The impact of del Nido cardioplegia solution on blood morphology parameters

Background: Crystalloid cardioplegic solutions are believed to reduce hemoglobin significantly and increase the transfusion rate. However, recent reports indicate that the del Nido cardioplegia may preserve blood morphology parameters. Methods: In “The del Nido versus cold blood cardioplegia in aortic valve Replacement” trial patients undergoing aortic valve replacement were randomized into the del Nido (DN) or cold blood cardioplegia (CB) group. For the subanalysis, patients who underwent blood transfusions were excluded from the study. Red blood cell (RBC) count, hemoglobin, white blood cell (WBC) count and platelet (PLT) count were measured before the surgery, 24-, 48-, and 96 hours postoperatively. Furthermore, percental variation in first-last measure was compared in groups. In addition, indexed normalized ratio (INR) and activated partial thromboplastin time (aPTT) were compared preoperatively and 24 hours after the surgery. Results: Eighteen (24%) patients from the del Nido group and 22 (29.3%) patients from the CB group received blood product transfusions (p = 0.560) and were excluded from further analysis. As such, 57 patients remained in DN group and 53 patients remained in CB group. No difference was found in RBC, hemoglobin, WBC, and platelet count in time intervals. Percental variation in first-last measure revealed higher fall in RBC (p = 0.0024) and hemoglobin (p = 0.0028) in the CB group. No difference was shown in preoperative and 24-hour postoperative INR and aPTT. Conclusions: The del Nido cardioplegia does not decrease blood morphology parameters when compared to cold blood cardioplegia and may be used alternatively regardless of bleeding and coagulopathy risk.

Myocardial Protection by Retrograde Application of HTK Solution Compare with Cold Blood Cardioplegic Solution during Heart Valve Surgery

Objective: Cardioplegic solution is one important principle for adequate myocardial protection in cardiac surgery. Bretschneider’s histidine-tryptophan-ketoglutarate (HTK) solution is an intracellular solution while blood cardioplegia solution is an extracellular solution. Both have been used to preserve the myocardium. The present study compared between the two cardioplegic solutions for incidence of ventricular fibrillation after aortic clamp removal in double valve replacement (DVR) and tricuspid annuloplasty (TVA) to assess the effectiveness for myocardial protection. Materials and Methods: A retrospective study was conducted among patients who underwent DVR with TVA operations between January 1, 2013 and June 30, 2017 and divided in two groups at Queen Sirikit Heart Center of the Northeast. The medical records were searched for detailed demographics, preoperative status, operative technique, and post-operative hospital course. Results: Thirty-six patients were included in the present study, 18 patients received HTK solution, the others received blood cardioplegia. The demographic data presented no statistical difference between the two groups. Incidence of ventricular fibrillation after aortic clamp removal occurred in 10 patients (55.6%) in the HTK group, which was more than the cold blood group [five patients (27.78%)]. Cardiopulmonary bypass (CPB) and aortic cross clamp time in the cold blood group was significantly longer than in the HTK group (p<0.001). The peak of Trop-T and CK-MB within six hours after surgery tended to be downward after 24 hours and was not related to perioperative myocardial ischemia in the HTK group. No statistically difference was observed in postoperative outcome, ICU stay, or hospital stay. Conclusion: The use of HTK solution has no significant different outcome compared to conventional cold blood cardioplegia via retrograde route in DVR with TVA operation. There was no significantly different incidence of ventricular fibrillation and there was no evidence of postoperative myocardial infarction. CPB and aortic cross clamp time in the HTK group were shorter than in the cold blood cardioplegia significantly. Keywords: Cardioplegia, HTK, Custodiol, Ventricular fibrillation

COMPARISON STUDY: INTERMITTENT ANTIGRADE WARM CARDIOPLEGIA VERSUS ANTIGRADE COLD INTERMITTENT BLOOD CARDIOPLEGIA FOR MYOCARDIAL PROTECTION DURING ELECTIVE ON PUMP CORONARY ARTERY BYPASS GRAFTING IN EARLY POST-OPERATIVE PERIOD

Background: Defending the heart against potential damage during cross-clamping is the most important and vital step to ensuring a successful surgical outcome(1). The creation of cardioplegia solutions was one of the major advances in cardiac surgery that allowed surgeons to conduct complicated surgical procedures to avoid myocardial injury (14). Treating cardioplegia at a cool temperature would be a significant factor in lowering myocardial metabolism. However, the reduction in myocardial metabolism due to hypothermia, compared with that achieved by diastolic arrest, is usually very negligible. Since Normothermias enzymatic and cellular processes work better (7). Owing to the propensity of the heart to resume electrical operation during normothermia, however, this must be administered consistently or only with short interruptions (4). Terminal warm blood cardioplegia (hot shot) is normally done just before the elimination of the aortic cross-clamp since it has been demonstrated that myocardial metabolism is increasing (23). Methods: A prospective controlled randomised study (200 hundred patients aged 40 to 65 years of both sexes underwent elective CABG pump surgery) will be included. They will be divided into three groups of patients: Group I:includes 100 Patients who received intermittent cold blood cardioplegia. Group II:includes 100 Patients who received intermittent warm blood cardioplegia with controlled reperfusion for 3 minutes before aortic unclamping. Study made from January, 2019 to August, 2020, at National Heart Institute.All patients were thoroughly evaluated preoperatively, intraoperatively, and postoperatively. Results: We hypothesized that in our patient cohort, warm blood cardioplegia could be as successful as or even better than the conventional antegrade cold blood cardioplegia. Patients were randomised into two similar blocks, each of which consisted of 100 patients, each of whom obtained one of the two cardioplegic solutions. Our analysis did not indicate a statistically important difference in the post-operative release of myocardial biomarkers (Troponin I) & CK in both classes. This finding did not significantly reflect the clinical outcome of our patient, which may indicate similar myocardial protection in primary low-risk CABG patients for both cold and warm blood cardioplegia. Conclusion: During the time of cardiac arrest, both methods tend to enable an equal and adequate approach for myocardial defence. To attain improved myocardial defence, warm blood cardioplegia needs a shorter administration interval. Therefore, the choice between one type of cardioplegia and the other remains at the discretion of the surgeon. The statistically minor variation found in the release of myocardial enzymes did not translate into distinct clinical results.

