Objective Our objective was to determine whether the use of unilateral (u-ACP) or bilateral antegrade cerebral perfusion (b-ACP) results in different mortality and neurologic outcomes after complex ...aortic surgery. Methods PubMed, Embase, and the Cochrane Library were searched for studies reporting on postoperative mortality and permanent (PND) and temporary neurologic dysfunction (TND) in complex aortic surgery requiring circulatory arrest with antegrade cerebral protection. Analysis of heterogeneity was performed with the Cochrane Q statistic. Results Twenty-eight studies were analyzed for a total of 1894 patients receiving u-ACP versus 3206 receiving b-ACP. Pooled analysis showed similar rates of 30-day mortality (8.6% vs 9.2% for u-ACP and b-ACP, respectively; P = .78), PND (6.1% vs 6.5%; P = .80), and TND (7.1% vs 8.8%; P = .46). Age, sex, and cardiopulmonary bypass time did not influence effect size estimates. Higher rates of postoperative mortality and PND were among nonelective operations and for highest temperatures and duration of the circulatory arrest. The Egger test excluded publication bias for the outcomes investigated. Conclusions This meta-analysis shows that b-ACP and u-ACP have similar postoperative mortality and both PND and TND rates after circulatory arrest for complex aortic surgery.
Cerebral microemboli have been associated with neurocognitive deficits after cardiac operations using cardiopulmonary bypass (CPB). Interventions by the perfusionist and alterations in blood flow ...account for a large proportion of previously unexplained microemboli. This study compared the incidence of microemboli during cardiac operations using conventional (multidose) and del Nido (single-dose) cardioplegia delivery. Transcranial Doppler ultrasonography was used to detect microemboli in bilateral middle cerebral arteries of 30 adult patients undergoing cardiac operations using CPB and aortic clamping. Multidose conventional blood cardioplegia (CBC) was used in 15 patients and single-dose del Nido cardioplegia (DNC) in 15. Manual count of microemboli during cross-clamp and during administration of cardioplegia was performed. Baseline preoperative characteristics were similar between groups. There were no differences in the ascending aortic atheroma grade (1.4 ± .4 CBC vs. 1.6 ± .7 DNC,
= .44), bypass times (141 ± 36 minutes CBC vs. 151 ± 33 minutes DNC,
= .64), and cross-clamp times (118 ± 32 minutes CBC vs. 119 ± 45 minutes DNC,
= .95). The use of multidose CBC was associated with a seven-fold increase in the number of microemboli per minute of bypass (1.65 ± 1 vs. .24 ± .18 emboli/min DNC,
= .0004). In this prospective pilot study, we found that the use of single-dose cardioplegia strategy led to fewer cerebral microemboli when compared with the traditional multidose approach. Our findings warrant further investigation of various cardioplegia strategies and neurologic outcomes in larger cohorts.
To evaluate the effectiveness of two cardioplegia techniques in patients with severe myocardial hypertrophy undergoing septal myectomy or aortic valve replacement.
A comparative pilot prospective ...single-center randomized study included 46 patients between 2022 and 2023. Patients were randomized into 2 groups: Del Nido (
=23) and Custodiol (
=23). We analyzed perioperative echocardiography data, troponin I at several time points, perioperative complications and histological data.
Both groups were comparable in time of myocardial ischemia, cardiopulmonary bypass, duration of anesthesia and surgery (
>0.05). The maximum ischemia time in the Del Nido group was 84 min. The same group showed significantly higher percentage of spontaneous rhythm recovery (65.2% vs. 30%,
=0.008). None patient required mechanical support, high-dose inotropes or vasopressors. Troponin I in 2 hours after cardiopulmonary bypass (
=0.415), 12 (
=0.528) and 24 hours after admission to the intensive care unit (
=0.281) were similar in both groups. No significant difference was found in ventilation time, ICU- and hospital-stay.
Del Nido cardioplegia has some advantages compared to Custodiol and does not lead to perioperative complications in case of aortic cross-clamping time <90 min in patients with myocardial hypertrophy.
