1
|
Drury NE, Handley K, Jarrett H, Griffin T, Sun Y, Bilkhoo I, Robertson A, Tooke C, Scholefield BR, Dunn WB, Kostolny M, Stoica S, van Doorn C, Pappachan JV, Jones TJ, Caputo M. del Nido versus St. Thomas' blood cardioplegia in the young (DESTINY) trial: protocol for a multicentre randomised controlled trial in children undergoing cardiac surgery. BMJ Open 2025; 15:e102029. [PMID: 40228861 PMCID: PMC11997810 DOI: 10.1136/bmjopen-2025-102029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2025] [Accepted: 04/01/2025] [Indexed: 04/16/2025] Open
Abstract
INTRODUCTION Myocardial protection against ischaemia-reperfusion injury is a key determinant of heart function and outcome following cardiac surgery in children. However, myocardial injury still occurs routinely following aortic cross-clamping, as demonstrated by the ubiquitous rise in circulating troponin. del Nido cardioplegia was designed to protect the immature myocardium and is widely used in the USA but has not previously been available in the UK, where St. Thomas' blood cardioplegia is most common. The del Nido versus St. Thomas' blood cardioplegia in the young (DESTINY) trial will evaluate whether one solution is better than the other at improving myocardial protection by reducing myocardial injury, shortening ischaemic time and improving clinical outcomes. METHODS AND ANALYSIS The DESTINY trial is a multicentre, patient-blinded and assessor-blinded, parallel-group, individually randomised controlled trial recruiting up to 220 children undergoing surgery for congenital heart disease. Participants will be randomised in a 1:1 ratio to either del Nido cardioplegia or St. Thomas' blood cardioplegia, with follow-up until 30 days following surgery. The primary outcome is area under the time-concentration curve for plasma high-sensitivity troponin I in the first 24 hours after aortic cross-clamp release. Secondary outcome measures include the incidence of low cardiac output syndrome and Vasoactive-Inotropic Score in the first 48 hours, total aortic cross-clamp time, duration of mechanical ventilation and lengths of stay in the paediatric intensive care unit and the hospital. ETHICS AND DISSEMINATION The trial was approved by the West Midlands-Coventry and Warwickshire National Health Service Research Ethics Committee (21/WM/0149) on 30 June 2021. Findings will be disseminated to the academic community through peer-reviewed publications and presentation at national and international meetings. Parents will be informed of the results through a newsletter in conjunction with a national charity. TRIAL REGISTRATION NUMBER ISRCTN13638147; Pre-results.
Collapse
Affiliation(s)
- Nigel E Drury
- Department of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
- Department of Paediatric Cardiac Surgery, Birmingham Children's Hospital, Birmingham, UK
| | - Kelly Handley
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
- Department of Applied Health Sciences, University of Birmingham, Birmingham, UK
| | - Hugh Jarrett
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Tina Griffin
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | - Yongzhong Sun
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Indie Bilkhoo
- Department of Paediatric Cardiac Surgery, Birmingham Children's Hospital, Birmingham, UK
| | - Alex Robertson
- Department of Paediatric Cardiac Surgery, Great Ormond Street Hospital for Children, London, UK
| | - Carly Tooke
- Paediatric Intensive Care, Birmingham Children's Hospital, Birmingham, UK
| | - Barnaby R Scholefield
- Paediatric Intensive Care, Birmingham Children's Hospital, Birmingham, UK
- Critical Care Medicine, Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Warwick B Dunn
- Centre for Metabolomics Research, Biochemistry, Cell and Systems Biology, University of Liverpool, Liverpool, UK
| | - Martin Kostolny
- Department of Paediatric Cardiac Surgery, Great Ormond Street Hospital for Children, London, UK
| | - Serban Stoica
- Department of Paediatric Cardiac Surgery, Bristol Royal Hospital for Children, Bristol, UK
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Carin van Doorn
- Department of Congenital Cardiac Surgery, Leeds Children's Hospital, Leeds, UK
| | - John V Pappachan
- Paediatric Intensive Care, Southampton General Hospital, Southampton, UK
- Faculty of Medicine, University of Southampton, Southampton, UK
- NIHR Southampton Biomedical Research Centre, Southampton, UK
| | - Timothy J Jones
- Department of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
- Department of Paediatric Cardiac Surgery, Birmingham Children's Hospital, Birmingham, UK
| | - Massimo Caputo
- Department of Paediatric Cardiac Surgery, Bristol Royal Hospital for Children, Bristol, UK
- Bristol Heart Institute, University of Bristol, Bristol, UK
