A Systematic Review and Meta-Analysis of del Nido Versus Conventional Cardioplegia in Adult Cardiac Surgery

Comparison of lactated Ringer's solution and Plasma-Lyte A as a base solution for del Nido cardioplegia: a prospective randomized trial

OBJECTIVES

The use of del Nido cardioplegia has been increasing in popularity for adult cardiac surgery. However, the base solution, Plasma-Lyte A, is not always available in many countries. This prospective randomized controlled trial evaluated myocardial preservation and clinical outcomes when using lactated Ringer's solution (LRS) compared to Plasma-Lyte A as a base solution for del Nido cardioplegia.

METHODS

Adult patients undergoing first-time elective cardiac surgery for acquired heart disease, including isolated coronary artery bypass grafting, isolated valve surgery, combined valve surgery or concomitant coronary artery bypass grafting and valve surgery were randomized to receive either LRS (n = 100) or Plasma-Lyte A (n = 100).

RESULTS

There were no significant differences between the 2 groups in terms of age, comorbidities, Society of Thoracic Surgeons risk score and type of procedures. The primary outcome, postoperative troponin-T at 24 h, was similar in both groups (0.482 vs 0.524 ng/ml; P = 0.464). Other cardiac markers were also similar at all time points. The LRS group had a lower pH (7.228 vs 7.246; P = 0.005) and higher calcium levels (0.908 vs 0.358 mmol/l; P < 0.001) in the delivered cardioplegia, but there were no significant differences in clinical outcomes, such as ventricular fibrillation, left ventricular ejection fraction, inotrope/vasopressor requirement, intra-aortic balloon pump support, intensive care unit stay, hospital stay, atrial fibrillation, red cell transfusion and complications.

CONCLUSIONS

The results suggest that LRS can be used as an alternative to Plasma-Lyte A as the base solution for del Nido cardioplegia, with similar myocardial preservation and clinical outcomes.

Del Nido cardioplegia or potassium induces Nrf2 and protects cardiomyocytes against oxidative stress

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.

Re-Dosing del Nido cardioplegia in adult cardiac surgery: Perfusion characteristics and outcomes--Is there an optimal redosing strategy?

OBJECTIVES

del Nido cardioplegia is utilized for myocardial protection in adult patients undergoing cardiac surgery; however, no standardized re-dosing protocol exists. We describe perfusion characteristics and clinical outcomes in adult cardiac surgery patients who were re-dosed with del Nido cardioplegia.

METHODS

Chart review was performed for adult patients undergoing cardiac surgery (specific inclusion/exclusion criteria below) who received exactly two doses of del Nido cardioplegia from 2012 to 2019; n = 542 patients. The main outcome was a composite endpoint comprised of operative mortality, myocardial infarction, post-operative cardiac support device (CSD), and postoperative decrease in ejection fraction (EF), which was analyzed via multivariable logistic regression (MVLR). A secondary analysis evaluated postoperative vasoactive-inotropic scores (VIS) via gamma log link regression (GLLR) as a more physiologic indication of myocardial recovery.

RESULTS

MVLR demonstrated that increased total cardiopulmonary bypass (CPB) time was associated with a positive composite outcome (p < .001), whereas time between doses (p = .237) and the volume of each dose was not (p = .626). GLLR also demonstrated that prolonged CBP, decreased EF, congestive heart failure at time of surgery, and low hematocrit at the start of the surgery were all associated with higher VIS.

CONCLUSIONS

In this retrospective study, variations in re-dosing strategy for del Nido cardioplegia do not affect postoperative outcomes and increased CPB time is associated with increased operative mortality, myocardial infarction, need for post-operative CSDs, and reduced postoperative EF, and increased VIS, irrespective of the re-dosing strategy. Further studies are warranted to to identify additional patient and operative characteristics that predispose to complications.

