Microcirculatory Response to Blood vs. Crystalloid Cardioplegia During Coronary Artery Bypass Grafting With Cardiopulmonary Bypass

Background: Blood cardioplegia attenuates cardiopulmonary bypass (CPB)-induced systemic inflammatory response in patients undergoing cardiac surgery, which may favorably influence the microvascular system in this cohort. The aim of this study was to investigate whether blood cardioplegia would offer advantages over crystalloid cardioplegia in the preservation of microcirculation in patients undergoing coronary artery bypass grafting (CABG) with CPB.Methods: In this prospective observational cohort study, 20 patients who received crystalloid (n = 10) or blood cardioplegia (n = 10) were analyzed. The microcirculatory measurements were obtained sublingually using incident dark-field imaging at five time points ranging from the induction of anesthesia (T0) to discontinuation of CPB (T5).Results: In the both crystalloid [crystalloid cardioplegia group (CCG)] and blood cardioplegia [blood cardioplegia group (BCG)] groups, perfused vessel density (PVD), total vessel density (TVD), and proportion of perfused vessels (PPV) were reduced after the beginning of CPB. The observed reduction in microcirculatory parameters during CPB was only restored in patients who received blood cardioplegia and increased to baseline levels as demonstrated by the percentage changes from T0 to T5 (%Δ)T0−T5 in all the functional microcirculatory parameters [%ΔTVDT0−T5(CCG): −10.86 ± 2.323 vs. %ΔTVDT0−T5(BCG): 0.0804 ± 1.107, p < 0.001; %ΔPVDT0−T5(CCG): −12.91 ± 2.884 vs. %ΔPVDT0−T5(BCG): 1.528 ± 1.144, p < 0.001; %ΔPPVT0−T5(CCG): −2.345 ± 1.049 vs. %ΔPPVT0−T5(BCG): 1.482 ± 0.576, p < 0.01].Conclusion: Blood cardioplegia ameliorates CPB-induced microcirculatory alterations better than crystalloid cardioplegia in patients undergoing CABG, which may reflect attenuation of the systemic inflammatory response. Future investigations are needed to identify the underlying mechanisms of the beneficial effects of blood cardioplegia on microcirculation.

Del Nido versus warm blood cardioplegia in adult patients with a low ejection fraction

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.

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.

Comparison of troponin 1 level among the patients who underwent coronary artery bypass grafting with and without adenosine as an adjunct to blood cardioplegia

Background: Cellular injury is not avoidable with current cardioplegic solutions. No method of cardioplegia has been shown to completely protect the myocardium against cellular injury. The objective of the study is to evaluate the safety and efficacy of adenosine as an adjunct to blood cardioplegia during CABG.Methods: A retrospective study at GMCT, Thiruvananthapuram in CABG patients for 3 years from January 1, 2016, to December 31, 2019, between the age of 40 and 70 years. Patients with other chronic diseases and pre-operative echo showing EF less than 40% were excluded. The study variables were level of troponin I intra and postoperative period, time taken for cardiac standstill, number of days in ventilator, ICU and on inotropic supports. Also, postoperative lactate levels, changes in RWMA and EF.Results: Of the total 75 subjects, 40 got adenosine while 35 didn’t. The mean post op EF for those who got adenosine is 55.30 and without is 56.46. The mean time of cardiac stand still with adenosine is 12.88 sec and without is 16.51 sec. The mean post op troponin I level in those who got adenosine is 6.43 and without is 12.94.Conclusions: Decreased level of troponin I and inotropic requirement suggests that an optimal myocardial protection. Adenosine usage helps in early extubation but doesn’t alter the number of days in ICU. Adenosine is safe, gives more rapid cardiac arrest but it will not alter the post op left ventricular function.