| |
Collapse
|
2
|
Holcomb RM, Ündar A. Are outcomes in congenital cardiac surgery better than ever? J Card Surg 2022; 37:656-663. [PMID: 35023592 DOI: 10.1111/jocs.16225] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Accepted: 12/06/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND AND AIM OF THE STUDY Congenital heart disease is the most common congenital defect among infants born in the United States. Within the first year of life, 1 in 4 of these infants will need surgery. Only one generation removed from an overall mortality of 14%, many changes have been introduced into the field. Have these changes measurably improved outcomes? METHODS The literature search was conducted through PubMed MEDLINE and Google Scholar from inception to October 31, 2021. Ultimately, 78 publications were chosen for inclusion. RESULTS The outcome of overall mortality has experienced continuous improvements in the modern era of the specialty despite the performance of more technically demanding surgeries on patients with complex comorbidities. This modality does not account for case-mix, however. In turn, clinical outcomes have not been consistent from center to center. Furthermore, variation in practice between institutions has also been documented. A recurring theme in the literature is a movement toward standardization and universalization. Examples include mortality risk-stratification that has allowed direct comparison of outcomes between programs and improved definitions of morbidities which provide an enhanced framework for diagnosis and management. CONCLUSIONS Overall mortality is now below 3%, which suggests that more patients are surviving their interventions than in any previous era in congenital cardiac surgery. Focus has transitioned from survival to improving the quality of life in the survivors by decreasing the incidence of morbidity and associated long-term effects. With the transformation toward standardization and interinstitutional collaboration, future advancements are expected.
Collapse
Affiliation(s)
- Ryan M Holcomb
- Penn State Hershey Pediatric Cardiovascular Research Center, Departments of Pediatrics, Penn State College of Medicine, Penn State Health Children's Hospital, Hershey, Pennsylvania, USA.,Surgery, Penn State College of Medicine, Penn State Health Children's Hospital, Hershey, Pennsylvania, USA
| | - Akif Ündar
- Penn State Hershey Pediatric Cardiovascular Research Center, Departments of Pediatrics, Penn State College of Medicine, Penn State Health Children's Hospital, Hershey, Pennsylvania, USA.,Biomedical Engineering, Penn State College of Medicine, Penn State Health Children's Hospital, Hershey, Pennsylvania, USA
| |
Collapse
|
3
|
Menon S, Mohammed S, Gadhinglajkar S, Baruah S, Ramanan S, Gopalakrishnan KA, Suneel PR, Dharan B. Clinical outcomes of del nido cardioplegia and st thomas blood cardioplegia in neonatal congenital heart surgery. Ann Card Anaesth 2022; 25:54-60. [PMID: 35075021 PMCID: PMC8865356 DOI: 10.4103/aca.aca_220_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objectives: Cardioplegia is essential for adequate myocardial protection. There continues to remain ambiguity regarding the ideal cardioplegia for adequate myocardial protection in congenital heart surgery. This study compares clinical outcomes using St Thomas II solution and Del Nido cardioplegia in neonates undergoing cardiac surgery. Methods: All neonates (<30 days) from 2011 to 2017 who underwent surgery requiring cardioplegic arrest were analyzed retrospectively. We divided the cohort into two groups depending on cardioplegia received, as group A (Blood cardioplegia with St Thomas II solution, n = 56) and group B (Del Nido cardioplegia, n = 48). Various demographic, intraoperative, early postoperative, and discharge variables were analyzed. Results: Two groups were similar in age, gender, pre-operative diagnosis, and risk category. Cardiopulmonary bypass (CPB) time (P = 0.002), aortic cross-clamp (ACC) time (P = 0.018), and the number of doses of cardioplegia (P < 0.001) were significantly lower with Del Nido group. Though vasoactive inotropic score (VIS) (P = 0.036) was high during the first 24 h in the immediate postoperative period in group A, there was no difference in early mortality among both groups (P = 0.749). Both groups did not show significant differences related to various postoperative and discharge variables. Conclusion: When compared to St. Thomas solution, the use of Del Nido cardioplegia solution in neonates is associated with a significant decrease in CPB and ACC times and VIS in the first 24 h after surgery. The choice of cardioplegia (St Thomas/Del Nido) in neonates does not affect early mortality and early postoperative clinical outcomes.