The effect of continuous myocardial perfusion (CMP) on the surgical results of acute type A aortic dissection (ATAAD) remains unclear.
From January 2017 to March 2022, 141 patients who underwent ...ATAAD (90.8%) or intramural hematoma (9.2%) surgery were reviewed. Fifty-one patients (36.2%) received proximal-first aortic reconstruction and CMP during distal anastomosis. Ninety patients (63.8%) underwent distal-first aortic reconstruction and were placed in traditional cold blood cardioplegic arrest (CA; 4°C, 4:1 blood-to-Plegisol) throughout the procedure. The preoperative presentations and intraoperative details were balanced using inverse probability of treatment weighting (IPTW). Their postoperative morbidity and mortality were analyzed.
The median age was 60 years. The incidence of arch reconstruction in the unweighted data was higher in the CMP compared with the CA group (74.5 vs 52.2%,
= 0.017) but was balanced after IPTW (62.4 vs 58.9%,
= 0.932, standardized mean difference = 0.073). The median cardiac ischemic time was lower in the CMP group (60.0 vs 130.9 minutes,
< 0.001), but cerebral perfusion time and cardiopulmonary bypass time were similar. The CMP group did not demonstrate any benefit in the reduction of the postoperative maximum creatine kinase-MB ratio (4.4 vs 5.1% in CA,
= 0.437) or postoperative low cardiac output (36.6 vs 24.8%,
= 0.237). Surgical mortality was comparable between groups (15.5% in CMP vs 7.5% in the CA group,
= 0.265).
Application of CMP during distal anastomosis in ATAAD surgery, irrespective of the extent of aortic reconstruction, reduced myocardial ischemic time but did not improve cardiac outcome or mortality.
Background: Studies assessing the safety and effectiveness of Del Nido cardioplegia for adult cardiac surgery remain limited. We investigated early outcomes after coronary artery bypass grafting ...(CABG) using single-dose Del Nido cardioplegia vs. conventional multi-dose blood cardioplegia. Methods and Results: The 81 consecutive patients underwent isolated CABG performed by a single surgeon. The initial 27 patients received anterograde blood cardioplegia, while the subsequent 54 patients received anterograde Del Nido cardioplegia. There were no differences in the baseline characteristics of each group nor any differences in the 30-day incidences of myocardial infarction, all-cause death, and readmission following surgery. The use of Del Nido cardioplegia was associated with shorter cardiopulmonary bypass time (98 vs. 115 min, P=0.011), shorter cross-clamp time (74 vs. 87 min, P=0.006), and decreased need for intraoperative defibrillation (13.0% vs. 33.3%, P=0.030) compared with blood cardioplegia. To control for the difference in cross-clamp time, we performed propensity score matching with a logistical treatment model and confirmed that Del Nido cardioplegia provided similar outcomes as blood cardioplegia and also reduced the need for defibrillation independent of cross-clamp time. Conclusions: Compared with conventional blood cardioplegia, Del Nido cardioplegia provided excellent myocardial protection with reduced need for intraoperative defibrillation, shorter bypass and cross-clamp times, and comparable early clinical outcomes for adult patients undergoing CABG.
