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Colangelo N, Sala A, Gallio G, Blasio A, De Simone F, Aina A, Buffa A, Verzini A, Alfieri O, Maisano F, Castiglioni A, De Bonis M. A novel versatile concept of cardioplegia delivery in cardiac surgery: The ReverseTWO cardioplegia circuit system. Perfusion 2024; 39:473-478. [PMID: 36598157 DOI: 10.1177/02676591221150168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Nowadays, the necessity of having a cardioplegia circuit capable of being adapted in order to administer different types of cardioplegia is strategically fundamental, both for the perfusionist and for the cardiac surgeon. This allows to avoid cutting tubes, guarantees sterility and, most of all, limits the number of cardioplegia circuits for the different strategies of cardiac arrest. The novel "ReverseTWO cardioplegia circuit system" is the development of the precedent "Reverse system" where mainly the 4:1 and crystalloid cardioplegia were used, It has the advantage of allowing immediate change of cardioplegia set-up versus four types of cardioplegia technique, when the strategy is unexpectedly changed before the beginning of cardiopulmonary bypass (CPB), is safe and enables the perfusionist to use one single custom pack of cardioplegia. Two pediatric roller pumps are usually used in our centre for cardioplegia administration; they have a standardized calibration (the leading with ¼ inch and the follower with 1/8 inch) and the circuit consequently has two different tube diameters for the two different pumps. The presence in the circuit of two different shunts coupled with two different coloured clamps allows the immediate set-up for different cardioplegia administration techniques utilizing a colour-coding mechanism The aim of this manuscript is to present the new ReverseTWO Circuit. This novel system allows to administer four different cardioplegic solutions (4:1, 1:4, crystalloid, ematic) based on multiple tubes, which can be selectively clamped, identified through a color-coding method. The specificity of this circuit is the great versatility, which leads to numerous advantages, such as reduced risk of perfusion accident and reduced costs related not only to the purchase of different cardioplegia kits but also to the storage. https://youtu.be/ovJBE4ok2Ds.
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Affiliation(s)
- Nicola Colangelo
- Extracorporeal Circulation Unit, IRCCS San Raffaele Hospital, Milan, Italy
| | - Alessandra Sala
- Department of Cardiac Surgery, Vita-Salute San Raffaele University, IRCCS San Raffaele Hospital, Milan, Italy
| | - Giulia Gallio
- Extracorporeal Circulation Unit, IRCCS San Raffaele Hospital, Milan, Italy
| | - Andrea Blasio
- Department of Cardiac Surgery, Vita-Salute San Raffaele University, IRCCS San Raffaele Hospital, Milan, Italy
| | | | - Alessandro Aina
- Extracorporeal Circulation Unit, IRCCS San Raffaele Hospital, Milan, Italy
| | - Antonino Buffa
- Extracorporeal Circulation Unit, IRCCS San Raffaele Hospital, Milan, Italy
| | - Alessandro Verzini
- Department of Cardiac Surgery, Vita-Salute San Raffaele University, IRCCS San Raffaele Hospital, Milan, Italy
| | - Ottavio Alfieri
- Department of Cardiac Surgery, Vita-Salute San Raffaele University, IRCCS San Raffaele Hospital, Milan, Italy
| | - Francesco Maisano
- Department of Cardiac Surgery, Vita-Salute San Raffaele University, IRCCS San Raffaele Hospital, Milan, Italy
| | - Alessandro Castiglioni
- Department of Cardiac Surgery, Vita-Salute San Raffaele University, IRCCS San Raffaele Hospital, Milan, Italy
| | - Michele De Bonis
- Department of Cardiac Surgery, Vita-Salute San Raffaele University, IRCCS San Raffaele Hospital, Milan, Italy
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Sanetra K, Gerber W, Domaradzki W, Mazur M, Synak M, Kubaszewska M, Kaźmierczak P, Buszman PP, Bochenek A. Use of del Nido cardioplegia in acute coronary syndrome cases with decreased ejection fraction. Perfusion 2024; 39:353-361. [PMID: 36472195 DOI: 10.1177/02676591221144166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2023]
Abstract
BACKGROUND There has been increasing interest in using del Nido cardioplegia in adult cardiac surgery. However, there is limited evidence for its efficacy in patients with acute coronary syndrome and reduced ejection fraction. METHODS This study examined patients with decreased ejection fraction (EF < 40%) who were hospitalized due to acute coronary syndrome and received either del Nido (DN) or cold blood cardioplegia (CB). The patients were matched based on age, gender, myocardial infarction at baseline, and number of conducted surgical procedures. An analysis was conducted on postoperative biomarker release (high-sensitivity troponin T and isoenzyme creatine kinase-MB (CK-MB)), changes in myocardial contractility and perioperative outcomes. RESULTS 62 pairs of patients with similar baseline characteristics were selected. 51.6% of pairs underwent isolated coronary artery bypass grafting, while 48.4% underwent a complex procedure. Postoperative troponin values did not differ significantly at 12 h (median (IQR): 606.7 (381.4-974.8) pg/mL vs. 552 (231.8-1579.5) pg/mL; p = 0.913), nor did CK-MB (median (IQR): 24.3 (12.6-45.5) ng/mL vs. 23.7 (12.3-49.8) ng/mL; p = 0.972). The postoperative EF was similar between groups (median (IQR): 30% (30-35%) vs. 34% (30-38%); p = 0.323). No difference in perioperative mortality, myocardial infarction, stroke, or composite endpoint was noted. In a multivariate analysis, the cardioplegia protocol did not affect biomarker release or changes in ejection fraction. The first stage of acute kidney injury was more frequent in the CB group (28.5% vs. 9.7%, p = 0.033). CONCLUSIONS Both del Nido and cold blood cardioplegia provide adequate cardioprotection in patients with acute coronary syndrome with decreased 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
- Department of Cardiac Surgery, American Heart of Poland, Bielsko-Biała, 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
| | - Marta Kubaszewska
- Department of Cardiology, Andrzej Frycz Modrzewski Krakow University, Krakow, Poland
| | | | - Piotr P Buszman
- Department of Cardiology, Andrzej Frycz Modrzewski Krakow University, Krakow, Poland
- Center for Cardiovascular Research and Development, American Heart of Poland, Katowice, 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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Ou CY, Hu HW, Lin TW, Roan JN, Hu YN, Wang YC, Tsai MT. Continuous Myocardial Perfusion during Distal Anastomosis of Acute Type A Aortic Dissection. Thorac Cardiovasc Surg 2024; 72:96-104. [PMID: 36812923 DOI: 10.1055/s-0043-1761218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
Abstract
BACKGROUND The effect of continuous myocardial perfusion (CMP) on the surgical results of acute type A aortic dissection (ATAAD) remains unclear. METHODS From January 2017 to March 2022, 141 patients who underwent ATAAD (90.8%) or intramural hematoma (9.2%) surgery were reviewed. Fifty-one patients (36.2%) received proximal-first aortic reconstruction and CMP during distal anastomosis. Ninety patients (63.8%) underwent distal-first aortic reconstruction and were placed in traditional cold blood cardioplegic arrest (CA; 4°C, 4:1 blood-to-Plegisol) throughout the procedure. The preoperative presentations and intraoperative details were balanced using inverse probability of treatment weighting (IPTW). Their postoperative morbidity and mortality were analyzed. RESULTS The median age was 60 years. The incidence of arch reconstruction in the unweighted data was higher in the CMP compared with the CA group (74.5 vs 52.2%, p = 0.017) but was balanced after IPTW (62.4 vs 58.9%, p = 0.932, standardized mean difference = 0.073). The median cardiac ischemic time was lower in the CMP group (60.0 vs 130.9 minutes, p < 0.001), but cerebral perfusion time and cardiopulmonary bypass time were similar. The CMP group did not demonstrate any benefit in the reduction of the postoperative maximum creatine kinase-MB ratio (4.4 vs 5.1% in CA, p = 0.437) or postoperative low cardiac output (36.6 vs 24.8%, p = 0.237). Surgical mortality was comparable between groups (15.5% in CMP vs 7.5% in the CA group, p = 0.265). CONCLUSION Application of CMP during distal anastomosis in ATAAD surgery, irrespective of the extent of aortic reconstruction, reduced myocardial ischemic time but did not improve cardiac outcome or mortality.
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Affiliation(s)
- Chia-Yu Ou
- Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Hsiang-Wei Hu
- Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Ting-Wei Lin
- Division of Cardiovascular Surgery, Department of Surgery, E-Da Hospital/I-Shou University, Kaohsiung, Taiwan
| | - Jun-Neng Roan
- Division of Cardiovascular Surgery, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Yu-Ning Hu
- Division of Cardiovascular Surgery, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Yi-Cheng Wang
- Division of Cardiovascular Surgery, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Meng-Ta Tsai
- Division of Cardiovascular Surgery, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Institue of Clinical Pharmacy and Pharmaceutical Sciences, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
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Gholampour Dehaki M, Gorjipour F, Gorjipour F, Mahdavi M, Kachoueian N, Heidarynia S. The effect of Del Nido versus custodiol cardioplegia on clinical outcomes and troponin-I changes among pediatrics with tetralogy of fallot undergoing cardiopulmonary bypass. Perfusion 2024; 39:317-323. [PMID: 36464918 DOI: 10.1177/02676591221141791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2023]
Abstract
BACKGROUND Myocardial protection during operations with cardiopulmonary bypass (CPB) and aortic cross clamping is vital. For this purpose, Del Nido (DN) and Custodiol cardioplegia (CC) solutions are used for single-dose cardioplegia in cardiac surgical procedures with CPB. Present study aimed to compare the effects of DN and CC on peri-operative clinical outcomes in pediatrics with Tetralogy of Fallot (TF) undergoing cardiopulmonary bypass. METHODS Present randomized clinical trial was performed in two trial groups with parallel design. One group received DN and another group received CC. We assessed circulatory Troponin-I (cTnI) and coronary sinus lactate level as primary outcomes. Secondary outcomes were ventilation time, electrolytes levels, pump time, cross-clamp time and other clinical parameters. RESULTS Duration of CPB and cross-clamp were the same in both groups. There were no significant differences in hemodynamic parameters, left ventricular ejection fraction after the surgery and discharge time between the two trial groups. Ventilation time (8.5 vs. 18; p = 0.001), ICU stay, Troponin-I in ICU admission and Coronary sinus lactate level (p = 0.001) were significantly higher among patients of Custodiol group compared to other trial group. Electrolytes Na, Cl and K levels, during CPB, were significantly less in Custodiol group. CONCLUSION When used for inducing cardiac arrest during CPB, DN solution offers better maintenance of the electrolyte balance during CPB, and is associated with less circulatory cTnI and coronary sinus lactate level compared with the CC.
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Affiliation(s)
- Maziar Gholampour Dehaki
- Iran University of Medical Sciences, Rajaie Cardiovascular Medical and Research Center, Tehran, Iran
| | - Farhad Gorjipour
- Iran University of Medical Sciences, Rajaie Cardiovascular Medical and Research Center, Tehran, Iran
- Iranian Scientific Society of Extracorporeal Technology, Iran University of Medical Sciences, Rajaie Cardiovascular Medical and Research Center, Tehran, Iran
| | - Fazel Gorjipour
- Physiology Research Center, Iran University of Medical Sciences, Tehran, Iran
- Qashqaei Biotechnology Laboratories, Tehran, Iran
| | - Mohammad Mahdavi
- Iran University of Medical Sciences, Rajaie Cardiovascular Medical and Research Center, Tehran, Iran
| | - Naser Kachoueian
- Imam Hossein Educational Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Saeid Heidarynia
- Iran University of Medical Sciences, Rajaie Cardiovascular Medical and Research Center, Tehran, Iran
- Iranian Scientific Society of Extracorporeal Technology, Iran University of Medical Sciences, Rajaie Cardiovascular Medical and Research Center, Tehran, Iran
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Kantathut N, Krathong P, Khajarern S, Leelayana P, Cherntanomwong P. Comparison of lactated Ringer's solution and Plasma-Lyte A as a base solution for del Nido cardioplegia: a prospective randomized trial. Eur J Cardiothorac Surg 2024; 65:ezae018. [PMID: 38244592 DOI: 10.1093/ejcts/ezae018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Revised: 12/08/2023] [Accepted: 01/16/2024] [Indexed: 01/22/2024] Open
Abstract
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.
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Affiliation(s)
- Narongrit Kantathut
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Pimchanok Krathong
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Siam Khajarern
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Parinya Leelayana
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Piya Cherntanomwong
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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Willekes H, Parker J, Neill J, Augustin G, Fanning J, Spurlock D, Murphy E, Leung S, Boeve T, Leacche M, Willekes C, Timek T. Efficacy of del Nido cardioplegia in adult cardiac procedures with prolonged aortic crossclamp time. J Thorac Cardiovasc Surg 2024; 167:996-1007.e4. [PMID: 35660325 DOI: 10.1016/j.jtcvs.2022.02.066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 01/16/2022] [Accepted: 02/23/2022] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Equivalent myocardial protection and clinical outcomes have been shown with the use of del Nido cardioplegia (DC) compared with blood cardioplegia (BC) in adult isolated coronary artery bypass grafting and valve patients. However, its safety and efficacy in cardiac procedures with aortic crossclamp times >90 minutes is still unknown. METHODS From May 2014 to September 2019, 2506 adult patients at our center underwent cardiac surgery requiring prolonged aortic crossclamp time defined as 90 minutes or longer. Myocardial protection was achieved with BC in 1955 patients and DC in 551 patients. Two surgeons used DC exclusively and 5 used blood exclusively over the study period. BC was delivered anterograde and retrograde whereas DC was delivered anterograde only. Propensity score matching of several preoperative characteristics, including primary cardiac pathology, yielded 526 well matched pairs. Emergency and reoperative cases were included. Troponin T levels were drawn at 12 hours postoperative in all patients. Clinical data were extracted from our local Society of Thoracic Surgeons database. Subgroup analyses were performed on the basis of crossclamp time stratification. RESULTS For the propensity score-matched cohort, the median crossclamp time was longer in the BC compared with the DC group (114 [interquartile range (IQR), 100-145] minutes for DC vs 153 [IQR, 122-200] minutes for BC; P < .0001) whereas intraoperative peak glucose was higher with BC (173 [IQR, 147-200] g/dL for DC vs 197 [IQR, 171-228] g/dL for BC; P < .001). In addition, perioperative mortality (3.4% vs 3.0%; P = .7273), stroke (3.2% vs 2.1%; P = .2504), renal failure (6.5% vs 4.6%; P = .1767), atrial fibrillation (34% vs 31.4%, P = .3575), intra-aortic balloon pump use (5.3% vs 4.6%, P = .5694), and extracorporeal membrane oxygenation use (3.0% vs 2.9%, P = .8596) did not differ between DC and BC. Postoperative troponin T levels were 0.53 (IQR, 0.30-0.96) ng/mL and 0.62 (IQR, 0.38-1.07) ng/mL for DC and BC, respectively (P = .0024). Subgroup analysis revealed higher troponin T levels with DC for crossclamp times between 150 and 180 minutes. Survival rates at 1, 2, and 5 years were 93.3%, 91.1%, and 78.7% for DC and 94.5%, 91.8%, and 81.5% for BC, respectively (P = .5140). CONCLUSIONS In adult cardiac surgical procedures with aortic crossclamp times >90 minutes, comparable myocardial protection, perioperative mortality and morbidity, and distant survival were observed with the use of DC compared with BC. Higher troponin levels were seen in DC patients with crossclamp times between 150 and 180 minutes, but this was not associated with increased mortality.