Collapse
|
4
|
Arafat AA, Hassan E, Alfonso JJ, Alanazi E, Alshammari AS, Mahmood A, Al-Otaibi K, Adam AI, Algarni KD, Pragliola C. Del Nido versus warm blood cardioplegia in adult patients with a low ejection fraction. THE CARDIOTHORACIC SURGEON 2021. [DOI: 10.1186/s43057-021-00061-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Del Nido cardioplegia was recently introduced to adult cardiac surgery with encouraging results. The effect of Del Nido cardioplegia in patients with low ejection fraction (EF) has not been thoroughly evaluated. The objective of this study was to assess the safety of Del Nido cardioplegia in adult patients with low EF compared to intermittent warm blood cardioplegia.
Results
During 2018 and 2019, 73 adult patients with an EF of ≤ 40% underwent cardiac surgery using Del Nido cardioplegia. The patients were compared to a historical cohort of consecutive patients with low EF who had intermitted warm blood cardioplegia (n = 81). Patients who had Del Nido cardioplegia had significantly lower EuroSCORE II (2.73 (1.7–4.1) vs. 4.5 (2.4–7.4), P = 0.004). There were no differences in creatinine clearance and preoperative echocardiographic data between the groups. Cardiopulmonary bypass and cross-clamp times were non-significantly lower with Del Nido cardioplegia. There were no differences in stroke and postoperative echocardiographic data between the groups. No hospital mortality was reported in both groups. Peak troponin levels were significantly higher in patients who had Del Nido cardioplegia (0.88 (0.58–1.47) vs. 0.7 (0.44–1.01) ng/dL; P = 0.01); however, after multivariable regression analysis, cardiopulmonary bypass time was the only predictor of postoperative troponin level (coefficient 0.005 (95% CI: 0.003–0.008); P < 0.001). ICU stay was significantly longer in patients who had Del Nido cardioplegia (4 (3–6) vs. 2(1–4) days, P < 0.001), while postoperative hospital stay did not differ between the groups. After multivariable regression, the use of intermittent warm blood cardioplegia was significantly associated with shorter ICU stay (coefficient − 1.80 (95% CI − 3.06 – -0.55); P = 0.01).
Conclusions
Prolonged ICU was reported with Del Nido cardioplegia; however, there were no differences in the duration of hospital stay and the clinical outcomes between the groups. Despite the proven efficacy of intermittent warm blood cardioplegia, the use of Del Nido cardioplegia might be safe in patients with low EF.
Collapse
|
5
|
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] [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.
Collapse
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
| |
Collapse
|
6
|
Haranal M, Chin HC, Sivalingam S, Raja N, Mohammad Shaffie MS, Namasiwayam TK, Fadleen M, Fakhri N. Safety and Effectiveness of Del Nido Cardioplegia in Comparison to Blood-Based St. Thomas Cardioplegia in Congenital Heart Surgeries: A Prospective Randomized Controlled Study. World J Pediatr Congenit Heart Surg 2020; 11:720-726. [DOI: 10.1177/2150135120936119] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: To compare the safety and effectiveness of del Nido cardioplegia with blood-based St Thomas Hospital (BSTH) cardioplegia in myocardial protection in congenital heart surgery. Methods: It is a prospective, open-labeled, randomized controlled study conducted at National Heart Institute, Kuala Lumpur from July 2018 to July 2019. All patients with simple and complex congenital heart diseases (CHD) with good left ventricular function (left ventricular ejection fraction [LVEF] >50%) were included while those with LVEF <50% were excluded. A total of 100 patients were randomized into two groups of 50 each receiving either del Nido or BSTH cardioplegia. Primary end points were the spontaneous return of activity following aortic cross-clamp release and ventricular function between two groups. Secondary end point was myocardial injury as assessed by troponin T levels. Results: Cardiopulmonary bypass and aortic cross-clamp time, return of spontaneous cardiac activity following the aortic cross-clamp release, the duration of mechanical ventilation, and intensive care unit stay were comparable between two groups. Statistically significant difference was seen in the amount and number of cardioplegia doses delivered ( P < .001). The hemodilution was significantly less in the del Nido complex CHD group compared to BSTH cardioplegia ( P = .001) but no difference in blood usage ( P = .36). The myocardial injury was lesser (lower troponin T release) with del Nido compared to BSTH cardioplegia ( P = .6). Conclusion: Our study showed that both del Nido and BSTH cardioplegia are comparable in terms of myocardial protection. However, single, less frequent, and lesser volume of del Nido cardioplegia makes it more suitable for complex repair.
