Custodiol versus Plegisol: A phase 3 multicentre myocardial protection study

Comparison of Bretschneider HTK cardioplegia solution and blood cardioplegia in terms of postoperative results in patients who underwent isolated supracoronary ascending aortic replacement

INTRODUCTION

Cardiac arrest with cardioplegia is the most common and reliable method of myocardial protection in cardiac surgery, but there is no definite consensus on the use of different types of cardioplegia. Two of the commonly used types of cardioplegia are Bretschneider histidine-tryptophan-ketoglutarate solution (Custodiol) and conventional blood cardioplegia. In this study, Custodiol solution and conventional blood cardioplegia used in patients with type A aortic dissection who underwent supracoronary ascending aortic replacement were aimed to be compared in terms of postoperative results.

METHODS

70 patients with type A aortic dissection who underwent supracoronary ascending aortic replacement in our clinic between January 2011 - October 2020 were included. Patients were divided into two groups, blood cardioplegia group (n = 48) and Custodiol group (n = 22) and they were compared regarding preoperative, perioperative and postoperative variables.

RESULTS

There was no significant difference between cardiopulmonary bypass time and cross-clamp time (p = 0.17 and p = 0.16, respectively). Mechanical ventilator weaning time, intensive care unit stay and hospital stay were shorter in Custodiol group (p = 0.04,p = 0.03 and p = 0.05, respectively). While inotropic support need was higher in the blood cardioplegia group (p = 0.001), there was no significant difference in terms of mortality, arrhythmia, neurological complications and renal complications.

CONCLUSIONS

Our results show that Custodiol cardioplegia solution may be superior to blood cardioplegia in reducing mechanical ventilation weaning period, intensive care and hospital stay, and reducing the use of inotropic agents in patients with type A aortic dissection undergoing supracoronary ascending aorta replacement.

Cardioplegia in Open Heart Surgery: Age Matters

INTRODUCTION

Cardioplegia is a pharmacological approach essential for the protection of the heart from ischemia-reperfusion (I-R) injury. Over the years, numerous cardioplegic solutions have been developed, with each cardioplegic approach having its advantages and disadvantages. Cardioplegic solutions can be divided into crystalloid and blood cardioplegic solutions, and an experienced surgeon chooses the type of solution based on the individual needs of patients in order to provide optimal heart protection. Importantly, the pediatric immature myocardium is structurally, physiologically, and metabolically different from the adult heart, and consequently its needs to achieve cardioplegic arrest strongly differ. Therefore, the present review aimed to provide a summary of the cardioplegic solutions available to pediatric patients with a special focus on emphasizing differences in heart injury after various cardioplegic solutions, the dosing strategies, and regimens.

MATERIAL AND METHODS

The PubMed database was searched using the terms cardioplegia, I-R, and pediatric population, and studies that investigated the influence of cardioplegic strategies on markers of cardiac muscle damage were further analyzed in this review.

CONCLUSIONS

A large body of evidence suggested more prominent benefits achieved with blood compared to those with crystalloid cardioplegia in pediatric myocardium preservation. However, standardized and uniform protocols have not been established so far, and an experienced surgeon chooses the type of cardioplegia solution based on the individual needs of patients, while the severity of myocardial damage strongly depends on the type and duration of the surgical procedure, overall patient condition, and presence of comorbidities, etc.

Single-Dose St. Thomas Versus Custodiol® Cardioplegia for Right Mini-thoracotomy Mitral Valve Surgery

OBJECTIVE

Custodiol® and St. Thomas cardioplegia are widely employed in mini-thoracotomy mitral valve (MV) operations. One-dose of the former provides 3 h of myocardial protection. Conversely, St. Thomas solution is usually reinfused every 30 min and safety of single delivery is unknown. We aimed to compare single-shot St. Thomas versus Custodiol® cardioplegia.

METHODS

Primary endpoint of the prospective observational study was cardiac troponin T level at different post-operative time-points. Propensity-weighted treatment served to adjust for confounding factors.

RESULTS

Thirty-nine patients receiving St. Thomas were compared with 25 patients receiving Custodiol® cardioplegia; cross-clamping always exceeded 45 min. No differences were found in postoperative markers of myocardial injury. Ventricular fibrillation at the resumption of electric activity was more frequent following Custodiol® cardioplegia (P = .01).