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Affiliation(s)
- Holliann Willekes
- Michigan State University College of Human Medicine, Grand Rapids, Mich
| | | | - Jere Neill
- Michigan State University College of Human Medicine, Grand Rapids, Mich
| | - Gabriel Augustin
- Michigan State University College of Human Medicine, Grand Rapids, Mich
| | - Justin Fanning
- Division of Cardiothoracic Surgery, Spectrum Health, Grand Rapids, Mich
| | - David Spurlock
- Division of Cardiothoracic Surgery, Spectrum Health, Grand Rapids, Mich
| | - Edward Murphy
- Division of Cardiothoracic Surgery, Spectrum Health, Grand Rapids, Mich
| | - Stephane Leung
- Division of Cardiothoracic Surgery, Spectrum Health, Grand Rapids, Mich
| | - Theodore Boeve
- Division of Cardiothoracic Surgery, Spectrum Health, Grand Rapids, Mich
| | - Marzia Leacche
- Division of Cardiothoracic Surgery, Spectrum Health, Grand Rapids, Mich
| | - Charles Willekes
- Division of Cardiothoracic Surgery, Spectrum Health, Grand Rapids, Mich
| | - Tomasz Timek
- Division of Cardiothoracic Surgery, Spectrum Health, Grand Rapids, Mich.
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Smartt H, Angelini GD, Gibbison B, Rogers CA. Efficacy of propofol-supplemented cardioplegia on biomarkers of organ injury in patients having cardiac surgery using cardiopulmonary bypass: a statistical analysis plan for the ProMPT-2 randomised controlled trial. Trials 2024; 25:153. [PMID: 38424570 PMCID: PMC10903038 DOI: 10.1186/s13063-024-08016-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 02/22/2024] [Indexed: 03/02/2024] Open
Abstract
BACKGROUND The ProMPT-2 trial (Propofol for Myocardial Protection Trial #2) aims to compare the safety and efficacy of low- and high-dose propofol supplementation of the cardioplegia solution during adult cardiac surgery versus sham supplementation. This update presents the statistical analysis plan, detailing how the trial data will be analysed and presented. Outlined analyses are in line with the Consolidated Standards of Reporting Trials and the statistical analysis plan has been written prior to database lock and the final analysis of trial data to avoid reporting bias (following recommendations from the International Conference on Harmonisation of Good Clinical Practice). METHODS/DESIGN ProMPT-2 is a multi-centre, blinded, parallel three-group randomised controlled trial aiming to recruit 240 participants from UK cardiac surgery centres to either sham cardioplegia supplementation, low dose (6 µg/ml) or high dose (12 µg/ml) propofol cardioplegia supplementation. The primary outcome is cardiac-specific troponin T levels (a biomarker of cardiac injury) measured during the first 48 h following surgery. The statistical analysis plan describes the planned analyses of the trial primary and secondary outcomes in detail, including approaches to deal with missing data, multiple testing, violation of model assumptions, withdrawals from the trial, non-adherence with the treatment and other protocol deviations. It also outlines the planned sensitivity analyses and exploratory analyses to be performed. DISCUSSION This manuscript prospectively describes, prior to the completion of data collection and database lock, the analyses to be undertaken for the ProMPT-2 trial to reduce risk of reporting and data-driven analyses. TRIAL REGISTRATION ISRCTN ISRCTN15255199. Registered on 26 March 2019.
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Affiliation(s)
- Helena Smartt
- Bristol Trials Centre, Bristol Medical School, University of Bristol, Bristol, UK.
| | - Gianni D Angelini
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust and University of Bristol, Bristol, UK
- Bristol Heart Institute, University of Bristol, Bristol, UK
| | - Ben Gibbison
- Department of Anaesthesia, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Chris A Rogers
- Bristol Trials Centre, Bristol Medical School, University of Bristol, Bristol, UK
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Sanetra K, Gerber W, Mazur M, Kubaszewska M, Pietrzyk E, Buszman PP, Kaźmierczak P, Bochenek A. Del Nido vs. Cold Blood Cardioplegia for High-Risk Isolated Coronary Artery Bypass Grafting in Patients with Reduced Ventricular Function. Braz J Cardiovasc Surg 2024; 39:e20220346. [PMID: 38315052 PMCID: PMC10836820 DOI: 10.21470/1678-9741-2022-0346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Accepted: 06/16/2023] [Indexed: 02/07/2024] Open
Abstract
INTRODUCTION The evidence for using del Nido cardioplegia protocol in high-risk patients with reduced ejection fraction undergoing isolated coronary surgery is insufficient. METHODS The institutional database was searched for isolated coronary bypass procedures. Patients with ejection fraction < 40% were selected. Propensity matching (age, sex, infarction, number of grafts) was used to pair del Nido (Group 1) and cold blood (Group 2) cardioplegia patients. Investigation of biomarker release, changes in ejection fraction, mortality, stroke, perioperative myocardial infarction, composite endpoint (major adverse cardiac and cerebrovascular events), and other perioperative parameters was performed. RESULTS Matching allowed the selection of 45 patient pairs. No differences were noted at baseline. After cross-clamp release, spontaneous sinus rhythm return was observed more frequently in Group 1 (80% vs. 48.9%; P=0.003). Troponin values were similar in both groups 12 and 36 hours after surgery, as well as creatine kinase at 12 hours. A trend favored Group 1 in creatine kinase release at 36 hours (median 4.9; interquartile range 3.8-9.6 ng/mL vs. 7.3; 4.5-17.5 ng/mL; P=0.085). Perioperative mortality, rates of myocardial infarction, stroke, or major adverse cardiac and cerebrovascular events were similar. No difference in postoperative ejection fraction was noted (median 35.0%; interquartile range 32.0-38.0% vs. 35.0%; 32.0-40.0%; P=0.381). There was a trend for lower atrial fibrillation rate in Group 1 (6.7% vs. 17.8%; P=0.051). CONCLUSION The findings indicate that del Nido cardioplegia provides satisfactory protection in patients with reduced ejection fraction undergoing coronary bypass surgery. Further prospective trials are required.
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Affiliation(s)
- Krzysztof Sanetra
- Division 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
| | - Marta Mazur
- Department of Cardiology, Andrzej Frycz Modrzewski Krakow
University, Krakow, Poland
| | - Marta Kubaszewska
- Department of Cardiology, Andrzej Frycz Modrzewski Krakow
University, Krakow, Poland
| | - Ewa Pietrzyk
- Department of Cardiology, Andrzej Frycz Modrzewski Krakow
University, Krakow, Poland
| | - Piotr Paweł Buszman
- Department of Cardiology, Andrzej Frycz Modrzewski Krakow
University, Krakow, Poland
- Center for Cardiovascular Research and Development, American Heart
of Poland, Katowice, 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
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9
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Yang XF, Zhao XT, Xie HX, Guan M, Fu L, Jiang Y, Hou XT, Hei FL. [Myocardial protection of del Nido cardioplegia in adult cardiac and major vascular surgery with long aortic cross-clamp time]. Zhonghua Yi Xue Za Zhi 2023; 103:3917-3923. [PMID: 38129168 DOI: 10.3760/cma.j.cn112137-20231008-00669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 12/23/2023]
Abstract
Objective: To explore the safety and myocardial protection efficacy of del Nido cardioplegia in adult cardiac and major vascular surgery with long aortic cross-clamp (ACC) time. Methods: A total of 2 536 patients who underwent adult cardiac and major vascular surgery with ACC time>90 min at Beijing Anzhen Hospital from March 2018 to March 2023 were collected. The patients were divided into two groups according to the type of cardioplegia solution: the del Nido cardioplegia solution group (DC group) and the cold blood cardioplegia solution group (BC group). Preoperative baseline data of the patients (age, gender, comorbidities, ejection fraction, etc) were adjusted using propensity score matching (PSM). Cardiopulmonary bypass (CPB) time, ACC time, total amount of cardioplegia solution, in-hospital mortality rate, length of intensive care unit (ICU) stay, mechanical ventilation time, postoperative complications, left ventricular ejection fraction, and troponin levels were compared between the two groups. Results: After PSM, a total of 306 patients were included, including 223 males and 83 females, with a mean age of (52.0±12.3) years. There were 153 cases in the DC group and 153 cases in the BC group. Compared with the DC group, the cross-clamp time was longer [109(100, 150) min vs 102(91, 133) min, P<0.001], the rate of return to spontaneous rhythm was lower [51.6% (79/153) vs 86.9%(133/153), P<0.001], and intraoperative peak glucose was higher [12.6 (6.5, 15.9) mmol/L vs 10.1 (8.5, 12.4) mmol/L, P=0.005] in the BC group. In addition, perioperative mortality [4.6% (7/153) vs 3.3% (5/153), P=0.132], stroke[3.9% (6/153) vs 3.3% (5/153), P=0.759], renal insufficiency [3.3% (5/153) vs 6.5% (10/153), P=0.186], atrial fibrillation [4.6% (7/153) vs 2.6% (4/153), P=0.652] and low cardiac output syndrome [3.9% (6/153) vs 4.6% (7/153), P=0.716] did not differ between the two groups. Compared with BC group, DC group had lower level of high sensitivity troponin (hsTnI) [1.2 (0.8, 1.8) μg/L vs 1.3 (0.9, 2.3) μg/L, P=0.030] and creatine kinase isoenzyme (CK-MB) [31.0 (20.0, 48.9) μg/L vs 37.0 (24.0, 58.9) μg/L, P=0.011] at 24 h postoperatively, and shorter length of ICU stay [35.6 (19.8, 60.5) h vs 42.6 (21.9, 83.6) h, P=0.015] and mechanical ventilation time [20.5 (15.5, 41.0) h vs 31.5 (17.1, 56.0) h, P=0.012]. Subgroup analysis showed that in the 120-180 minute subgroup, patients in the DC group had a shorter cross-clamp time [132 (124, 135) min vs 136 (124, 138) min, P<0.001], while levels of hsTnI [1.6 (1.1, 2.0) μg/L vs 1.4 (1.0, 2.6) μg/L, P=0.030] and CK-MB [38.8 (23.5, 55.5) μg/L vs 37.0 (24.5, 62.3) μg/L, P=0.011] were higher than those in the BC group. Conclusions: In adult cardiac and major vascular surgery with ACC times>90 min, comparable myocardial protection is observed with the use of DC compared with BC. Additional advantages in glycemic control, return to spontaneous rhythm, and improved surgical procedures make DN an attractive alternative for myocardial protection in adult cardiac surgery.
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Affiliation(s)
- X F Yang
- Center for Cardiac Intensive Care, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
| | - X T Zhao
- Department of Extracorporeal Circulation and Mechanical Circulation Assistants, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
| | - H X Xie
- Department of Extracorporeal Circulation and Mechanical Circulation Assistants, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
| | - M Guan
- Department of Extracorporeal Circulation and Mechanical Circulation Assistants, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
| | - L Fu
- Department of Extracorporeal Circulation and Mechanical Circulation Assistants, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
| | - Y Jiang
- Department of Extracorporeal Circulation and Mechanical Circulation Assistants, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
| | - X T Hou
- Center for Cardiac Intensive Care, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
| | - F L Hei
- Department of Extracorporeal Circulation and Mechanical Circulation Assistants, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
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10
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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11
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Mukharyamov M, Schneider U, Kirov H, Caldonazo T, Doenst T. Myocardial protection in cardiac surgery-hindsight from the 2020s. Eur J Cardiothorac Surg 2023; 64:ezad424. [PMID: 38113432 DOI: 10.1093/ejcts/ezad424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 11/15/2023] [Accepted: 12/18/2023] [Indexed: 12/21/2023] Open
Abstract
Myocardial protection and specifically cardioplegia have been extensively investigated in the beginnings of cardiac surgery. After cardiopulmonary bypass had become routine, more and more cardiac operations were possible, requiring reliable and reproducible protection for times of blood flow interruptions to the most energy-demanding organ of the body. The concepts of hypothermia and cardioplegia evolved as tools to extend cardiac ischaemia tolerance to a degree considered safe for the required operation. A plethora of different solutions and delivery techniques were developed achieving remarkable outcomes with cross-clamp times of up to 120 min and more. With the beginning of the new millennium, interest in myocardial protection research declined and, as a consequence, conventional cardiac surgery is currently performed using myocardial protection strategies that have not changed in decades. However, the context, in which cardiac surgery is currently performed, has changed during this time. Patients are now older and suffer from more comorbidities and, thus, other organs move more and more into the centre of risk assessment. Yet, systemic effects of cardioplegic solutions have never been in the focus of attention. They say hindsight is always 20-20. We therefore review the biochemical principles of ischaemia, reperfusion and cardioplegic extension of ischaemia tolerance and address the concepts of myocardial protection with 'hindsight from the 2020s'. In light of rising patient risk profiles, minimizing surgical trauma and improving perioperative morbidity management becomes key today. For cardioplegia, this means accounting not only for cardiac, but also for systemic effects of cardioplegic solutions.
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Affiliation(s)
- Murat Mukharyamov
- Department of Cardiothoracic Surgery, Jena University Hospital, Friedrich Schiller University of Jena, Jena, Germany
| | - Ulrich Schneider
- Department of Cardiothoracic Surgery, Jena University Hospital, Friedrich Schiller University of Jena, Jena, Germany
| | - Hristo Kirov
- Department of Cardiothoracic Surgery, Jena University Hospital, Friedrich Schiller University of Jena, Jena, Germany
| | - Tulio Caldonazo
- Department of Cardiothoracic Surgery, Jena University Hospital, Friedrich Schiller University of Jena, Jena, Germany
| | - Torsten Doenst
- Department of Cardiothoracic Surgery, Jena University Hospital, Friedrich Schiller University of Jena, Jena, Germany
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12
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Garcia-Suarez J, Garcia-Fernandez J, Martinez Lopez D, Reques L, Sanz S, Carballo D, Martin CE, Ospina VM, Villar S, Martin A, Casado M, Villafranca A, Gonzalez AI, Serrano S, Forteza A. Clinical impact of del Nido cardioplegia in adult cardiac surgery: A prospective randomized trial. J Thorac Cardiovasc Surg 2023; 166:1458-1467. [PMID: 35279289 DOI: 10.1016/j.jtcvs.2022.01.044] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 01/09/2022] [Accepted: 01/23/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVE The study objective was to assess the benefits of del Nido cardioplegia compared with cold blood cardioplegia solution in terms of myocardial protection during adult cardiac surgery. METHODS A total of 474 adult patients undergoing coronary artery bypass grafting, heart valve surgery, thoracic aortic surgery, or combined procedures were randomized to the del Nido cardioplegia group (n = 234) or the cold blood cardioplegia solution group (n = 240) after provided informed consent. The primary end points assessed inotropic support requirements, severe cardiovascular events, and troponin trend within the first 48 hours of intensive care unit stay. Reperfusion arrhythmias, aortic crossclamp and cardiopulmonary bypass times, and other clinical perioperative variables were considered as secondary end points. RESULTS No statistically significant differences were found regarding postoperative inotropic support requirements or the incidence of severe cardiovascular events. The del Nido cardioplegia group showed a higher return to spontaneous sinus rhythm (P< .001), a lower number of defibrillation attempts (P< .001), and an earlier peak troponin value in the postoperative period. Peak blood glucose levels and intravenous insulin requirements were significantly lower in the del Nido cardioplegia group. We found no significant differences regarding aortic crossclamp or cardiopulmonary bypass time. We did observe a lower incidence of postoperative stroke in the del Nido cardioplegia group (2.6% vs 6.7%; P= .035). CONCLUSIONS del Nido cardioplegia can be used safely and with comparable outcomes compared with traditional cardioplegia solutions. Additional advantages over glycemic control, reperfusion arrhythmias, and its comfortable redosing interval make del Nido an interesting alternative for myocardial protection in adult cardiac surgery. A significant decrease in postoperative stroke will require further research to shed light on the results of this study. VIDEO ABSTRACT.