Collapse
Affiliation(s)
- Maruti Haranal
- Department of Pediatric Cardiac Surgery, National Heart Institute, Kuala Lumpur, Malaysia
| | - Hew Chee Chin
- Department of Pediatric Cardiac Surgery, National Heart Institute, Kuala Lumpur, Malaysia
| | - Sivakumar Sivalingam
- Department of Pediatric Cardiac Surgery, National Heart Institute, Kuala Lumpur, Malaysia
| | - Natesan Raja
- Department of Cardiac Anesthesia, National Heart Institute, Kuala Lumpur, Malaysia
| | | | | | - Mohammad Fadleen
- Department of Perfusion Sciences, National Heart Institute, Kuala Lumpur, Malaysia
| | - Nurul Fakhri
- Department of Clinical Research, National Heart Institute, Kuala Lumpur, Malaysia
| |
Collapse
|
7
|
Algarni KD. Routine use of del Nido cardioplegia compared with blood cardioplegia in all types of adult cardiac surgery procedures. J Card Surg 2020; 35:3340-3346. [DOI: 10.1111/jocs.15060] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 09/04/2020] [Accepted: 09/12/2020] [Indexed: 12/17/2022]
Affiliation(s)
- Khaled D. Algarni
- Department of Cardiac Sciences, College of Medicine King Saud University Riyadh Saudi Arabia
- Department of Adult Cardiac Surgery Prince Sultan Cardiac Center Riyadh Saudi Arabia
| |
Collapse
|
8
|
Bigdelian H, Hosseini A. Effect of single-dose crystalloid cardioplegic agent compared to bloody cardioplegic agent in cardiac surgery in children with Tetralogy of Fallot. ARYA ATHEROSCLEROSIS 2020; 16:24-32. [PMID: 32499828 PMCID: PMC7244793 DOI: 10.22122/arya.v16i1.1943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Cardioplegia is one of the main post-operative cardiac protective factors widely used in recent decades in the form of crystalloid (St. Thomas) and bloody solutions [del Nido (DN)]. The purpose of this study was to compare the effect of a crystalloid cardioplegic agent (St. Thomas) with that of a bloody cardioplegic agent (DN) in pediatric cardiac surgery among children with Tetralogy of Fallot (TOF). METHODS This study was performed on 60 children with TOF, who were candidates for heart repair surgery. The participants were randomly divided into two groups of crystalloid cardioplegic agent and bloody cardioplegic agent. Operative outcomes such as required time for onset of heart arrest, duration of returning to normal heart rhythm, and cardiopulmonary bypass (CPB) time, and operative complications were compared between the two groups. RESULTS The duration of returning to normal heart rhythm (50.43 ± 10.93 seconds vs. 43.03 ± 16.35 seconds; P = 0.044) and duration of inotropy (80.40 ± 27.14 hours vs. 63.20 ± 26.91 hours; P = 0.017) were significantly higher in the DN group compared to the St. Thomas group. However, there were no significant differences between the two groups in terms of heart arrest time, cross-clamp time, CPB time, supplementary lasix time, duration of intubation, and intensive care unit (ICU) and hospital length of stay (LOS) (P > 0.050). CONCLUSION The use of St. Thomas cardioplegic solution was more effective in reducing the duration of returning to normal heart rhythm and inotropy compared with DN cardioplegic agent, and a single dose of these two cardioplegic agents can keep the mean cardiac arrest duration within the range of 50-70 minutes. It seems that the use of St. Thomas cardioplegic solution can be suggested in pediatric heart surgery.