CONCLUSION

Effective myocardial protection exceeding 1 h of ischemic arrest can be achieved with a single-dose St. Thomas cardioplegia in selected patients undergoing right mini-thoracotomy MV surgery.

Nucleotide metabolism during experimental preservation for transplantation with Transmedium Transplant Fluid (TTF) in comparison to Histidine-Tryptophan-Ketoglutarate (HTK)

Organ preservation solutions are essential to diminish ischemic/hypoxic injury during cold storage and to improve graft survival. In our experiments, we investigated novel solutions that target such mechanisms as Transmedium Transplant Fluid (TTF) in comparison to PlegiStore solution (HTK). Rat hearts were infused with TTF or HTK and then subjected to 4 hours of 4 °C preservation followed by 25 minutes of reperfusion in the Langendorff system. Assessment of purine release from the heart, mechanical function, and cardiac nucleotide content in the heart homogenates was done. A significant increase in the uric acid, hypoxanthine, inosine, and total purine metabolite concentrations were observed in the HTK hearts when compared to TTF. The TTF group had lower left ventricular systolic pressure and left ventricular end-diastolic pressure when compared to the HTK. Left ventricular diastolic pressure, minimal dp/dt, and maximal dp/dt in both groups were similar. The concentration of ADP in the heart homogenates of the HTK group was increased when compared to the TTF group. ATP and GTP concentration showed a tendency to increase in the homogenates of TTF hearts when NAD, AMP, GDP, GMP, and ADPR were similar in both groups of rats. TTF provided enhanced cardioprotection as evidenced by inhibiting the purine nucleotide metabolites released from the rat hearts during reperfusion and enhanced systolic and diastolic mechanical function recovery. In particular, better preservation of GTP and ATP concentrations may translate into enhanced protection of endothelium and the cytoskeleton, which are not adequately protected with current preservation techniques.

Histidine-tryptophan-ketoglutarate solution versus multidose cardioplegia for myocardial protection in cardiac surgeries: a systematic review and meta-analysis

Background

Surgical procedures in the heart requires protection of the heart from ischemia–reperfusion injury. Cardioplegia is the primary myocardial protective method in use. Histidine–tryptophan–ketoglutarate (HTK) solution is an intracellular cardioplegic solution that was initially used to preserve organs for transplantation.

Methods

A systematic electronic search was conducted in July 2021, in four databases; PubMed, Scopus, Web of Science, and Cochrane Library for eligible randomized controlled trials. The results were screened and the eligible trials were identified. Thereafter, the relevant data were extracted and pooled as mean difference or risk ratio, and 95% confidence interval in an inverse variance method using RevMan software.

Results

This review included 12 trials (n = 1327). HTK solution has resulted significantly in shorter intensive care unit stay (MD = − 0.09; 95% CI [− 0.15, − 0.03], p = 0.006), and shorter hospital stay (MD = − 0.51; 95% CI [− 0.71, − 0.31], p < 0.00001). Moreover, the patients who received the HTK solution had significantly lower levels of creatine kinase (after 4–7 h (MD = − 157.52; 95% CI [− 272.31, − 42.19], p = 0.007), and 24 h (MD = − 136.62; 95% CI [− 267.20, − 6.05], p = 0.04)), as well as creatine kinase muscle brain band (after 44–48 h (MD = − 3.35; 95% CI [− 5.69, − 1.02], p = 0.005)).

Conclusion

HTK solution had the same efficacy and safety as other cardioplegic solutions in most of the clinical parameters. Furthermore, the solution showed superiority in fastening the recovery and protecting the myocardium at the biochemical level. HTK solution provides longer myocardial protection; therefore, it limits surgical interruption. HTK solution can be used as an alternative to the currently used cardioplegic solutions.

Custodiol HTK versus Plegisol: in-vitro comparison with the use of immature (H9C2) and mature (HCM) cardiomyocytes cultures

Background

Although cardioplegia is used since the ‘70s of the last century, debate on cardioprotection during cardio-surgical procedures is still actual. The selection of a particular method depends mainly on the preferences and experience of a specific center or even surgeon. Crystalloid cardioplegia is an aqueous ion solution similar to intracellular (Custodiol HTK) or extracellular (Plegisol) fluid. The potensional clinical advantages of relatively new idea of cardioplegia solution based on intracellular composition (Custodiol HTK) justifies futher research, but only a few used cultured cells in laboratory conditions.

