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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 7  |  Issue : 4  |  Page : 145-149

Comparison of del Nido's cardioplegia with St. Thomas's cardioplegia for myocardial protection in adult open-heart surgery


1 Departments of Cardiovascular and Thoracic Surgery, King George's Medical University, Lucknow, Uttar Pradesh, India
2 Department of Paediatric Cardiac Sciences, Sir Ganga Ram Hospital, New Delhi, India
3 Department of Cardiology, King George's Medical University, Lucknow, Uttar Pradesh, India
4 Department of Cardiovascular and Thoracic Surgery, Divine Heart and Multispecialty Hospital, Lucknow, Uttar Pradesh, India

Date of Submission29-Jul-2019
Date of Decision30-Jul-2019
Date of Acceptance05-Aug-2019
Date of Web Publication11-Dec-2019

Correspondence Address:
Ajaykumar Raghunath Pandey
Department of Paediatric Cardiac Sciences, Sir Ganga Ram Hospital, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/heartindia.heartindia_34_19

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  Abstract 


Objective: The del Nido cardioplegia solution provides a long period of arrest with single dose as compare to St. Thomas cardioplegia solution. In our study we compared outcomes of del Nido and St. Thomas cardioplegia in adult open cardiac surgeries. Methods: Sixty patients were studied between January 2017 to December 2017. Out of which 30 patients were operated on St. Thomas cardioplegia and 30 patients were on del Nido cardioplegia solution. Outcome was compared in both group in relation to demographic, cardiac enzymes level, cardiopulmonary bypass data and post operative results. Results: Total cardiopulmonary bypass time (111.27 ± 40.791 vs. 131.77 ± 37.97, P = 0.049), Aortic cross clamp time (71.67 ± 27.68 vs. 87.00 ± 30.95, P = 0.048), Time taken for return of cardiac contraction after de-clamping the aorta (2.40 ±1.453 vs. 3.67 ± 1.971, P = 0.006), dose of cardioplegia required (1361.67 ± 362.388 vs. 2716.67 ± 927.021, P=0.001) repetition of Cardioplegia needed (1.37±0.490 vs. 4.07±1.437, P=0.001), time to wean off from bypass (21.93±4.934 vs. 32.67±10.535 , P=0.001) and intraoperative cardioversion requirement (p=0.001) were significantly lower in del Nido group as compared to St. Thomas group. Postoperative PRO BNP level (2269.8 ±2098.97 pg/mL vs. 10220.0 ± 8343.62 pg/mL, P= 0.001) was significantly lower in the DN group. While troponin T levels (P= 0.314), CPK-MB level (P=0.111) were comparable in between groups. Conclusion: Del Nido cardiplegia is associated with lower bypass and cross clamp time, less dose and repetition of cardioplegia and early return of cardiac activity as compared to ST Thomas solution. There is better myocardial protection with del Nido cardioplegia as assessed with less increase in PRO BNP level.

Keywords: Cardioplegia, cardiopulmonary bypass, myocardial protection, surgery


How to cite this article:
Kumar A, Pandey AR, Chandra S, Kumar B. Comparison of del Nido's cardioplegia with St. Thomas's cardioplegia for myocardial protection in adult open-heart surgery. Heart India 2019;7:145-9

How to cite this URL:
Kumar A, Pandey AR, Chandra S, Kumar B. Comparison of del Nido's cardioplegia with St. Thomas's cardioplegia for myocardial protection in adult open-heart surgery. Heart India [serial online] 2019 [cited 2020 Jan 21];7:145-9. Available from: http://www.heartindia.net/text.asp?2019/7/4/145/272663




  Introduction Top


Dr. Pedro del Nido (dN) developed a cardioplegic solution, especially for the myocardial protection in neonatal and pediatric cardiac surgery patients. dN cardioplegia induces a depolarizing cardiac arrest during cardiac surgery. It is more diluted and contains lesser amount of Ca 2+ and lidocaine as compared to St. Thomas cardioplegic solution [Table 1].[1]
Table 1: Composition of the del Nido and St. Thomas cardioplegia solution

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St. Thomas cardioplegia required repetition of doses at short intervals which can cause myocardial acidosis during intervals and affect postoperative results.[2],[3] The dN cardioplegia solution provides a long period of depolarizing cardiac arrest.[4] Few researches have observed better outcome with dN cardioplegia in adult patients too.[5],[6],[7],[8] In our study, we compared and evaluated the outcomes of dN cardioplegia and St. Thomas cardioplegia in adult open cardiac surgeries.


