Del Nido Cardioplegia Solution Research Articles

Traditional vs. modified Ringer lactate-based del Nido cardioplegia impacts on clinical outcomes in patients undergoing coronary artery bypass grafting: results from a clinical trial

Introduction: myocardial protection with cardioplegia solution is one of the precautions during coronary bypass grafting surgery (CABG) with cardiopulmonary bypass (CPB) to reduce myocardial damage and ischemia/reperfusion injuries. Unfortunately, the major component of the del Nido cardioplegia solution, Plasma-Lyte A, is unreachable in Iran due to high cost. Therefore, we have utilized lactate Ringer's solution as the base solution for our modified del Nido solution (LR DN). Study design and methods: the present clinical trial was performed on 18-75 year old patients (EF>35%) undergoing CABG with CPB in Imam Hossein hospital Tehran-Iran in 2021. Patients were randomly allocated to LR DN (modified del Nido cardioplegia) and PL DN (standard del Nido cardioplegia solution) groups. Serum level of cardiac troponin I (cTnI) at baseline, declamp, ICU admission, and 24 hours after admission, the type and dosage of inotrope agents, EF, rate of arrhythmia after clamp removal and lactate level were measured and compared between groups. Results: 109 patients were recruited. There were no statistically significant differences between the PL DN cardioplegia and LR DN groups for cardiopulmonary bypass times, cardiac enzymes, transfusion requirements, and arterial blood gases. However, postoperative serum levels of cTnI among patients in the LR DN group was significantly higher than patients of the PL DN group after ICU admission and 24 hours postoperatively. Also, more patients needed epinephrine administration in the operating room in the LR DN group (29.8% vs. 11.5%; p: 0.019 vs. PL DN group). Conclusion: we concluded that standard del Nido cardioplegia solution offers better myocardial protection compared with Ringer's lactate-based del Nido cardioplegia in adult patients undergoing CABG with CPB. We recommend using standard del Nido cardioplegia with a base of Plasma-Lyte A for patients presenting for CABG surgery.

Association between Aquaporin 7 Expression and Myocardial Protection with Nicorandil or Del Nido Cardioplegia: An Experimental Study

Background: Aquaporin 7 (AQP7), a member the aquaglyceroporin subgroup of the AQP family, is a water channel that controls transport of glycerol and water in heart tissues. It facilitates the uptake of glycerol, a substrate for cardiac energy production, in cardiomyocytes. St. Thomas' Hospital cardioplegic solution No. 2 has cardio-protective effect even in AQP7-deficient hearts. Here, we aimed to determine whether nicorandil or del Nido cardioplegia (DNC) solution can protect AQP7-deficient hearts. Methods: The hearts of male AQP7 knockout (KO) and wild-type (WT) C57/B6N mice (age >15 weeks) were aerobically perfused using the Langendorff technique, and cardiac function was measured as left ventricular diastolic pressure (LVDP) throughout the study. Troponin T was measured as an indicator of myocardial damage after reperfusion for 60 min. We compared WT and KO controls subjected to 25 min of global ischemia as well as WT and KO groups infused with nicorandil (100 µM) for 10 min followed by 25 min of global ischemia. We also compared WT-DNC and KO-DNC hearts administered with DNC for 2 min followed by 23 min of global ischemia (Study 2). Results: The final recovery rates of LVDP were 20.8 ± 7.0%, 28.1 ± 7.6%, 40.0 ± 8.4%, and 38.7 ± 4.7% in the WT control, KO control, WT nicorandil, and KO nicorandil groups, respectively. The LVDP recovered faster in the hearts treated with DNC and reached a significantly higher plateau in the KO than in the WT hearts. Troponin T values were 2144 ± 493 and 1313 ± 717 in the WT and KO groups, respectively (p = 0.041). Conclusion: The Langendorff perfusion model revealed similar myocardial protective effects of nicorandil in AQP7-deficient mice as in WT mice. AQP7 deficiency did not impair the cardioprotective effects of DNC solution.

Comparison of Del Nido (a different application) and crystalloid blood cardioplegia on arrhythmia and early results.

