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Li C, Xiang H, Yang H, Liu W, Lan W, Luo C, Han S, Li Y, Tang Y. Del Nido cardioplegia versus cold blood cardioplegia in adult cardiac surgery: a meta-analysis of randomized clinical trials. J Cardiothorac Surg 2024; 19:356. [PMID: 38909234 PMCID: PMC11193264 DOI: 10.1186/s13019-024-02846-0] [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: 02/24/2024] [Accepted: 06/14/2024] [Indexed: 06/24/2024] Open
Abstract
OBJECTIVE Systematic evaluation of the safety of del Nido cardioplegia compared to cold blood cardioplegia in adult cardiac surgery. METHODS We systematically searched PubMed, EMbase, The Cochrane Library and ClinicalTrials.gov for randomized clinical trials (published by 14 January 2024) comparing del Nido cardioplegia to cold blood cardioplegia in adult. Our main endpoints were myocardial injury markers and clinical outcomes. We assessed pooled data by use of a random-effects model or a fixed-effects model. RESULTS A total of 10 studies were identified, incorporating 889 patients who received del Nido cardioplegia and 907 patients who received cold blood cardioplegia. The meta-analysis results showed that compared with the cold blood cardioplegia, the del Nido cardioplegia had less volume of cardioplegia, higher rate of spontaneous rhythm recovery after cross clamp release, lower levels of postoperative cardiac troponin T and creatinine kinase-myocardial band, all of which were statistically significant. However, there was no statistically significant difference in postoperative troponin I and postoperative left ventricular ejection fraction. The clinical outcomes including mechanical ventilation time, intensive care unit stay time, hospital stay time, postoperative stroke, postoperative new-onset atrial fibrillation, postoperative heart failure requiring intra-aortic balloon pump mechanical circulation support, and in-hospital mortality of both are comparable. CONCLUSION Existing evidence suggests that del Nido cardioplegia reduced volume of cardioplegia administration and attempts of defibrillation. The superior postoperative results in CTnT and CK-MB may provide a direction for further research on improvement of the composition of cardioplegia.
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Affiliation(s)
- Congcong Li
- Department of Cardiovascular Surgery, The Second Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, Jiangxi Province, 330006, China
| | - Haiyan Xiang
- Department of Cardiovascular Surgery, The Second Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, Jiangxi Province, 330006, China
| | - Heng Yang
- Department of Cardiovascular Surgery, The Second Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, Jiangxi Province, 330006, China
| | - Wu Liu
- Department of Cardiovascular Surgery, The Second Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, Jiangxi Province, 330006, China
| | - Wanqi Lan
- Department of Cardiovascular Surgery, The Second Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, Jiangxi Province, 330006, China
| | - Chao Luo
- Department of Cardiovascular Surgery, The Second Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, Jiangxi Province, 330006, China
| | - Shuangjian Han
- Department of Cardiovascular Surgery, The Second Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, Jiangxi Province, 330006, China
| | - Yongqin Li
- Department of Cardiovascular Surgery, The Second Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, Jiangxi Province, 330006, China
| | - Yanhua Tang
- Department of Cardiovascular Surgery, The Second Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, Jiangxi Province, 330006, China.
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Kirmani BH, Shirley S, Kandaswamy M, Steele DJK. Cardioplegia-and science-for global surgery. Eur J Cardiothorac Surg 2024; 65:ezae068. [PMID: 38409742 DOI: 10.1093/ejcts/ezae068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2024] [Accepted: 02/23/2024] [Indexed: 02/28/2024] Open
Affiliation(s)
- Bilal H Kirmani
- Dept of Cardiac Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Sarah Shirley
- Dept of Clinical Perfusion, Liverpool Heart and Chest Hospital, Liverpool, UK
| | | | - Duncan J K Steele
- Dept of Cardiac Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK
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3
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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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Iacona GM, Bakhos JJ, Tong MZ, Bakaeen FG. Coronary artery bypass grafting in left ventricular dysfunction: when and how. Curr Opin Cardiol 2023; 38:464-470. [PMID: 37751395 DOI: 10.1097/hco.0000000000001090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/28/2023]
Abstract
PURPOSE OF REVIEW The surgical management of patients undergoing coronary artery bypass grafting (CABG) with low ejection fraction presents unique challenges that require meticulous attention to details and good surgical technique and judgement. This review details the latest evidence and best practices in the care of such patients. RECENT FINDINGS CABG in patients with low ejection fraction carries a significant risk of perioperative mortality and morbidity related to the development of postcardiotomy shock. Preoperative optimization with pharmacological or mechanical support is required, especially in patients with cardiogenic shock. Rapid and complete revascularization is what CABG surgeons aim to achieve. Multiple arterial revascularization should be reserved to selected patients. Off-pump CABG, on-pump breathing heart CABG, and new cardioplegic solutions remain of uncertain benefit compared with traditional CABG. SUMMARY Tremendous advancements in CABG allowed surgeons to offer revascularization to patients with severe left ventricular dysfunction and multivessel disease with acceptable risk. Despite that, there is a lack of comprehensive and robust studies particularly on long-term outcomes. Individualized patient assessment and a heart team approach should be used to determine the optimal surgical strategy for each patient.