Network meta-analysis comparing blood cardioplegia, Del Nido cardioplegia and custodiol cardioplegia in minimally invasive cardiac surgery

INTRODUCTION

Minimally invasive cardiac surgery has been evolving, with the intention of reducing surgical trauma, improve cosmesis and patient satisfaction. Single dose, crystalloid cardioplegia such as Del Nido cardioplegia and Custoidol solution have been increasingly used to reduce the interruption from repeating cardioplegia dosing to minimise the cardiopulmonary bypass and cross clamp time. However, the best cardioplegia for myocardial protection in adult minimally invasive cardiac surgery remains controversial. We aimed to conduct a meta-analysis to analyse the current evidence in the literature.

METHOD

A systematic review and meta-analysis was performed following the updated 2020 PRISMA guideline. Articles published in the five major electronic databases up 1st of April 2021 were identified and reviewed. The primary outcome was in-hospital or 30-day mortality. Traditional pairwise and Bayesian network meta-analyses were conducted.

RESULTS

Nine articles were included in this study. The use of Del Nido cardioplegia was associated with a lower volume of cardioplegia used (Del Nido vs Blood, 1105.62 mL+/-123.47 vs 2569.46 mL+/-1515.52, p<0.001), cardiopulmonary bypass (Del Nido vs Custoidol vs Blood: 91.67+/-14.78 vs 138.05 +/- 21.30 vs 119.38+/-26.91 minutes, p<0.001) and cross-clamp time (Del Nido vs Custoidol vs Blood: 74.99+/-18.55 vs 82.01 +/- 17.28 vs 93.66+/-8.88 minutes, p < 0.001). No differences were observed in the incidence of in-hospital/30-day mortality rate, new onset of atrial fibrillation and stroke. Ranking analysis showed the Custoidol solution has the highest probability to be the first ranked cardioplegia.

CONCLUSION

No differences were found between blood and crystalloid cardioplegia in adult minimally invasive cardiac surgery in several clinical outcomes. The cardioplegia of choice in minimally invasive cardiac surgery remains the surgeons' decision and preference.

The comparison of del nido cardioplegia and crystalloid-based blood cardioplegia in adult isolated coronary bypass surgery: A randomized controlled trial

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 0^th hour (baseline), 12^th, 36^th, and 60^th hours. There was no statistical difference between groups in troponin T levels of the baseline 0^th hour (18[33] vs. 22[27] pg/ml; P = 0.724). Troponin T levels at the 12^th 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 36^th and 60^th 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.

Guidelines on enhanced recovery after cardiac surgery under cardiopulmonary bypass or off-pump

OBJECTIVE

To provide recommendations for enhanced recovery after cardiac surgery (ERACS) based on a multimodal perioperative medicine approach in adult cardiac surgery patients with the aim of improving patient satisfaction, reducing postoperative mortality and morbidity, and reducing the length of hospital stay.

DESIGN

A consensus committee of 20 experts from the French Society of Anaesthesia and Intensive Care Medicine (Société française d'anesthésie et de réanimation, SFAR) and the French Society of Thoracic and Cardiovascular Surgery (Société française de chirurgie thoracique et cardio-vasculaire, SFCTCV) was convened. A formal conflict-of-interest policy was developed at the onset of the process and enforced throughout. The entire guideline process was conducted independently of any industry funding. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide the assessment of the quality of evidence.

METHODS

Six fields were defined: (1) selection of the patient pathway and its information; (2) preoperative management and rehabilitation; (3) anaesthesia and analgesia for cardiac surgery; (4) surgical strategy for cardiac surgery and bypass management; (5) patient blood management; and (6) postoperative enhanced recovery. For each field, the objective of the recommendations was to answer questions formulated according to the PICO model (Population, Intervention, Comparison, Outcome). Based on these questions, an extensive bibliographic search was carried out and analyses were performed using the GRADE approach. The recommendations were formulated according to the GRADE methodology and then voted on by all the experts according to the GRADE grid method.