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Affiliation(s)
- Jessica Garcia-Suarez
- Department of Anesthesiology and Critical Care, Puerta de Hierro University Hospital, Madrid, Spain.
| | - Javier Garcia-Fernandez
- Department of Anesthesiology and Critical Care, Puerta de Hierro University Hospital, Madrid, Spain
| | | | - Leticia Reques
- Cardiac Surgery Perfusion Department, Puerta de Hierro University Hospital, Madrid, Spain
| | - Sergio Sanz
- Department of Anesthesiology and Critical Care, Puerta de Hierro University Hospital, Madrid, Spain
| | - Daniel Carballo
- Department of Anesthesiology and Critical Care, Puerta de Hierro University Hospital, Madrid, Spain
| | | | - Victor Manuel Ospina
- Department of Cardiac Surgery, Puerta de Hierro University Hospital, Madrid, Spain
| | - Susana Villar
- Department of Cardiac Surgery, Puerta de Hierro University Hospital, Madrid, Spain
| | - Ana Martin
- Cardiac Surgery Perfusion Department, Puerta de Hierro University Hospital, Madrid, Spain
| | - Maria Casado
- Department of Anesthesiology and Critical Care, Puerta de Hierro University Hospital, Madrid, Spain
| | - Ana Villafranca
- Department of Anesthesiology and Critical Care, Puerta de Hierro University Hospital, Madrid, Spain
| | - Ana Isabel Gonzalez
- Department of Anesthesiology and Critical Care, Puerta de Hierro University Hospital, Madrid, Spain
| | - Santiago Serrano
- Department of Cardiac Surgery, Puerta de Hierro University Hospital, Madrid, Spain
| | - Alberto Forteza
- Department of Cardiac Surgery, Puerta de Hierro University Hospital, Madrid, Spain
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13
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Pozzoli A, Gabriella Surace G, Torre T, Bagnato P, Gallo M, Toto F, Ferrari E, Demertzis S. del Nido versus hematic cardioplegia in minimally invasive aortic valve surgery. Asian Cardiovasc Thorac Ann 2023; 31:795-801. [PMID: 37876227 DOI: 10.1177/02184923231209858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2023]
Abstract
BACKGROUND The quality of a myocardial protection of a single-dose del Nido cardioplegia versus multiple dose blood-based cardioplegia on myocardial injury, outcomes and operative times in patients undergoing minimally invasive aortic valve replacement is basically unreported. METHODS AND RESULTS Preoperative and post-operative data, as well as technical details from isolated minimally invasive aortic valve replacements, performed using single-dose or multiple-dose cardioplegia were prospectively collected and retrospectively analysed. A total of 110 patients undergoing minimally invasive valve replacements at our institution composed two groups: 55 patients in the blood cardioplegia group (BloCa) and 55 in the del Nido group (DeNiCa). The two-matched groups were comparable in terms of preoperative variables. In the DeNiCa group, there was a statistically significant less need for cardiac defibrillation after aortic cross-clamp release (p < 0.001). Moreover, the BloCa group received intraoperatively more blood transfusions (p = 0.001) and more insulin administration for higher glucose levels (p < 0.001). The BloCa group showed higher intraoperative lactate levels (p = 0.01). Need for post-operative inotropic and vasoactive support, Creatine Kinase-MB levels after 6 and 12 h, onset of post-operative atrial fibrillation and length of stay were similar. No deaths occurred in neither groups. CONCLUSION Single-dose del Nido cardioplegia in the setting of minimally invasive aortic surgery seems to offer adequate myocardial protection, comparable to multiple dose hematic cardioplegia. It has been documented a lower peri-operative need of defibrillation after cross-clamp release, lactate- and glucose peak values, as well as less blood transfusions compared to blood cardioplegic strategy.
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Affiliation(s)
- Alberto Pozzoli
- Heart Surgery Unit, Cardiocentro Ticino Institute, EOC, Lugano, Switzerland
| | | | - Tiziano Torre
- Heart Surgery Unit, Cardiocentro Ticino Institute, EOC, Lugano, Switzerland
| | - Pietro Bagnato
- Heart Surgery Unit, Cardiocentro Ticino Institute, EOC, Lugano, Switzerland
| | - Michele Gallo
- Heart Surgery Unit, Cardiocentro Ticino Institute, EOC, Lugano, Switzerland
| | - Francesca Toto
- Heart Surgery Unit, Cardiocentro Ticino Institute, EOC, Lugano, Switzerland
| | - Enrico Ferrari
- Heart Surgery Unit, Cardiocentro Ticino Institute, EOC, Lugano, Switzerland
- Faculty of Biomedical Sciences, Università della Svizzera Italiana (USI), Lugano, Switzerland
- Faculty of Medicine, University of Zurich, Zurich, Switzerland
| | - Stefanos Demertzis
- Heart Surgery Unit, Cardiocentro Ticino Institute, EOC, Lugano, Switzerland
- Faculty of Biomedical Sciences, Università della Svizzera Italiana (USI), Lugano, Switzerland
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14
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Elmahrouk AF, Shihata MS, Al-Radi OO, Arafat AA, Altowaity M, Alshaikh BA, Galal MN, Bogis AA, Al Omar HY, Assiri WJ, Jamjoom AA. Custodiol versus blood cardioplegia in pediatric cardiac surgery: a randomized controlled trial. Eur J Med Res 2023; 28:404. [PMID: 37798628 PMCID: PMC10552411 DOI: 10.1186/s40001-023-01372-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 09/17/2023] [Indexed: 10/07/2023] Open
Abstract
BACKGROUND Blood-based cardioplegia is the standard myocardial protection strategy in pediatric cardiac surgery. Custadiol (histidine-tryptophan-ketoglutarate), an alternative, may have some advantages but is potentially less effective at myocardial protection. This study aimed to test whether custadiol is not inferior to blood-based cardioplegia in pediatric cardiac surgery. METHODS The study was designed as a randomized controlled trial with a blinded outcome assessment. All pediatric patients undergoing cardiac surgery with cardiopulmonary bypass and cardioplegia, including neonates, were eligible. Emergency surgery was excluded. The primary outcome was a composite of death within 30 days, an ICU stay longer than 5 days, or arrhythmia requiring intervention. Secondary endpoints included total hospital stay, inotropic score, cardiac troponin levels, ventricular function, and extended survival postdischarge. The sample size was determined a priori for a noninferiority design with an expected primary outcome of 40% and a clinical significance difference of 20%. RESULTS Between January 2018 and January 2021, 226 patients, divided into the Custodiol cardioplegia (CC) group (n = 107) and the blood cardioplegia (BC) group (n = 119), completed the study protocol. There was no difference in the composite endpoint between the CC and BC groups, 65 (60.75%) vs. 71 (59.66%), respectively (P = 0.87). The total length of stay in the hospital was 14 (Q2-Q3: 10-19) days in the CC group vs. 13 (10-21) days in the BC group (P = 0.85). The inotropic score was not significantly different between the CC and BC groups, 5 (2.6-7.45) vs. 5 (2.6-7.5), respectively (P = 0.82). The cardiac troponin level and ventricular function did not differ significantly between the two groups (P = 0.34 and P = 0.85, respectively). The median duration of follow-up was 32.75 (Q2-Q3: 18.73-41.53) months, and there was no difference in survival between the two groups (log-rank P = 0.55). CONCLUSIONS Custodial cardioplegia is not inferior to blood cardioplegia for myocardial protection in pediatric patients. Trial registration The trial was registered in Clinicaltrials.gov, and the ClinicalTrials.gov Identifier number is NCT03082716 Date: 17/03/2017.
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Affiliation(s)
- Ahmed F Elmahrouk
- Cardiothoracic Surgery Department, King Faisal Specialist Hospital and Research Centre,, MBC J-16, P.O. Box: 40047, 21499, Jeddah, Saudi Arabia.
- Cardiothoracic Surgery Department, Tanta University, Tanta, Egypt.
| | - Mohammad S Shihata
- Cardiothoracic Surgery Department, King Faisal Specialist Hospital and Research Centre,, MBC J-16, P.O. Box: 40047, 21499, Jeddah, Saudi Arabia
| | - Osman O Al-Radi
- Cardiothoracic Surgery Department, King Faisal Specialist Hospital and Research Centre,, MBC J-16, P.O. Box: 40047, 21499, Jeddah, Saudi Arabia
- Department of Surgery, Cardiac Surgery Section, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Amr A Arafat
- Cardiothoracic Surgery Department, Tanta University, Tanta, Egypt
| | - Musleh Altowaity
- Cardiothoracic Surgery Department, King Faisal Specialist Hospital and Research Centre,, MBC J-16, P.O. Box: 40047, 21499, Jeddah, Saudi Arabia
| | - Bayan A Alshaikh
- Cardiac Surgery Department, King Fahad Armed Forces Hospital, Jeddah, Saudi Arabia
| | - Mohamed N Galal
- Pediatric Cardiac Surgery Department, King Fahad Armed Forces Hospital, Jeddah, Saudi Arabia
| | - Abdulbadee A Bogis
- Cardiothoracic Surgery Department, King Faisal Specialist Hospital and Research Centre,, MBC J-16, P.O. Box: 40047, 21499, Jeddah, Saudi Arabia
| | - Haneen Y Al Omar
- Research Centre, King Faisal Specialist Hospital and Research Centre, Jeddah, Saudi Arabia
| | - Wesal J Assiri
- Department of Nursing, King Faisal Specialist Hospital and Research Centre, Jeddah, Saudi Arabia
| | - Ahmed A Jamjoom
- Cardiothoracic Surgery Department, King Faisal Specialist Hospital and Research Centre,, MBC J-16, P.O. Box: 40047, 21499, Jeddah, Saudi Arabia
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15
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Matsumoto R, Fujiyoshi T, Kamiya K, Matsubayashi J, Fukuda S, Nishibe T, Ogino H. Complete Resection of a Cavoatrial Metastatic Liposarcoma under Hypothermic Circulatory Arrest. Ann Thorac Cardiovasc Surg 2023; 29:206-209. [PMID: 35095053 PMCID: PMC10466114 DOI: 10.5761/atcs.cr.21-00226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Accepted: 12/19/2021] [Indexed: 11/16/2022] Open
Abstract
A patient underwent surgical resection twice for primary and metastatic dedifferentiated liposarcomas. Computed tomography revealed a tumor mass at the cavoatrial junction. Prompt surgical resection of the tumor with thrombectomy was successfully performed using cardiopulmonary bypass with hypothermic circulatory arrest. Despite the poor prognosis of metastatic or recurrent liposarcoma, the patient has survived for 8 years since the first tumor resection.
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Affiliation(s)
- Ryumon Matsumoto
- Department of Cardiovascular Surgery, Tokyo Medical University, Tokyo, Japan
| | - Toshiki Fujiyoshi
- Department of Cardiovascular Surgery, Tokyo Medical University, Tokyo, Japan
| | - Kentaro Kamiya
- Department of Cardiovascular Surgery, Tokyo Medical University, Tokyo, Japan
| | | | - Shoji Fukuda
- Department of Cardiovascular Surgery, Tokyo Medical University, Tokyo, Japan
| | - Toshiya Nishibe
- Department of Cardiovascular Surgery, Tokyo Medical University, Tokyo, Japan
| | - Hitoshi Ogino
- Department of Cardiovascular Surgery, Tokyo Medical University, Tokyo, Japan
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16
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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17
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Jia B, Luo C, Li C, Ge Y, Zhong Y, Qiao Z, Hu H, Yang Y, Yu H, Zhu J. Aortic Arch-Clamping Technique in Hemiarch Replacement Without Circulatory Arrest. Heart Lung Circ 2023; 32:e47-e50. [PMID: 37308365 DOI: 10.1016/j.hlc.2023.04.292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 03/11/2023] [Accepted: 04/16/2023] [Indexed: 06/14/2023]
Abstract
The open anastomosis technique has become more popular since it was first used in hemiarch replacement; however, hypothermic circulatory arrest is unavoidable. This institution performed a novel surgical technique called the arch-clamping technique. It has been used in the treatment of patients with ascending aortic aneurysm extending to the proximal aortic arch and avoids the use of hypothermic circulatory arrest. Thirty patients had a hemiarch replacement with the arch-clamping technique from 2021 to 2022; all of them were discharged uneventfully.
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Affiliation(s)
- Bo Jia
- Department of Cardiovascular Surgery, Beijing Aortic Disease Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Cheng Luo
- Department of Cardiovascular Surgery, Beijing Aortic Disease Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Chengnan Li
- Department of Cardiovascular Surgery, Beijing Aortic Disease Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Yipeng Ge
- Department of Cardiovascular Surgery, Beijing Aortic Disease Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Yongliang Zhong
- Department of Cardiovascular Surgery, Beijing Aortic Disease Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Zhiyu Qiao
- Department of Cardiovascular Surgery, Beijing Aortic Disease Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Haiou Hu
- Department of Cardiovascular Surgery, Beijing Aortic Disease Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Yi Yang
- Department of Cardiovascular Surgery, Beijing Aortic Disease Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Hai Yu
- Department of Cardiovascular Surgery, Beijing Aortic Disease Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Junming Zhu
- Department of Cardiovascular Surgery, Beijing Aortic Disease Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.
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Stoica S, Smartt HJM, Heys R, Sheehan K, Walker-Smith T, Parry A, Beringer R, Ttofi I, Evans R, Dabner L, Ghorbel MT, Lansdowne W, Reeves BC, Angelini GD, Rogers CA, Caputo M. Warm versus cold blood cardioplegia in paediatric congenital heart surgery: a randomized trial. Eur J Cardiothorac Surg 2023; 63:ezad041. [PMID: 36799559 PMCID: PMC10097434 DOI: 10.1093/ejcts/ezad041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 12/06/2022] [Indexed: 02/18/2023] Open
Abstract
OBJECTIVES Intermittent cold blood cardioplegia is commonly used in children, whereas intermittent warm blood cardioplegia is widely used in adults. We aimed to compare clinical and biochemical outcomes with these 2 methods. METHODS A single-centre, randomized controlled trial was conducted to compare the effectiveness of warm (≥34°C) versus cold (4-6°C) antegrade cardioplegia in children. The primary outcome was cardiac troponin T over the 1st 48 postoperative hours. Intensive care teams were blinded to group allocation. Outcomes were compared by intention-to-treat using linear mixed-effects, logistic or Cox regression. RESULTS 97 participants with median age of 1.2 years were randomized (49 to warm, 48 to cold cardioplegia); 59 participants (61%) had a risk-adjusted congenital heart surgery score of 3 or above. There were no deaths and 92 participants were followed to 3-months. Troponin release was similar in both groups [geometric mean ratio 1.07; 95% confidence interval (CI) 0.79-1.44; P = 0.66], as were other cardiac function measures (echocardiography, arterial and venous blood gases, vasoactive-inotrope score, arrhythmias). Intensive care stay was on average 14.6 h longer in the warm group (hazard ratio 0.52; 95% CI 0.34-0.79; P = 0.003), with a trend towards longer overall hospital stays (hazard ratio 0.66; 95% CI 0.43-1.02; P = 0.060) compared with the cold group. This could be related to more unplanned reoperations on bypass in the warm group compared to cold group (3 vs 1). CONCLUSIONS Warm blood cardioplegia is a safe and reproducible technique but does not provide superior myocardial protection in paediatric heart surgery.
