Del Nido versus HTK cardioplegia for myocardial protection during adult complex valve surgery: a retrospective study

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.

Hemoadsorption and Coagulation Systemic Rebalance in Patients Undergoing Nonelective Cardiac Surgery and Treated with Antithrombotics

INTRODUCTION

Insufficient withdrawal duration of antithrombotics leads to excessive bleeding after major surgery. We hypothesize that intraoperative hemoadsorption (HA) can reduce postoperative allogeneic transfusion requirements and excessive bleeding events (EBE), without an increase in ischemic/thromboembolic events (ITE) in patients who have taken antithrombotics and undergone nonelective cardiac surgery.

METHODS

A total of 460 patients admitted to our hospital from 2018 to 2022 were included in this study and divided into two groups: HA and non-HA. Because of the risk of bias due to differences in antithrombotic type, withdrawal duration, or basic coagulation function, propensity score matching was used for analyses.

RESULTS

Out of 154 cases in the HA group, 144 pairs were successfully matched. No HA safety events such as hemolysis, hypotension, or device failure occurred. After matching, the two groups were found to be comparable in preoperative antithrombotic type, withdrawal duration, platelets and coagulation function, and demographic and perioperative characteristics. Although the HA group did not have a reduced incidence of EBE, this group exhibited significant decreases in the transfusion rate and volume, the incidence of ITE, acute kidney injury, and central nervous system injury.

CONCLUSIONS

For patients who have undergone nonelective cardiac surgery and taken antithrombotics, HA can simply and safely rebalance the postoperative coagulation system and have associations with reduced transfusion and postoperative ITE.

Comparison of Single-Dose Cardioplegia in Valvular Heart Surgery: Lactated Ringer's-Based del Nido vs. Histidine-Tryptophan-Ketoglutarate Cardioplegia Solution

INTRODUCTION

This study evaluated myocardial protection and clinical outcomes when using lactated Ringer's solution as the base solution for del Nido cardioplegia compared with histidine-tryptophan-ketoglutarate (HTK) solution in valvular surgery.

METHODS

From January 2017 to May 2018, 71 adult patients who underwent valvular surgery with del Nido cardioplegia (n=37) or HTK cardioplegia (n=34) were retrospectively analyzed.

RESULTS

Patients' characteristics were comparable between groups. Postoperative peak troponin T levels were similar. The del Nido group had a decreased incidence of ventricular fibrillation after aortic cross-clamp removal (13.51 vs. 55.88%; P<0.001), lower total volume of cardioplegia administered (1,000 [1,000, 1,250] vs. 1,800 [1,500, 2,000] mL; P<0.001), shorter hospital stay (6 [5, 8] vs. 7 [6, 10] days; P=0.03), and less postoperative red cell transfusion (34.29 vs. 61.11%; P=0.024). There is no difference in aortic cross-clamping time, postoperative change in left ventricular ejection fraction, intensive care unit stay, duration of inotropic support, new onset of atrial fibrillation, in-hospital mortality, complications, and three-year overall survival rate.

CONCLUSION

Lactated Ringer's-based del Nido cardioplegia can be safely used for valvular surgery with acceptable clinical outcomes compared to HTK cardioplegia.

Non-selective Del Nido and St Thomas cardioplegia in adults: analysis of early clinical experience using propensity matching

BACKGROUND

Del Nido cardioplegia (DNC) is a single-dose, high potassium, low-volume cardioplegia solution that has grown in favor recently. However, the use of DNC in the Asian population may be associated with certain challenges.

METHODS

Between January 2017 and April 2022, DNC was used for myocardial protection in this single-center retrospective study. In total, 5731 patients underwent open heart surgeries, where 310 patients received DNC for single or multiple procedures. A total of 307 pair of propensity-matched patients from DNC and cold blood St. Thomas cardioplegia (STC) were compared.

RESULTS

In total, 5085 patients with STC and 310 patients with DNC from the cohort were matched, reflecting the initial group sizes before propensity matching. About 307 patient pairs were included in the final analysis after propensity matching with the interest variables. In the STC group, the requirement for an immediate postoperative intra-aortic balloon pump (IABP) was significantly higher [18 (5.9%) in DNC versus 28 (9.1%) in STC, p = 0.021]. A 30-day mortality was comparable between the DNC and STC groups (2.9% versus 3.3%, p = 1.00). Major adverse cardiac events (MACE) (2.6% versus 3.6%, p = 0.648) showed no difference between the groups. In both single and multiple procedure subgroups, there were no statistically significant differences in 30-day mortality and MACE incidences when comparing STC and DNC.

CONCLUSION

The use of DNC in adults is acceptable and adaptable. Comparable clinical outcomes between STC patients and DNC were revealed by our investigation. There were no appreciable differences in 30-day mortality or MACE despite the STC group having a much higher need for immediate postoperative IABP.

Comparison of the efficacy between Del Nido cardioplegia and HTK cardioplegia in Stanford type A aortic dissection patients undergoing open-heart surgery

OBJECTIVES

Acute Stanford type A aortic dissection is an extremely dangerous and life-threatening cardiovascular disease, usually treated with extracorporeal circulation heart surgery. Histidine-tryptophan-ketoglutarate (HTK) cardioplegia is a protective intracellular myocardial fluid that has been used extensively in different types of extracorporeal circulation surgeries. Del Nido cardioplegia is an extracellular myocardial protection fluid, which was first used in pediatric heart surgery and has been gradually used in a variety of pediatric and adult heart procedures. This study aims to compare the myocardial protection effect between Del Nido and HTK in patients undergoing extracorporeal circulation heart surgery for acute Stanford type A dissection and its impact on patients' prognosis by analyzing selected parameters and clinical manifestations at different time points.

METHODS

Clinical data were collected from 431 patients with acute Stanford type A dissection who were diagnosed and underwent surgery between January 1, 2018 and December 31, 2020 at Xiangya Hospital, Central South University. After excluding some of the data based on exclusion criteria, patients were divided into a HTK group and a Del Nido (DN) group based on type of intraoperative cardioplegia. Propensity score-matching was performed subsequently using the the R statistical software to determine the DN group ( n =40) and HTK group ( n =41). The matching factors were age, sex, hypertension, cardiopulmonary bypass time, and aortic occlusion time. Perioperative data, postoperative complications, blood gas data, and myocardial injury data were collected from the patients, and SPSS 26.0 was used to analyze the data of each group.

RESULTS

The DN group had a higher rate of spontaneous cardioversion (41.5% vs 15.0%, P =0.005) and a lower postoperative hospital stay [10.0(8.0,14.0) d vs 13.0(11.0,19.0) d, P <0.05] compared to the HTK group. In terms of changes in blood gas analysis, immediate sodium and potassium concentrations were significantly higher in the DN group than that in the HTK group (both P <0.05). There was no significant difference in myocardial injury indexes between the two groups at different time points (all P >0.05). In terms of postoperative complications, the cardiac complications in DN group were much lower than those in the HTK Group (0 vs 12.5%, P =0.026).

CONCLUSIONS

Del Nido cardioplegia has similar myocardial protective effects as HTK cardioplegia used in Stanford type A aortic dissection, with a higher rate of cardiac recurrence and fewer cardiac complications. Del Nido cardioplegia should play an important role in future application for acute Stanford type A aortic dissection, but our findings need to be further validated in a large sample of prospective clinical studies.