RESULTS

The SFAR/SFCTCV guideline panel provided 33 recommendations on the management of patients undergoing cardiac surgery under cardiopulmonary bypass or off-pump. After three rounds of voting and several amendments, a strong agreement was reached for the 33 recommendations. Of these recommendations, 10 have a high level of evidence (7 GRADE 1+ and 3 GRADE 1-); 19 have a moderate level of evidence (15 GRADE 2+ and 4 GRADE 2-); and 4 are expert opinions. Finally, no recommendations were provided for 3 questions.

CONCLUSIONS

Strong agreement existed among the experts to provide recommendations to optimise the complete perioperative management of patients undergoing cardiac surgery.

Diazoxide preserves myocardial function in a swine model of hypothermic cardioplegic arrest and prolonged global ischemia

OBJECTIVE

Adenosine triphosphate potassium sensitive channels provide endogenous myocardial protection via coupling of cell membrane potential to myocardial metabolism. Adenosine triphosphate potassium sensitive channel openers, such as diazoxide, mimic ischemic preconditioning, prevent cardiomyocyte swelling, preserve myocyte contractility after stress, and provide diastolic protection. We hypothesize that diazoxide combined with hyperkalemic cardioplegia provides superior myocardial protection compared with cardioplegia alone during prolonged global ischemia in a large animal model.

METHODS

Twelve pigs were randomized to global ischemia for 2 hours with a single dose of cold blood (4:1) hyperkalemic cardioplegia alone (n = 6) or with diazoxide (500 μmol/L) (n = 6) and reperfused for 1 hour. Cardiac output, myocardial oxygen consumption, left ventricular developed pressure, left ventricular ejection fraction, diastolic function, myocardial troponin, myoglobin, markers of apoptosis, and left ventricular infarct size were compared.

RESULTS

Four pigs in the cardioplegia alone group could not be weaned from cardiopulmonary bypass. There were no differences in myoglobin, troponin, or apoptosis between groups. Diazoxide preserved cardiac output versus control (74.5 vs 18.4 mL/kg/min, P = .01). Linear mixed regression modeling demonstrated that the addition of diazoxide to cardioplegia preserved left ventricular developed pressure by 36% (95% confidence interval, 9.9-61.5; P < .01), dP/dt max by 41% (95% confidence interval, 14.5-67.5; P < .01), and dP/dt min by 33% (95% confidence interval, 8.9-57.5; P = .01). It was also associated with higher (but not significant) myocardial oxygen consumption (3.7 vs 1.4 mL O2/min, P = .12).

CONCLUSIONS

Diazoxide preserves systolic and diastolic ventricular function in a large animal model of prolonged global myocardial ischemia. Diazoxide as an adjunct to hyperkalemic cardioplegia may allow safer prolonged ischemic times during increasingly complicated cardiac procedures.

Comparison of del Nido Cardioplegia vs blood cardioplegia in adult aortic surgery is the single-dose cardioplegia technique really advantageous?

BACKGROUND

/objective: The aim of the present study was to compare the operative and early postoperative results of the use of del Nido Cardioplegia solution (dNCS) with traditional blood cardioplegia (BC) in adult aortic surgery.

METHODS

A retrospective single-center study was performed on 118 patients who underwent aortic surgery with cardiopulmonary bypass (CPB) between January 2016 and June 2020. Patients were divided in to two groups according to the type of cardioplegia solution used. Cardiac arrest was achieved in Group 1 (n = 65) with traditional BC and in Group 2 (n = 53) with dNCS. Operative and postoperative outcomes of the patients were compared between the two groups.