The results of the use of del-Nido(DN) solution using a different method or crystalloid blood cardioplegia in coronary bypass patients were compared. We aimed to investigate the effects on intraoperative and postoperative arrhythmias, arrhythmia durations and early results. The study included 175 patients using crystalloid blood cardioplegia (Group 1) and 150 patients using DN solution(Group 2). In the DN group, 75% of the calculated plegia dose was given first. the remaining part was applied by giving from grafts. Intraoperative/postoperative data were compared. There was no significant difference between the groups in terms of demographic characteristics. Preop troponin level was similar.(p = 0.190) However, there was a statistical difference between the postoperative 6th hour.(p = 0.001) There was no difference in troponin values at the postoperative 24th hour. (p = 0.631) Spontaneous rhythm occurred at the cardiopulmonary by pass (CPB) weaning stage in most of the patients in Group 2 (95.3%). Although the need for temporary pacing was less in Group 2, it was not significant.(p = 0.282) No patient required permanent pacing. CPB duration, cross clamp times and intraoperative glucose levels, intensive care follow-up times and hospitalization times were found to be shorter in Group 2. Although the postoperative atrial fibrillation frequency was similar (p = 0.261), the time to return to sinus was lower in Group 2.(p = 0.001). The use of DN cardioplegia solution provides significant positive contributions to avoid arrhythmias compared to crystalloid blood cardioplegia. DN solution applied with this method may contribute to reducing the anxieties associated with its use in isolated coronary artery bypass surgery.

Serum Lidocaine Levels in Adult Patients Undergoing Cardiac Surgery With del Nido Cardioplegia

BackgroundLidocaine in del Nido cardioplegia solution prolongs the refractory period of cardiomyocytes, yielding a longer arrest per dose. Serum lidocaine concentrations >8 mg/L are associated with seizure and cardiotoxicity. We evaluated serum lidocaine concentrations in patients receiving del Nido solution during cardiac surgery. MethodsForty consecutive patients undergoing cardiac surgical procedures with del Nido cardioplegia were selected for serum lidocaine concentration measurements determined immediately after aortic cross-clamp removal. Variables included weight, body surface area, operation, cardiopulmonary bypass time, aortic cross-clamp time, and total volume of del Nido solution. The primary outcome was serum lidocaine concentration relative to total volume of del Nido solution. Descriptive statistics and Pearson correlations were computed. ResultsMedian weight was 78.3 kg (range, 43-132.4 kg), and mean body surface area was 1.9 ± 0.2 m2. Operations included coronary artery bypass grafting (n = 26 [65%]), a combination procedure (n = 5 [12.5%]), isolated mitral valve repair or replacement (n = 4 [10%]), isolated aortic valve replacement (n = 3 [7.5%]), and aortic repair or replacement (n = 2 [5%]). Median total volume of del Nido solution was 1870 mL (range, 800-5800 mL). Mean serum lidocaine concentration was 2.2 ± 0.6 mg/L. Serum lidocaine concentration was weakly correlated with del Nido solution volume (R2 = 0.21). The highest total volume of del Nido solution (5800 mL) did not yield the highest serum lidocaine concentration of 3.5 mg/L. ConclusionsSerum lidocaine concentration during cardiac surgical procedures weakly correlates with the volume of del Nido solution used and does not reach toxic levels even at high doses of del Nido solution. The results of this study may help alleviate concerns for lidocaine toxicity with high doses of del Nido solution.

Self-constituted modified del Nido cardioplegia solution in pediatric congenital heart defect surgery.

ABSTRACT… Objective: To present our experience of modified del Nido Cardioplegia for chemical arrest and myocardial protection during congenital heart defect in pediatric cardiac surgeries. Study Design: Retrospective Cross Sectional. Setting: Department of Cardiac Surgery, PAQSJIMS, Gambat, Khairpur. Period: 15th March, 2021 to 10th October, 2022. Material & Methods: del Nido solution is generally constituted in plasma lyte A solution, not available in Pakistan; therefore, we constituted del Nido solution in ringer lactate solution. We had collected our data retrospectively for our study to assess the safety and efficacy of modified del Nido cardioplegic arrest during the open heart surgeries for congenital heart defects. We report clinical outcomes of our patients that include spontaneous rhythm, ionotropic score and duration of mechanical ventilation underwent open heart surgeries with. Results: During the study period we had performed 102 surgeries for correction or palliation of congenital heart defects. We have included 54 patients in our study co with 28 (52%) male and 26 female (48%) patients; had a mean age 8.9 (±3.7) years and mean weight 22.4 (±12.7) kg. Majority of patients 29 (54%) belonged to Category 2 on RACHS-1 scale. Our average cross clamp time was 39.7min, and 37(68%) patients required a single dose of cardioplegia. Spontaneous sinus rhythm was established in 48(89%) patients; average ionotropic score of patients at the time of PICU arrival was 8.6 (±5.6) with 31(57%) have score of less than 10, while 2(4%) patients were received without the ionotrope. All the patients were shifted on mechanical ventilators with average time of 253.6 (±219.6) min of mechanical ventilation. Conclusion: Our results show modified del Nido solution is safe, with added benefits of fewer interruption in surgery, greater magnitude of spontaneous sinus rhythm and fewer ionotropic requirements.

