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Kang J, Hoyer A, Dieterlen MT, Oetzel H, Otto W, Ginther A, Pfannmüller B, Misfeld M, Noack T, Kiefer P, Borger MA. Comparison of modified Del Nido and Custodiol® cardioplegia in minimally invasive mitral valve surgery. Eur J Cardiothorac Surg 2024; 65:ezae161. [PMID: 38627243 DOI: 10.1093/ejcts/ezae161] [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: 01/10/2024] [Revised: 03/20/2024] [Accepted: 04/15/2024] [Indexed: 05/01/2024] Open
Abstract
OBJECTIVES In this study, we evaluated if modified Del Nido cardioplegia delivers comparable cardiac protection in comparison to Custodiol® in patients undergoing isolated minimally invasive mitral valve repair. METHODS From January 2018 to October 2021, all patients undergoing non-emergent isolated minimally invasive mitral valve repair were included in this study. The cardioplegia was chosen at the surgeons' discretion. The primary end points of this study were peak postoperative cardiac enzyme levels. Secondary end points were in-hospital mortality, hospital stay, occurrence of cardiac arrhythmias, pacemaker implantations, postoperative lactate and sodium levels and postoperative incidence of renal failure requiring dialysis. RESULTS A total of 355 patients were included in this study. The mean age of patients was 57. After propensity score matching, a total of 156 pairs were identified. There was no difference in cross-clamp time between both groups. Postoperative creatine kinase levels were higher in patients receiving Custodiol on the 1st and 2nd postoperative days. Creatine kinase isoenzyme MB levels were higher in patients receiving Custodiol on the 2nd postoperative day (0.5 ± 0.2 vs 0.4 ± 0.1 µmol/l s; P < 0.001). Postoperative Troponin T concentrations were similar between both groups. Maximum lactate concentrations were higher in patients receiving Custodiol on the day of surgery (2.4 ± 1.9 vs 2.0 ± 1.1 mmol/l; P = 0.04). The overall hospital stay was longer in patients receiving Del Nido cardioplegia (10.6 ± 3.2 vs 8 ± 4.1 days; P < 0.01). CONCLUSIONS Modified Del Nido cardioplegia based on Ionosteril® solution offers equivalent protection compared to Custodiol for isolated minimally invasive mitral valve repair.
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Affiliation(s)
- Jagdip Kang
- University Department of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
| | - Alexandro Hoyer
- University Department of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
| | | | - Hanna Oetzel
- University Department of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
| | - Wolfgang Otto
- University Department of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
| | - André Ginther
- University Department of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
| | - Bettina Pfannmüller
- University Department of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
| | - Martin Misfeld
- University Department of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
- Department of Cardiothoracic Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Sydney Medical School, University of Sydney, Sydney, NSW, Australia
- Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia
- The Baird Institute of Applied Heart and Lung Surgical Research, Sydney, NSW, Australia
| | - Thilo Noack
- University Department of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
| | - Philipp Kiefer
- University Department of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
| | - Michael A Borger
- University Department of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
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Diao H, Dai W, Wurm D, Lu Y, Shrestha L, He A, Wong RK, Chen QM. Del Nido cardioplegia or potassium induces Nrf2 and protects cardiomyocytes against oxidative stress. Am J Physiol Cell Physiol 2023; 325:C1401-C1414. [PMID: 37842750 PMCID: PMC10861178 DOI: 10.1152/ajpcell.00436.2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Revised: 10/10/2023] [Accepted: 10/10/2023] [Indexed: 10/17/2023]
Abstract
Open heart surgery is often an unavoidable procedure for the treatment of coronary artery disease. The procedure-associated reperfusion injury affects postoperative cardiac performance and long-term outcomes. We addressed here whether cardioplegia essential for cardiopulmonary bypass surgery activates Nrf2, a transcription factor regulating the expression of antioxidant and detoxification genes. With commonly used cardioplegic solutions, high K+, low K+, Del Nido (DN), histidine-tryptophan-ketoglutarate (HTK), and Celsior (CS), we found that DN caused a significant increase of Nrf2 protein in AC16 human cardiomyocytes. Tracing the ingredients in DN led to the discovery of KCl at the concentration of 20-60 mM capable of significant Nrf2 protein induction. The antioxidant response element (ARE) luciferase reporter assays confirmed Nrf2 activation by DN or KCl. Transcriptomic profiling using RNA-seq revealed that oxidation-reduction as a main gene ontology group affected by KCl. KCl indeed elevated the expression of classical Nrf2 downstream targets, including TXNRD1, AKR1C, AKR1B1, SRXN1, and G6PD. DN or KCl-induced Nrf2 elevation is Ca2+ concentration dependent. We found that KCl decreased Nrf2 protein ubiquitination and extended the half-life of Nrf2 from 17.8 to 25.1 mins. Knocking out Keap1 blocked Nrf2 induction by K+. Nrf2 induction by DN or KCl correlates with the protection against reactive oxygen species generation or loss of viability by H2O2 treatment. Our data support that high K+ concentration in DN cardioplegic solution can induce Nrf2 protein and protect cardiomyocytes against oxidative damage.NEW & NOTEWORTHY Open heart surgery is often an unavoidable procedure for the treatment of coronary artery disease. The procedure-associated reperfusion injury affects postoperative cardiac performance and long-term outcomes. We report here that Del Nido cardioplegic solution or potassium is an effective inducer of Nrf2 transcription factor, which controls the antioxidant and detoxification response. This indicates that Del Nido solution is not only essential for open heart surgery but also exhibits cardiac protective activity.
