Supplemental Cardioplegia Immediately before Graft Implantation may Improve Early Post-Transplantation Outcome

The Effect of Supplemental Cardioplegia Infusion before Anastomosis in Patients Undergoing Heart Transplantation with Long Ischemic Times

Background

Prolonged ischemic time is a risk factor for primary graft dysfunction in patients who undergo heart transplantation. We investigated the effect of a supplemental cardioplegia infusion before anastomosis in patients with long ischemic times.

Methods

We identified 236 consecutive patients who underwent orthotopic heart transplantation between February 2010 and December 2014. Among them, the patients with total ischemic times of longer than 3 hours (n=59) were categorized based on whether they were administered a complementary cardioplegia solution (CPS) immediately before implantation (CPS+, n=30; CPS−, n=29).

Results

The mean total ischemic times in the CPS+ and CPS− groups were 238.1±30.1 minutes and 230.1±28.2 minutes, respectively (p=0.3). The incidence of left ventricular primary graft dysfunction (CPS+, n=6 [20.0%]; CPS−, n=5 [17.2%]; p=0.79) was comparable between the groups. In the Kaplan-Meier survival analysis, no significant difference in overall survival at 5 years was observed between the CPS+ and CPS− groups (83.1%±6.9% vs. 89.7%±5.7%, respectively; log-rank p=0.7). No inter-group differences in early mortality (CPS+, n=0; CPS−, n=1 [3.4%]; p=0.98) or complications were observed.

Conclusion

The additional infusion of a cardioplegia solution immediately before implantation in patients with longer ischemic times is a simple, reproducible, and safe procedure. However, we did not observe benefits of this strategy in the present study.

Supplemental Cardioplegia During Donor Heart Implantation: A Systematic Review and Meta-Analysis

BACKGROUND

The optimal donor heart preservation and management strategy during heart transplantation remains controversial. We report the results of a systematic review and meta-analysis of the effect of supplemental cardioplegia administration during donor heart implant for transplantation.

METHODS

We searched MEDLINE and Embase databases until February 2019 for studies comparing patients who received transplants with the donor heart given supplemental cardioplegia or not. Data were extracted by 2 independent investigators. The main outcomes were early morbidity and mortality.

RESULTS

Included were 7 retrospective observational studies (4 comparing to historical controls) and 3 randomized controlled trials enrolling 1125 patients. Supplemental cardioplegia included crystalloid and blood cardioplegia given continuous retrograde or as terminal "hot shots." Supplemental cardioplegia was associated with improved early mortality (risk ratio [RR], 0.55; 95% confidence interval [CI], 0.35-0.87; P < .01), greater rates of spontaneous return of sinus rhythm (RR, 2.62; 95% CI, 1.50-4.56; P < .01), shorter intensive care stay (mean difference, -3.4 days; 95% CI, -5.1 to -1.6; P < .01), and lower incidence of ischemic changes seen on endomyocardial biopsy specimens (RR, 0.49; 95% CI, 0.35-0.69; P < .01) compared with controls. Midterm mortality was not different between groups (incident rate ratio, 0.80; 95% CI, 0.51-1.26; P = .34).

CONCLUSIONS

Administration of supplemental cardioplegia may be associated with a reduction in organ ischemic injury and shorter intensive care stay as well as improvement in early survival after transplantation. This strategy may be a simple and cost-effective adjunct to improve outcomes of heart transplantation, especially in an era of increasing use of marginal donor organs. Further investigation will be needed to confirm the findings of this hypothesis-generating study.

Myocardial protection with complementary dose of modified Del Nido cardioplegia during heart transplantation

Myocardial protection during heart transplantation is achieved by a first dose of heart preservation solution during donor heart harvesting, while there is no consensus about the management of complementary doses during implantation in the recipient. We describe a preliminary case series where modified Del Nido Cardioplegia was used as complementary dose at the time of donor heart implantation.