Comparison of the cardioprotective effects of St. Thomas and del Nido cardioplegia

Objectives: This study aimed to histopathologically examine the cardioprotective effects of St. Thomas and del Nido (DN) cardioplegia. Materials and methods: A total of 18 rabbits aged 23 weeks and weighing 2000 g were included in the experimental animal study. The animals were randomized to three groups, with six rabbits in each group. The first group was determined as the control group and no cardioprotective agent was given after ligation of the aorta. The rabbits in the second group received DN cardioplegia solution, and those in the third group received the St. Thomas cardioplegia solution. The groups were histopathologically graded and evaluated with six different scores. Results: There were statistically significant differences between St. Thomas, DN, and control groups with hematoxylin and eosin, caspase 3 and connexin 43 staining at 30, 60, and 90 min (p<0.05). However, the St. Thomas, DN, and control groups showed equal score 2- and score 3-weighted, score 3-weighted, and score 3-weighted distributions with connexin 43 at 90 min, respectively; there was no statistically significant difference between the groups (p=0.144). Conclusion: The most adverse tissue damage observed were localized hemorrhage and localized necrosis areas at the end of 90 min of cellular damage. Both cardioplegia applications significantly reduced tissue loss compared to the control group. However, we believe that DN cardioplegia has a longer application time and has better protection.

Comparative study between conventional crystalloid cardioplegic solution with modified del nido cardioplegia in mitral valve regurgitation surgery

Background: Cardioplegia is crucial for protecting the heart. Long-term cardiac protection is offered by the Del Nido Cardioplegia solution (dNCS). Aim: To compare conventional crystalloid cardioplegia with modified del Nido cardioplegia in mitral valve regurgitation replacement surgery. Objectives and Methods: This randomized clinical study included 80 patients undergoing to elective mitral regurgitation replacement surgery of both sex and age from 21 to 60 years with ASA (III and IV). All 80 patients were randomly assigned to receive conventional cardioplegia (St. Thomas’ cardioplegic solutions) or to obtain a modified del Nido cardioplegia (using normal saline) (groups A and B, respectively). The laboratory data for assessment of myocardial protection were obtained through measurements of preoperative serum levels of cardiac enzymes as, CK-MB, troponin, and lactate, immediately after operation, 12 and 24 hours postoperatively. Results: There was a significant increase in CK-MB only after 1 h (p < .001) in group (A) and after 12 h. CK-MB and lactate levels were significantly increased (p < 0.05). Also, after 24 h. CK-MB and Troponin T levels were significantly increased (p < .001). Regarding complications, one patient had atrial fibrillation and one case had permanent stroke in group (A), and two patients died in group (A), while one patient died in group (B) without a significant difference between the groups. Conclusions: We report that Modified Del Nido Cardioplegia has better postoperative chemical parameters as CK-MB, Troponin T and Lactate in mitral valve surgery in adults. DNC is a safe alternative to conventional cardioplegia and has achieved at least the same results.

Del Nido Cardioplegia for patients of adult congenital heart disease.

Objective: To assess the efficacy of del Nido cardioplegia for patients of adult congenital heart diseases undergoing cardiac surgery. Study Design: Descriptive Observational Case Series. Setting: Department of Paediatric Cardiac Surgery, Faisalabad Institute of Cardiology, Faisalabad. Period: October 2019 to September 2021. Material & Methods: All consecutive patients of age fifteen years or above who underwent open-heart surgery for congenital heart disease by using ante grade del Nido cardioplegia during the study period were included. Dedicated hospital database used to retrieve the data of patients regarding type of surgery for CHD and operative or postoperative outcome parameters. The data was entered in excel sheet and descriptive analysis done. Results: One hundred and twenty five patients underwent open heart bypass surgery for congenital heart disease by using del Nido cardioplegia during the study period. Majority of patients were male (n=83, 66.4%) with male to female ratio 1.97:1. Sixty eight percent were less than thirty years of age. Primary repair of TOF was the most frequently performed surgery (49.6%, n=62) while 28.8% had repair of VSD. Average bypass time was 136 ±57 minutes and average cross clamp time of 103 ± 44 minutes. Total duration of mechanical ventilation was 6.6 ±11.9 hours, ICU stay of 38 ±34 hours and stay in the hospital of 5.2 ± 2.6 days. Cardiac tamponade was seen in 0.8% of patients (n=1) while moderate LV systolic dysfunction in 1.6 % of patients. Conclusion: Del Nido cardioplegia solution is as safe as conventional blood cardioplegia with short ventilation time, ICU stay and lowest postoperative complications.