  Materials and Methods Top


This is a single-center prospective case–control study done in the department of CVTS, King George Medical University, Lucknow, from January 2017 to December 2017 after approval by the ethical committee of the institute. Sixty patients who fulfill the selection criteria were randomly allocated, of which thirty patients were operated on with the use of St. Thomas cardioplegia solution (ST group) and thirty patients were operated on with the use of dN cardioplegia solution (dN group). Thorough history taking and clinical examination were done for all participating patients.

Demographic data such as age, sex, weight, New York Heart Association Functional Class, comorbidities (diabetes mellitus, hypertension, and smoking), echocardiographic finding, and preoperative cardiac rhythm were recorded. Pre- and postoperative serum such as proBNP (brain natriuretic peptide), CPK-MB (creatinine phosphokinase muscle brain isoform), troponin T, liver function test (serum bilirubin, serum aspartate aminotransferase, and alanine aminotransferase), and serum creatinine were recorded. Cardiopulmonary bypass time, aortic cross-clamp time, cardioversion requirement after aortic declamping, the number of cardioplegia used, total volume of cardioplegia solution used, time taken for return of cardiac activity, time to wean off bypass, need for intra aortic baloon pump (IABP), and new-onset rhythm disturbance were recorded. Duration and quantity of inotropes needed, need for prolonged ventilation, postoperative requirement of blood products, and intensive care unit (ICU) stay were analyzed.

Patients in both the groups underwent surgery via median sternotomy. Bicaval cannulation and aortic cannulation were done (cannulae size as per the body surface area). Cardioplegia was delivered by antegrade route in all patients by a cardioplegia catheter or by a coronary ostial catheter.

dN group received freshly prepared dN's cardioplegia solution with repetition of dosage if required after 90 min, while the ST group received freshly prepared St Thomas solution with repetition dose after every 20 min. The initial dose of cardioplegia was 20 ml/kg of the body weight and was repeated at the dose of 10 ml/kg of the body weight in both the solutions if required. All patients above 12 years of age who are admitted for elective cardiac surgery requiring cardiopulmonary bypass and cardioplegia were included in the study. Patients who are admitted for emergency cardiac procedures and redo surgeries and patients with ejection fraction <20% were excluded.

Statistical analysis

In this observational study, the sample size was calculated using the formula: N=[Z 2 × P (1-P)]/E 2. The data were entered in the MS Excel spreadsheet, and the analysis was done using the Statistical Package for the Social Sciences software version 21.0 (IBM Corp., Armonk, NY, USA). Categorical variables were presented in number and percentage (%), and continuous variables were presented as mean and standard deviation. Quantitative variables were compared using the unpaired t-test between two groups and, paired t-test was used to compare pre- and postdata. Qualitative variables were compared using the Chi-square test/Fisher's exact test as appropriate. P < 0.05 has been considered statistically significant.


  Results Top


A total of 60 patients were studied during a period of 1 year, of which 30 patients were operated with on the St. Thomas' solution No. 2 cardioplegia (ST group) and 30 were operated with on dN cardioplegia (dN group). In our study, 16 patients were operated for DVR (double valve replacement), 8 patients for AVR (aortic valve replacement), 2 patients for MVR (mitral valve replacement), 3 for VSD (ventricular septal defect) closure, and 1 for ASD (atrial septal defect) closure in the dN group. Seventeen patients were operated for DVR, 8 for AVR, 2 for MVR, 2 for VSD, and 1 for ASD in the ST group. The mean age of the patients was 36.93 ± 16.20 years (range: 14–69 years) in the dN group and 34.77 ± 10.50 years (range: 37-82 years) in the ST group. In the dN group, 9 patients were in atrial fibrillation (AF), while 11 patients were in AF in ST group. All other demographic characteristics were similar between the groups as shown in [Table 2].
Table 2: Comparison of demographic characteristics, morbidities, and clinical features (n=30)