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Affiliation(s)
- Serban Stoica
- Bristol Royal Hospital for Children, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Helena J M Smartt
- Bristol Trials Centre, Bristol Medical School, University of Bristol, Bristol, UK
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust and University of Bristol, Bristol, UK
| | - Rachael Heys
- Bristol Trials Centre, Bristol Medical School, University of Bristol, Bristol, UK
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust and University of Bristol, Bristol, UK
| | - Karen Sheehan
- Bristol Royal Hospital for Children, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust and University of Bristol, Bristol, UK
| | - Terrie Walker-Smith
- Bristol Trials Centre, Bristol Medical School, University of Bristol, Bristol, UK
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust and University of Bristol, Bristol, UK
| | - Andrew Parry
- Bristol Royal Hospital for Children, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Richard Beringer
- Bristol Royal Hospital for Children, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Iakovos Ttofi
- Bristol Royal Hospital for Children, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Rebecca Evans
- Bristol Trials Centre, Bristol Medical School, University of Bristol, Bristol, UK
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust and University of Bristol, Bristol, UK
| | - Lucy Dabner
- Bristol Trials Centre, Bristol Medical School, University of Bristol, Bristol, UK
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust and University of Bristol, Bristol, UK
| | | | - William Lansdowne
- Bristol Royal Hospital for Children, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Barnaby C Reeves
- Bristol Trials Centre, Bristol Medical School, University of Bristol, Bristol, UK
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust and University of Bristol, Bristol, UK
| | - Gianni D Angelini
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust and University of Bristol, Bristol, UK
- Bristol Heart Institute, University of Bristol, Bristol, UK
| | - Chris A Rogers
- Bristol Trials Centre, Bristol Medical School, University of Bristol, Bristol, UK
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust and University of Bristol, Bristol, UK
| | - Massimo Caputo
- Bristol Royal Hospital for Children, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
- Bristol Heart Institute, University of Bristol, Bristol, UK
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19
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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20
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Sazzad F, Ong ZX, Ong GS, Luo HD, Guim Goh S, Kofidis T, Vitaly S. Non-selective Del Nido and St Thomas cardioplegia in adults: analysis of early clinical experience using propensity matching. Ther Adv Cardiovasc Dis 2023; 17:17539447231210713. [PMID: 37991005 PMCID: PMC10666688 DOI: 10.1177/17539447231210713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 10/12/2023] [Indexed: 11/23/2023] Open
Abstract
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.
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Affiliation(s)
- Faizus Sazzad
- Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Centre for Translational Medicine, MD6, 14 Medical Drive, Level-8 (South), Singapore 117599, Singapore
| | - Zhi Xian Ong
- Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Geok Seen Ong
- Department of Cardiac, Thoracic and Vascular Surgery, National University Heart Centre, Singapore, Singapore
| | - Hai Dong Luo
- Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Si Guim Goh
- Department of Cardiac, Thoracic and Vascular Surgery, National University Heart Centre, Singapore, Singapore
| | - Theo Kofidis
- Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Department of Cardiac, Thoracic and Vascular Surgery, National University Heart Centre, Singapore, Singapore
| | - Sorokin Vitaly
- Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Department of Cardiac, Thoracic and Vascular Surgery, National University Heart Centre, Singapore, Singapore
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21
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Demir D, Balci AB, Kahraman N, Sunbul SA, Gucu A, Seker IB, Badem S, Yuksel A, Ozyazicioglu AF, Goncu MT. The comparison of del nido cardioplegia and crystalloid-based blood cardioplegia in adult isolated coronary bypass surgery: A randomized controlled trial. Niger J Clin Pract 2022; 25:1998-2004. [PMID: 36537457 DOI: 10.4103/njcp.njcp_435_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
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 0th hour (baseline), 12th, 36th, and 60th hours. There was no statistical difference between groups in troponin T levels of the baseline 0th hour (18[33] vs. 22[27] pg/ml; P = 0.724). Troponin T levels at the 12th 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 36th and 60th 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.
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Affiliation(s)
- D Demir
- Department of Cardiovasculary Surgery, Bursa City Hospital, Bursa, Turkey
| | - A B Balci
- Department of Cardiovasculary Surgery, Şırnak State Hospital, Şırnak, Turkey
| | - N Kahraman
- Department of Cardiovasculary Surgery, Bursa City Hospital, Bursa, Turkey
| | - S A Sunbul
- Department of Cardiovasculary Surgery, Bursa Yüksek İhtisas Hospital, Bursa, Turkey
| | - A Gucu
- Department of Cardiovasculary Surgery, Bursa Yüksek İhtisas Hospital, Bursa, Turkey
| | - I B Seker
- Department of Cardiovasculary Surgery, Bursa Yüksek İhtisas Hospital, Bursa, Turkey
| | - S Badem
- Department of Cardiovasculary Surgery, Bursa City Hospital, Bursa, Turkey
| | - A Yuksel
- Department of Cardiovasculary Surgery, Bursa City Hospital, Bursa, Turkey
| | - A F Ozyazicioglu
- Department of Cardiovasculary Surgery, Bursa Yüksek İhtisas Hospital, Bursa, Turkey
| | - M T Goncu
- Department of Cardiovasculary Surgery, Bursa Yüksek İhtisas Hospital, Bursa, Turkey
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22
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Honzel E, Nemeth S, Kazzi BE, Kossar AP, Sun J, Kaku Y, Takeda K, Takayama H, Argenziano M, Spellman J, Miltiades A, Fung K, Beck J, Smith CR, Kurlansky P, George I. Assessing sex-based differences in postsurgical clinical outcomes after use of del Nido cardioplegia. Eur J Cardiothorac Surg 2022; 62:ezac472. [PMID: 36165688 PMCID: PMC9531685 DOI: 10.1093/ejcts/ezac472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 08/25/2022] [Accepted: 09/25/2022] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES del Nido cardioplegia is used to pharmacologically arrest the heart during cardiac surgery and decrease reperfusion- and ischaemia-related myocardial injury. Studies have demonstrated the physiological differences between male and female hearts, potentially related to cardiac size or myocyte calcium handling; we aimed to assess for between-sex differences in clinical outcomes after receipt of del Nido cardioplegia. METHODS Patients who underwent coronary artery bypass or coronary artery bypass graft/valve surgery at our institution using del Nido cardioplegia (January 2014 to December 2019) were included (n = 2118). Clinical data were collected retrospectively. After the creation of a propensity-matched cohort (n = 1252), multivariable logistic regression was used to analyse binary postoperative outcomes, and a Gamma model was used for a continuous postoperative outcome. Our primary end-point was a composite end-point comprised of 30-day mortality and/or need for a post-bypass mechanical support device. RESULTS The final cohort included 459 females and 793 males (matched up to 1:2, all standardized mean differences <0.1). Multivariable logistic regression showed that biological sex was not associated with the composite primary end-point (odds ratio = 0.898, P = 0.779). A Gamma model indicated that there were no sex-related differences in vasoactive-inotropic scores reflecting vasopressor and inotrope usage at the time of patient operating room exit (exp[est] = 1.394, P = 0.189). CONCLUSIONS Our findings showed no significant between-sex differences in clinical outcomes after receiving del Nido cardioplegia, suggesting adequate myocardial protection as currently administered. Further research is warranted to elicit if there are sex-based differences between cardioplegic solutions. IRB APPROVAL DATE (PROTOCOL NUMBER) 26 May 2021 (AAAR8359).
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Affiliation(s)
- Emily Honzel
- Division of Cardiothoracic Surgery, NewYork Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY, USA
| | - Samantha Nemeth
- Center for Innovation and Outcomes Research, Columbia University Irving Medical Center, New York, NY, USA
| | - Brigitte E Kazzi
- Department of Medicine, The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Alexander P Kossar
- Division of Cardiothoracic Surgery, NewYork Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY, USA
| | - Jocelyn Sun
- Center for Innovation and Outcomes Research, Columbia University Irving Medical Center, New York, NY, USA
| | - Yuji Kaku
- Division of Cardiothoracic Surgery, NewYork Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY, USA
| | - Koji Takeda
- Division of Cardiothoracic Surgery, NewYork Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY, USA
| | - Hiroo Takayama
- Division of Cardiothoracic Surgery, NewYork Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY, USA
| | - Michael Argenziano
- Division of Cardiothoracic Surgery, NewYork Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY, USA
| | - Jessica Spellman
- Division of Cardiothoracic Surgery, NewYork Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY, USA
| | - Andrea Miltiades
- Division of Cardiothoracic Surgery, NewYork Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY, USA
| | - Kenmond Fung
- Division of Cardiothoracic Surgery, NewYork Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY, USA
| | - James Beck
- Division of Cardiothoracic Surgery, NewYork Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY, USA
| | - Craig R Smith
- Division of Cardiothoracic Surgery, NewYork Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY, USA
| | - Paul Kurlansky
- Center for Innovation and Outcomes Research, Columbia University Irving Medical Center, New York, NY, USA
| | - Isaac George
- Division of Cardiothoracic Surgery, NewYork Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY, USA
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23
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Kramer AM, Kiss A, Heber S, Chambers DJ, Hallström S, Pilz PM, Podesser BK, Santer D. Normothermic blood polarizing versus depolarizing cardioplegia in a porcine model of cardiopulmonary bypass. Interact Cardiovasc Thorac Surg 2022; 35:ivac152. [PMID: 35640544 PMCID: PMC9199933 DOI: 10.1093/icvts/ivac152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 04/30/2022] [Accepted: 05/25/2022] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES We have previously demonstrated beneficial cardiac protection with hypothermic polarizing cardioplegia compared to a hyperkalemic depolarizing cardioplegia. In this study, a porcine model of cardiopulmonary bypass was used to compare the protective effects of normothermic blood-based polarizing and depolarizing cardioplegia during cardiac arrest. METHODS Thirteen pigs were randomized to receive either normothermic polarizing (n = 8) or depolarizing (n = 5) blood-based cardioplegia. After initiation of cardiopulmonary bypass, normothermic arrest (34°C, 60 min) was followed by 60 min of on-pump and 90 min of off-pump reperfusion. Primary outcome was myocardial injury measured as arterial myocardial creatine kinase concentration. Secondary outcome was haemodynamic function and the energy state of the hearts. RESULTS During reperfusion, release of myocardial creatine kinase was comparable between groups (P = 0.36). In addition, most haemodynamic parameters showed comparable results between groups, but stroke volume (P = 0.03) was significantly lower in the polarizing group. Adenosine triphosphate levels were significantly (18.41 ± 3.86 vs 22.97 ± 2.73 nmol/mg; P = 0.03) lower in polarizing hearts, and the requirement for noradrenaline administration (P = 0.002) and temporary pacing (6 vs 0; P = 0.02) during reperfusion were significantly higher in polarizing hearts. CONCLUSIONS Under normothermic conditions, polarizing blood cardioplegia was associated with similar myocardial injury to depolarizing blood cardioplegia. Reduced haemodynamic and metabolic outcome and a higher need for temporary pacing with polarized arrest may be associated with the blood-based dilution of this solution.
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Affiliation(s)
- Anne-Margarethe Kramer
- Ludwig Boltzmann Institute for Cardiovascular Research at the Center for Biomedical Research, Medical University of Vienna, Vienna, Austria
| | - Attila Kiss
- Ludwig Boltzmann Institute for Cardiovascular Research at the Center for Biomedical Research, Medical University of Vienna, Vienna, Austria
| | - Stefan Heber
- Institute of Physiology, Center for Physiology and Pharmacology, Medical University of Vienna, Vienna, Austria
| | - David J Chambers
- Cardiac Surgical Research, The Rayne Institute (King’s College London), Guy’s and St Thomas’ NHS Foundation Trust, St Thomas’ Hospital, London, UK
| | - Seth Hallström
- Division of Physiological Chemistry, Otto Loewi Research Center, Medical University of Graz, Graz, Austria
| | - Patrick M Pilz
- Ludwig Boltzmann Institute for Cardiovascular Research at the Center for Biomedical Research, Medical University of Vienna, Vienna, Austria
| | - Bruno K Podesser
- Ludwig Boltzmann Institute for Cardiovascular Research at the Center for Biomedical Research, Medical University of Vienna, Vienna, Austria
| | - David Santer
- Ludwig Boltzmann Institute for Cardiovascular Research at the Center for Biomedical Research, Medical University of Vienna, Vienna, Austria
- Department of Cardiac Surgery, University Hospital of Basel, Basel, Switzerland
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Suarez-Pierre A, Lui C, Zhou X, Kearney S, Jones M, Wang J, Thomas RP, Gaughan N, Metkus TS, Brady MB, Cho BC, Dodd-O JM, Lawton JS. Diazoxide preserves myocardial function in a swine model of hypothermic cardioplegic arrest and prolonged global ischemia. J Thorac Cardiovasc Surg 2022; 163:e385-e400. [PMID: 32977969 DOI: 10.1016/j.jtcvs.2020.08.069] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2020] [Revised: 08/18/2020] [Accepted: 08/18/2020] [Indexed: 10/23/2022]
Abstract
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.
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Affiliation(s)
| | - Cecillia Lui
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Xun Zhou
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Sean Kearney
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Melissa Jones
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Jie Wang
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Rosmi P Thomas
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Natalie Gaughan
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Thomas S Metkus
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Mary B Brady
- Division of Cardiac Anesthesiology, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Brian C Cho
- Division of Cardiac Anesthesiology, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Jeffrey M Dodd-O
- Division of Cardiac Anesthesiology, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Jennifer S Lawton
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Md.
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Nagashima K, Inoue T, Nakanaga H, Matsuyama S, Geshi E, Tabata M. Impact of the Cardioplegia Interval on Myocardial Protection Using the Modified St. Thomas Solution in Minimally Invasive Mitral Valve Surgery: A Double-Center Study. J Extra Corpor Technol 2022; 54:135-141. [PMID: 35928335 PMCID: PMC9302395 DOI: 10.1182/ject-135-141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 05/23/2022] [Indexed: 06/15/2023]
Abstract
It has been reported that a single-dose cardioplegia interval is useful, but the safe interval doses are not clear. We aimed to investigate the impact of the cardioplegia interval on myocardial protection using the modified St. Thomas solution. We included consecutive isolated minimally invasive mitral valvuloplasty procedures (n = 229) performed at a hospital and medical center from January 2014 to December 2020. We compared postoperative peak creatine kinase MB and creatine kinase levels and other indicators between the short (Group S, n = 135; maximum myocardial protection interval <60 minutes) and long (Group L, n = 94; maximum myocardial protection interval ≥60 minutes) interval groups. Propensity score matching was used to adjust for confounders between the two groups. After propensity score matching, Groups S and L contained 47 patients each. Groups S and L did not differ significantly in peak creatine kinase MB (45.8 ± 26.3 IU/L and 41.5 ± 27.9 IU/L, respectively; p = .441) and creatine kinase levels (1,133 ± 567 IU/L and 1,100 ± 916 IU/L, respectively; p = .837) after admission to the intensive care unit on the day of surgery based on propensity score matching. In multivariate analysis, a cardioplegia dosing interval ≥60 minutes was not significantly associated with the maximum creatine kinase MB level after admission to the intensive care unit on the day of surgery (p = .354; 95% confidence interval: -1.67 to 4.65). Using the antegrade modified St. Thomas solution, the long interval dose method is useful and safe in minimally invasive mitral valvuloplasty.
