzhou University Second Hospital, Lanzhou University, Lanzhou, China
- Laboratory of Extracorporeal Life Support, Lanzhou University Second Hospital, Lanzhou University, Lanzhou, China
| | - Xiangyang Wu
- Department of Cardiac Surgery, Lanzhou University Second Hospital, Lanzhou University, Lanzhou, China
| | - Bingren Gao
- Department of Cardiac Surgery, Lanzhou University Second Hospital, Lanzhou University, Lanzhou, China
| | - Yongnan Li
- Department of Cardiac Surgery, Lanzhou University Second Hospital, Lanzhou University, Lanzhou, China
- Laboratory of Extracorporeal Life Support, Lanzhou University Second Hospital, Lanzhou University, Lanzhou, China
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Demir D, Balci AB, Kahraman N, Sunbul SA, Gucu A, Seker IB, Badem S, Yuksel A, Ozyazicioglu AF, Goncu MT. The comparison of del nido cardioplegia and crystalloid-based blood cardioplegia in adult isolated coronary bypass surgery: A randomized controlled trial. Niger J Clin Pract 2022; 25:1998-2004. [PMID: 36537457 DOI: 10.4103/njcp.njcp_435_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
BACKGROUND AND AIM In our study, patients who underwent isolated coronary artery bypass surgery (CABG) using Del Nido cardioplegia (DNC) and crystalloid-based cold blood cardioplegia (CBC) were compared. SUBJECT AND METHODS In this study, two groups of patients who underwent isolated CABG using DNC (n = 106) and CBC (n = 107) were prospectively randomized. Groups were compared in terms of many results such as troponin T, returning spontaneous rhythm, and cardioplegia volume. RESULTS AND CONCLUSIONS Median troponin T levels of the DNC and CBC groups were compared for the 0th hour (baseline), 12th, 36th, and 60th hours. There was no statistical difference between groups in troponin T levels of the baseline 0th hour (18[33] vs. 22[27] pg/ml; P = 0.724). Troponin T levels at the 12th hour were less in the DNC group than the CBC group but no statistical difference between the groups (790[735] vs. 826[820] pg/ml; P = 0.068), respectively. Troponin T levels at 36th and 60th hours were higher in the CBC group compared to the DNC group, and a statistical difference was observed (580[546] vs. 650[550] pg/ml; P = 0.030) and (359[395] vs. 421[400] pg/ml; P = 0.020), respectively. After X-clamping, the spontaneous rhythm rate was statistically higher in the DNC group than the CBC group (72.60% vs. 37.40%; P < 0.001). There was no statistical difference between the groups in terms of postoperative arrhythmia, hospital stay, and mortality rates (P > 0.05). Based on data we acquired from the study, we think that DNC is at least as safe and effective as CBC in adult CABG cases.
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Affiliation(s)
- D Demir
- Department of Cardiovasculary Surgery, Bursa City Hospital, Bursa, Turkey
| | - A B Balci
- Department of Cardiovasculary Surgery, Şırnak State Hospital, Şırnak, Turkey
| | - N Kahraman
- Department of Cardiovasculary Surgery, Bursa City Hospital, Bursa, Turkey
| | - S A Sunbul
- Department of Cardiovasculary Surgery, Bursa Yüksek İhtisas Hospital, Bursa, Turkey
| | - A Gucu
- Department of Cardiovasculary Surgery, Bursa Yüksek İhtisas Hospital, Bursa, Turkey
| | - I B Seker
- Department of Cardiovasculary Surgery, Bursa Yüksek İhtisas Hospital, Bursa, Turkey
| | - S Badem
- Department of Cardiovasculary Surgery, Bursa City Hospital, Bursa, Turkey
| | - A Yuksel
- Department of Cardiovasculary Surgery, Bursa City Hospital, Bursa, Turkey
| | - A F Ozyazicioglu
- Department of Cardiovasculary Surgery, Bursa Yüksek İhtisas Hospital, Bursa, Turkey
| | - M T Goncu
- Department of Cardiovasculary Surgery, Bursa Yüksek İhtisas Hospital, Bursa, Turkey
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Skeffington KL, Moscarelli M, Abdul-Ghani S, Fiorentino F, Emanueli C, Reeves BC, Punjabi PP, Angelini GD, Suleiman MS. Pathology-related changes in cardiac energy metabolites, inflammatory response and reperfusion injury following cardioplegic arrest in patients undergoing open-heart surgery. Front Cardiovasc Med 2022; 9:911557. [PMID: 35935655 PMCID: PMC9354251 DOI: 10.3389/fcvm.2022.911557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Accepted: 06/29/2022] [Indexed: 11/13/2022] Open
Abstract