Methods

In this study, the authors sought to compare Custodiol HTK with Plegisol cardioplegia solutions using an in-vitro model simulating cardioplegic arrest. The efficacy of myocardial protection during ischemia was investigated with susceptible indicators like the appearance of the deleterious effect of reactive oxygen species and oxidative stress markers. Immersed human cardiomyocytes and rat cardiomyoblasts H9C2 in cardioplegia for 4 h were examined for expression of oxidative stress markers (MnSOD, iNOS, HSP27), cardioplegic solutions cytotoxicity, and peroxidation damage of the cell’s lipids and proteins. All tests were performed after 0.5 h, 1 h, 2 h, and 4 h of incubation in identical physical and biological conditions, which is difficult to achieve in clinical trials.

Results

The lower cytotoxicity index performed on matured cells of human cardiomyocytes and highest dehydrogenase level showed after incubation with Custodiol HTK. This did not apply to tests on immature cells H9C2. Custodiol HTK induced significantly stronger iNOS expression. The decrease of HSP27 concentration has been instantaneous and maintained troughout the study only in both cultures incubated with Custodiol HTK. The other tests: lipid peroxidation, carbonyl groups concentration and MnSOD expression show no clear superiority evidence of used cardioplegic solutions.

Conclusions

Considering proceeded examinations on cultured cardiomyocytes, Custodiol HTK appears to be safer than Plegisol.

Myocardial Protection With Different Cardioplegia in Adult Cardiac Surgery: A Network Meta-Analysis

AIM

Cardioplegia is one of the most studied fields of myocardial protection during cardiac surgery. However, the most effective cardioplegia for protection in adult cardiac surgery remains unknown.

METHOD

PubMed and other databases were searched and a network meta-analysis with a Bayesian framework was performed. The primary outcomes were the serum concentrations of creatine kinase-myocardial band (CK-MB), cardiac troponin I, and cardiac troponin T (cTnT) at four time points. Several clinical outcomes were evaluated, including low output syndrome, myocardial infarction, and risk of early mortality. All studies that involved crystalloid cardioplegia without reference to St Thomas cardioplegia or histidine-tryptophan-ketoglutarate solution, and if the cardioplegia was used at a temperature between 4°C and 16°C were classified as cold crystalloid (cCCP) or cold blood cBCP cardioplegia. Warm blood cardioplegia (wBCP) was defined as the blood cardioplegia used at a temperature between 32°C and 37°C.

RESULTS

Forty-seven (47) studies with a total of 4,175 patients were included. Seven (7) cardioplegia solutions were used, including cold CCP or BCP, del Nido solution, histidine-tryptophan-ketoglutaratesolution, St Thomas cardioplegia, wBCP and warm terminal blood cardioplegia (wtBCP). The serum concentrations of CK-MB at 2 hours (mean difference [MD], 213.56; 95% confidence interval [CI], -25.79 to -1.59) and cTnT at 24 hours of wBCP (MD, -1.50; 95% CI, -2.69 to -0.31) were significantly lower than that of cCCP. There were no significant differences in other outcomes of these six cardioplegia solutions, when compared to cCCP.

CONCLUSIONS

The seven cardioplegia solutions analysed had similar myocardial protective effects after adult cardiac surgery, although wBCP had a lower CK-MB at 2 hours and lower cTnT at 24 hours.

HTK versus multidose cardioplegias for myocardial protection in adult cardiac surgery: A meta-analysis

BACKGROUND

Histidine-tryptophan-ketoglutarate (HTK) cardioplegia for myocardial protection obviates the need for maintenance cardioplegia doses, and thus allows for greater focus on procedure accuracy. The aim of this meta-analysis is to evaluate the safety and efficacy of HTK versus multidose cardioplegias during cardiac surgery in an adult population.