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Affiliation(s)
- Kohei Nagashima
- Department of Clinical Engineering, Toranomon Hospital, Tokyo, Japan
- Showa University Postgraduate School of Health Sciences, Tokyo, Japan
| | - Takafumi Inoue
- Department of Cardiovascular Surgery, Toranomon Hospital, Tokyo, Japan; and
| | - Hiroshi Nakanaga
- Department of Cardiovascular Surgery, Toranomon Hospital, Tokyo, Japan; and
| | | | - Eiichi Geshi
- Showa University Postgraduate School of Health Sciences, Tokyo, Japan
| | - Minoru Tabata
- Showa University Postgraduate School of Health Sciences, Tokyo, Japan
- Department of Cardiovascular Surgery, Tokyo Bay Urayasu Ichikawa Medical Center, Chiba, Japan
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Matsuno Y, Mitta S, Umeda Y, Mori Y. [Stanford Type A Acute Aortic Dissection with Persistent Left Superior Vena Cava in a Turner Syndrome Patient:Report of a Case]. Kyobu Geka 2022; 75:199-202. [PMID: 35249953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
A 48-year-old woman who was diagnosed with Turner syndrome in her childhood presented with sudden onset of low back pain and respiratory discomfort. Contrast enhanced computed tomography scan revealed Stanford type A acute aortic dissection with persistent left superior vena cava (PLSVC). Emergency ascending aortic replacement was performed. After cardiopulmonary bypass was established through cannulating right femoral artery and right superior vena cava, inferior vena cava, another venous cannula was directly placed into the left superior vena cava. After core cooling, the right atrium was incised for retrograde cardioplegia. At a tympanic temperature of 25 ℃, circulatory arrest was started and retrograde cerebral perfusion was performed through right and left superior vena cava. Her postoperative course was uneventful.
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Affiliation(s)
- Yukihiro Matsuno
- Department of Cardiovascular Surgery, Gifu Prefectural General Medical Center, Gifu, Japan
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Nowicki R, Bieżuńska-Kusiak K, Kulbacka J, Choromanska A, Daczewska M, Potoczek S, Rachwalik M, Saczko J. St. Thomas Modified Cardioplegia Effects on Myoblasts’ Viability and Morphology. Medicina (B Aires) 2022; 58:medicina58020280. [PMID: 35208603 PMCID: PMC8879905 DOI: 10.3390/medicina58020280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 02/02/2022] [Accepted: 02/11/2022] [Indexed: 11/16/2022] Open
Abstract
Background and Objectives: The cardioplegic arrest of the heart during cardiosurgical procedures is the crucial element of a cardioprotection strategy. Numerous clinical trials compare different cardioplegic solutions and cardioprotective protocols, but a relatively small number of papers apply to in vitro conditions using cultured cells. This work aimed to analyze whether it is possible to use the rat heart myocardium cells as an in vitro model to study the protective properties of St. Thomas cardioplegia (ST2C). Methods: The rat heart myocardium cells-H9C2 were incubated with cold cardioplegia for up to 24 h. After incubation, we determined: viability, confluency, and cell size, the thiol groups’ level by modifying Ellman’s method, Ki67, and Proliferating Cell Nuclear Antigen expression (PCNA). The impact on cells’ morphology was visualized by the ultrastructural (TEM) study and holotomograpic 3D imaging. Results: The viability and confluency analysis demonstrated that the safest exposure to ST2C, should not exceed 4h. An increased expression of Ki67 antigen and PCNA was observed. TEM and 3D imaging studies revealed vacuolization after the longest period of exposure (24). Conclusions: According to obtained results, we conclude that STC can play a protective role in cardiac surgery during heart arrest.
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Affiliation(s)
- Rafał Nowicki
- Department of Cardiac Surgery, Wroclaw Medical University, Curie-Skłodowskiej, 50-369 Wrocław, Poland;
- Correspondence:
| | - Katarzyna Bieżuńska-Kusiak
- Department of Molecular and Cellular Biology, Wroclaw Medical University, Borowska 211A, 50-368 Wrocław, Poland; (K.B.-K.); (J.K.); (A.C.); (J.S.)
| | - Julita Kulbacka
- Department of Molecular and Cellular Biology, Wroclaw Medical University, Borowska 211A, 50-368 Wrocław, Poland; (K.B.-K.); (J.K.); (A.C.); (J.S.)
| | - Anna Choromanska
- Department of Molecular and Cellular Biology, Wroclaw Medical University, Borowska 211A, 50-368 Wrocław, Poland; (K.B.-K.); (J.K.); (A.C.); (J.S.)
| | - Małgorzata Daczewska
- Department of Animal Developmental Biology, Institute of Experimental Biology, University of Wroclaw, Sienkiewicza 21 St., 50-335 Wrocław, Poland;
| | - Stanisław Potoczek
- Department of Hematology, Blood Neoplasms and Bone Marrow Transplantation, Wroclaw Medical University, Wybrzeże Pasteura 4, 50-367 Wrocław, Poland;
| | - Maciej Rachwalik
- Department of Cardiac Surgery, Wroclaw Medical University, Curie-Skłodowskiej, 50-369 Wrocław, Poland;
| | - Jolanta Saczko
- Department of Molecular and Cellular Biology, Wroclaw Medical University, Borowska 211A, 50-368 Wrocław, Poland; (K.B.-K.); (J.K.); (A.C.); (J.S.)
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Isildak FU, Yavuz Y. Comparison of Del Nido and Blood Cardioplegia in Pediatric Patients Undergoing Surgical Repair for Congenital Heart Disease. Pediatr Cardiol 2021; 42:1388-1393. [PMID: 33937960 DOI: 10.1007/s00246-021-02623-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 04/17/2021] [Indexed: 11/27/2022]
Abstract
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.
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Affiliation(s)
- Fatma Ukil Isildak
- Department of Anesthesiology and Reanimation, Kartal Koşuyolu High Speciality Educational and Research Hospital, Istanbul, Turkey.
- T. C. Saglik Bakanligi Kartal Kosuyolu Yuksek Ihtisas Egitim ve Arastirma Hastanesi, Cevizli, 2, Denizer Caddesi, Cevizli Kavsagi, Kartal, 34865, Istanbul, Turkey.
| | - Yasemin Yavuz
- Department of Anesthesiology and Reanimation, Kartal Koşuyolu High Speciality Educational and Research Hospital, Istanbul, Turkey
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Russo M, Di Mauro M, Saitto G, Lio A, Berretta P, Taramasso M, Scrofani R, Della Corte A, Sponga S, Greco E, Saccocci M, Calafiore A, Bianchi G, Leviner DB, Biondi A, Della Ratta E, Livi U, Sharoni E, Werner P, De Vincentiis C, Di Eusanio M, Kocher A, Antona C, Miraldi F, Troise G, Solinas M, Maisano F, Laufer G, Musumeci F, Andreas M. Beating vs Arrested Heart Isolated Tricuspid Valve Surgery: Long-term Outcomes. Ann Thorac Surg 2021; 113:585-592. [PMID: 33831392 DOI: 10.1016/j.athoracsur.2021.03.070] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 02/22/2021] [Accepted: 03/15/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Isolated tricuspid valve (TV) surgery is a rare procedure generally considered at high risk of perioperative mortality and poor long-term outcomes. Surgical treatment can be performed with either an arrested heart (AH) or beating heart (BH) technique. Aim of this study is to compare the outcomes of isolated tricuspid surgery with two different approaches. METHODS The SUR-TRI study is a multicenter international retrospective study enrolling adult patients who underwent isolated tricuspid valve procedures (n=406, 56±16 years; 56% female) at 13 international sites. AH and BH strategies were performed in 253 and 153 cases, respectively. Propensity score-matched analysis was used to compare groups. RESULTS After matching, 129 pairs were obtained and analyzed. The 30-day mortality rate was 6.2 vs 5.0% in the AH and BH groups, respectively (p=0.9). The rates of acute renal failure requiring replacement therapy (3 vs 10%, p=0.02) and stroke (0 vs 1.8%, p=0.08) were numerically higher in the AH group. The 6-year survival rate was 67±6 vs 78±5% in the AH and BH groups, respectively (p=0.18), while freedom from cardiac death was 75±5 vs 84±4% (p=0.21). The six-year composite cardiac endpoint of cardiac death and reoperation rate was 60±9 vs 86±5% (p=0.024) comparing AH-TV replacement and BH-TV repair groups. CONCLUSIONS Isolated tricuspid valve surgery performed with a beating heart strategy is a safe option and resulted in a trend of increased long-term survival and freedom from reoperation when compared with the standard arrested heart technique. Patients undergoing beating heart valve repair had the best long-term outcome.
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Affiliation(s)
- Marco Russo
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria; Department of Cardiac Surgery and Heart Transplantation, San Camillo Forlanini Hospital, Rome, Italy.
| | - Michele Di Mauro
- Cardio-Thoracic Surgery Unit, Heart and Vascular Centre, Maastricht University Medical Centre, Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands
| | - Guglielmo Saitto
- Department of Cardiac Surgery and Heart Transplantation, San Camillo Forlanini Hospital, Rome, Italy; Department of Cardiac Surgery, IRCCS Policlinico San Donato, Milan, Italy
| | - Antonio Lio
- Department of Cardiac Surgery and Heart Transplantation, San Camillo Forlanini Hospital, Rome, Italy; Department of Cardiac Surgery, IRCCS Policlinico San Donato, Milan, Italy
| | - Paolo Berretta
- Cardiac Surgery Unit, Lancisi Cardiovascular Center, Polytechnic University of Marche, Ancona, Italy
| | - Maurizio Taramasso
- Cardiac Surgery Department, University Heart Center of Zurich, Zurich, Switzerland
| | - Roberto Scrofani
- Cardiac Surgery Unit, Ospedale Fatenefratelli Sacco, Milano, Italy
| | - Alessandro Della Corte
- Department of Translational Medical Sciences, University of Campania "L. Vanvitelli," Unit of Cardiac Surgery, V Monaldi Hospital, Neaples, Italy
| | - Sandro Sponga
- Cardiac Surgery Unit, University Hospital of Udine, Udine, Italy
| | - Ernesto Greco
- Department of Cardiovascular, Respiratory, Nephrological, Anesthesiological, and Geriatric Sciences, Sapienza University, Rome, Italy
| | - Matteo Saccocci
- Cardiac Surgery Unit, Poliambulanza Foundation Hospital, Brescia, Italy
| | | | - Giacomo Bianchi
- Pasquinucci Heart Hospital, G. Monasterio Foundation, Massa, Italy
| | | | - Andrea Biondi
- Department of Cardiac Surgery, IRCCS Policlinico San Donato, Milan, Italy
| | - Ester Della Ratta
- Department of Translational Medical Sciences, University of Campania "L. Vanvitelli," Unit of Cardiac Surgery, V Monaldi Hospital, Neaples, Italy
| | - Ugolino Livi
- Cardiac Surgery Unit, University Hospital of Udine, Udine, Italy
| | | | - Paul Werner
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | | | - Marco Di Eusanio
- Cardiac Surgery Unit, Lancisi Cardiovascular Center, Polytechnic University of Marche, Ancona, Italy
| | - Alfred Kocher
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Carlo Antona
- Cardiac Surgery Unit, Ospedale Fatenefratelli Sacco, Milano, Italy
| | - Fabio Miraldi
- Department of Cardiovascular, Respiratory, Nephrological, Anesthesiological, and Geriatric Sciences, Sapienza University, Rome, Italy
| | - Giovanni Troise
- Cardiac Surgery Unit, Poliambulanza Foundation Hospital, Brescia, Italy
| | - Marco Solinas
- Pasquinucci Heart Hospital, G. Monasterio Foundation, Massa, Italy
| | - Francesco Maisano
- Cardiac Surgery Department, University Heart Center of Zurich, Zurich, Switzerland
| | - Guenther Laufer
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Francesco Musumeci
- Department of Cardiac Surgery and Heart Transplantation, San Camillo Forlanini Hospital, Rome, Italy
| | - Martin Andreas
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
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Stigall KS, Neidert LE, Morgan CG, Hemond PJ, Brown DR, Salas M, Hathaway EN, Tiller MM, Cardin S, Glaser JJ. Therapeutic cardiac arrest as an adjunct to resuscitative endovascular balloon occlusion of the aorta: Bridging the gap from fatal hemorrhage to definitive surgical control in swine. J Trauma Acute Care Surg 2021; 90:369-375. [PMID: 33502148 DOI: 10.1097/ta.0000000000003024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Uncontrolled hemorrhage is the leading cause of potentially survivable combat casualty mortality, with 86.5% of cases resulting from noncompressible torso hemorrhage. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a minimally invasive technique used to stabilize patients with noncompressible torso hemorrhage; however, its application can take an average of 8 minutes to place. One therapeutic capable of bridging this gap is adenosine-lidocaine-magnesium (ALM), which at high doses induces a reversible cardioplegia. We hypothesize by using ALM as an adjunct to REBOA, the ALM-induced cardiac arrest will temporarily halt exsanguination and reduce blood loss, allowing for REBOA placement and control of bleeding. METHODS Male Yorkshire swine (60-80 kg) were randomly assigned to REBOA only or ALM-REBOA (n = 8/group). At baseline, uncontrolled hemorrhage was induced via a 1.5-cm right femoral arteriotomy, and hemorrhaged blood was quantified. One minute after injury (S1), ALM was administered, and 7 minutes later (T0), zone 1 REBOA inflation occurred. If cardiac arrest ensued, cardiac function either recovered spontaneously or advanced life support was initiated. At T30, surgical hemostasis was obtained, and REBOA was deflated. Animals were resuscitated until they were humanely euthanized at T90. RESULTS During field care phase, heart rate and end-tidal CO2 of the ALM-REBOA group were significantly lower than the REBOA only group. While mean arterial pressure significantly decreased from baseline, no significant differences between groups were observed throughout the field care phase. There was no significant difference in survival between the two groups (ALM-REBOA = 89% vs. REBOA only = 100%). Total blood loss was significantly decreased in the ALM-REBOA group (REBOA only = 24.32 ± 1.89 mL/kg vs. ALM-REBOA = 17.75 ± 2.04 mL/kg, p = 0.0499). CONCLUSION Adenosine-lidocaine-magnesium is a novel therapeutic, which, when used with REBOA, can significantly decrease the amount of blood loss at initial presentation, without compromising survival. This study provides proof of concept for ALM and its ability to bridge the gap between patient presentation and REBOA placement.