Introduction Changes in cardiac metabolites in adult patients undergoing open-heart surgery using ischemic cardioplegic arrest have largely been reported for non-ventricular tissue or diseased left ventricular tissue, with few studies attempting to assess such changes in both ventricular chambers. It is also unknown whether such changes are altered in different pathologies or linked to the degree of reperfusion injury and inflammatory response. The aim of the present work was to address these issues by monitoring myocardial metabolites in both ventricles and to establish whether these changes are linked to reperfusion injury and inflammatory/stress response in patients undergoing surgery using cold blood cardioplegia for either coronary artery bypass graft (CABG, n = 25) or aortic valve replacement (AVR, n = 16). Methods Ventricular biopsies from both left (LV) and right (RV) ventricles were collected before ischemic cardioplegic arrest and 20 min after reperfusion. The biopsies were processed for measuring selected metabolites (adenine nucleotides, purines, and amino acids) using HPLC. Blood markers of cardiac injury (Troponin I, cTnI), inflammation (IL- 6, IL-8, Il-10, and TNFα, measured using Multiplex) and oxidative stress (Myeloperoxidase, MPO) were measured pre- and up to 72 hours post-operatively. Results The CABG group had a significantly shorter ischemic cardioplegic arrest time (38.6 ± 2.3 min) compared to AVR group (63.0 ± 4.9 min, p = 2 x 10-6). Cardiac injury (cTnI release) was similar for both CABG and AVR groups. The inflammatory markers IL-6 and Il-8 were significantly higher in CABG patients compared to AVR patients. Metabolic markers of cardiac ischemic stress were relatively and significantly more altered in the LV of CABG patients. Comparing diabetic and non-diabetic CABG patients shows that only the RV of diabetic patients sustained major ischemic stress during reperfusion and that diabetic patients had a significantly higher inflammatory response. Discussion CABG patients sustain relatively more ischemic stress, systemic inflammatory response and similar injury and oxidative stress compared to AVR patients despite having significantly shorter cross-clamp time. The higher inflammatory response in CABG patients appears to be at least partly driven by a higher incidence of diabetes amongst CABG patients. In addition to pathology, the use of cold blood cardioplegic arrest may underlie these differences.
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Affiliation(s)
- Katie L. Skeffington
- Bristol Heart Institute and Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Marco Moscarelli
- National Heart and Lung Institute, Imperial College, London, United Kingdom
- GVM Care & Research, Anthea Hospital, Bari, Italy
| | - Safa Abdul-Ghani
- Department of Physiology, Faculty of Medicine, Al-Quds University, Jerusalem, Palestine
| | - Francesca Fiorentino
- Nightingale-Saunders Clinical Trials and Epidemiology Unit (King's Clinical Trials Unit), King's College London, London, United Kingdom
| | - Costanza Emanueli
- National Heart and Lung Institute, Imperial College, London, United Kingdom
| | - Barnaby C. Reeves
- Bristol Heart Institute and Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Prakash P. Punjabi
- National Heart and Lung Institute, Imperial College, London, United Kingdom
| | - Gianni D. Angelini
- Bristol Heart Institute and Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - M-Saadeh Suleiman
- Bristol Heart Institute and Bristol Medical School, University of Bristol, Bristol, United Kingdom
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(Del Nido cardioplegia in adult patients). COR ET VASA 2022. [DOI: 10.33678/cor.2021.088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Shu C, Hong L, Shen X, Zhang W, Niu Y, Song X, Kong J, Zhang C. Effect of Del Nido cardioplegia on ventricular arrhythmias after cardiovascular surgery. BMC Cardiovasc Disord 2021; 21:32. [PMID: 33441080 PMCID: PMC7805093 DOI: 10.1186/s12872-020-01844-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Accepted: 12/28/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Del Nido cardioplegia (DNC) has been proven safe and effective in pediatric patients. However, the use of DNC in adult undergoing cardiovascular surgery lacks support with substantial evidence. This study aimed to evaluate the efficacy of DNC as a cardioplegia of prophylaxis to ventricular arrhythmias associated to cardiovascular surgery in adult patients. METHODS This study recruited nine hundred fifty-four patients who underwent cardiopulmonary bypass surgeries in Nanjing Hospital affiliated to Nanjing Medical University between January 2019 and December 2019. Among 954 patients, 324 patients were treated with DNC (DNC group), and 630 patients were treated with St. Thomas cardioplegia (STH group). The incidence of postoperative arrhythmia as well as other cardiovascular events relavant to the surgery were investigated in both groups. RESULTS In DNC group, the incidence of postoperative ventricular arrhythmias was lower (12.4% vs. 17.4%, P = 0.040), and the length of ICU stay was shorter (1.97 ± 1.49 vs. 2.26 ± 1.46, P = 0.004). Multivariate logistic regression demonstrated that the use of DNC helped to reduce the incidence of postoperative ventricular arrhythmias (adjusted odds ratio 0.475, 95% CI 0.266-0.825, P = 0.010). The propensity score-based analysis and subgroup analysis indicated that DNC has the same protecting effects towards myocardial in all kinds of cardiopulmonary bypass surgeries. CONCLUSIONS Del Nido cardioplegia may potentially reduce the incidence of postoperative ventricular arrhythmias, shorten the length of ICU stay and improve the overall outcome of the patients undergoing cardiovascular surgery.