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Total cardiopulmonary bypass time (111.27 ± 40.791 vs. 131.77 ± 37.97, P = 0.049), aortic cross-clamp time (71.67 ± 27.68 vs. 87.00 ± 30.95, P = 0.048), time taken for return of cardiac contraction after declamping the aorta (2.40 ± 1.453 vs. 3.67 ± 1.971, P = 0.006), dose of cardioplegia required (1361.67 ± 362.388 vs. 2716.67 ± 927.021, P = 0.001), repetition of cardioplegia needed (1.37 ± 0.490 vs. 4.07 ± 1.437, P = 0.001), time to wean off from bypass (21.93 ± 4.934 vs. 32.67 ± 10.535, P = 0.001), and intraoperative electrical cardioversion requirement (P = 0.001) were significantly lower in the dN group as compared to the ST group. No cases of new-onset rhythm disturbance was seen in the dN group as compared to five cases in the ST group, (P = 0.02) [Table 3].
Table 3: Comparison of operative data (n=30)

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Postoperative proBNP (2269.8 ± 2098.97 pg/mL vs. 10220.0 ± 8343.62 pg/mL, P = 0.001) was significantly lower in the dN group. While rising in troponin T levels (1.052 ± 1.112 ng/ml vs. 0.830 ± 0.451 ng/ml, P = 0.314), CPK-MB level (13.19 ± 11.09 vs. 17.33 ± 8.56, P = 0.111) was seen in both the groups, but variations between the groups were not significant.

The requirement of transfusion of blood product (P = 0.001), inotropes in ICU (P = 0.036), and duration of hospital stays (P = 0.010) were significantly lower in the dN group as compared to the ST group [Table 4].
Table 4: Comparison of postoperative characteristics

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  Discussion Top


dN group was associated with significantly shorter total cardiopulmonary bypass time (111.27 ± 40.791 vs. 131.77 ± 37.97, P = 0.049), aortic cross-clamp time (71.67 ± 27.68 vs. 87.00 ± 30.95, P = 0.048), and time taken for return of cardiac contraction after declamping the aorta (2.40 ± 1.453 vs. 3.67 ± 1.971, P = 0.006) as compared to the ST group. Dose of cardioplegia required (1361.67 ± 362.388 vs. 2716.67 ± 927.021, P = 0.001) and repetition of cardioplegia needed (1.37 ± 0.490 vs. 4.07 ± 1.437, P = 0.001) were also significantly lower in the dN group as compared to the ST group. These findings were in accordance with the previous studies conducted. Mick et al. did a retrospective study at Cleveland Clinic, Ohio, comparing 170 patients undergoing AVR and MVR divided into dN group and Buckberg group found overall aortic cross-clamp time, cardiopulmonary bypass (CPB) time, and total operating room time shorter for dN group (44 ± 14 vs. 56 ± 19 min, 56 ± 18 vs. 70 ± 24 min and 285 ± 44 vs. 308 ± 61, respectively, P < 0.0001).[8] Similarly, Timek et al. compared 100 consecutive patients undergoing Coronary artery bypass grafting (CABG) receiving dN cardioplegia with previous 100 consecutive patients who received blood cardioplegia, found need for fewer number and volume of cardioplegia in the dN group.[9] In another retrospective study done by Yerebakan et al. comparing 88 patients divided in dN (48) versus whole blood cardioplegia (40) found significantly shorter CPB time and aortic cross-clamp time (P<0.001) for DN group. Fewer dose and volume of cardioplegia was needed in dN group (996 ± 235 vs. 1988 ± 198 ml).[7] Similar results were seen in other studies like Sorabella et al. (2014), Mishra et al. (2016), and Najjar et al. (2015).[6],[10],[11] These results can be attributed to prolonged arrest time obtained with dN cardioplegia; as a result, redosing is required less frequently and surgery can be continued uninterrupted so need for less total CPB time.