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Affiliation(s)
- Kyle S Stigall
- From the Department of Surgery, San Antonio Military Medical Center (K.S.S., E.N.H., M.M.T., J.J.G.); Department of Expeditionary and Trauma Medicine, Naval Medical Research Unit San Antonio (L.E.N., C.G.M., P.J.H., D.R.B., M.S., M.M.T., S.C., J.J.G.), JBSA-Fort Sam Houston; and Austin Shock Trauma (J.J.G.), St David's South Austin Medical Center, Austin, Texas
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Panos A, Mpellos K, Vlad S, Myers PO. Antegrade Cardioplegia Decannulation Made Simple With the Cor-Knot System: Technique and Tips After 20 Consecutive and Controlled Patients. Innovations (Phila) 2020; 15:494-496. [PMID: 32865452 DOI: 10.1177/1556984520951283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Closing the cardioplegia cannulation site can be challenging in minimally invasive video-assisted cardiac surgery. The Cor-Knot system is used to tie down valve sutures within the heart efficiently, although erosions to neighboring structures are reported. We hypothesized that a modification of the Cor-Knot system could enable safe hemostasis of the cardioplegia aortic root site and avoid erosions of the aorta or right atrium. This is a single-arm prospective study including 20 consecutive patients operated through a video-assisted method at our clinic between January 2019 and February 2019. At the end of the procedure, the suture was passed through a Cor-Knot device and crimped on a band of Teflon-felt. The two tips of the Teflon-felt toward the right atrium were put together and tightened with a 5/0 Prolene suture in order to protect the sharp ends of the device. Hemostasis was achieved using the technique in all 20 patients, with no requirement for further suture placement to ensure hemostasis of the cardioplegia cannulation site. The device was protected from the right atrial appendage and there was no bleeding. At 6-month follow-up, no patients required a reoperation for aortic or right atrial erosion. The Cor-Knot system was used off-label to close the cardioplegia cannulation site in minimally invasive surgery. This appears safe and effective in our initial 20-patient experience.
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Affiliation(s)
- Aristotelis Panos
- 537314 Cardiovascular Surgery, La Tour Hospital, Meyrin/Geneva, Switzerland
- Hygeia Hospital, Athens, Greece
- Cardiac Surgery, HUG, University Hospital Geneva, Switzerland
| | | | | | - Patrick O Myers
- 537314 Cardiovascular Surgery, La Tour Hospital, Meyrin/Geneva, Switzerland
- 30635 Cardiac Surgery, CHUV - University Hospital Lausanne, Switzerland
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Abstract
This study aimed to investigate the myocardial protective effect of liquid sodium phosphocreatine cardiac arrest in extracorporeal circulation surgery treating infants with atrial septal defects.Eighty-four infants with atrial septal defects who required extracorporeal circulation surgery treatment at our hospital from January 2016 to June 2018 were divided into an observation group and a control group through a digitally randomized method, with 42 cases in each group. The control group adopted the conventional modified St Thomas II high potassium cold liquid crystal cardiac arrest, while the observation group adopted the liquid sodium phosphocreatine cardiac arrest.The myocardial enzyme indexes of the 2 groups 3, 6, 12, and 24 hours postoperatively were higher than before establishing the cardiopulmonary bypass and the enzyme indexes of the control group at the same time were higher than that of the observation group; adenosine triphosphate, adenosine diphosphate, and other energy levels and the postoperative recovery rate energy levels of the observation group were higher than those in the control group, the difference was statistically significant (P < .05).Liquid sodium phosphocreatine cardiac arrest used in extracorporeal circulation surgery treating infants with atrial septal defects can reduce myocardial ischemia-reperfusion injury, maintain energy supply during ischemia, strengthen the St Thomas II effect, and aid postoperative cardiac function recovery of high potassium cold liquid crystal cardiac arrest used in infants with atrial septal defects and treated with extracorporeal circulation surgery.
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Aceros H, Der Sarkissian S, Borie M, Pinto Ribeiro RV, Maltais S, Stevens LM, Noiseux N. Novel heat shock protein 90 inhibitor improves cardiac recovery in a rodent model of donation after circulatory death. J Thorac Cardiovasc Surg 2020; 163:e187-e197. [PMID: 32354629 DOI: 10.1016/j.jtcvs.2020.03.042] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Revised: 02/29/2020] [Accepted: 03/14/2020] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Organ donation after circulatory death (DCD) is a potential solution for the shortage of suitable organs for transplant. Heart transplantation using DCD donors is not frequently performed due to the potential myocardial damage following warm ischemia. Heat shock protein (HSP) 90 has recently been investigated as a novel target to reduce ischemia/reperfusion injury. The objective of this study is to evaluate an innovative HSP90 inhibitor (HSP90i) as a cardioprotective agent in a model of DCD heart. METHODS A DCD protocol was initiated in anesthetized Lewis rats by discontinuation of ventilation and confirmation of circulatory death by invasive monitoring. Following 15 minutes of warm ischemia, cardioplegia was perfused for 5 minutes at physiological pressure. DCD hearts were mounted on a Langendorff ex vivo heart perfusion system for reconditioning and functional assessment (60 minutes). HSP90i (0.01 μmol/L) or vehicle was perfused in the cardioplegia and during the first 10 minutes of ex vivo heart perfusion reperfusion. Following assessment, pro-survival pathway signaling was evaluated by western blot or polymerase chain reaction. RESULTS Treatment with HSP90i preserved left ventricular contractility (maximum + dP/dt, 2385 ± 249 vs 1745 ± 150 mm Hg/s), relaxation (minimum -dP/dt, -1437 ± 97 vs 1125 ± 85 mm Hg/s), and developed pressure (60.7 ± 5.6 vs 43.9 ± 4.0 mm Hg), when compared with control DCD hearts (All P = .001). Treatment abrogates ischemic injury as demonstrated by a significant reduction of infarct size (2,3,5-triphenyl-tetrazolium chloride staining) of 7 ± 3% versus 19 ± 4% (P = .03), troponin T release, and mRNA expression of Bax/Bcl-2 (P < .05). CONCLUSIONS The cardioprotective effects of HSP90i when used following circulatory death might improve transplant organ availability by expanding the use of DCD hearts.
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Affiliation(s)
- Henry Aceros
- Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), Montréal, Canada
| | - Shant Der Sarkissian
- Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), Montréal, Canada; Faculty of Medicine, Department of Surgery, Université de Montréal, Montréal, Canada
| | - Mélanie Borie
- Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), Montréal, Canada
| | - Roberto Vanin Pinto Ribeiro
- Division of Cardiovascular Surgery, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Simon Maltais
- Division of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn
| | - Louis-Mathieu Stevens
- Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), Montréal, Canada; Faculty of Medicine, Department of Surgery, Université de Montréal, Montréal, Canada
| | - Nicolas Noiseux
- Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), Montréal, Canada; Faculty of Medicine, Department of Surgery, Université de Montréal, Montréal, Canada.
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Pérez-Andreu J, Fernández-Doblas J, Sao Avilés A, de la Torre García T, Roses Noguer F, Abella RF. Myocardial protection in the arterial switch operation: Custodiol versus cold blood cardioplegia. Interact Cardiovasc Thorac Surg 2020; 30:136-143. [PMID: 31873745 DOI: 10.1093/icvts/ivz216] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 08/09/2019] [Accepted: 08/11/2019] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES The optimal myocardial protective solution in the neonatal arterial switch operation remains controversial. The aim of this study was to demonstrate that Bretschneider's histidine-tryptophan-ketoglutarate crystalloid solution (Custodiol) offers protection at least similar to that of cold blood cardioplegia. METHODS Patients who underwent the neonatal arterial switch operation with Custodiol between January 2016 and December 2018 (n = 23) were compared with an historical cohort from August 2010 to December 2015 in which cold blood cardioplegia was used (n = 41). A linear mixed-effect model for repeated measures was performed to test the recovery of myocardial function based on inotropic and vasoactive inotropic scores, cardiac enzyme release and left ventricular ejection fraction. RESULTS Patients in the cold blood cardioplegia group had higher inotropic scores in the first 24 h (0 h, P = 0.001 and 24 h, P = 0.006) and higher vasoactive inotropic scores in the first 72 h (0 h, 24 h and 48 h, P < 0.001; 72 h, P = 0.012). Cardiac troponin-I concentrations were higher in the cold blood cardioplegia group at postoperative hours 1-72 (1 h, 6 h, 12 h and 24 h, P < 0.001; 48 h, P = 0.001 and 72 h, P = 0.003). Creatinine-kinase-MB concentrations were higher in the cold blood cardioplegia group at postoperative hours 1-24 (1 h, 6 h and 12 h, P < 0.001; 24 h, P = 0.042). The left ventricular ejection fraction was higher in the Custodiol group just after the operation (P = 0.005), at 24 h (P = 0.001) and on the first day without inotropic support (P = 0.011). CONCLUSIONS Neonatal myocardium protected with Custodiol during the arterial switch operation presented optimal ventricular function recovery with less inotropic support and less myocardial damage compared with cold blood cardioplegia.
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Affiliation(s)
- Joaquín Pérez-Andreu
- Paediatric Cardiac Surgery Department, Vall d´Hebron University Hospital, Barcelona, Spain
| | | | - Augusto Sao Avilés
- Biostatistics, Cardiology Department, Vall d´Hebron University Hospital, Barcelona, Spain
| | | | - Ferrán Roses Noguer
- Paediatric Cardiology Department, Vall d´Hebron University Hospital, Barcelona, Spain
| | - Raúl F Abella
- Paediatric Cardiac Surgery Department, Vall d´Hebron University Hospital, Barcelona, Spain
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Steindl J, Kirnbauer M, Fierlbeck J, Krieghofer M, Hitzl W, Hinterbuchner L, Seitelberger R, Dinges C. Aortic Root Pressurizing Device: Aortic Valve Evaluation During Cardioplegic Arrest. Ann Thorac Surg 2019; 109:1605-1610. [PMID: 31881195 DOI: 10.1016/j.athoracsur.2019.10.080] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Revised: 10/17/2019] [Accepted: 10/21/2019] [Indexed: 11/18/2022]
Abstract
PURPOSE The aortic root pressurizing device was developed for aortic valve repair surgery. It allows echocardiographic evaluation of the aortic valve during cardioplegic arrest by mimicking diastolic afterload. DESCRIPTION This polyoxymethylene or polyether ether ketone-based device consists of a sealing cap nut, a sealing ring, a plug screw, and both a filling and a ventilation line. It can be easily connected to any size of aortic Dacron grafts. EVALUATION The device was tested in 15 porcine hearts using a beating heart biosimulator including hemodynamic and echocardiographic monitoring. Valve competence was analyzed on both the beating and resting heart at 60 and 45 mm Hg root pressure. Aortic insufficiency was surgically induced by leaflet manipulation. Native aortic valves showed either none or trivial aortic insufficiency. After leaflet manipulation echocardiographic proof of valve insufficiency was possible in all specimen. Jet direction was identic in all cases at 60 mm Hg and 93% at 45 mm Hg root pressure. CONCLUSIONS The aortic root pressurizing device shows highly comparable results of echocardiographic aortic valve evaluation between static and dynamic settings under experimental conditions.
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Affiliation(s)
- Johannes Steindl
- Department of Cardiovascular & Endovascular Surgery, Paracelsus Medical University, Salzburg, Austria
| | - Michael Kirnbauer
- Department of Anesthesiology, Perioperative Care and Intensive Care Medicine, Paracelsus Medical University, Salzburg, Austria
| | | | | | - Wolfgang Hitzl
- Research Office (Biostatistics), Paracelsus Medical University, Salzburg, Austria; Department of Ophthalmology and Optometry, Paracelsus Medical University, Salzburg, Austria
| | - Lynne Hinterbuchner
- Department of Internal Medicine, Cardiology and Intensive Care, Paracelsus Medical University, Salzburg, Austria
| | - Rainald Seitelberger
- Department of Cardiovascular & Endovascular Surgery, Paracelsus Medical University, Salzburg, Austria
| | - Christian Dinges
- Department of Cardiovascular & Endovascular Surgery, Paracelsus Medical University, Salzburg, Austria.
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Peeters LEJ, den Uil CA, Feyz L, van den Bemt PMLA, Daemen J, Versmissen J. Acute calcium channel blocker withdrawal-induced cardiac arrest. Neth J Med 2019; 77:341-343. [PMID: 31814590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Acute withdrawal of calcium channel blockers can lead to the so-called calcium channel blocker withdrawal phenomenon, in particular, when high dosages are used. In the case presented, inadequate drug substitution led to this phenomenon which resulted in a serious course of events. Careful monitoring the process of drug substitution with respect to equal therapeutic dosages is therefore a necessity, especially in vulnerable patients.
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Affiliation(s)
- L E J Peeters
- Departments of Hospital Pharmacy, Erasmus University Medical Centre, Rotterdam, the Netherlands
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Gambardella I, Gaudino MFL, Antoniou GA, Rahouma M, Worku B, Tranbaugh RF, Nappi F, Girardi LN. Single- versus multidose cardioplegia in adult cardiac surgery patients: A meta-analysis. J Thorac Cardiovasc Surg 2019; 160:1195-1202.e12. [PMID: 31590948 DOI: 10.1016/j.jtcvs.2019.07.109] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Revised: 07/11/2019] [Accepted: 07/26/2019] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To compare outcomes of single (intervention group: del Nido [DN], and histamine-tryptophan-ketoglutarate) versus multidose (control group) cardioplegia in the adult cardiac surgery patients. METHODS Medical search engines were interrogated to identify relevant randomized controlled trials and propensity-score matched cohorts. Meta-analysis was conducted for primary (in-hospital/30-day mortality) and secondary (ischemic and cardiopulmonary bypass [CPB] times, reperfusion fibrillation, peak of cardiac enzymes, myocardial infarction) endpoints. Subgroup analyses were conducted for study design and type of intervention, and meta-regression for primary outcome included type of surgery and left ventricular ejection fraction as moderators. RESULTS Ten randomized controlled trials and 13 propensity-score matched cohorts were included, reporting on 5516 patients. Estimates are expressed as (parameter value [OR, odds ratio; MD, mean difference; SMD, standardized mean difference]/unit of measure [95% confidence interval], P value). DN reduced ischemic time (MD, -7.18 minutes [-12.52 to -1.84], P < .01), CPB time (MD, -10.44 minutes [-18.99 to -1.88], P .01), reperfusion fibrillation (OR, 0.16 [0.05-0.54], P < .01), and cardiac enzymes (SMD -0.17 [-0.29, 0.05], P < .01) compared with multidose cardioplegia. None of these beneficial effects were reproduced by histamine-tryptophan-ketoglutarate, which instead increased CPB time (MD, 2.04 minutes [0.73-3.37], P < .01) and reperfusion fibrillation (OR, 1.80 [1.20-2.70], P < .01). There was no difference in mortality and myocardial infarction between single and multidose, independently of type of surgery or left ventricular ejection fraction. CONCLUSIONS DN decreases operative times, reperfusion fibrillation, and surge of cardiac enzymes compared with multidose cardioplegia.