Plasmalyte-A Based del Nido Cardioplegia Versus Plain Ringer Based del Nido Cardioplegia: Double-Blind Randomized Trial.

Background: In this prospective randomized controlled trial, we compared the standard del Nido cardioplegia solution (SDN) with the modified del Nido cardioplegia solution (MDN) in which the base solution was the plain Ringer solution. Methods: A total of 80 patients aged < 12 years undergoing intracardiac repair of Tetralogy of Fallot were randomized into SDN (n = 39) or MDN (n = 41) groups. The primary outcome was a change in cardiac index (CI). Secondary outcomes were ventricular arrhythmias after the release of aortic-cross clamp, postoperative inotropic score (IS), time to peripheral rewarming, duration of mechanical ventilation, intensive care unit (ICU) length of stay, and hospital length of stay, and electron microscopic differences between the 2 groups. Cardiac Troponin-I, inflammatory markers tumor necrosis factor-α (TNF-α), and interleukin-L (IL-6) were measured. Results: Applying the noninferiority confidence interval approach, the difference between the changes in CI between the 2 groups was -0.093 L/min/m2 (95% CI: -0.46-0.27 L/min/m2) which was within the noninferiority threshold of -0.5 indicating that CI was similar in both SDN and MDN. Ventricular arrhythmias postclamp release (P = .91), IS (P = .09), duration of mechanical ventilation (P = .27), ICU length of stay (P = .50), hospital length of stay (P = .57), IL-6 (P = .19), TNF-α (P = .17), Troponin-I (P = .15), electron microscopy changes (P > .05) were not different between groups. Conclusion: MDN was shown to be noninferior to the SDN cardioplegia in terms of preservation of cardiac index. In addition, other metrics indicative of myocardial protection were similar between groups. In developing nations where SDN is not available or is expensive, MDN cardioplegia is an acceptable alternative.

Use of del Nido cardioplegia in adult cardiac surgery

In most adult cardiac surgery operations, the heart must be completely immobile and isolated from the blood. Therefore, the heart is stopped in diastole and a still operative site is obtained. Cardiac arrest results in ischemia-reperfusion injury. For these reasons, myocardial protection and the prevention of damages are required. Various cardioplegia solutions are used for this purpose. It can be said that cardioplegia is the gold standard method of myocardial protection in cardiac arrest. Nowadays, "Single-dose cardioplegia" applications are increasingly used, especially in minimally invasive cardiac surgery and basic coronary bypass procedures due to the advantages they provide, which include reduction of aortic cross-clamp time, prevention of frequent interruption of the procedure due to cardioplegia, and reduced postoperative myocardial dysfunction incidence. The two main solutions used in single dose cardioplegia applications are the Bretschneider solution and the del Nido extracellular cardioplegia solution. The del Nido cardioplegia solution (dNCS), which was originally developed for use in pediatric cardiac surgery, has recently increased its use in adult cardiac surgery due to straightforward application and long-term effectiveness. The del Nido cardioplegia reduces the aortic cross clamp duration, cardiopulmonary bypass time and required cardioplegia solution volume, and is a safer and superior cardioplegia solution and technique in terms of myocardial protection with regards to many organs and cardiac-biochemical parameters.

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

Background/objective: The aim of the present study was to compare the operative and early postoperative results of the use of del Nido Cardioplegia solution (dNCS) with traditional blood cardioplegia (BC) in adult aortic surgery. MethodsA retrospective single-center study was performed on 118 patients who underwent aortic surgery with cardiopulmonary bypass (CPB) between January 2016 and June 2020. Patients were divided in to two groups according to the type of cardioplegia solution used. Cardiac arrest was achieved in Group 1 (n = 65) with traditional BC and in Group 2 (n = 53) with dNCS. Operative and postoperative outcomes of the patients were compared between the two groups. ResultsPatient demographic characteristics were similar between the two groups. dNCS group showed significantly lower aortic cross-clamp (ACC) time (73.3 vs. 87.5 min, P = 0.001), cardioplegia volume (1323.9 ± 368.5 vs. 2773.8 ± 453.8 ml, P< 0.001), defibrillation rate (44.4%vs. 69.2%, P = 0.006), drainage amount (412 ± 73.2 vs. 446.9 ± 95.1 ml, P = 0.026) and inotropic support need (37% vs. 55.3%, P = 0.046). Also dNCS group had significantly lower high sensitive troponin I (hsTnI) levels at 6th (203.5 ± 68.6 vs. 275.7 ± 76.2 ng/L, P< 0.001) and 24th (253.1 ± 101 vs. 293.4 ± 80.1 ng/L, P = 0.017) postoperative hours. And dNCS group showed significantly higher hematocrit levels at 6th (25.1 ± 3.2 vs. 22.5 ± 2.5%, P< 0.001) and 24th (25.8 ± 2.7 vs. 24.6 ± 2.8%, P = 0.024) postoperative hours. Times of intensive care unit stay, durations of intuabation and hospital stay times were similar in both groups. There was no significant difference in terms of postoperative ejection fraction values (P = 0.714). ConclusionCompared with conventional BC, dNCS provided significantly shorter ACC times, reduced the need for intraoperative defibrillation, lowered postoperative hsTnI levels with comparable early clinical outcomes for adult patients undergoing aortic surgery. dNCS is a safe and efficient alternative to the traditional BC solution in adult aortic cardiac surgery.