RESULTS

Patient demographic characteristics were similar between the two groups. dNCS group showed significantly lower aortic cross-clamp (ACC) time (73.3 vs. 87.5 min, P = 0.001), cardioplegia volume (1323.9 ± 368.5 vs. 2773.8 ± 453.8 ml, P< 0.001), defibrillation rate (44.4%vs. 69.2%, P = 0.006), drainage amount (412 ± 73.2 vs. 446.9 ± 95.1 ml, P = 0.026) and inotropic support need (37% vs. 55.3%, P = 0.046). Also dNCS group had significantly lower high sensitive troponin I (hsTnI) levels at 6th (203.5 ± 68.6 vs. 275.7 ± 76.2 ng/L, P< 0.001) and 24th (253.1 ± 101 vs. 293.4 ± 80.1 ng/L, P = 0.017) postoperative hours. And dNCS group showed significantly higher hematocrit levels at 6th (25.1 ± 3.2 vs. 22.5 ± 2.5%, P< 0.001) and 24th (25.8 ± 2.7 vs. 24.6 ± 2.8%, P = 0.024) postoperative hours. Times of intensive care unit stay, durations of intuabation and hospital stay times were similar in both groups. There was no significant difference in terms of postoperative ejection fraction values (P = 0.714).

CONCLUSION

Compared with conventional BC, dNCS provided significantly shorter ACC times, reduced the need for intraoperative defibrillation, lowered postoperative hsTnI levels with comparable early clinical outcomes for adult patients undergoing aortic surgery. dNCS is a safe and efficient alternative to the traditional BC solution in adult aortic cardiac surgery.

Modified del Nido versus blood cardioplegia in congenital cardiac surgery

BACKGROUND

Lactated Ringer-based del Nido cardioplegia has been reported to be safe for acquired cardiac surgery. The original Plasma-Lyte-based solution has been proved for congenital cardiac surgery but its modification has not been adequately examined. We compared the clinical outcomes of congenital cardiac surgery using lactated Ringer-based del Nido cardioplegia versus cold blood cardioplegia.

METHODS

Between September 2018 and November 2020, 116 consecutive patients with congenital heart disease undergoing operations with cardioplegic arrest performed by a single surgeon at Faculty of Medicine Siriraj hospital; 66 with modified del Nido solution and 50 with institutional's blood cardioplegia. The patient risk profiles, operative details, mortality rates, care durations, inotrope use, blood transfusion and complications were compared.

RESULTS

Preoperative characteristics were similar between groups, including median age (2.5 vs. 3.1 years; p = 0.49), size, and gender. The Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery score of 3 to 5 was more prevalent in the del Nido group (24.2% vs. 10%; p = 0.049). There were 4 deaths in the modified del Nido group (risk category score of 4) but none in the cold blood group (p = 0.13). There was no significant difference in median intubation duration, length of intensive care unit stay, and vasoactive medications immediately and 24 h after the operation. The del Nido group required 70 to 100 ml less blood transfusion (p = 0.04). All complications were similar between the two groups.

CONCLUSIONS

Clinical outcomes of lactated Ringer-based del Nido cardioplegia were comparable to those of blood cardioplegia in congenital cardiac surgery.

Comparison between Custodiol, del Nido and modified del Nido in the myocardial protection - Cardioplegia Trial: a study protocol for a randomised, double-blind clinical trial

INTRODUCTION

Myocardial protection is essential for successful cardiac surgery, and the search for an ideal cardioplegic solution has continued since its beginning. In this context, Custodiol, del Nido and modified del Nido are single-dose cardioplegic solutions with good safety profiles and great relevance in modern surgical practice. While these solutions have all been evaluated for their impact on patient outcomes independently, limited research exists comparing them directly. Thus, the present study aims to examine the effects of these cardioplegic solutions on myocardial protection and clinical outcomes in adult patients undergoing elective cardiac surgery. The assessment of the increase in myocardial injury biomarkers in patients submitted to all treatment methods may be considered a major strength of our study.

METHODS AND ANALYSIS

This is a clinical trial study protocol that will compare myocardial protection and clinical outcomes among three patient groups based on which cardioplegic solution was used. Patients will be randomised to receive del Nido (n=30), modified del Nido (n=30) or Custodiol (n=30). Myocardial injury biomarkers will be measured at the baseline and 2 hours, 12 hours and 24 hours after the cardiopulmonary bypass. Clinical outcomes will be assessed during the trans operative period and the intensive care unit stay, in addition to other haematological parameters.