Collapse
Affiliation(s)
- Hamid Bigdelian
- Associate Professor, Department of Cardiac Surgery, School of Medicine AND Cardiac Rehabilitation Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Alireza Hosseini
- Assistant Professor, Department of Cardiac Surgery, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| |
Collapse
|
9
|
Ler A, Sazzad F, Ong GS, Kofidis T. Comparison of outcomes of the use of Del Nido and St. Thomas cardioplegia in adult and paediatric cardiac surgery: a systematic review and meta-analysis. Perfusion 2020; 35:724-735. [DOI: 10.1177/0267659120919350] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Background: In recent years, the use of del Nido cardioplegia, initially intended for paediatric cardiac surgery, has been extended to adult cardiac surgery in many institutions. Our aim was thus to compare the outcomes of the use of del Nido cardioplegia with that of conventional cardioplegia and discuss its role in both adult and paediatric cardiac surgery. Method: A systematic literature search was conducted in August 2019 on Medline (via PubMed), Embase and Cochrane electronic databases according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Any retrospective studies and randomised controlled trials that reported findings comparing the outcomes of the use of del Nido cardioplegia with that of St. Thomas cardioplegia were included. Results: We observed shorter aortic cross-clamp time (mean difference: −15.18, confidence interval: −27.21 to −3.15, p = 0.01) and cardiopulmonary bypass time (mean difference: −13.52, confidence interval: −20.64 to −6.39, p = 0.0002) associated with the use of del Nido cardioplegia in adult cardiac surgery as compared to St. Thomas cardioplegia. Defibrillation rates were significantly lower in patients who had been given del Nido cardioplegia, in both adult (relative risk: 0.28, confidence interval: 0.12 to 0.64, p = 0.003) and paediatric patients (relative risk: 0.25, confidence interval: 0.08 to 0.79, p = 0.02). Conclusion: Del Nido cardioplegia may be a viable alternative to the use of St. Thomas cardioplegia in both adult and paediatric patients, providing similar postoperative outcomes while also affording the additional advantage of shorter aortic cross-clamp time and cardiopulmonary bypass time (in adult cardiac surgery) and decreased rates of defibrillation (in both adult and paediatric cardiac surgery).
Collapse
Affiliation(s)
- Ashlynn Ler
- Department of Cardiac, Thoracic and Vascular Surgery, National University Heart Centre, Singapore
- School of Medicine, National University of Ireland, Galway, Ireland
| | - Faizus Sazzad
- Department of Cardiac, Thoracic and Vascular Surgery, National University Heart Centre, Singapore
- Cardiovascular Research Institute, National University of Singapore, Singapore
| | - Geok Seen Ong
- Department of Cardiac, Thoracic and Vascular Surgery, National University Heart Centre, Singapore
| | - Theo Kofidis
- Department of Cardiac, Thoracic and Vascular Surgery, National University Heart Centre, Singapore
- Cardiovascular Research Institute, National University of Singapore, Singapore
- Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| |
Collapse
|
10
|
Kavala AA, Turkyilmaz S. Comparison of del Nido Cardioplegia with Blood Cardioplegia in Coronary Artery Bypass Grafting Combined with Mitral Valve Replacement. Braz J Cardiovasc Surg 2019; 33:496-504. [PMID: 30517259 PMCID: PMC6257536 DOI: 10.21470/1678-9741-2018-0152] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2018] [Accepted: 07/31/2018] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To compare del Nido cardioplegia (DNC) with blood cardioplegia (BC) in coronary artery bypass grafting (CABG) combined with mitral valve replacement. METHODS A 3-year single-center retrospective cohort study was carried out. Subjects who underwent CABG (up to triple bypass) combined with mitral valve replacement were divided into DNC and BC groups. Each group had thirty subjects. RESULTS Both groups demonstrated similar baseline characteristics, including age, gender, cardiac/non-cardiac comorbidity, and preoperative echocardiographic parameters. Compared with the BC group, the DNC group demonstrated significantly lower cardioplegia volume (BC = 1130.00±194.1 mL, DNC = 884.33±156.8 mL, P=0.001), cardiopulmonary bypass time (DNC = 110.90±12.52 min, BC = 121.70±13.57 min, P=0.002), aortic clamp time (DNC = 91.37±11.58 min, BC = 101.37±13.87 min, P=0.004), and need for intraoperative defibrillation (DNC = 6 events, BC = 21 events, P=0.001). Postoperative creatine kinase-MB levels and troponin levels were significantly lower in the DNC group than in the BC group. Postoperative haemoglobin and haematocrit levels were significantly higher in the DNC group than in the BC group. The intubation period (hours) in intensive care unit (ICU) was significantly small in the BC group (DNC = 8.13±12.21, BC = 6.82±1.57, P=0.037); however, ICU stay, total hospital stay, and postoperative complication rates were not significantly different between them. At pre-discharge echocardiography, the DNC group demonstrated significantly higher ejection fraction rates than the BC group (47.79±5.50 and 45.72±5.86, respectively, P=0.005). CONCLUSION DNC presented better intraoperative and postoperative parameters and it is an effective and safe alternative to BC for CABG combined with mitral valve replacement.