Effect of del nido cardioplegia use on kidney injury after coronary bypass operations.

After cardiac surgery, acute kidney injury is observed at a rate of 5-30%, and the second most common cause of acute kidney injury in intensive care units is cardiac surgery. In this study, we aimed to investigate the effect of del Nido cardioplegia solution use on postoperative acute kidney injury development in patients who underwent coronary artery bypass grafting operation with cardiopulmonary bypass. Consecutive patients who underwent an elective coronary artery bypass grafting operation with cardiopulmonary bypass in our clinic between March 15, 2019, and March 15, 2020, were included in the study retrospectively. The patients were divided into two groups as those who received del Nido cardioplegia solution (Group 1) and blood cardioplegia (Group 2), and factors affecting the development of renal failure were examined. A total of 350 consecutive patients were included in the study. There were 156 patients in the del Nido cardioplegia group and 194 patients in the blood cardioplegia group. Among the patient group, 74 (21.1%) patients developed acute kidney injury. The total acute kidney injury development rate was significantly higher in Group 2 (p=0.018). In multivariate logistic regression analysis, advanced age (OR 1.128; 95%CI 1.044-1.217; p=0.042), increased blood product use (OR 1.318; 95%CI 1.154-1.998; p=0.019), preoperative creatinine elevation (OR 2.434; 95%CI 1.655-4.639; p=0.005), and increased cardioplegia volume (OR 1.254; 95%CI 1.109-2.980; p=0.009) were independent predictors of acute kidney injury. With this study, we showed that the use of del Nido cardioplegia solution can reduce the incidence of acute kidney injury.

Initial experience with del Nido cardioplegia solution at a Pediatric and Congenital Cardiac Surgery Program in Brazil.

The aim of this study was to evaluate outcome measures between our standard multidose cardioplegia protocol and a del Nido cardioplegia protocol in congenital heart surgery patients. Retrospective single-center study including 250 consecutive patients that received del Nido cardioplegia (DN group) with a mandatory reperfusion period of 30% of cross clamp time and 250 patients that received a modified St. Thomas' solution (ST group). Groups were matched by age, weight, gender, and Risk Adjustment for Congenital Heart Surgery (RACHS-1) scores. Preoperative hematocrit and oxygen saturation were also recorded. Outcomes analyzed were the vasoactive inotropic score (VIS), lactate, ventilation time, ventricular dysfunction with low cardiac output syndrome (LCOS), intensive care unit (ICU) length of stay (LOS), hospital LOS, bypass and aortic cross-clamp times, and in-hospital mortality. Both groups were comparable demographically. Statistically significant differences (p ⩽ 0.05) were noted for cardiac dysfunction with LCOS, hematocrit at end of surgery (p = 0.0038), VIS on ICU admission and at end of surgery (p = 0.0111), and ICU LOS (p = 0.00118) with patients in the DN group having more desirable values for those parameters. Other outcome measures did not reach statistical significance. In our congenital cardiac surgery population, del Nido cardioplegia strategy was associated with less ventricular dysfunction with LCOS, a lower VIS and decreased ICU LOS compared with patients that received our standard myocardial protection using a modified St. Thomas' solution. Despite the limitation of this study, including its retrospective nature and cohort size, these data supported our transition to incorporate del Nido cardioplegia solution with a mandatory reperfusion period as the preferred myocardial protection method in our program.