Intermittent antegrade warm-blood versus cold-blood cardioplegia in children undergoing open heart surgery: a protocol for a randomised controlled study (Thermic-3)

IntroductionSurgical repair of congenital heart defects often requires the use of cardiopulmonary bypass (CPB) and cardioplegic arrest. Cardioplegia is used during cardiac surgery requiring CPB to keep the heart still and to reduce myocardial damage as a result of ischaemia–reperfusion injury. Cold cardioplegia is the prevalent method of myocardial protection in paediatric patients; however, warm cardioplegia is used as part of usual care throughout the UK in adults. We aim to provide evidence to support the use of warm versus cold blood cardioplegia on clinical and biochemical outcomes during and after paediatric congenital heart surgery.Methods and analysisWe are conducting a single-centre randomised controlled trial in paediatric patients undergoing operations requiring CPB and cardioplegic arrest at the Bristol Royal Hospital for Children. We will randomise participants in a 1:1 ratio to receive either ‘cold-blood cardioplegia’ or ‘warm-blood cardioplegia’. The primary outcome will be the difference between groups with respect to Troponin T levels over the first 48 postoperative hours. Secondary outcomes will include measures of cardiac function; renal function; cerebral function; arrythmias during and postoperative hours; postoperative blood loss in the first 12 hours; vasoactive-inotrope score in the first 48 hours; intubation time; chest and wound infections; time from return from theatre until fit for discharge; length of postoperative hospital stay; all-cause mortality to 3 months postoperative; myocardial injury at the molecular and cellular level.Ethics and disseminationThis trial has been approved by the London – Central Research Ethics Committee. Findings will be disseminated to the academic community through peer-reviewed publications and presentation at national and international meetings. Patients will be informed of the results through patient organisations and newsletters to participants.Trial registration numberISRCTN13467772; Pre-results.

Custodiol cardioplegia solution compared to cold blood cardioplegia in pediatric cardiac surgery: a single-institution experience

Objective: Custodiol is an intracellular, crystalloid cardioplegia solution that is a single-dose alternative to multi-dose cold blood cardioplegia; however, there is scarce data regarding its use in infants and children. The objective of this study was to compare its impact on myocardial function in infants. Methods: Single-center retrospective review including 132 patients <12 months old undergoing biventricular repair. There were 106 patients who received single-dose Custodiol and 27 patients who received multi-dose blood cardioplegia. Demographic and echocardiographic data were compared between the two groups. Results: Patients receiving Custodiol were slightly younger (100 ± 62 days) and lower weight (4.7 ± 1.3 kg) compared to 152 ± 86 days and 5.2 ± 1.3 kg for blood cardioplegia (p < 0.05). The Society of Thoracic Surgeons/European Association for Cardio-Thoracic Surgery Congenital Heart Surgery score was similar between both groups. Average cardiopulmonary bypass time was similar between both groups (Custodiol 93 ± 54 minutes vs. blood 81 ± 44 minutes, p = 0.46) as was aortic cross-clamp time (Custodiol 58 ± 33 minutes vs. cold blood 53 ± 33 minutes, p = 0.62). Pre-operative left ventricular ejection fraction was similar for blood 73 ± 8% versus Custodiol 70 ± 9%, p = 0.21. There was also no intergroup difference in left ventricular ejection fraction 24 hours post op (blood 64 ± 9% vs. Custodiol 65 ± 12%, p = 0.53) or at discharge (blood 66 ± 10% vs. Custodiol 66 ± 11%, p = 0.95). The pre-operative right ventricle function by fractional area change was also similar in blood cardioplegia (46 ± 13%) versus Custodiol (48 ± 9%, p = 0.38) and showed similar drops in parameters in the two groups 24 hours after surgery and at discharge. Conclusion: Single-dose Custodiol is as safe as blood cardioplegia for myocardial protection in congenital cardiac surgery for the cross-clamp times evaluated in this study. Evaluation at longer cross-clamp times would be helpful to determine if there is a greater benefit to single-dose Custodiol versus more repeated doses of blood cardioplegia for longer cross-clamp times.

Myocardial protection in the arterial switch operation: Custodiol versus cold blood cardioplegia

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 &lt; 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 &lt; 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 &lt; 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.