Modified del Nido versus blood cardioplegia in congenital cardiac surgery

Background Lactated Ringer-based del Nido cardioplegia has been reported to be safe for acquired cardiac surgery. The original Plasma-Lyte-based solution has been proved for congenital cardiac surgery but its modification has not been adequately examined. We compared the clinical outcomes of congenital cardiac surgery using lactated Ringer-based del Nido cardioplegia versus cold blood cardioplegia. Methods Between September 2018 and November 2020, 116 consecutive patients with congenital heart disease undergoing operations with cardioplegic arrest performed by a single surgeon at Faculty of Medicine Siriraj hospital; 66 with modified del Nido solution and 50 with institutional's blood cardioplegia. The patient risk profiles, operative details, mortality rates, care durations, inotrope use, blood transfusion and complications were compared. Results Preoperative characteristics were similar between groups, including median age (2.5 vs. 3.1 years; p = 0.49), size, and gender. The Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery score of 3 to 5 was more prevalent in the del Nido group (24.2% vs. 10%; p = 0.049). There were 4 deaths in the modified del Nido group (risk category score of 4) but none in the cold blood group (p = 0.13). There was no significant difference in median intubation duration, length of intensive care unit stay, and vasoactive medications immediately and 24 h after the operation. The del Nido group required 70 to 100 ml less blood transfusion (p = 0.04). All complications were similar between the two groups. Conclusions Clinical outcomes of lactated Ringer-based del Nido cardioplegia were comparable to those of blood cardioplegia in congenital cardiac surgery.

Effects of Del Nido and Terminal Warm Blood Cardioplegia on Myocardial Protection and Rhythm in Isolated CABG Patients

Objective: To investigate the effect of using del Nido cardioplegia+terminal hot-shot blood cardioplegia on myocardial protection and rhythm in isolated coronary bypass patients. Material and methods: A total of 122 patients were given cold (+4-8C') del Nido cardioplegia antegrade and evaluated. Del Nido+terminal warm blood cardioplegia (TWBCP) was applied to 63 patients out of 122 patients, while del Nido cardioplegia alone was applied to the other 59 patients. The preoperative and postoperative data of the patients were recorded and compared. Results: There was a significant statistical difference between the groups, in terms of volume with more cardioplegia in the del Nido+terminal warm blood cardioplegia group. Although there was no significant difference between cardiac arrest times in both groups, a statistically significant difference was found in the del Nido+terminal warm blood cardioplegia group in the starting to work time of the heart. No difference found between the groups regarding myocardial preservation. Conclusions: We can add a return to spontaneous sinus rhythm to the advantages of terminal warm blood cardioplegia and del Nido cardioplegia in literature. We think it would be a good strategy to extend the safe ischemic time limit of del Nido to 120 minutes with a terminal warm blood cardioplegia. It seems that cardioplegia techniques that will be developed by adding the successful and superior results of crystalloid cardioplegia applications, such as single dose del Nido in various open heart surgery operations and the superior myocardial return effects of terminal warm blood cardioplegia, will be used routinely in the future.

Cardioplegia Application with A Hand-Squeezed Cardioplegia Bag. Is It Safe?