English

BACKGROUND The del Nido cardioplegia was devised and introduced as a single dose cardioplegia for myocardial protection in congenital heart surgery by Petro del Nido and team. The most commonly used cardioplegia in adult cardiac surgery was multidose blood cardioplegia which has to be repeated every 25 to 30 minutes to maintain cardiac arrest. For this, the surgery has to be interrupted leading to prolonged cardiopulmonary bypass and aortic cross clamp time. With promising results of del Nido cardioplegia in adult cardiac surgery, more and more centres adopted this single dose cardioplegia in adult cardiac surgery. We retrospectively analysed the safety and efficacy of del Nido cardioplegia and compared them with those of conventional blood cardioplegia in isolated coronary artery bypass surgery. METHODS We have been using multidose conventional blood cardioplegia (CBCP) solution for all our cardiac surgeries. We changed the cardioplegia protocol to single dose del Nido cardioplegia (DNCP) solution in October 2016. We collected the preoperative, intraoperative and post-operative data of 100 patients in each group, who underwent elective isolated coronary artery bypass surgery. RESULTS The baseline demographic features, pre- and post-operative cardiac function, number of coronary arteries involved, and comorbidities were similar in both groups. There was a statistically significant reduction in cardiopulmonary bypass time (77.16 ± 13.13 minutes vs. 121.69 ± 28.18 minutes, P-value &lt; .00001) and aortic cross clamp time (57.71 ± 10.6 minutes vs. 77.26 ± 20.29 minutes, p value &lt; .00001) in the DNCP group. The total dose of cardioplegia solution required was significantly less in DNCP group (1000 mL vs. 2393.56 ± 592.42 mL, P-value &lt; .00001). The mean post-operative hospital stay in DNCP group was 7.87 ± 1.25 days as compared to 12.49 ± 1.29 days in CBCP group with a P-value &lt; .00001. CONCLUSIONS The del Nido cardioplegia solution is associated with shorter cardiopulmonary bypass and aortic cross clamp time, less volume of cardioplegia solution and shorter mean hospital stay. The del Nido cardioplegia can be used in adult cardiac surgery with the same safety of conventional blood cardioplegia in adult isolated coronary artery bypass surgery. KEYWORDS Del Nido Cardioplegia, Isolated Coronary Artery Bypass Surgery, Myocardial Protection, Cardiopulmonary Bypass Time, Aortic Cross Clamp Time

DelNido cardioplegia versus St Thomas cardioplegia solution in double valve replacement: a single centre experience.

The role of cardioplegia cannot be underrated in cardiac surgery. St Thomas solution is the most widely used cardioplegic, but needs repeated dosing. Del Nido solution provides long duration of asystole with adequate protection; but has been used mainly in paediatric patients. This study was aimed to compare Del Nido cardioplegia with St Thomas cardioplegia in adult cardiac surgeries, requiring double valve replacement and compare the outcomes. This retrospective, observational, descriptive study was conducted over a time period spanning from January 2016 to December 2019. A total of 209 patients were included and were separated in two groups DC group (n = 114) and BC group (n = 95) on the basis of cardioplegic solution used. Del Nido solution was administered as single dose. Parameters noted were CPB time, cross clamp time, wean off bypass time, DC shocks given, inotropic support required, ventilation duration, duration of ICU and hospital stay. There was significantly shorter aortic cross clamp time (72.6 ± 10.2 vs. 98.2 ± 9.2), CPB time (92.1 ± 12.3 vs.129.5 ± 11) and wean off bypass time (19.4 ± 5.9 vs. 31.3 ± 7.6) and less requirement of DC shocks (21.2% vs. 65.9%) in DC group. Inotropic requirement in immediate post-operative period was significantly less in DC group both on day of surgery (5.35 ± 1.44 vs. 7.52 ± 3.8) and 24 hours later (3.4 ± 2.12 vs. 2.18 ± 0.72). There was no significant difference in duration of ventilation, ICU and hospital stay. Del Nido can be used safely in long duration adult cardiac surgeries and in a single dose with better intra operative and immediate post-operative outcomes as compared to St Thomas solution.

Myocardial Protection by Blood-Based Del Nido versus St. Thomas Cardioplegia in Cardiac Surgery for Adults and Children.

St. Thomas (ST) and Del Nido (DN) cardioplegic solutions are widely used for myocardial protection during cardiac surgery. In 2016, our university hospital shifted from modified St. Thomas to Del Nido solution for both adult and pediatric cardiac surgery. This retrospective study was conducted to compare ST and DN solutions regarding surgical workflow and clinical outcome in pediatric and adult patients undergoing cardiac surgery. We reviewed 220 patients who underwent cardiac surgery requiring cardioplegic arrest. Patients were categorized in 2 groups: ST (n = 110) and DN (n = 110). Each group included 60 pediatric and 50 adult patients. Demographic, intraoperative, and postoperative variables were collected. In pediatric patients, no significant difference was found between the 2 groups regarding clamping time, bypass time, need for defibrillation, inotropic score, postoperative ejection fraction (EF), period of mechanical ventilation, intensive care unit stay, or postoperative arrhythmias. One patient in the ST group required mechanical support by extracorporeal membrane oxygenation. We had 5 cases of pediatric mortality (3 in DN and 2 in ST, P = .64). In adult patients, significantly fewer patients in the DN group needed defibrillation than in the ST group. No significant difference was found regarding clamping time, inotropic score, or intraaortic balloon pump use. Mortality in adult patients was 6 cases (4 in ST group and 2 in DN group). DN cardioplegia solution is as safe as ST solution in pediatric and adult cardiac surgery. It has comparable results of myocardial protection and clinical outcome, with superiority regarding uninterrupted surgery and lower rate of defibrillation.

