J Extra Corpor Technol 2024 , 56 , 149 – 158 Ó The Author ( s ), published by EDP Sciences , 2024 https :// doi . org / 10.1051 / ject / 2024029
Available online at : ject . edpsciences . org
ORIGINAL ARTICLE
Outcomes of Del Nido and hyperkalemic blood cardioplegia in adult cardiac surgery with prolonged aortic cross-clamp times w
Malgorzata Szpytma ( MD ) 1 , Damian Gimpel ( MBBS ) 1 , Jordan Ross ( MBBS ) 1 , Richard F . Newland ( PhD , CCP ( ANZ )) 2 , 3 , Gareth Crouch ( FRACS ) 1 , Gregory D . Rice ( FRACS ) 1 , 3 Jayme S . Bennetts ( FRACS ) 1 , 3 , and Robert A . Baker ( PhD , CCP ( ANZ )) 3 , 4 ,*
1 Cardiothoracic Surgical Unit , Division of Surgery , Flinders Medical Centre , Adelaide , South Australia , Australia 2 Perfusion Service , Cardiothoracic Surgical Unit , Division of Surgery , Flinders Medical Centre , Adelaide , South Australia , Australia 3 College of Medicine and Public Health , Flinders University 4 Quality and Outcomes Unit , Cardiothoracic Surgical Unit , Division of Surgery , Flinders Medical Centre , Adelaide , South Australia ,
Australia Received 19 February 2024 , Accepted 25 September 2024
Abstract – Background : The utility and uptake of Del Nido cardioplegia in adult cardiac surgery is rapidly increasing . Cases with prolonged aortic cross-clamp times necessitate multi-dosing however an understanding of safe ischaemic times and definitive guidelines in this domain are lacking . Therefore , this study aimed to assess the safety and efficacy of our DNC strategy by comparing post-operative troponin profiles and clinical outcomes between Del Nido and hyperkalaemic cardioplegia for cases with aortic cross-clamp times of greater than 90 min . Methods : A single-centre , retrospective cohort study at Flinders Medical Centre and Flinders Private Hospital of patients undergoing composite cardiac surgery with a cross-clamp time longer than 90 min . Data was prospectively collected from the Flinders Cardiac Surgery Registry from June 2014 to December 2022 . A propensity-matched ( 1:1 ) analysis was performed comparing patients receiving Del Nido cardioplegia ( n = 194 ) to those receiving hyperkalemic blood cardioplegia ( n = 194 ). The primary outcome was the postoperative troponin release profile with clinical events reported as secondary outcomes . Results : There was no difference in the peak or median troponin at 6 , 12 and 72 h nor the number of patients with positive troponin profiles postoperatively between cohorts . There was no difference in clinical outcomes between groups with aortic cross-clamp times of 90 min which remained true in sensitivity analysis extending out to 120 min . The Del Nido cohort received less cardioplegia volume ( p < 0.001 ) and were more likely to return to spontaneous rhythm ( p < 0.002 ). Conclusion : Del Nido cardioplegia for anticipated aortic cross-clamp times of greater than 90 min provided equivocal post-operative troponin profiles and clinical outcomes compared to multidose hyperkalemic blood cardioplegia .
Key words : Troponin , Del Nido , Cardioplegia , Hyperkalemic .
Introduction
The use of Del Nido Cardioplegia ( DNC ) as an alternative to hyperkalaemic crystalloid blood cardioplegia ( HKB ) is an accepted practice in cardiothoracic surgery [ 1 ]. The use of single-dose DNC for a cross-clamp time of less than 90 min originates from paediatric cardiac surgery [ 2 , 3 ]. A single dose of DNC provides satisfactory myocardial protection for approximately 90 min [ 4 ]. The use of single-dose DNC in adult
w Presented at the Inaugural Tri-Society Cardiac and Thoracic
Symposium ( 3CTS ), Cairns Queensland Australia , 16 – 19th November 2022 . * Corresponding author : rob . baker @ sa . gov . au ; flinderscardiothoracicresearch @ sa . gov . au cardiac surgery with cross-clamp times of less than 90 min is now supported by randomized control trials including that published by Ad et al . [ 5 ]. The recent prospective randomized trial by Garcia-Suarez included 474 patients in different settings of adult cardiac surgery not excluding complex procedures and showed comparable outcomes between HKB and DNC [ 6 ]. The outcomes of multi dose DNC and determination of safe ischaemic time in adults and in adults with extended crossclamp time remain unclear . To date there is no clinical guideline supporting the delivery of DNC in cases with extended bypass times .
Current animal models and trials in explanted hearts have shown superior myocardial function and troponin profiles with single dose compared to multi dose DNC regiments [ 7 , 8 ]. There is also clear evidence of ischaemic changes inferenced
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