Objectives: Cardioplegia solutions have a role not only in arresting the heart but also in protecting the myocardium from ischemia. While antegrade cardioplegia is given by the heart-lung machine in many centers, it is given by a hand-squeezed bag in very few centers. The pressure of cardioplegia given antegrade from the heart-lung machine is certain (60-90 mmHg). The pressure applied in the cardioplegia method, which is given antegrade with a hand-squeezed bag, is uncertain and variable. We compared the antegrade cardioplegia method applied with a hand-squeezed bag with the antegrade cardioplegia method applied with a roller pump from the heart-lung machine in terms of protecting the myocardium from ischemia. Methods: Seventy-six patients who did not have an acute myocardial infarction, had normal preoperative cardiac marker (troponin and CK-MB) values, did not undergo redo open heart surgery, had an ejection fraction of 50% and above, and underwent elective two or three-vessel isolated coronary artery bypass surgery were evaluated. While tepid (30-32°C) blood cardioplegia was administered antegrade to 33 patients (Group A) with a hand-squeezed bag, the other 34 patients (Group B) received tepid (30-32°C) antegrade blood cardioplegia from the heart-lung machine. The perioperative and postoperative data of the patients were recorded and compared. To evaluate myocardial damage, postoperative cardiac markers and echocardiography data were evaluated and compared at the fourth hour after the cross-clamp was removed in both groups. Results: When evaluated in terms of preoperative demographic data, preoperative mean EF values and intraoperative data, there was no statistical difference between both groups. When we evaluated in terms of myocardial protection, the mean TnT level was 4.31 ± 1.95 at the 4th hour in Group A and 3.91 ± 1.69 in Group B. Mean 4th hour CK-MB level was 40.84 ± 9.07 in Group A and 38.56 ± 8.07 in Group B. Mean change in EF (%) was -4.09 ± 4.41 in Group A and 3.53 ± 4.53 in Group B. In line with the current data when we evaluated in terms of myocardial protection, we found that there is no statistical difference between the two groups (P = 0.373; P = 0.158; P = 0.523). There was no statistical difference between both groups, in terms of postoperative arrhythmias. None of the patients died, and no patients required an intra-aortic balloon pump. Results: As a result of our study, cardioplegia administration with a certain constant pressure from the roller pump and hand-squeezed bag with uncertain pressure does not make a difference, in terms of myocardial protection. We think that the content and amount of cardioplegia and the preferred time for repeated cardioplegia applications are more important for the protection of the myocardium. Methods: 76 patients who did not have an acute myocardial infarction, had normal preoperative cardiac marker (troponin and CK-MB) values, did not undergo redo open heart surgery, had an ejection fraction of 50% and above, and underwent elective two or three-vessel isolated coronary artery bypass surgery were evaluated. While tepid(30-32 ° C) blood cardioplegia was administered antegrade to 33 patients(Group A) with a hand-squeezed bag, the other 34 patients(Group B) received tepid(30-32 °C) antegrade blood cardioplegia from the heart-lung machine. The perioperative and postoperative data of the patients were recorded and compared. To evaluate myocardial damage, postoperative cardiac markers and echocardiography data were evaluated and compared at the fourth hour after the cross-clamp was removed in both groups. Results: When evaluated in terms of preoperative demographic data, preoperative mean EF values and intraoperative data there was no statistical difference between both groups. When we evaluated in terms of myocardial protection, the mean TnT level was 4.31 ± 1.95 at the 4th hour in group A and 3.91 ± 1.69 in group B. Mean 4th hour CK-MB level was 40.84 ± 9.07 in group A and 38.56 ± 8.07 in group B. Mean change in EF (%) was -4.09 ± 4.41 in group A and 3.53 ± 4.53 in group B. In line with the current data when we evaluated in terms of myocardial protection; we found that there is no statistical difference between the two groups (p = 0.373; p = 0.158; p = 0.523). There was no statistical difference between both groups in terms of postoperative arrhythmia's. None of the patients died and none of the patients required an intra-aortic balloon pump.

Blood Cardioplegia Induction, Perfusion Storage and Graft Dysfunction in Cardiac Xenotransplantation

BackgroundPerioperative cardiac xenograft dysfunction (PCXD) describes a rapidly developing loss of cardiac function after xenotransplantation. PCXD occurs despite genetic modifications to increase compatibility of the heart. We report on the incidence of PCXD using static preservation in ice slush following crystalloid or blood-based cardioplegia versus continuous cold perfusion with XVIVO© heart solution (XHS) based cardioplegia.MethodsBaboons were weight matched to genetically engineered swine heart donors. Cardioplegia volume was 30 cc/kg by donor weight, with del Nido cardioplegia and the addition of 25% by volume of donor whole blood. Continuous perfusion was performed using an XVIVO © Perfusion system with XHS to which baboon RBCs were added.ResultsPCXD was observed in 5/8 that were preserved with crystalloid cardioplegia followed by traditional cold, static storage on ice. By comparison, when blood cardioplegia was used followed by cold, static storage, PCXD occurred in 1/3 hearts and only in 1/5 hearts that were induced with XHS blood cardioplegia followed by continuous perfusion. Survival averaged 17 hours in those with traditional preservation and storage, followed by 11.47 days and 15.03 days using blood cardioplegia and XHS+continuous preservation, respectively. Traditional preservation resulted in more inotropic support and higher average peak serum lactate 14.3±1.7 mmol/L compared to blood cardioplegia 3.6±3.0 mmol/L and continuous perfusion 3.5±1.5 mmol/L.ConclusionBlood cardioplegia induction, alone or followed by XHS perfusion storage, reduced the incidence of PCXD and improved graft function and survival, relative to traditional crystalloid cardioplegia-slush storage alone.