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Affiliation(s)
- Hongting Diao
- Perfusion Sciences Graduate Program, Department of Pharmacology College of Medicine, University of Arizona, Tucson, Arizona, United States
| | - Wujing Dai
- Perfusion Sciences Graduate Program, Department of Pharmacology College of Medicine, University of Arizona, Tucson, Arizona, United States
| | - Daniel Wurm
- Perfusion Sciences Graduate Program, Department of Pharmacology College of Medicine, University of Arizona, Tucson, Arizona, United States
| | - Yingying Lu
- Interdisciplinary Program in Statistics and Data Science, University of Arizona, Tucson, Arizona, United States
| | - Lenee Shrestha
- Perfusion Sciences Graduate Program, Department of Pharmacology College of Medicine, University of Arizona, Tucson, Arizona, United States
| | - Amy He
- Perfusion Sciences Graduate Program, Department of Pharmacology College of Medicine, University of Arizona, Tucson, Arizona, United States
| | - Raymond K Wong
- Perfusion Sciences Graduate Program, Department of Pharmacology College of Medicine, University of Arizona, Tucson, Arizona, United States
| | - Qin M Chen
- Perfusion Sciences Graduate Program, Department of Pharmacology College of Medicine, University of Arizona, Tucson, Arizona, United States
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Tunca NU, Yesilkaya NK, Karaagac E, Durmaz H, Besir Y, Gokalp O, Iner H, Yılık L, Gurbuz A. Comparison of Bretschneider HTK cardioplegia solution and blood cardioplegia in terms of postoperative results in patients who underwent isolated supracoronary ascending aortic replacement. Perfusion 2023:2676591231182587. [PMID: 37290096 DOI: 10.1177/02676591231182587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
INTRODUCTION Cardiac arrest with cardioplegia is the most common and reliable method of myocardial protection in cardiac surgery, but there is no definite consensus on the use of different types of cardioplegia. Two of the commonly used types of cardioplegia are Bretschneider histidine-tryptophan-ketoglutarate solution (Custodiol) and conventional blood cardioplegia. In this study, Custodiol solution and conventional blood cardioplegia used in patients with type A aortic dissection who underwent supracoronary ascending aortic replacement were aimed to be compared in terms of postoperative results. METHODS 70 patients with type A aortic dissection who underwent supracoronary ascending aortic replacement in our clinic between January 2011 - October 2020 were included. Patients were divided into two groups, blood cardioplegia group (n = 48) and Custodiol group (n = 22) and they were compared regarding preoperative, perioperative and postoperative variables. RESULTS There was no significant difference between cardiopulmonary bypass time and cross-clamp time (p = 0.17 and p = 0.16, respectively). Mechanical ventilator weaning time, intensive care unit stay and hospital stay were shorter in Custodiol group (p = 0.04,p = 0.03 and p = 0.05, respectively). While inotropic support need was higher in the blood cardioplegia group (p = 0.001), there was no significant difference in terms of mortality, arrhythmia, neurological complications and renal complications. CONCLUSIONS Our results show that Custodiol cardioplegia solution may be superior to blood cardioplegia in reducing mechanical ventilation weaning period, intensive care and hospital stay, and reducing the use of inotropic agents in patients with type A aortic dissection undergoing supracoronary ascending aorta replacement.