Collapse
Affiliation(s)
- Ali Aycan Kavala
- Department of Cardiovascular Surgery, Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Istanbul, Turkey
| | - Saygin Turkyilmaz
- Department of Cardiovascular Surgery, Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Istanbul, Turkey
| |
Collapse
|
11
|
Medikonda R, Ong CS, Wadia R, Goswami D, Schwartz J, Wolff L, Hibino N, Vricella L, Nyhan D, Barodka V, Steppan J. Trends and Updates on Cardiopulmonary Bypass Setup in Pediatric Cardiac Surgery. J Cardiothorac Vasc Anesth 2019; 33:2804-2813. [PMID: 30738750 DOI: 10.1053/j.jvca.2019.01.025] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2018] [Indexed: 02/07/2023]
Abstract
Perfusion strategies for cardiopulmonary bypass have direct consequences on pediatric cardiac surgery outcomes. However, inconsistent study results and a lack of uniform evidence-based guidelines for pediatric cardiopulmonary bypass management have led to considerable variability in perfusion practices among, and even within, institutions. Important aspects of cardiopulmonary bypass that can be optimized to improve clinical outcomes of pediatric patients undergoing cardiac surgery include extracorporeal circuit components, priming solutions, and additives. This review summarizes the current literature on circuit components and priming solution composition with an emphasis on crystalloid, colloid, and blood-based primes, as well as mannitol, bicarbonate, and calcium.
Collapse
Affiliation(s)
| | - Chin Siang Ong
- Department of Surgery, Johns Hopkins University, Baltimore, MD
| | - Rajeev Wadia
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD
| | - Dheeraj Goswami
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD
| | - Jamie Schwartz
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD
| | - Larry Wolff
- Department of Surgery, Johns Hopkins University, Baltimore, MD
| | | | - Luca Vricella
- Department of Surgery, Johns Hopkins University, Baltimore, MD
| | - Daniel Nyhan
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD
| | - Viachaslau Barodka
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD
| | - Jochen Steppan
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD.
| |
Collapse
|
12
|
Medikonda R, Ong CS, Wadia R, Goswami D, Schwartz J, Wolff L, Hibino N, Vricella L, Barodka V, Steppan J. A Review of Goal-Directed Cardiopulmonary Bypass Management in Pediatric Cardiac Surgery. World J Pediatr Congenit Heart Surg 2018; 9:565-572. [PMID: 30157729 DOI: 10.1177/2150135118775964] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Cardiopulmonary bypass perfusion management significantly affects postoperative outcomes. In recent years, the principles of goal-directed therapy have been applied to the field of cardiothoracic surgery to improve patient outcomes. Goal-directed therapy involves continuous peri- and postoperative monitoring of vital clinical parameters to tailor perfusion to each patient's specific needs. Closely measured parameters include fibrinogen, platelet count, lactate, venous oxygen saturation, central venous oxygen saturation, mean arterial pressure, perfusion flow rate, and perfusion pulsatility. These parameters have been shown to influence postoperative fresh frozen plasma transfusion rate, coagulation state, end-organ perfusion, and mortality. In this review, we discuss the recent paradigm shift in pediatric perfusion management toward goal-directed perfusion.
Collapse
Affiliation(s)
| | - Chin Siang Ong
- 2 Department of Surgery, Johns Hopkins University, Baltimore, MD, USA
| | - Rajeev Wadia
- 3 Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Dheeraj Goswami
- 3 Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Jamie Schwartz
- 3 Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Larry Wolff
- 2 Department of Surgery, Johns Hopkins University, Baltimore, MD, USA
| | - Narutoshi Hibino
- 2 Department of Surgery, Johns Hopkins University, Baltimore, MD, USA
| | - Luca Vricella
- 2 Department of Surgery, Johns Hopkins University, Baltimore, MD, USA
| | - Viachaslau Barodka
- 3 Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Jochen Steppan
- 3 Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA
| |
Collapse
|
13
|
Affiliation(s)
- Jonathan M Chen
- Congenital Cardiac Surgery, Seattle Children's Hospital, Seattle, Washington.
| |
Collapse
|