Assessment of myocardial protection was done by biochemical parameters (proBNP, troponin T, and CPK-MB). Postoperative proBNP (2269.8 ± 2098.97 pg/mL vs. 10220.0 ± 8343.62 pg/mL, P = 0.001) was significantly lower in the dN group [Figure 1]. While rising in troponin T levels (1.052 ± 1.112 vs. 0.830 ± 0.451, P = 0.314), CPK-MB level (13.19 ± 11.09 vs. 17.33 ± 8.56, P = 0.111) was seen postoperatively in both the groups, but variations between the groups were not significant. Other markers used for the assessment of myocardial protection were need for defibrillation, the number of defibrillatory shock required, time to regain cardiac activity after declamping the aorta, time to wean off from bypass, inotropes requirement, and new-onset rhythm disturbances. In dN group, fewer number of patients needed defibrillation as compared to the ST group (4 vs. 16, P = 0.001). Time taken for the return of cardiac contraction after declamping the aorta (2.40 ± 1.453 vs. 3.67 ± 1.971, P = 0.006) and time needed to wean off the patient from bypass were significantly less in the dN group (21.93 ± 4.934 vs. 32.67 ± 10.535, P < 0.001). Need for perioperative and postoperative inotropes was seen in 17 patients in the dN group as compared to 26 patients in the ST group (P = 0.036). New-onset rhythm disturbance was seen in 5 patients in the ST group (3 AF, 2 ventricular tachycardia) as against 0 patients in the dN group. Comparing with other studies, Yerebakan et al. 2014 found no significant difference in the requirement of postoperative inotropic support (28 vs. 26, P = 0.152).[7] Mishra et al. 2016 compared retrospectively 100 patients undergoing CABG and DVR, found less requirement of inotropic support in the postoperative period for dN group, but this was statistically insignificant, (26 vs. 23, respectively, P = 0.548); there was no difference in the requirement of DC shock between the two groups.[10] Mick et al. 2015 found less requirement of inotropic support in the dN group, although it could not reach statistical significance (15 vs. 12, P = 0.5).[8] Similar results were seen in the study by Sorabella et al. (20140 at Columbia University.[6] Other parameters that we have assessed, i.e., time taken to regain cardiac activity, time to wean off bypass, and new-onset rhythm disturbance, have not been studied in great details in the previous studies.
Figure 1: proBNP level level in between groups

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In this study, total postoperative ventilator requirement for the patient and stay in the ICU between the two groups were comparable (P = 0.183 and P = 0.101, respectively). The requirement of transfusion of blood product (P = 0.001) and duration of hospital stays (P = 0.010) were significantly lower in the dN group as compared to the ST group. These results were similar to the study done by Yerebakan et al. 2015, where there was no significant difference in ventilation duration (P = 0.37) and no significant difference in total ICU stay (P = 0.133). Total packed red blood cell (PRBC) requirement was more in the ST group (2.3 ± 2.4 vs. 1.3 ± 1.5, P = 0.033), and postoperative hospital stay was less in the dN group (12.4 ± 9 vs. 20.2 ± 24 days, P = 0.048).[7] Similar results were seen in the study by Sorabella et al. 2014; no statistical difference was found in ventilation time (dN vs. ST: 2.4 ± 4 vs. 1.6 ± 2.7, P = 0.191), and ICU stay (2.8 ± 2 vs. 4.1 ± 7.0, P = 0.193). Although there was no significant difference in the requirement of PRBC (1.4 ± 1.7 vs. 2.1 ± 2.6, P = 0.07), more PRBC was needed in the ST group. Postoperative hospitalization was more in the ST group (dN vs. ST: 7.9 ± 3.4 vs. 10.1 ± 7.2, P = 0.035).[6]

No patient needed IABP in both the groups; no death was seen in either groups. Complication in the form of liver derangement postoperatively was seen in 1 patient in each group which persisted for a few days and resolved thereafter with conservative treatment. Two patients in the ST group had acute renal failure and needed renal replacement therapy in the form of dialysis, which later improved.