ETHICS AND DISSEMINATION

This protocol and its related documents were approved by the Research Ethics Committee of the Hospital Nossa Senhora da Conceição, Brazil, registered under no. 4.029.545. The findings of this study will be published in a peer-reviewed journal in the related field.

TRIAL REGISTRATION NUMBER

RBR-7g5s66.

Comparison of Del Nido and Blood Cardioplegia in Pediatric Patients Undergoing Surgical Repair for Congenital Heart Disease

The aim of the study is to investigate the impact of two different cardioplegia solutions, the del Nido (dN) and blood cardioplegia (BC), on postoperative troponin concentrations, vasoactive-inotrope score, and length of hospital stay in pediatric patients undergoing cardiovascular surgery for CHD. 80 subjects aged between 1 and 120 months who were scheduled for surgical repair for a CHD were prospectively enrolled in this study. Study subjects were allocated to one of the study groups using simple randomization technique as follows: The del Nido cardioplegia group (n = 40, median age 8.5 [5.5-14] months) and conventional blood cardioplegia group (n = 40, median age 11 [5-36] months). Aortic cross-clamp time and cardiopulmonary bypass time were recorded in all subjects. Troponin I and vasoactive-inotropic score, which indicates the amount of cardiovascular support by various inotropes or vasopressors, were recorded following the repair. The difference in troponin I, vasoactive-inotropic score (VIS), length of ICU stay, and length of hospital stay between the two groups was the primary outcome measure of this study. The volume of cardioplegia was significantly lower in dN group than that of the BC group (p < 0.001). Cardiopulmonary bypass time and aortic cross-clamp time were significantly shorter in subjects receiving dN cardioplegia than those receiving BC (p = 0.006, and p = 0.001, respectively). Subjects assigned to BC had higher Troponin I concentrations at postoperative 24th hour compared to subjects receiving dN cardioplegia [1.60 (0.92-2.49) ng/mL vs. 1.03 (0.55-1.83) ng/mL, p = 0.045]. VIS was also significantly higher in BC group at 24th [10 (10-13) vs. 10 (5-10), p = 0.032] and 48th hours [10 (1.5-10) vs. 0 (0-10), p = 0.005] compared to that of the dN cardioplegia group. The median extubation time was 7.5 (3.5-20.5) hours in dN cardioplegia group and 5 (4-10) hours in the BC group (p = 0.384). There were no significant differences between the groups with respect to the length of ICU stay and length of hospital stay. No mortality and no significant arrhythmias requiring medical or electrical cardioversion were noted in any of the groups. In conclusion, dN cardioplegia provides shorter aortic cross-clamp time and cardiopulmonary bypass time, and lower postoperative troponin I concentration and vasoactive-inotrope scores compared to BC in pediatric subjects undergoing surgical repair for CHD. However, lengths of ICU and hospital stay are similar in dN cardioplegia and BC groups.

Single-Dose Del Nido Cardioplegia vs. Blood Cardioplegia in Aortic Valve Replacement Surgery

INTRODUCTION

In this study, we aimed to compare Del Nido cardioplegia (DNC) with blood cardioplegia (BC) in aortic valve replacement.

METHODS

A two-year single-institute retrospective cohort study was accomplished. Subjects who underwent aortic valve replacement surgery were divided into two groups (DNC and BC) and outcomes were compared.

RESULTS

Preoperative demographics and clinical data of the patients in both groups were similar. The time until cardiac arrest following administration of the first dose of cardioplegia was statistically significantly shorter in the BC group (47.0 sec. 25-103) than in the DNC group (63.0 sec. 48-140) (P=0.012). Cross-clamping time was longer in the BC group (48.7±12.3 min. vs. 41.5±11.8 min.) (P=0.041). Cardiopulmonary bypass time was statistically significantly shorter in the DNC group (BC 60.8±18.5 min., DNC 53.7±15.2 min.) (P=0.046). The rate of postoperative use of intravenous positive inotropic support drugs (dopamine, dobutamine, norepinephrine, etc.) for more than two hours was significantly higher in the BC group (20 [23.5%] in the BC group and nine [17.3%] in the DNC group) (P=0.035). Creatine kinase myocardial band and troponin I levels were slightly lower in patients receiving DNC, but no statistically significant difference was detected.