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Affiliation(s)
- Chang Shu
- Department of Intensive Care Unit, Nanjing First Hospital, Nanjing Medical University, 68 Changle Road, Nanjing, 210006, Jiangsu Province, China
| | - Liang Hong
- Department of Intensive Care Unit, Nanjing First Hospital, Nanjing Medical University, 68 Changle Road, Nanjing, 210006, Jiangsu Province, China
| | - Xiao Shen
- Department of Intensive Care Unit, Nanjing First Hospital, Nanjing Medical University, 68 Changle Road, Nanjing, 210006, Jiangsu Province, China
| | - Wenhao Zhang
- Department of Intensive Care Unit, Nanjing First Hospital, Nanjing Medical University, 68 Changle Road, Nanjing, 210006, Jiangsu Province, China
| | - Yongsheng Niu
- Department of Intensive Care Unit, Nanjing First Hospital, Nanjing Medical University, 68 Changle Road, Nanjing, 210006, Jiangsu Province, China
| | - Xiaochun Song
- Department of Intensive Care Unit, Nanjing First Hospital, Nanjing Medical University, 68 Changle Road, Nanjing, 210006, Jiangsu Province, China
| | - Jie Kong
- Department of Interventional Radiology, Nanjing First Hospital, Nanjing Medical University, 68 Changle Road, Nanjing, 210006, Jiangsu Province, China
| | - Cui Zhang
- Department of Intensive Care Unit, Nanjing First Hospital, Nanjing Medical University, 68 Changle Road, Nanjing, 210006, Jiangsu Province, China.
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10
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Misra S, Srinivasan A, Jena SS, Bellapukonda S. Myocardial Protection in Adult Cardiac Surgery With del Nido Versus Blood Cardioplegia: A Systematic Review and Meta-Analysis. Heart Lung Circ 2020; 30:642-655. [PMID: 33281072 DOI: 10.1016/j.hlc.2020.10.016] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Revised: 09/24/2020] [Accepted: 10/16/2020] [Indexed: 12/27/2022]
Abstract
BACKGROUND Myocardial protection in adult cardiac surgery is commonly achieved with either multidose blood cardioplegia or single-dose del Nido crystalloid cardioplegia. AIM The aim of this systematic review and meta-analysis was to compare the outcomes of del Nido cardioplegia versus blood cardioplegia in adult cardiac surgery. METHOD All English-language articles were searched in MEDLINE (PubMed), the Cochrane Central Register of Controlled Trials (CENTRAL), and Google Scholar up to March 2020, to identify randomised control trials, prospective observational studies, and retrospective analyses (with or without propensity matching) reporting any or all of the primary and secondary endpoints. The primary endpoint was all-cause mortality. Secondary endpoints included cardiopulmonary bypass (CPB) and aortic cross-clamp (AoX) time; cardioplegia volume; need for defibrillation after AoX release; intraoperative glucose; postoperative myocardial enzyme release; postoperative left ventricular ejection fraction (LVEF); incidence of postoperative acute kidney injury (AKI), atrial fibrillation (AF), stroke, and low cardiac output syndrome (LCOS); postoperative blood transfusion; duration of mechanical ventilation; and length of intensive care unit (ICU) and hospital stay. RESULTS Twenty-nine (29) studies were included. There was no difference in the primary outcome of mortality between the two groups (odds ratio [OR], 1.18; 95% confidence interval [CI], 0.82-1.72 [p=0.37]). del Nido cardioplegia was associated with significantly shorter CPB (mean difference [MD], -7.42 minutes; 95% CI, -12.53 to -2.31 [p=0.004]) and AoX times (MD, -6.39 minutes; 95% CI, -10.30 to -2.48 [p=0.001]), and lower cardioplegia volumes. Significantly fewer patients required defibrillation after AoX release in the del Nido group. Intraoperative glucose homeostasis was better preserved in the del Nido group. Postoperative cardiac troponin T release and the number of patients needing transfusions were less in the del Nido group. No differences were seen in postoperative LVEF, or in the incidence of AKI, stroke, AF, and LCOS. Duration of mechanical ventilation, and length of ICU and hospital stay were similar. CONCLUSIONS Although this meta-analysis failed to find any mortality benefits with del Nido cardioplegia, significant benefits were seen in a number of intraoperative and postoperative variables. del Nido cardioplegia is a safe and favourable alternative to blood cardioplegia in adult cardiac surgery.
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Affiliation(s)
- Satyajeet Misra
- Department of Anesthesiology and Critical Care, All India Institute of Medical Sciences (AIIMS), Bhubaneswar, Odisha, India.
| | - Anand Srinivasan
- Department of Pharmacology, All India Institute of Medical Sciences (AIIMS), Bhubaneswar, Odisha, India
| | - Sritam Swarup Jena
- Department of Anesthesiology and Critical Care, All India Institute of Medical Sciences (AIIMS), Bhubaneswar, Odisha, India
| | - Snigdha Bellapukonda
- Department of Anesthesiology and Critical Care, All India Institute of Medical Sciences (AIIMS), Bhubaneswar, Odisha, India
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