A proposed redosing interval of del Nido cardioplegia solution in adult cardiac surgery: a propensity-matched study.

Recently, del Nido cardioplegia solution (DN) has been utilized in adult cardiac surgery. However, adequate interval of maintenance dose(s) is still unclear. The purpose of this study was to assess the safety and efficacy of our DN protocol by comparing with conventional cold whole blood cardioplegia (CWB). A total of 1003 consecutive patients (DN group, N = 350 vs. CWB group, N = 653) underwent cardiovascular surgery between July 2013 and September 2018 were included in this study. The DN protocol was to administer 1000 to 1200 ml as an initial dose and to add maintenance dose(s) (500 ml each) every 60 minutes when the estimated cross-clamp time was over 90 minutes. CWB was given every 20 minutes, regardless of cross-clamp time. Propensity matching identified 254 matched pairs for analysis. The preoperative and postoperative data were reviewed. Cross-clamp time was significantly shorter in the DN group compared with the CWB group (107 ± 56 minutes vs. 116 ± 49 minutes, p = 0.0458). A retrograde cannula was used in 124 (48.8%) patients in the DN group and 181 (71.3%) patients in the CWB group (p < 0.0001). There were no significant differences in requiring postoperative cardiac supports (inotropes, mechanical circulatory supports) and major complications. In-hospital mortality was similar between two groups (DN group: 3.2% vs. CWB group: 2.4%, p = 0.5872). Short-term clinical outcomes in the patients underwent cardiovascular surgery with the DN protocol including the redosing interval strategy were acceptable. Also, DN protocol was associated with shortened cross-clamp time and less usage of the retrograde cannula.

Use of del Nido cardioplegia in acute aortic dissection surgery.

Del Nido cardioplegia solution provides a depolarized hyperkalemic arrest lasting up to 60 minutes. Single-dose del Nido cardioplegia solution may offer an alternative myocardial protection strategy to conventional whole blood cardioplegia following acute aortic dissection surgery. We retrospectively reviewed 122 consecutive patients with acute aortic dissection undergoing arch reconstruction surgery procedure with cardioplegia arrest from January 2017 to December 2019. Patients exclusively received with whole blood cardioplegia (n = 60, January 2017-December 2018) or del Nido cardioplegia (n = 62, January 2018-December 2019). Preoperative and postoperative data were retrospectively reviewed. No significant difference between two groups in mortality (4/60 vs 3/62, p = 0.964), cardiopulmonary bypass time (168.0 ± 10.5 minute vs 165.0 ± 12.5 minute, p = 0.154), aortic cross-clamp time (91.8 ± 9.0 minute vs 93.2 ± 9.5 minute, p = 0.405), selective antegrade cerebral perfusion time (21.8 ± 5.0 minute vs 22.4 ± 4.7 minute, p = 0.496) and postoperative vasoactive inotropic score (34.8 ± 1.9 vs 35.2 ± 2.1, p = 0.272), neurological complications rate (8/60 vs 12/62, p = 0.523), renal insufficiency rate (5/60 vs 7/62, p = 0.807) and the troponin T level (304.8 ± 111.3 vs 315.0 ± 94.9, p = 0.588), respectively. Mean volume of crystalloid was significantly higher in the del Nido group compared to the whole blood cardioplegia group (1010.2 ± 20.3 mL vs 300.0 ± 19.6 mL, p < 0.001). Patients requiring defibrillation was 7/62 vs 28/60 (p < 0.001), with statistical difference in both groups. Short-term outcomes in acute aortic dissection surgery using del Nido cardioplegia solution were acceptable and comparable to conventional multi-dose whole blood cardioplegia. Del Nido cardioplegia technique is associated with lower defibrillations rate and requires a reduced frequency of infusions that results in longer durations between infusions and may be a feasible alternative to conventional whole blood cardioplegia solution in acute aortic dissection surgery.

