Del Nido Cardioplegia in Coronary Artery Bypass Grafting Surgery: A safe, efficacious and economic alternative to St. Thomas solution; an experience from a developing nation

Del Nido cardioplegia versus cold blood cardioplegia in adult cardiac surgery: a meta-analysis of randomized clinical trials

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.

Which is better for pediatric and adult cardiac surgery: del Nido or St. Thomas cardioplegia? A systematic review and meta-analysis

Background

Although recently it has been extended for use in adult cardiac surgery, del Nido cardioplegia was originally indicated for pediatric cardiac surgery. In this meta-analysis, we compare del Nido cardioplegia vs St. Thomas cardioplegia in pediatric and adult cardiac surgery.

Methods

A comprehensive systematic literature review was performed to identify observational and randomized controlled trials (RCTs) comparing del Nido cardioplegia with St. Thomas cardioplegia. An analysis of both random and fixed effects was conducted. The measure of the effect was by the mean difference (MD) and the risk ratio (RR) with a 95% confidence interval (95% CI).

Results

A total of 1893 patients from 12 studies were included (5 RCTs and 7 observational studies). Compared to St. Thomas solution, del Nido cardioplegia was associated with a shorter aortic cross-clamp in adult cardiac surgery (RCT MD - 19.83, 95% CI - 21.89-17.78; observational - 5.85; 95% CI - 11.59, - 0.11 respectively), but no difference in pediatric cardiac surgery. Additionally, del Nido cardioplegia was associated with lower cardiopulmonary bypass time in both adults (observational, MD - 29.15; 95% CI - 31.76-26.55) and pediatric cardiac surgery (RCTs, MD - 7.15; 95% CI - 13.25-1.05). Defibrillation rates were also significantly lower with del Nido cardioplegia group in both adult (RR 0.35, 95% CI 0.24-0.50, I2 = 50%) and pediatric cardiac surgery (odds ratio (OR) 0.30, 95% CI 0.18-0.49, I2 = 92%).

Conclusion

In both adults and pediatric cardiac surgery, del Nido cardioplegia helps in lowering cardiopulmonary bypass duration, defibrillation rates, and hospital stay, compared to St. Thomas solution. Among adults, del Nido cardioplegia lessens the aortic cross clamp times with no difference observed in all-cause mortality, intensive care unit stay, or mechanical ventilation.

Pretreatment with a modified St. Thomas' solution in patients with severe upper limb injuries: Four case reports

BACKGROUND

This study aims to describe the application of a modified St. Thomas' solution in patients with severe limb injuries.

CASE SUMMARY

Four patients who sustained a high-energy trauma and underwent complete upper limb amputation were pretreated with a modified St. Thomas' solution before upper limb replantation. After the perfusion solution stopped flowing from the blood vessel, the amputated upper limb amputation was replanted. The patients were instructed to perform functional rehabilitation training after the operation. All 4 patients were followed up for 5 years. All the severed upper limbs survived. Routine re-examination after the operation showed that the function of the affected limb was restored. All the patients were satisfied with the sensory and functional recovery of the affected limb.

CONCLUSION

The modified St. Thomas' solution can effectively improve the success rate of limb salvage surgery and the recovery of limb function in patients with a severe limb injury.

Pretreatment with a modified St. Thomas' solution in patients with severe upper limb injuries: Four case reports

BACKGROUND

This study aims to describe the application of a modified St. Thomas' solution in patients with severe limb injuries.

CASE SUMMARY

Four patients who sustained a high-energy trauma and underwent complete upper limb amputation were pretreated with a modified St. Thomas' solution before upper limb replantation. After the perfusion solution stopped flowing from the blood vessel, the amputated upper limb amputation was replanted. The patients were instructed to perform functional rehabilitation training after the operation. All 4 patients were followed up for 5 years. All the severed upper limbs survived. Routine re-examination after the operation showed that the function of the affected limb was restored. All the patients were satisfied with the sensory and functional recovery of the affected limb.

CONCLUSION

The modified St. Thomas' solution can effectively improve the success rate of limb salvage surgery and the recovery of limb function in patients with a severe limb injury.

Efficacy of Whole-Blood Del Nido Cardioplegia Compared with Diluted Del Nido Cardioplegia in Coronary Artery Bypass Grafting: A Retrospective Monocentric Analysis of Pakistan

Background and Objectives: Cardioplegia is one of the most significant components used to protect the myocardium during cardiac surgery. There is a paucity of evidence regarding the utilization of whole-blood Del Nido cardioplegia (WB-DNC) on clinical outcomes in coronary artery bypass grafting (CABG). The purpose of this retrospective cross-sectional study is to compare the effectiveness of diluted (blood to crystalloid; 1:4) Del Nido cardioplegia (DNC) with WB-DNC in patients who underwent elective CABG in a tertiary care hospital in Lahore-Pakistan. Materials and Methods: This was a retrospective descriptive study conducted at the Department of Cardiovascular Surgery, King Edward Medical University, Lahore. The medical database of all consecutive patients admitted from January 2018 to March 2020 and who fulfilled the inclusion criteria were reviewed. Results: Out of 471 patients admitted during the study period, 450 underwent various elective cardiac surgeries. Out of 450, 321 patients (71.33%) were operated on for CABG. Only 234/321 (72.89%) CABG patients fulfilled our inclusion criteria; 120 (51.28%) patients received WB-DNC, while 114 (48.71%) patients were administered with DNC. The former group presented with better clinical outcomes compared with the latter in terms of lesser requirements of inotropic support, low degree of hemodilution, shorter in-hospital stay, improved renal function, and cost-effectiveness. Peak values of serum Troponin-T (Trop-T), creatine kinase-myocardial band (CK-MB) release, and activated clotting time (ACT) were also lower in the WB-DNC group compared with the DNC group. Conclusions: The WB-DNC conferred better myocardial protection, improved early clinical outcomes, and also proved to be economical for patients undergoing elective CABG compared with classical crystalloid cardioplegia solution.