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Affiliation(s)
- Ivancarmine Gambardella
- Department of Cardiothoracic Surgery, Weill Cornell Medicine-NewYork Presbyterian Medical Center, New York, NY; Department of Cardiothoracic Surgery, Weill Cornell Medicine-NewYork Presbyterian Brooklyn Methodist Hospital, Brooklyn, NY.
| | - Mario F L Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine-NewYork Presbyterian Medical Center, New York, NY
| | - George A Antoniou
- Department of Cardiothoracic Surgery, Weill Cornell Medicine-NewYork Presbyterian Brooklyn Methodist Hospital, Brooklyn, NY; Department of Vascular & Endovascular Surgery, The Royal Oldham Hospital, Pennine Acute Hospitals NHS Trust, Manchester, United Kingdom; Division of Cardiovascular Sciences, School of Medical Sciences, University of Manchester, Manchester, United Kingdom
| | - Mohamad Rahouma
- Department of Cardiothoracic Surgery, Weill Cornell Medicine-NewYork Presbyterian Medical Center, New York, NY
| | - Berhane Worku
- Department of Cardiothoracic Surgery, Weill Cornell Medicine-NewYork Presbyterian Medical Center, New York, NY; Department of Cardiothoracic Surgery, Weill Cornell Medicine-NewYork Presbyterian Brooklyn Methodist Hospital, Brooklyn, NY
| | - Robert F Tranbaugh
- Department of Cardiothoracic Surgery, Weill Cornell Medicine-NewYork Presbyterian Medical Center, New York, NY; Department of Cardiothoracic Surgery, Weill Cornell Medicine-NewYork Presbyterian Brooklyn Methodist Hospital, Brooklyn, NY
| | - Francesco Nappi
- Cardiac Surgery Center, Cardiologique du Nord de Saint-Denis, Paris, France
| | - Leonard N Girardi
- Department of Cardiothoracic Surgery, Weill Cornell Medicine-NewYork Presbyterian Medical Center, New York, NY
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Magro PL, Marques S, Calquinha J, Neves JP. Cold Agglutinins and Cardiac Surgey: a Case Report. Rev Port Cir Cardiotorac Vasc 2019; 26:223-224. [PMID: 31734976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Indexed: 06/10/2023]
Abstract
Cold agglutinins (CA) are autoantibodies whose clinical significance depends upon titer and thermal amplitude. Patients, which undergo cardio-pulmonary bypass and especially hypothermic cardioplegia myocardial protection, represent a challenge regarding operative management, as tissue temperature should be maintained above the threshold of agglutination. We report on a case in which the presence of CA was discovered during elective aortic valve replacement surgery, and managed with normothermic cardiopulmonary bypass and continuous retrograde warm blood cardioplegia administration.
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Affiliation(s)
- Pedro Lamares Magro
- Department of Cardiothoracic Surgery, Santa Cruz Hospital, Carnaxide, Portugal
| | - Sofia Marques
- Department of Perfusion, Santa Cruz Hospital, Carnaxide, Portugal
| | - José Calquinha
- Department of Cardiothoracic Surgery, Santa Cruz Hospital, Carnaxide, Portugal
| | - José Pedro Neves
- Department of Cardiothoracic Surgery, Santa Cruz Hospital, Carnaxide, Portugal
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Hoyer A, Then Bergh F, Klaeske K, Lehmann S, Misfeld M, Borger M, Dieterlen MT. Custodiol-N™ cardioplegia lowers cerebral inflammation and activation of hypoxia-inducible factor-1α. Interact Cardiovasc Thorac Surg 2019; 28:884-892. [PMID: 30668864 DOI: 10.1093/icvts/ivy347] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Revised: 11/13/2018] [Accepted: 11/25/2018] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Cardioplegic solutions induce cardiac arrest and protect cardiac tissue from ischaemia-reperfusion injury. However, the effects on the brain, which is vulnerable to cardiopulmonary bypass (CPB) surgery and ischaemia-reperfusion injury, mostly remain unknown. We investigated if cardioplegic solutions differ in their effects in altered oxygen conditions and in their ability to induce cerebral inflammation. METHODS Thirty pigs were subjected to a midline sternotomy and CPB at 34°C with 90 min cardiac arrest followed by 120 min reperfusion. Following randomization on a 1:1:1 basis, they received either a single shot of histidine-tryptophan-α-ketoglutarate (HTK)-Bretschneider solution (n = 10), histidine-tryptophan-α-ketoglutarate-N (HTK-N; n = 10) or HTK plus 1.2 mg/l cyclosporine A (HTK/CsA; n = 10). Brain regions of interest (frontal cortex, cerebellum, brain stem, diencephalon, colliculus superior) were analysed by real time quantitative reverse transcriptase polymerase chain reaction for hypoxia-inducible factor-1α (HIF-1α), tumour necrosis factor-α, interleukin (IL)-10, IL-1β and IL-1β receptor as well as by immunohistochemical analysis for HIF-1α. Blood gas and electrolyte analyses were performed. RESULTS Comparisons between baseline and reperfusion period levels revealed that HTK-N cardioplegia induced a smaller reduction of the haemoglobin content and blood calcium concentrations (hbbaseline: 5.97 ± 0.63 mmol/l; hbreperfusion: 6.16 ± 0.66 mmol/l; P = 0.428; Cabaseline2+: 1.36 ± 0.05 mmol/l; Careperfusion2+: 1.28 ± 0.05 mmol/l; P < 0.001) compared to HTK (hbbaseline: 5.93 ± 0.45 mmol/l; hbreperfusion: 4.72 ± 0.79 mmol/l; P = 0.001; Cabaseline2+: 1.34 ± 0.07 mmol/l; Careperfusion2+: 1.24 ± 0.06 mmol/l; P = 0.004) and HTK/CsA cardioplegia (hbbaseline: 5.88 ± 0.44 mmol/l; hbreperfusion: 5.14 ± 0.87 mmol/l; P = 0.040; Cabaseline2+: 1.38 ± 0.04 mmol/l; Careperfusion2+: 1.20 ± 0.14 mmol/l; P = 0.001). Brain region-specific regulation of the HIF-1α expression, no general HIF-1α activation and a lower tumour necrosis factor-α expression (pto HTK = 0.050, pto HTK/CsA = 0.013) were documented for HTK-N cardioplegia. CONCLUSIONS HTK-N (Custodiol-N) induced fewer cerebral effects and less inflammation during CPB surgery than HTK and HTK/CsA cardioplegia. These data suggest that HTK-N exerts brain protective effects during and after CPB surgery.
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Affiliation(s)
- Alexandro Hoyer
- Department of Cardiac Surgery, Heart Center, Helios Clinic, Leipzig, Germany
| | | | - Kristin Klaeske
- Department of Cardiac Surgery, Heart Center, Helios Clinic, Leipzig, Germany
| | - Sven Lehmann
- Department of Cardiac Surgery, Heart Center, Helios Clinic, Leipzig, Germany
| | - Martin Misfeld
- Department of Cardiac Surgery, Heart Center, Helios Clinic, Leipzig, Germany
| | - Michael Borger
- Department of Cardiac Surgery, Heart Center, Helios Clinic, Leipzig, Germany
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Kim M, Lorinsky MK, Gold CA, Lahey SJ, Fusco DS, Rosinski DJ, Pawlak D, Liang BT. Usefulness of Circulating Caspase-3 p17 and Caspase-1 p20 Peptides and Cardiac Troponin 1 During Cardioplegia to Gauge Myocardial Preservation. Am J Cardiol 2019; 123:899-904. [PMID: 30617008 DOI: 10.1016/j.amjcard.2018.12.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2018] [Revised: 12/08/2018] [Accepted: 12/13/2018] [Indexed: 11/18/2022]
Abstract
Evidence is accumulating that cardiac apoptosis occurs and contributes to myocyte cell death during myocardial ischemia. Cardioplegia, defined as the temporary cessation of cardiac activity during cardiac surgery, is a clinically controlled condition with myocardial ischemia and reperfusion. Our goal was to determine whether the apoptotic biomarker caspase-3 p17 is elevated in the coronary sinus (CS) during cardioplegia and if any elevations were reflected in the peripheral venous (PV) blood. Levels of the necrotic biomarker cardiac troponin I (cTnI) and the inflammatory marker caspase-1 p20 were also quantified in CS and PV. Blood was drawn before and at the end of cardioplegia in PV and CS and levels of p20, p17, and cTnI were measured. cTnI, p20, and p17 PV levels were significantly elevated compared with the control population before and at the end of cardioplegia. PV levels of all 3 markers increased after cardioplegia. CS levels were higher than PV levels for all 3 markers at both time points. Our data are consistent with the occurrence of cardiac apoptosis and inflammation during cardioplegia, in addition to necrosis. The heart-derived markers contributed to the peripheral levels and suggest that measurement of PV biomarker concentrations can be used to gauge cardiac preservation.
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Affiliation(s)
- Minjung Kim
- The Pat and Jim Calhoun Cardiology Center, University of Connecticut School of Medicine, Farmington, Connecticut
| | - Michael K Lorinsky
- Beth Israel Deaconess Medical Center, Department of Medicine, Boston, Massachusetts
| | - Courtney A Gold
- The Pat and Jim Calhoun Cardiology Center, University of Connecticut School of Medicine, Farmington, Connecticut
| | - Stephen J Lahey
- Division of Cardiothoracic Surgery, University of Connecticut School of Medicine, Farmington, Connecticut
| | - Daniel S Fusco
- Division of Cardiothoracic Surgery, University of Connecticut School of Medicine, Farmington, Connecticut
| | - David J Rosinski
- Division of Cardiothoracic Surgery, University of Connecticut School of Medicine, Farmington, Connecticut
| | - Dorota Pawlak
- Division of Cardiothoracic Surgery, University of Connecticut School of Medicine, Farmington, Connecticut
| | - Bruce T Liang
- The Pat and Jim Calhoun Cardiology Center, University of Connecticut School of Medicine, Farmington, Connecticut.
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Yoshitake A, Tochii M, Asakura T, Takazawa A, Nakajima H. Distal Limited Open Stenting for Aortic Diverticulum in the Right Aortic Arch. Ann Vasc Surg 2019; 57:272.e5-272.e7. [PMID: 30684611 DOI: 10.1016/j.avsg.2018.10.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2018] [Revised: 09/17/2018] [Accepted: 10/09/2018] [Indexed: 11/18/2022]
Abstract
An aortic diverticulum, including Kommerell's diverticulum, is an uncommon, congenital, aortic arch anomaly. Surgery for a diverticulum is challenging, and several surgical strategies have been reported. Here, we present the case of an asymptomatic 57-year-old man who was referred to our hospital. Computed tomography revealed right aortic arch and aortic diverticulum, and he underwent distal limited open stenting under hypothermic circulatory arrest with selective cerebral perfusion via median sternotomy. The postoperative course was uneventful. Thus, this report shows that our procedure is useful and safe for treating aortic diverticulum.
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Affiliation(s)
- Akihiro Yoshitake
- Department of Cardiovascular Surgery, Saitama Medical University International Medical Center, Saitama, Japan.
| | - Masato Tochii
- Department of Cardiovascular Surgery, Saitama Medical University International Medical Center, Saitama, Japan
| | - Toshihisa Asakura
- Department of Cardiovascular Surgery, Saitama Medical University International Medical Center, Saitama, Japan
| | - Akitoshi Takazawa
- Department of Cardiovascular Surgery, Saitama Medical University International Medical Center, Saitama, Japan
| | - Hiroyuki Nakajima
- Department of Cardiovascular Surgery, Saitama Medical University International Medical Center, Saitama, Japan
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Puri GD, Bagchi A, Anandamurthy B, Dhaliwal RS. The Bispectral Index and Induced Hypothermia— Electrocerebral Silence at an Unusually High Temperature. Anaesth Intensive Care 2019; 31:578-80. [PMID: 14601285 DOI: 10.1177/0310057x0303100515] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The optimal temperature for deep hypothermic circulatory arrest remains undefined. We present a case in which Bispectral Index monitoring during hypothermic cardiopulmonary bypass showed electrocerebral silence at a higher temperature than previously reported. Bispectral Index monitoring may be a potentially useful tool in surgery employing deep hypothermic circulatory arrest.
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Affiliation(s)
- G D Puri
- Department of Anaesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research, Chandigarh-160012, India
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Sellke N, Gordon C, Lawandy I, Gorvitovskaia AY, Scrimgeour LA, Fingleton JG, Sellke FW, Feng J. Impaired coronary contraction to phenylephrine after cardioplegic arrest in diabetic patients. J Surg Res 2018; 230:80-86. [PMID: 30100044 PMCID: PMC6310168 DOI: 10.1016/j.jss.2018.04.045] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Revised: 03/21/2018] [Accepted: 04/17/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND We have previously found that hyperkalemic cardioplegic arrest in the setting of cardiopulmonary bypass (CP/CPB) is associated with impairment of the coronary arteriolar response to phenylephrine in nondiabetic (ND) patients. We hypothesized that diabetes may alter coronary arteriolar response to alpha-1 adrenergic agonist in the setting of CP/CPB. In this study, we further investigated the effects of diabetes on the altered coronary arteriolar response to phenylephrine in patients undergoing cardiac surgery. METHODS Coronary arterioles (90-150 μm in diameter) were harvested pre- and post-CP/CPB from the ND and diabetic mellitus (DM) patients (n = 8/group) undergoing cardiac surgery. In-vitro microvascular reactivity was examined in response to phenylephrine. The protein expression/localization of the alpha-1 adrenergic receptors in the atrial myocardium was measured by Western blotting and immunohistochemistry. RESULTS Phenylephrine (10-9 to 10-4 M) induced a dose-dependent contractile response in both ND and DM vessels pre- and post-CP/CPB. There was no significant difference in the pre-CP/CPB contractile responses to phenylephrine between ND and DM groups. The post-CP/CPB contractile response was significantly diminished in both ND and DM groups compared with the respective pre-CP/CPB response (P < 0.05 versus pre-CP/CPB). This diminished contractile response was more pronounced in vessels from DM patients compared with vessels from ND patients (P < 0.05 versus ND). There were no significant differences in the protein expression of alpha-1A and alpha-1B receptors in the atrial myocardium between the ND and DM groups or tissue harvested pre- or post-CP/CPB. CONCLUSIONS Diabetes is associated with a decreased contractile response of coronary arterioles to phenylephrine in the setting of CP/CPB versus that observed in ND patients. This alteration may contribute to the vasomotor dysfunction of coronary microcirculation seen early after CP/CPB in patients with diabetes.
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Affiliation(s)
- Nicholas Sellke
- Division of Cardiothoracic Surgery, Cardiovascular Research Center, Rhode Island Hospital, Alpert Medical School of Brown University, Providence, Rhode Island
| | - Caroline Gordon
- Division of Cardiothoracic Surgery, Cardiovascular Research Center, Rhode Island Hospital, Alpert Medical School of Brown University, Providence, Rhode Island
| | - Isabella Lawandy
- Division of Cardiothoracic Surgery, Cardiovascular Research Center, Rhode Island Hospital, Alpert Medical School of Brown University, Providence, Rhode Island
| | - Anastassia Y Gorvitovskaia
- Division of Cardiothoracic Surgery, Cardiovascular Research Center, Rhode Island Hospital, Alpert Medical School of Brown University, Providence, Rhode Island
| | - Laura A Scrimgeour
- Division of Cardiothoracic Surgery, Cardiovascular Research Center, Rhode Island Hospital, Alpert Medical School of Brown University, Providence, Rhode Island
| | - James G Fingleton
- Division of Cardiothoracic Surgery, Cardiovascular Research Center, Rhode Island Hospital, Alpert Medical School of Brown University, Providence, Rhode Island
| | - Frank W Sellke
- Division of Cardiothoracic Surgery, Cardiovascular Research Center, Rhode Island Hospital, Alpert Medical School of Brown University, Providence, Rhode Island
| | - Jun Feng
- Division of Cardiothoracic Surgery, Cardiovascular Research Center, Rhode Island Hospital, Alpert Medical School of Brown University, Providence, Rhode Island.