  Conclusion Top


Cardiac surgeries done under cardiopulmonary bypass using the dN cardioplegia is associated with lower total bypass time, lower aortic cross-clamp time, less volume and number of cardioplegia needed, and early return of cardiac activity as compared to ST Thomas solution.

There is better myocardial protection with dN cardioplegia as assessed with less increase in proBNP level, no new postsurgery rhythm disturbance, less need of defibrillation, and lower need of inotropic support.

There is less need of packed red blood cell in cases done under dN cardioplegia due to less hemodilution.

Total postoperative ventilation and ICU stay are comparable between the two, but overall total hospital stay in the postoperative period is less with dN cardioplegia cases.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Matte GS, del Nido PJ. History and use of del Nido cardioplegia solution at Boston children's hospital. J Extra Corpor Technol 2012;44:98-103.  Back to cited text no. 1
    
2.
Graffigna AC, Nollo G, Pederzolli C, Ferrari P, Widesott L, Antolini R. Continuous monitoring of myocardial acid-base status during intermittent warm blood cardioplegia. Eur J Cardiothorac Surg 2002;21:995-1001.  Back to cited text no. 2
    
3.
Khuri SF, Healey NA, Hossain M, Birjiniuk V, Crittenden MD, Josa M, et al. Intraoperative regional myocardial acidosis and reduction in long-term survival after cardiac surgery. J Thorac Cardiovasc Surg 2005;129:372-81.  Back to cited text no. 3
    
4.
Charette K, Gerrah R, Quaegebeur J, Chen J, Riley D, Mongero L, et al. Single dose myocardial protection technique utilizing del Nido cardioplegia solution during congenital heart surgery procedures. Perfusion 2012;27:98-103.  Back to cited text no. 4
    
5.
Smigla G, Jaquiss R, Walczak R, Bonadonna D, Kaemmer D, Schwimer C, et al. Assessing the safety of del Nido cardioplegia solution in adult congenital cases. Perfusion 2014;29:554-8.  Back to cited text no. 5
    
6.
Sorabella RA, Akashi H, Yerebakan H, Najjar M, Mannan A, Williams MR, et al. Myocardial protection using del Nido cardioplegia solution in adult reoperative aortic valve surgery. J Card Surg 2014;29:445-9.  Back to cited text no. 6
    
7.
Yerebakan H, Sorabella RA, Najjar M, Castillero E, Mongero L, Beck J, et al. Del Nido cardioplegia can be safely administered in high-risk coronary artery bypass grafting surgery after acute myocardial infarction: A propensity matched comparison. J Cardiothorac Surg 2014;9:141.  Back to cited text no. 7
    
8.
Mick SL, Robich MP, Houghtaling PL, Gillinov AM, Soltesz EG, Johnston DR, et al. Del Nido versus Buckberg cardioplegia in adult isolated valve surgery. J Thorac Cardiovasc Surg 2015;149:626-34.  Back to cited text no. 8
    
9.
Timek T, Willekes C, Hulme O, Himelhoch B, Nadeau D, Borgman A, et al. Propensity matched analysis of del Nido cardioplegia in adult coronary artery bypass grafting: Initial experience with 100 consecutive patients. Ann Thorac Surg 2016;101:2237-41.  Back to cited text no. 9
    
10.
Mishra P, Jadhav RB, Mohapatra CK, Khandekar J, Raut C, Ammannaya GK, et al. Comparison of del Nido cardioplegia and St. Thomas hospital solution – Two types of cardioplegia in adult cardiac surgery. Kardiochir Torakochirurgia Pol 2016;13:295-9.  Back to cited text no. 10
    
11.
Najjar M, George I, Akashi H, Nishimura T, Yerebakan H, Mongero L, et al. Feasibility and safety of continuous retrograde administration of del Nido cardioplegia: A case series. J Cardiothorac Surg 2015;10:176.  Back to cited text no. 11
    


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  [Table 1], [Table 2], [Table 3], [Table 4]



 

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