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Affiliation(s)
- Gabriele M Iacona
- Coronary Center, Department of Thoracic and Cardiovascular Surgery, Heart Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
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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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Sanetra K, Gerber W, Domaradzki W, Mazur M, Synak M, Pietrzyk E, Buszman PP, Kaźmierczak P, Bochenek A. Del Nido versus cold blood cardioplegia in adult patients with impaired ejection fraction undergoing valvular and complex heart surgery. THE JOURNAL OF CARDIOVASCULAR SURGERY 2023; 64:112-120. [PMID: 36534124 DOI: 10.23736/s0021-9509.22.12498-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND There is sparse evidence on the efficacy of del Nido cardioplegia in high-risk patients with reduced ejection fraction undergoing valvular or complex heart surgery, and further investigation is required. METHODS An institutional registry was searched for patients who underwent valvular or complex heart surgery and had an ejection fraction <40%. Subjects who received del Nido cardioplegia (DNC) and cold blood cardioplegia (CBC) were selected. Propensity matching was performed with age, gender, and number of conducted procedures as matching criteria. A comparative analysis was performed on primary endpoints of the troponin rise and changes in ejection fraction (EF). A composite endpoint of a troponin rise of ≥20× baseline or fall of EF≥5% was assessed in a multivariate analysis. Other perioperative complications are reported. RESULTS One hundred patients from the DNC group were matched to the 100 patients in the CBC group. There were no differences between groups at baseline. Postoperatively, lower troponin values were observed in the DNC group at 12 hours (median; IQR: 523.2;349.1-740.4 pg/mL vs. 787.6;443.6-1689.0 pg/mL; P=0.016) and 36 hours (median; IQR: 426.1;337.2-492.1 pg/mL vs. 653.7;398.8-1737.5 pg/mL; P=0.044). Fewer patients in the DNC group had a fall in EF≥5% (7% vs. 16%; P=0.046). The multivariable analysis did not reveal a significant predictor of composite endpoint. CONCLUSIONS In patients with impaired contractility undergoing valvular and complex procedures, the use of del Nido cardioplegia as an alternative to cold blood cardioplegia is associated with lower troponin release and improved preservation of ejection fraction.
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Affiliation(s)
- Krzysztof Sanetra
- Clinic 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
| | - Wojciech Domaradzki
- Center for Cardiovascular Research and Development, American Heart of Poland, Katowice, Poland
| | - Marta Mazur
- Department of Cardiology, Andrzej Frycz Modrzewski Krakow University, Krakow, Poland
| | - Magdalena Synak
- Department of Cardiology, Andrzej Frycz Modrzewski Krakow University, Krakow, Poland
| | - Ewa Pietrzyk
- Department of Cardiology, Andrzej Frycz Modrzewski Krakow University, Krakow, Poland
| | - Piotr P Buszman
- Center for Cardiovascular Research and Development, American Heart of Poland, Katowice, Poland.,Department of Cardiology, Andrzej Frycz Modrzewski Krakow University, Krakow, 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.,Center for Cardiovascular Research and Development, American Heart of Poland, Katowice, Poland
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7
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Belov YV, Lysenko AV, Akselrod BA, Kulinchenko OS, Lednev PV, Salagaev GI, Solovyova SE, Ivanova AG. [Clinical, biochemical and histological indicators of Del Nido cardioplegia efficacy in patients with severe myocardial hypertrophy]. Khirurgiia (Mosk) 2023:59-66. [PMID: 38088842 DOI: 10.17116/hirurgia202312159] [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: 12/18/2023]
Abstract
OBJECTIVE To evaluate the effectiveness of two cardioplegia techniques in patients with severe myocardial hypertrophy undergoing septal myectomy or aortic valve replacement. MATERIAL AND METHODS A comparative pilot prospective single-center randomized study included 46 patients between 2022 and 2023. Patients were randomized into 2 groups: Del Nido (n=23) and Custodiol (n=23). We analyzed perioperative echocardiography data, troponin I at several time points, perioperative complications and histological data. RESULTS Both groups were comparable in time of myocardial ischemia, cardiopulmonary bypass, duration of anesthesia and surgery (p>0.05). The maximum ischemia time in the Del Nido group was 84 min. The same group showed significantly higher percentage of spontaneous rhythm recovery (65.2% vs. 30%, p=0.008). None patient required mechanical support, high-dose inotropes or vasopressors. Troponin I in 2 hours after cardiopulmonary bypass (p=0.415), 12 (p=0.528) and 24 hours after admission to the intensive care unit (p=0.281) were similar in both groups. No significant difference was found in ventilation time, ICU- and hospital-stay. CONCLUSION Del Nido cardioplegia has some advantages compared to Custodiol and does not lead to perioperative complications in case of aortic cross-clamping time <90 min in patients with myocardial hypertrophy.
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Affiliation(s)
- Yu V Belov
- Petrovsky National Research Center of Surgery, Moscow, Russia
- Sechenov First Moscow State Medical University, Moscow, Russia
| | - A V Lysenko
- Petrovsky National Research Center of Surgery, Moscow, Russia
| | - B A Akselrod
- Petrovsky National Research Center of Surgery, Moscow, Russia
| | - O S Kulinchenko
- Petrovsky National Research Center of Surgery, Moscow, Russia
| | - P V Lednev
- Petrovsky National Research Center of Surgery, Moscow, Russia
| | - G I Salagaev
- Petrovsky National Research Center of Surgery, Moscow, Russia
| | - S E Solovyova
- Petrovsky National Research Center of Surgery, Moscow, Russia
| | - A G Ivanova
- Petrovsky National Research Center of Surgery, Moscow, Russia
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