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Mukdad L, Toppen W, Sanaiha Y, Mantha A, Bland S, Shemin R, Benharash P. Incidence of Cerebral Microemboli in Single-Dose vs. Multidose Cardioplegia in Adult Cardiac Surgery. J Extra Corpor Technol 2018; 50:143-148. [PMID: 30250339 PMCID: PMC6146277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Accepted: 06/12/2018] [Indexed: 06/08/2023]
Abstract
Cerebral microemboli have been associated with neurocognitive deficits after cardiac operations using cardiopulmonary bypass (CPB). Interventions by the perfusionist and alterations in blood flow account for a large proportion of previously unexplained microemboli. This study compared the incidence of microemboli during cardiac operations using conventional (multidose) and del Nido (single-dose) cardioplegia delivery. Transcranial Doppler ultrasonography was used to detect microemboli in bilateral middle cerebral arteries of 30 adult patients undergoing cardiac operations using CPB and aortic clamping. Multidose conventional blood cardioplegia (CBC) was used in 15 patients and single-dose del Nido cardioplegia (DNC) in 15. Manual count of microemboli during cross-clamp and during administration of cardioplegia was performed. Baseline preoperative characteristics were similar between groups. There were no differences in the ascending aortic atheroma grade (1.4 ± .4 CBC vs. 1.6 ± .7 DNC, p = .44), bypass times (141 ± 36 minutes CBC vs. 151 ± 33 minutes DNC, p = .64), and cross-clamp times (118 ± 32 minutes CBC vs. 119 ± 45 minutes DNC, p = .95). The use of multidose CBC was associated with a seven-fold increase in the number of microemboli per minute of bypass (1.65 ± 1 vs. .24 ± .18 emboli/min DNC, p = .0004). In this prospective pilot study, we found that the use of single-dose cardioplegia strategy led to fewer cerebral microemboli when compared with the traditional multidose approach. Our findings warrant further investigation of various cardioplegia strategies and neurologic outcomes in larger cohorts.
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Affiliation(s)
| | | | | | | | | | | | - Peyman Benharash
- Department of Cardiac Surgery, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
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45
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Rosenbloom M, Hancock M, Weinstock P, Paterek A, Highbloom R, Bowen F, Patel K. Asanguinous Del Nido Cardioplegia for an Aortic Valve Replacement Patient with Cold Agglutinins. J Extra Corpor Technol 2018; 50:187-188. [PMID: 30250347 PMCID: PMC6146281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Accepted: 07/25/2018] [Indexed: 06/08/2023]
Abstract
A patient with known cold agglutinins requiring an aortic valve replacement was referred for surgery. Asanguinous, Del Nido cardioplegia was used for myocardial protection. Warm induction followed by cold infusion prevented any agglutination and eliminated the need for subsequent cardioplegia doses. Following the cross-clamp period, the heart returned to normal sinus rhythm without need for defibrillation. Postoperative ejection fraction and systolic function were normal.
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Affiliation(s)
- Michael Rosenbloom
- Division of Cardiothoracic Surgery, Cooper University Hospital, Camden, New Jersey
| | - Michael Hancock
- Division of Cardiothoracic Surgery, Cooper University Hospital, Camden, New Jersey
| | - Perry Weinstock
- Division of Cardiothoracic Surgery, Cooper University Hospital, Camden, New Jersey
| | - Allyson Paterek
- Division of Cardiothoracic Surgery, Cooper University Hospital, Camden, New Jersey
| | - Richard Highbloom
- Division of Cardiothoracic Surgery, Cooper University Hospital, Camden, New Jersey
| | - Frank Bowen
- Division of Cardiothoracic Surgery, Cooper University Hospital, Camden, New Jersey
| | - Kinjal Patel
- Division of Cardiothoracic Surgery, Cooper University Hospital, Camden, New Jersey
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46
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Ali JM, Miles LF, Abu-Omar Y, Galhardo C, Falter F. Global Cardioplegia Practices: Results from the Global Cardiopulmonary Bypass Survey. J Extra Corpor Technol 2018; 50:83-93. [PMID: 29921986 PMCID: PMC6002645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 09/23/2017] [Accepted: 02/15/2018] [Indexed: 06/08/2023]
Abstract
Despite the ubiquitous use of cardioplegia in cardiac surgery, there is a lack of agreement on various aspects of cardioplegia practice. To discover current cardioplegia practices throughout the world, we undertook a global survey to document contemporary cardiopulmonary bypass practices. A 16-question, Internet-based survey was distributed by regional specialist societies, targeting adult cardiac anesthesiologists. Ten questions concerned caseload and cardioplegia practices, the remaining questions examined anticoagulation and pump-priming practices. The survey was available in English, Spanish, and Portuguese. The survey was launched in June 2015 and remained open until May 2016. A total of 923 responses were analyzed, summarizing practice in Europe (269), North America (334), South America (215), and Australia/New Zealand (105). Inter-regional responses differed for all questions asked (p < .001). In all regions other than South America, blood cardioplegia was the common arrest technique used. The most commonly used cardioplegia solutions were: St. Thomas, Bretschneider, and University of Wisconsin with significant regional variation. The use of additives (most commonly glucose, glutamate, tris-hydroxymethyl aminomethane, and aspartate) varied significantly. This survey has revealed significant variation in international practice with regards to myocardial protection, and is a reminder that there is no clear consensus on the use of cardioplegia. It is unclear why regional practice groups made the choices they have and the clinical impact remains unclear.
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Affiliation(s)
- Jason M. Ali
- Department of Cardiothoracic Surgery, Royal Papworth Hospital, Cambridge, UK
| | | | - Yasir Abu-Omar
- Department of Cardiothoracic Surgery, Royal Papworth Hospital, Cambridge, UK
| | - Carlos Galhardo
- Department of Anesthesiology, National Institute of Cardiology, Rio-de-Janiero, Brazil; and
| | - Florian Falter
- Department of Anesthesia, Royal Papworth Hospital, Cambridge, UK
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47
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Guo H, Sun X, Yu C, Shu C. A case report of frozen elephant trunk combined with endovascular treatment for acute aortic dissection of Kommerell's diverticulum involving right aortic arch and descending aorta. Medicine (Baltimore) 2018; 97:e0166. [PMID: 29642141 PMCID: PMC5908621 DOI: 10.1097/md.0000000000010166] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
RATIONALE Acute aortic dissection of Kommerell's diverticulum in the right aortic arch is extremely rare. There are several different procedures for the disease. With advances in endovascular treatment, hybrid surgical and endovascular management may provide a treatment of choice for this kind of disease. PATIENT CONCERNS A 43-year-old man was admitted to the hospital with intermittent pain of left arm, chest, and back. DIAGNOSES Computed tomography demonstrated an aberrant left subclavian artery originating from Kommerell's diverticulum in the right aortic arch, acute aortic dissection of Kommerell's diverticulum involving arch and descending aorta. INTERVENTIONS Total arch replacement combined with frozen elephant trunk was performed to create an adequate landing zone through a median sternotomy by circulatory arrest. Thoracic endovascular aortic repair was performed to isolate Kommerell's diverticulum from descending aorta completely, extending from the frozen elephant trunk to the distal descending aorta at the same time. OUTCOMES The patient got an uneventful postoperative course. LESSONS Hybrid surgical and endovascular management is a safe and effective procedure for this rare disease.
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48
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Mongero LB, Tesdahl EA, Stammers AH, Stasko AJ, Weinstein S. Does the Type of Cardioplegia Solution Affect Intraoperative Glucose Levels? A Propensity-Matched Analysis. J Extra Corpor Technol 2018; 50:44-52. [PMID: 29559754 PMCID: PMC5848084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 06/23/2017] [Accepted: 11/17/2017] [Indexed: 06/08/2023]
Abstract
Myocardial protection during cardiac surgery is a multifaceted process that is structured to limit injury and preserve function. Evolving techniques use solutions with varying constituents that enter the systemic circulation and alter intrinsic systemic concentrations. This study compared two distinct cardioplegia solutions on affecting intraoperative glucose levels. Data were abstracted from a multi-institutional perfusion registry, including a total of 1,188 propensity-matched cases performed from January through October 2016, at 17 cardiac surgical centers across the United States in which both del Nido and 4:1 cardioplegia were used during the study period. Covariate data included insulin administration, crystalloid cardioplegia volume, diabetes history, glucose at operating room entry, and nine additional variables. Primary and secondary endpoints were the highest intraoperative glucose level and maximum glucose in excess of 180 mg/dL. Mixed-effects multivariable linear and logistic regression models were used to assess the primary and secondary endpoints, respectively, allowing for statistical control of center and surgeon effects. Greater median crystalloid cardioplegia volume was given in the del Nido group (n = 594) 1,040 mL [interquartile range (IQR) = {800, 1,339}] compared with the 4:1 group (n = 594) 466 mL [IQR = {360, 660}] in the 4:1 group (p < .001) despite these groups being statistically indistinguishable in terms of bypass and cross-clamp times as well as seven other patient covariates. More patients required intraoperative insulin drip in the 4:1 group compared with del Nido (65.7% vs. 56.2%, p < .001). Multivariable linear mixed-effects analysis yielded an estimated maximum intraoperative glucose for the del Nido group of 177.8 mg/dL compared with that of the 4:1 group, 183.5 mg/dL-a statistically significant reduction of 5.7 mg/dL (p = .03). Multivariable logistic mixed-effects analysis showed a statistically nonsignificant reduction in the likelihood of crossing the 180 mg/dL threshold for del Nido compared with 4:1 (odds ratio [OR] = .79, p = .214). After controlling for known confounding variables, intraoperative maximum glucose levels for the del Nido group were 5.7 mg/dL lower than that of the 4:1 group; there was limited evidence suggesting a difference between methods in the likelihood of exceeding the threshold of 180 mg/dL intraoperatively. Further research is warranted to examine the differential effects of cardioplegia solution on intraoperative glucose levels.
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Affiliation(s)
- Linda B Mongero
- Medical Department, SpecialtyCare, Inc., Nashville, Tennessee
| | - Eric A Tesdahl
- Medical Department, SpecialtyCare, Inc., Nashville, Tennessee
| | | | - Andrew J Stasko
- Medical Department, SpecialtyCare, Inc., Nashville, Tennessee
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49
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Ad N, Holmes SD, Massimiano PS, Rongione AJ, Fornaresio LM, Fitzgerald D. The use of del Nido cardioplegia in adult cardiac surgery: A prospective randomized trial. J Thorac Cardiovasc Surg 2018; 155:1011-1018. [PMID: 29246552 PMCID: PMC5929134 DOI: 10.1016/j.jtcvs.2017.09.146] [Citation(s) in RCA: 93] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Revised: 09/08/2017] [Accepted: 09/22/2017] [Indexed: 11/30/2022]
Abstract
OBJECTIVES The del Nido cardioplegia solution has been used extensively in congenital heart surgery for more than 20 years and more recently for adults. This randomized controlled trial examined whether expanding this technique to adult cardiac surgery confers benefits in surgical workflow and clinical outcome compared with blood-based cardioplegia. METHODS Adult first-time coronary artery bypass grafting (CABG), valve, or CABG/valve surgery patients requiring cardiopulmonary bypass (CPB) were randomized to del Nido cardioplegia (n = 48) or whole blood cardioplegia (n = 41). Primary outcomes assessed myocardial preservation. Troponin I was measured at baseline, 2 hours after CPB termination, 12 and 24 hours after cardiovascular intensive care unit admission. Alpha was set at P < .001. RESULTS Preoperative characteristics were similar between groups, including age, Society of Thoracic Surgeons risk score, CABG, and valve procedures. There was no significant difference on CPB time (97 vs 103 minutes; P = .288) or crossclamp time (70 vs 83 minutes; P = .018). The del Nido group showed higher return to spontaneous rhythm (97.7% vs 81.6%; P = .023) and fewer patients required inotropic support (65.1% vs 84.2%; P = .050), but did not reach statistical significance. Incidence of Society of Thoracic Surgeons-defined morbidity was low, with no strokes, myocardial infarctions, renal failure, or operative deaths. For del Nido group patients, troponin levels did not increase as much as for control patients (P = .040), but statistical significance was not reached. CONCLUSIONS Evidence from this study suggests del Nido cardioplegia use in routine adult cases may be safe, result in comparable clinical outcomes, and streamline surgical workflow. The trend for troponin should be investigated further because it may suggest superior myocardial protection with the del Nido solution.
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Affiliation(s)
- Niv Ad
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, WVa; Adventist HealthCare, Takoma Park, Md; Inova Fairfax Hospital, Falls Church, Va.
| | - Sari D Holmes
- Heart and Vascular Institute, West Virginia University Medicine, Morgantown, WVa
| | | | | | - Lisa M Fornaresio
- Heart and Vascular Institute, West Virginia University Medicine, Morgantown, WVa
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50
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Stammers AH, Tesdahl EA, Mongero LB, Stasko AJ, Weinstein S. Does the Type of Cardioplegic Technique Influence Hemodilution and Transfusion Requirements in Adult Patients Undergoing Cardiac Surgery? J Extra Corpor Technol 2017; 49:231-240. [PMID: 29302113 PMCID: PMC5737423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 04/30/2017] [Accepted: 07/10/2017] [Indexed: 06/07/2023]
Abstract
During cardiac surgery, myocardial protection is performed using diverse cardioplegic (CP) solutions with and without the presence of blood. New CP formulations extend ischemic intervals but use high-volume, crystalloid-based solutions. The present study evaluated four commonly used CP solutions and their effect on hemodilution during cardiopulmonary bypass (CPB). Records from 16,670 adult patients undergoing cardiac surgery with CPB between February 2016 and January 2017 were reviewed. Patients were classified into one of four groups according to CP type: 4-1 blood to crystalloid (4:1), microplegia (MP), del Nido (DN) and histidine-tryptophan-ketoglutarate (HTK). Covariate-adjusted estimates of group differences were calculated using multivariable logistic and linear mixed effects regression models. The primary end point was intraoperative transfusion of allogeneic red blood cells (RBCs), with a secondary end point of intraoperative hematocrit change. Among all patients, 8,350 (50.1%) received 4:1, 4,606 (27.6%) MP, 3,344 (20.1%) DN, and 370 (2.2%) HTK. Both 4:1 and MP were more likely to be used in patients undergoing coronary revascularization surgery, whereas DN and HTK were seen more often in patients undergoing valve surgery (p < .001). The highest volume of crystalloid CP solution was seen in the HTK group, 2,000 [1,754, 2200], whereas MP had the lowest, 50 [32, 67], p < .001. Ultrafiltration usage was as follows: HTK-84.9%. DN-83.7%, MP-40.1%, and 4:1-34.0%, p < .001. There were no statistically significant differences on the primary outcome risk of intraoperative RBC transfusion. However, statistically significant differences among all but one of the pair-wise comparisons of CP methods on hematocrit change (p < .05 or smaller), with MP having the lowest predicted drift (-7.8%) and HTK having the highest (-9.4%). During cardiac surgery, the administration of different CP formulations results in varying intraoperative hematocrit changes related to the volume of crystalloid solution administered.
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