CONCLUSION

Del Nido cardioplegia is safe and can be used efficiently as an alternative to blood cardioplegia in isolated aortic valve replacement surgery.

Comparison of Del Nido Cardioplegia and Blood Cardioplegia in Terms of Development of Postoperative Atrial Fibrillation in Patients Undergoing Isolated Coronary Artery Bypass Grafting

Objective

Del Nido cardioplegia (DNC) has been used in pediatric cardiac surgery for many years with a single dose application and its usage in adult cardiac surgery has been increasing in recent years, with results being published. In this study, we aimed to investigate the effect of DNC on the development of postoperative atrial fibrillation (PoAF).

Methods

In this retrospective observational comparative study, 255 patients who underwent isolated on-pump coronary artery bypass grafting, between January 2019 and November 2019, were enrolled. The patients were divided into two groups: DNC (n=132) and blood cardioplegia (BC) (n=123). Intraoperative and postoperative data were evaluated and compared in terms of the development of PoAF.

Results

We found that the development of PoAF and the length of hospital stay remain significantly higher in the BC group (P=0.044, P<0.001, respectively). In addition, the aortic cross-clamp time and the cardioplegia volume delivered were significantly lower in the DNC group (P=0.042, P<0.001, respectively). In multivariate logistic regression analysis, only higher cardioplegia volume was determined as an independent predictor for PoAF development (OR 1.001; 95% CI 1.000-1.001; P=0.033). We did not found difference between groups in terms of troponin T, inotropic drug support, need for intraaortic balloon pump and mortality.

Conclusion

This study showed that DNC can be used safely in adult coronary bypass surgery and PoAF development effect is reduced.

Myocardial Protection in Adult Cardiac Surgery With del Nido Versus Blood Cardioplegia: A Systematic Review and Meta-Analysis

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.

Comparative Effects of Single-Dose Cardioplegic Solutions Especially in Repeated Doses During Minimally Invasive Aortic Valve Surgery

OBJECTIVE

This study aims to compare del Nido cardioplegia (DNC) and histidine-tryptophan-ketoglutarate (HTK) cardioplegic solutions in minimally invasive aortic valve replacement (mini-AVR) surgery to discuss the safety level of myocardial protection and rationale for redosing intervals.

METHODS

During the period from January 2017 to June 2019, 200 patients undergoing mini-AVR (solely or with concomitant procedures) were prospectively randomized to DNC (n = 100) andHTK (n = 100), both up to 90 minutes ischemic time. Patients with ischemic time over 90 minutes, needing a redosing, were further analyzed in 2 subgroups with DNC-R (n = 30) and HTK-R (n = 36). Sensitive biomarkers, in addition to routine biochemistry, were also documented at baseline (T1), after cessation of cardiopulmonary bypass (T2), and on the first postoperative day (T3). Transmural myocardial biopsies were sampled for staining.

RESULTS

No statistical differences could be demonstrated in DNC and HTK groups with up to 90 minutes cross-clamp times in routine biochemical measurements and basic perioperative clinical outcomes. DNC-R showed significantly more arrhythmia/AV block incidence resulting in more extended intensive care unit (ICU) stay. Interleukin-6 and syndecan-1 in DNC and DNC-R groups were substantially higher at T2. Aquaporin-4 levels were significantly lower in the DNC-R group, demonstrating unsatisfactory response of cells to an excessive volume at T2.

CONCLUSIONS

DNC and HTK provided acceptable myocardial protection as single-dose applications. DNC-R had significantly unbalanced levels of biomarkers, and more arrhythmia/AV block incidence resulting in more extended ICU stay. For patients who may need redosing HTK may be preferable to DNC.