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Affiliation(s)
- Nuri Utkan Tunca
- Department of Cardiovascular Surgery, Mus State Hospital, Mus, Turkey
| | - Nihan Karakas Yesilkaya
- Department of Cardiovascular Surgery, Izmir Katip Celebi University Faculty of Medicine, Izmir, Turkey
| | - Erturk Karaagac
- Department of Cardiovascular Surgery, Mus State Hospital, Mus, Turkey
| | - Huseyin Durmaz
- Department of Cardiovascular Surgery, Konya City Hospital, Konya, Turkey
| | - Yuksel Besir
- Department of Cardiovascular Surgery, Izmir Katip Celebi University Faculty of Medicine, Izmir, Turkey
| | - Orhan Gokalp
- Department of Cardiovascular Surgery, Izmir Katip Celebi University Faculty of Medicine, Izmir, Turkey
| | - Hasan Iner
- Department of Cardiovascular Surgery, Izmir Katip Celebi University Faculty of Medicine, Izmir, Turkey
| | - Levent Yılık
- Department of Cardiovascular Surgery, Izmir Katip Celebi University Faculty of Medicine, Izmir, Turkey
| | - Ali Gurbuz
- Department of Cardiovascular Surgery, Izmir Katip Celebi University Faculty of Medicine, Izmir, Turkey
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Barbero C, Pocar M, Marchetto G, Cura Stura E, Calia C, Dalbesio B, Filippini C, Salizzoni S, Boffini M, Rinaldi M, Ricci D. Single-Dose St. Thomas Versus Custodiol® Cardioplegia for Right Mini-thoracotomy Mitral Valve Surgery. J Cardiovasc Transl Res 2023; 16:192-198. [PMID: 35939196 PMCID: PMC9944000 DOI: 10.1007/s12265-022-10296-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 07/23/2022] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Custodiol® and St. Thomas cardioplegia are widely employed in mini-thoracotomy mitral valve (MV) operations. One-dose of the former provides 3 h of myocardial protection. Conversely, St. Thomas solution is usually reinfused every 30 min and safety of single delivery is unknown. We aimed to compare single-shot St. Thomas versus Custodiol® cardioplegia. METHODS Primary endpoint of the prospective observational study was cardiac troponin T level at different post-operative time-points. Propensity-weighted treatment served to adjust for confounding factors. RESULTS Thirty-nine patients receiving St. Thomas were compared with 25 patients receiving Custodiol® cardioplegia; cross-clamping always exceeded 45 min. No differences were found in postoperative markers of myocardial injury. Ventricular fibrillation at the resumption of electric activity was more frequent following Custodiol® cardioplegia (P = .01). CONCLUSION Effective myocardial protection exceeding 1 h of ischemic arrest can be achieved with a single-dose St. Thomas cardioplegia in selected patients undergoing right mini-thoracotomy MV surgery.
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Affiliation(s)
- Cristina Barbero
- Cardiovascular and Thoracic Department, Division of Cardiac Surgery, , Città Della Salute E Della Scienza", University of Turin, Corso Dogliotti, 14, Turin, Italy.
| | - Marco Pocar
- Cardiovascular and Thoracic Department, Division of Cardiac Surgery, , Città Della Salute E Della Scienza”, University of Turin, Corso Dogliotti, 14 Turin, Italy ,Department of Surgical Sciences, University of Turin, Turin, Italy ,Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Giovanni Marchetto
- Cardiovascular and Thoracic Department, Division of Cardiac Surgery, , Città Della Salute E Della Scienza”, University of Turin, Corso Dogliotti, 14 Turin, Italy
| | - Erik Cura Stura
- Cardiovascular and Thoracic Department, Division of Cardiac Surgery, , Città Della Salute E Della Scienza”, University of Turin, Corso Dogliotti, 14 Turin, Italy
| | - Claudia Calia
- Cardiovascular and Thoracic Department, Division of Cardiac Surgery, , Città Della Salute E Della Scienza”, University of Turin, Corso Dogliotti, 14 Turin, Italy ,Department of Surgical Sciences, University of Turin, Turin, Italy
| | - Bianca Dalbesio
- Cardiovascular and Thoracic Department, Division of Cardiac Surgery, , Città Della Salute E Della Scienza”, University of Turin, Corso Dogliotti, 14 Turin, Italy
| | | | - Stefano Salizzoni
- Cardiovascular and Thoracic Department, Division of Cardiac Surgery, , Città Della Salute E Della Scienza”, University of Turin, Corso Dogliotti, 14 Turin, Italy ,Department of Surgical Sciences, University of Turin, Turin, Italy
| | - Massimo Boffini
- Cardiovascular and Thoracic Department, Division of Cardiac Surgery, , Città Della Salute E Della Scienza”, University of Turin, Corso Dogliotti, 14 Turin, Italy ,Department of Surgical Sciences, University of Turin, Turin, Italy
| | - Mauro Rinaldi
- Cardiovascular and Thoracic Department, Division of Cardiac Surgery, , Città Della Salute E Della Scienza”, University of Turin, Corso Dogliotti, 14 Turin, Italy ,Department of Surgical Sciences, University of Turin, Turin, Italy
| | - Davide Ricci