Del Nido Cardioplegia Versus Cold Blood Cardioplegia in Adult Cardiac Surgery: Protocol for a Randomized Controlled Trial.

BackgroundThe use of cardioplegia solutions as a myocardial protection technique is essential during cardiac surgery with cardiopulmonary bypass. The del Nido cardioplegia solution (DNS) has been widely used as a myocardial preservation technique for pediatric patients undergoing cardiac surgery with cardiopulmonary bypass. Its unique pharmacological features have created growing interest for adult cardiac surgery, especially for elderly patients or those with ventricular dysfunction who are more prone to ischemia-reperfusion injury. Ever since its implementation, several retrospective studies have been published to validate the efficacy, safety, and efficiency of DNS in adult patients undergoing coronary revascularization, valve replacement, or combined procedures. Recently, a meta-analysis based on nine retrospective studies was published claiming the noninferiority of DNS compared to other conventional cardioplegia solutions. Few prospective randomized studies have been conducted whose primary outcome was the assessment of DNS clinical efficacy compared to other solutions commonly used in adult patients.ObjectiveThe aim of this randomized clinical trial is to assess the benefits of DNS compared to Cardi-Braun blood cardioplegia solution in clinical and biochemical terms regarding myocardial protection during adult cardiac surgery.MethodsThis is the protocol of a controlled, randomized, single-center clinical trial carried out at the Puerta de Hierro Majadahonda University Hospital in Spain. A total of 474 participants over the age of 18 years undergoing elective cardiac surgery with cardiopulmonary bypass will be assigned to groups by simple randomization to receive either DNS or Cardi-Braun blood cardioplegia solution. The primary outcome will be the differences between groups in myocardial protection in biochemical terms (ie, perioperative troponin levels) and clinical terms (ie, presence of the composite variable acute cardiovascular event). The clinical trial will be carried out under conditions of respect for the fundamental rights of the person and the ethical principles that affect biomedical research with human beings, as well as in accordance with international recommendations contained in the Declaration of Helsinki and its subsequent revisions.ResultsThe inclusion process started in 2018. Data cleaning and analyses are expected to take place in the fall of 2020 and the results are expected in January 2021.ConclusionsThis study is particularly relevant as it will be one of the first to analyze the clinical effects of del Nido cardioplegia on the basis of direct myocardial protection parameters. In light of published studies, carrying out prospective studies based on primary clinical objectives with a larger sample, high-risk patients, and longer cardiopulmonary bypass times continues to be necessary. We believe that our study addresses an important gap in the knowledge of del Nido cardioplegia in adult patient cardiac surgery and will be able to clarify the possible benefits of this method in a large population of patients undergoing these procedures.Trial RegistrationEuropean Union Drug Regulating Authorities Clinical Trials Database (EudraCT) 2017-005144-14; https://www.clinicaltrialsregister.eu/ctr-search/search?query=2017-005144-14+; ClinicalTrials.gov NCT04094168; https://clinicaltrials.gov/ct2/show/NCT04094168International Registered Report Identifier (IRRID)DERR1-10.2196/17826

Lidocaine adsorption to ethylene-vinyl acetate infusion bags decreases its availability in del Nido cardioplegia solution

Del Nido cardioplegia solution (dNCS) is frequently used in cardiac surgery. As dNCS is often in-house prepared by hospital pharmacies, an appropriate preparation and storage conditions need to be found and validated. In this study, an 8-week (i.e., 56 days) stability test was performed to monitor the effect of several variables on the stability of dNCS manufactured internally at a hospital pharmacy. Six dNCS variants were prepared that differed in the material of container used, i.e., ethylene-vinyl acetate (EVA) infusion bags or glass infusion bottles, magnesium ions source, and the presence or absence of sodium bicarbonate. Each variant was evaluated for its stability while maintaining at 4 °C, 22 °C, or 50 °C. The concentrations of constituents were monitored using HPLC and capillary electrophoresis. It was found that dNCS is stable at 4 °C for 8 weeks and that the replacement of magnesium chloride with magnesium sulfate and/or the absence of sodium bicarbonate has no effect on the stability. On the other hand, if dNCS is not refrigerated or maintained at elevated temperature, the lidocaine concentration in the solution stored in EVA bags can be significantly altered by adsorption of lidocaine to infusion bag material (within 25 days, lidocaine concentration decreases as low as to one half of the original value). Therefore, the dNCS stored in EVA bags should be maintained at 4 °C to avoid alternation of its pharmacological effect, because when the solution stored in EVA bag is maintained at elevated temperature, the concentration of lidocaine can be significantly changed. Such change influences the pharmacological effect of the solution leads to serious complications and even endangers the health or life of patients.