METHODS

Electronic searches were performed using PubMed, Science Direct, and Google Scholar databases. The key search terms included HTK cardioplegia AND cardiac surgery AND adult. This was followed by a meta-analysis investigating cardiopulmonary bypass (CPB) duration, cross-clamp duration, spontaneous defibrillation, inotropic support, mortality, atrial fibrillation, creatine kinase muscle brain band (CK-MB) and troponin I (TnI).

RESULTS

Seven randomized controlled trials (n = 804) were analyzed. Spontaneous defibrillation following aortic cross-clamp removal significantly favored HTK (odds ratio [OR], 2.809; 95% confidence interval [CI], 1.574 to 5.012; I²  = 0%; p < .01). There were no other notable significant differences between HTK and multidose cardioplegia in any of the parameters measured. In particular, the OR for mortality was 1.237 (95% CI, 0.385 to 3.978; I²  = 0%; p = .721) and the mean difference for CPB duration overall was 2.072 min (95% CI, -2.405 to 6.548; I²  = 74%; p = .364).

CONCLUSION

HTK is safe and effective during adult cardiac surgery when compared with multidose cardioplegias for myocardial protection during surgical correction of acquired pathology in the adult population. HTK may, therefore, be suitable for complex cases or those of extensive duration, without the prospect of increased postoperative morbidity or mortality.

Safety of Custodiol cardioplegia: a cohort study in patients undergoing cardiac surgery with elongated aortic cross-clamp time

BACKGROUND/OBJECTIVES

The increasing complexity of patients undergoing cardiac surgery requires extended myocardial ischaemic periods. Cardiac surgeons demand a cardioplegic solution with prolonged myocardial protection. Therefore, we introduced Custodiol in our centre in 2011. The aim of this study was to investigate the safety and efficacy of Custodiol compared with the standard method of cardioplegia.

METHODS

Between 2011 and 2016, 188 adult patients who underwent mitral valve surgery combined with coronary artery bypass grafting were included in this retrospective study. In 113 patients, Custodiol cardioplegia was used to achieve cardiac arrest, while St. Thomas Hospital solution was used in 75 patients. The primary endpoint of the study was the degree myocardial damage which was estimated by the measurement of creatine kinase-myocardial band on the first postoperative day. A linear regression analysis was performed to compare the aortic cross-clamp time with the postoperative myocardial damage in both groups.

RESULTS

The extracorporeal circulation time and aortic cross-clamp were significantly longer in the Custodiol group than in the St. Thomas group: 125.6 ± 32.5 minutes versus 93.1 ± 27.7 minutes (p < 0.001), respectively. However, there was no significant difference between the two groups regarding the postoperative levels of creatine kinase-myocardial band (96 (70-140) U/L vs. 86 (69-120) U/L, respectively; p = 0.321). There was no significant differences between the two groups regarding the 30-day mortality (6.1% vs. 5.5%, respectively; p = 1.000) or 120-day mortality (9.6% vs. 11.0%, respectively; p = 0.806).

CONCLUSION

Our findings demonstrate that Custodiol is a safe method of myocardial protection for patients who underwent mitral valve surgery with coronary artery bypass grafting in our hospital. Further investigations extended to more cardiac surgery populations are needed to confirm clinical benefits of Custodiol cardioplegia.

Comparison of heat monitoring-based myocardial protection strategy with classic myocardial protection method in isolated coronary artery bypass surgery patients

OBJECTIVE

In this study, we aimed to compare patients who have a myocardial protection strategy based on myocardial temperature monitorization with those who had myocardial protection with conventional intermittent cardioplegia.

METHODS

Twenty-six patients undergoing coronary artery bypass graft surgery were included into the study. Patients were prospectively grouped into two; myocardial protection based on temperature monitoring (group 1, n = 11) and those who had cardioplegia every 20 min (group 2, n = 15) during aortic cross-clamping. In all patients, cold blood cardioplegia was used. Coronary sinus blood sampling was performed immediately before aortic cross-clamping, after 2, 20, and 40 min of aortic clamping and tumor necrosis factor-alpha, malondialdehyde, creatinine kinase-myocardial band isoenzyme (MB), troponin I, lactate, and pH were studied. In addition, myocardial biopsy was taken before and immediately after cross-clamping to evaluate cardiomyocyte apoptosis with caspase-3 tunnel immunostaining.