- Department of Integrated Surgical and Diagnostic Sciences, University of Genova, Genoa, Italy
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Cocchieri R, van de Wetering B, van Tuijl S, Mousavi I, Riezebos R, de Mol B. At the Crossroads of Minimally Invasive Mitral Valve Surgery—Benching Single Hospital Experience to a National Registry: A Plea for Risk Management Technology. J Cardiovasc Dev Dis 2022; 9:jcdd9080261. [PMID: 36005425 PMCID: PMC9410306 DOI: 10.3390/jcdd9080261] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 07/15/2022] [Accepted: 08/09/2022] [Indexed: 11/26/2022] Open
Abstract
Almost 30 years after the first endoscopic mitral valve repair, Minimally Invasive Mitral Valve Surgery (MIMVS) has become the standard at many institutions due to optimal clinical results and fast recovery. The question that arises is can already good results be further improved by an Institutional Risk Management Performance (IRMP) system in decreasing risks in minimally invasive mitral valve surgery (MIMVS)? As of yet, there are no reports on IRMP and learning systems in the literature. (2) Methods: We described and appraised our five-year single institutional experience with MIMVS in isolated valve surgery included in the Netherlands Heart Registry (NHR) and investigated root causes of high-impact complications. (3) Results: The 120-day and 12-month mortality were 1.1% and 1.9%, respectively, compared to the average of 4.3% and 5.3% reported in the NHR. The regurgitation rate was 1.4% compared to 5.2% nationwide. The few high-impact complications appeared not to be preventable. (4) Discussion: In MIMVS, freedom from major and minor complications is a strong indicator of an effective IRMP but remains concealed from physicians and patients, despite its relevance to shared decision making. Innovation adds to the complexity of MIMVS and challenges surgical competence. An IRMP system may detect and control new risks earlier. (5) Conclusion: An IRMP system contributes to an effective reduction of risks, pain and discomfort; provides relevant input for shared decision making; and warrants the safe introduction of new technology. Crossroads conclusions: investment in machine learning and AI for an effective IRMP system is recommended and the roles for commanding and operating surgeons should be considered.
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Affiliation(s)
- Riccardo Cocchieri
- Cardiothoracic Surgeon, OLVG Hospital, 1091 AC Amsterdam, The Netherlands
| | - Bertus van de Wetering
- Biomedical Engineer, LifeTec Group BV, 5611 ZS Eindhoven, The Netherlands
- Correspondence: (B.v.d.W.); (B.d.M.)
| | - Sjoerd van Tuijl
- Biomedical Engineer, LifeTec Group BV, 5611 ZS Eindhoven, The Netherlands
| | - Iman Mousavi
- Cardiothoracic Surgery Resident, OLVG Hospital, 1091 AC Amsterdam, The Netherlands
| | - Robert Riezebos
- Cardiologist, OLVG Hospital, 1091 AC Amsterdam, The Netherlands
| | - Bastian de Mol
- Department of Cardiothoracic Surgery, Amsterdam University Medical Center, 1105 AZ Amsterdam, The Netherlands
- Department of Biomedical Engineering, Eindhoven University of Technology, 5600 MB Eindhoven, The Netherlands
- Correspondence: (B.v.d.W.); (B.d.M.)
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Russell S, Butt S, Vohra HA. In search of optimal cardioplegia for minimally invasive valve surgery. Perfusion 2021; 37:668-674. [PMID: 34080459 PMCID: PMC9500165 DOI: 10.1177/02676591211012554] [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] [Indexed: 11/28/2022]
Abstract
Cardioplegic solutions are used in cardiac surgery to achieve controlled cardiac arrest during operations, making surgery safer. Cardioplegia can either be blood or crystalloid based, with perceived pros and cons of each type. Whilst it is known that cardioplegia causes cardiac arrest, there is debate over which cardioplegic solution provides the highest degree of myocardial protection during arrest. Myocardial damage is measured post-operatively by biomarkers such as serum TnT, TnI or CK-MB. It is known that the outcomes of minimally invasive valve surgery are comparable to full sternotomy valve operations. Despite there being a wide diversity in use of different cardioplegic solutions across the world, this comprehensive literature review found no superiority of one cardioplegic solution over the other for myocardial protection during minimally invasive valve procedures.
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Affiliation(s)
- Sion Russell
- Department of Cardiac Surgery/Cardiovascular Sciences, Bristol Heart Institute, University of Bristol, Bristol, UK
| | - Salman Butt
- Department of Perfusion Sciences, St George's Hospital, London, UK
| | - Hunaid A Vohra
- Department of Cardiac Surgery/Cardiovascular Sciences, Bristol Heart Institute, University of Bristol, Bristol, UK
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