Clinical outcomes of single-dose cardioplegia in high-risk coronary bypass

BACKGROUND

Despite the increasing popularity of single-dose cardioplegia techniques in coronary artery bypass grafting, the time window for successful reperfusion remains unclear. This study aimed to compare different cardioplegic techniques based on early and 30-day clinical outcomes via thorough monitoring.

METHODS

This prospective cohort study included high-risk patients undergoing coronary artery bypass grafting and receiving 3 different types of cardioplegia between January 2017 and June 2019. Group 1 (n = 101) had a single dose of del Nido cardioplegia, group 2 (n = 92) had a single dose of histidine-tryptophane-ketoglutarate, and group 3 (n = 119) had cold blood cardioplegia. Patients were examined perioperatively by memory loop recording and auto-triggered memory loop recording for 30 days, with documentation of predefined events.

RESULTS

Interleukin-6 and cardiac troponin levels in group 1 were significantly higher than those in groups 2 and 3. The incidence of predefined events as markers of inadequate myocardial protection was significantly higher group 1, with more frequent atrial fibrillation attacks and more hospital readmissions. The readmission rate was 17.6% in group 1, 9% in group 2, and 8% in group 3.

CONCLUSIONS

Our data demonstrate the long-term efficacy of cardioplegic techniques, which may become more crucial in high-risk patients who genuinely have a chance to benefit from adjunct myocardial protection. Patients given del Nido cardioplegia had a significantly more prominent inflammatory response and higher troponin levels after cardiopulmonary bypass. This group had issues in the longer term with significantly more cardiac events and a higher rehospitalization rate.

Serial ultrastructural evaluation of myocardial ischemic injury after infusion of del Nido cardioplegia in the human heart

OBJECTIVES

The safe ischemic time after a single-dose del Nido cardioplegia (DNC) infusion has not yet been established. This study evaluated the progression of myocardial ischemic injury to establish the safe ischemic time after a single-dose DNC infusion in the human heart using a transmission electron microscope.

METHODS

Seven hearts extracted from heart transplant recipients after infusion of 1000 mL single-dose DNC were evaluated. Serial left ventricular myocardial tissue samples were collected every 30 minutes for 180 minutes. Ischemic injuries in the mitochondria and nuclei were scored from 0 to 3 (0 = normal, 0.5 = slight, 1 = moderate, 2 = severe, and 3 = irreversible).

RESULTS

At the time of extraction, 83.5% of the mitochondria were normal. The proportion of mitochondria with moderate ischemic injury increased gradually from 1.4% at extraction to 52.5% at 180 minutes. From 90 minutes to 180 minutes, the proportion of mitochondria with severe and irreversible injury increased from 0.8% to 4.4% and 0.3% to 1.3%, respectively. A significant linear correlation was identified between the average ischemic injury score of mitochondria and ischemic time (P < .001). Most nuclei showed moderate to severe ischemic injury at every time point (61.0%-85.2%). A significant linear correlation was also found between the average ischemic injury score of nuclei and ischemic time (P < .001).

CONCLUSIONS

Myocardial ischemic injury progresses gradually, and irreversible ischemic injury begins to occur 90 minutes after initial DNC infusion in the adult human heart. Therefore, redosing of DNC may be required after 90 minutes of aortic crossclamp time during adult cardiac surgery.

Noteworthy Literature in Cardiac Anesthesia for 2019

This article represents a selective review of literature published in 2019. Initial results from PubMed searching for a combination of terms, including cardiac anesthesiology and anesthesiology outcomes, yielded more than 1400 publications. From there, we manually screened the results and identified 5 major themes for the year of 2019, including transcatheter techniques, delirium and anesthesiology, coagulation management following cardiopulmonary bypass, perfusion management with del Nido cardioplegia, and applied clinical research. The following research accomplishments have expanded what is possible and set ambitious goals for the future.