RESULTS

There were no differences in clinical parameters like early mortality, extubation time, inotropic requirements, postoperative drainage, intensive care unit, and hospitalization time between two groups. In addition, blood and blood products were similar in two groups. In group 2, after cross-clamping, troponin I and creatinine kinase-MB values were significantly higher than the other group. In myocardial biopsies, the caspase immunostaining score, before removal of aortic cross-clamp was significantly higher in group 2 than the samples taken before aortic clamping.

CONCLUSION

Our results show that there is no difference between temperature-based myocardial protection strategy with conventional intermittent cardioplegia delivery. We think that the number of patients in our study is less and that the patient population is not a homogeneous structure is the most important limiting factor of our study. Increasing the number of patients, with particularly those who have myocardial dysfunction would help augment the possible different effects of two cardioplegic techniques on myocardial protection.

Single- versus multidose cardioplegia in adult cardiac surgery patients: A meta-analysis

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.

Cold Agglutinin Autoantibodies in a Patient without a Visible Coronary Sinus Ostium: Strategies for Myocardial Protection without Using Retrograde Cardioplegia

The presence of cold agglutinins (CA) during cardiac surgery with cardiopulmonary bypass usually creates the need for an altered surgical plan. In this case, the CA were discovered after the initiation of bypass, limiting the time, and cardioplegia solutions that could be used in the new approach. The inability to cannulate the coronary sinus with a retrograde cardioplegia catheter excluded the standard approach to myocardial preservation with CA of using continuous warm blood. For this case, we used intermittent cold crystalloid delivered via the antegrade needle for the first half of the procedure and through the saphenous vein graft anastomosis during the aortic valve portion of the cross-clamp period.

Relevance of Endoplasmic Reticulum Stress Cell Signaling in Liver Cold Ischemia Reperfusion Injury

The endoplasmic reticulum (ER) is involved in calcium homeostasis, protein folding and lipid biosynthesis. Perturbations in its normal functions lead to a condition called endoplasmic reticulum stress (ERS). This can be triggered by many physiopathological conditions such as alcoholic steatohepatitis, insulin resistance or ischemia-reperfusion injury. The cell reacts to ERS by initiating a defensive process known as the unfolded protein response (UPR), which comprises cellular mechanisms for adaptation and the safeguarding of cell survival or, in cases of excessively severe stress, for the initiation of the cell death program. Recent experimental data suggest the involvement of ERS in ischemia/reperfusion injury (IRI) of the liver graft, which has been considered as one of major problems influencing outcome after liver transplantation. The purpose of this review is to summarize updated data on the molecular mechanisms of ERS/UPR and the consequences of this pathology, focusing specifically on solid organ preservation and liver transplantation models. We will also discuss the potential role of ERS, beyond the simple adaptive response and the regulation of cell death, in the modification of cell functional properties and phenotypic changes.

Custodiol for myocardial protection and preservation: a systematic review

INTRODUCTION

Custodiol cardioplegia is attractive for minimally invasive cardiac surgery, as a single dose provides a long period of myocardial protection. Despite widespread use in Europe, there is little data confirming its efficacy compared with conventional (blood or crystalloid) cardioplegia. There is similar enthusiasm for its use in organ preservation for transplant, but also a lack of data. This systematic review aimed to assess the evidence for the efficacy of Custodiol in myocardial protection and as a preservation solution in heart transplant.

METHODS

Electronic searches were performed of six databases from inception to October 2013. Reviewers independently identified studies that compared Custodiol with conventional cardioplegia (blood or extracellular crystalloid) in adult patients for meta-analysis; large case series that reported results using Custodiol were analyzed. Next, we identified studies that compared Custodiol with other organ preservation solutions for organ preservation in heart transplant.

RESULTS

Fourteen studies compared Custodiol with conventional cardioplegia for myocardial protection in adult cardiac surgery. No difference was identified in mortality; there was a trend for increased incidence of ventricular fibrillation in the Custodiol group that did not reach statistical significance. No difference was identified in studies that compared Custodiol with other solutions for heart transplant.

CONCLUSIONS

Despite widespread clinical use, the evidence supporting the superiority of Custodiol over other solutions for myocardial protection or organ preservation is limited. Large randomised trials are required.