del Nido and Histidine-Tryptophan-Ketoglutarate cardioplegia in minimally invasive mitral valve surgery: A propensity-Match study

INTRODUCTION

In the last decade, del Nido cardioplegia has been embedded in adult cardiac surgery involving CABG and aortic valve surgical procedures. We reviewed our early experience with del Nido cardioplegia in the setting of minimally invasive mitral valve surgery.

METHODS

Data on 120 consecutive patients operated between 03/2021 and 06/2022 were retrieved from our internal database (infective endocarditis and urgent operations were excluded). Patients were divided into two groups according to the use of Histidine-Tryptophan-Ketoglutarate or del Nido cardioplegia. A propensity match analysis was performed using thirteen preoperative and intraoperative variables. Several intraoperative data and early postoperative outcomes were investigated, including cardiac enzymes (Troponin I HS and CK-MB) measured upon arrival in the Intensive Care Unit (ICU), after 12 hours and everyday thereafter.

RESULTS

There was no difference in preoperative characteristics and surgical techniques between both unmatched and matched Histidine-Tryptophan-Ketoglutarate and del Nido populations. Patients in the del Nido group received a lower volume of cardioplegia (p < 0.001) and ultrafiltration during CPB (p < 0.001). Histidine-Tryptophan-Ketoglutarate was associated with a lower rate of post cross-clamp spontaneous defibrillation (p < 0.001) and showed a lower level of blood sodium after CPB (p < 0.001). The release of cardiac enzymes was similar between the two groups (p = 0.72). There was no difference in terms of postoperative morbidity and 30 day mortality.

CONCLUSIONS

del Nido cardioplegia in the setting of minimally invasive mitral valve surgery seemed safe with acceptable myocardial protection and excellent early outcomes.

Efficacy of del Nido cardioplegia in adult cardiac procedures with prolonged aortic crossclamp time

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.

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.

Del Nido cardioplegia for myocardial protection in adult cardiac surgery: a systematic review and update meta-analysis

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.