Summary Background Orthotopic heart transplantation is the gold-standard long-term treatment for medically refractive end-stage heart failure. However, suitable cardiac donors are scarce. Although ...donation after circulatory death has been used for kidney, liver, and lung transplantation, it is not used for heart transplantation. We report a case series of heart transplantations from donors after circulatory death. Methods The recipients were patients at St Vincent's Hospital, Sydney, Australia. They received Maastricht category III controlled hearts donated after circulatory death from people younger than 40 years and with a maximum warm ischaemic time of 30 min. We retrieved four hearts through initial myocardial protection with supplemented cardioplegia and transferred to an Organ Care System (Transmedics) for preservation, resuscitation, and transportation to the recipient hospital. Findings Three recipients (two men, one woman; mean age 52 years) with low transpulmonary gradients (<8 mm Hg) and without previous cardiac surgery received the transplants. Donor heart warm ischaemic times were 28 min, 25 min, and 22 min, with ex-vivo Organ Care System perfusion times of 257 min, 260 min, and 245 min. Arteriovenous lactate values at the start of perfusion were 8·3–8·1 mmol/L for patient 1, 6·79–6·48 mmol/L for patient 2, and 7·6–7·4 mmol/L for patient 3. End of perfusion lactate values were 3·6–3·6 mmol/L, 2·8–2·3 mmol/L, and 2·69–2·54 mmol/L, respectively, showing favourable lactate uptake. Two patients needed temporary mechanical support. All three recipients had normal cardiac function within a week of transplantation and are making a good recovery at 176, 91, and 77 days after transplantation. Interpretation Strict limitations on donor eligibility, optimised myocardial protection, and use of a portable ex-vivo organ perfusion platform can enable successful, distantly procured orthotopic transplantation of hearts donated after circulatory death. Funding NHMRC, John T Reid Charitable Trust, EVOS Trust Fund, Harry Windsor Trust Fund.
Initially developed for myocardial protection in immature cardiomyocytes, del Nido cardioplegia has been increasingly used over the past decade in adult patients. Our aim is to analyse the results ...from randomized controlled trials and observational studies comparing early mortality and postoperative troponin release in patients who underwent cardiac surgery using del Nido solution and blood cardioplegia.
A literature search was performed through three online databases between January 2010 and August 2022. Clinical studies providing early mortality and/or postoperative troponin evaluation were included. A random-effects meta-analysis with a generalized linear mixed model, incorporating random study effects, was implemented to compare the two groups.
Forty-two articles were included in the final analysis for a total of 11 832 patients, 5926 of whom received del Nido solution and 5906 received blood cardioplegia. del Nido and blood cardioplegia populations had comparable age, gender distribution, history of hypertension and diabetes mellitus. There was no difference in early mortality between the two groups. There was a trend towards lower 24 h mean difference -0.20; 95% confidence interval (CI) -0.40 to 0.00; I2 = 89%; P = 0.056 and lower peak postoperative troponin levels (mean difference -0.10; 95% CI -0.21 to 0.01; I2 = 0.87; P = 0.087) in the del Nido group.
del Nido cardioplegia can be safely used in adult cardiac surgery. The use of del Nido solution was associated with similar results in terms of early mortality and postoperative troponin release when compared with blood cardioplegia myocardial protection.
There are a wide variety of reported techniques with few comparative trials and no current data available by which surgeons can compare their myopreservation strategies across the specialty. We ...therefore surveyed congenital heart surgeons to develop a profile of current practice.
One hundred twenty-two members of the Congenital Heart Surgeons' Society were surveyed, and 56 responses were analyzed. The survey focused on cardioplegia formulations, dosage and administration, and perfusion strategies for four age groups: neonates, infants, children, and adolescents. All percentages are expressed as percentage of the entire reporting cohort (n=56).
Eighty-six percent of surgeons use blood-based cardioplegia versus crystalloid cardioplegia. Microplegia is used in 5%. Blood-based cardioplegia additives include del Nido (38%), customized solutions (32%), St. Thomas, Plegisol, or Baxter (11%), and microplegia (5%). Crystalloid cardioplegia types are Custodiol (7%), St. Thomas, Plegisol, or Baxter (5%), and customized solutions (2%). Cold (<10°C) cardioplegia is most common (93%), and "hot shots" are used in 21%. Moderate (26° to 30°C) hypothermic cardiopulmonary bypass is more common in neonates and infants compared with older children and adolescents. Antegrade administration is most common (89%). Longer intervals between cardioplegia doses were associated with surgeons using del Nido and Custodiol solutions, and these solutions were commonly administered with a single dose regardless of aortic cross-clamp time.
Myocardial protection techniques still remained highly variable among congenital heart surgeons. This survey demonstrates that there is a perception that del Nido and Custodiol solutions can offer appropriate myocardial protection for longer intervals with decreased repeat dosing. An observational study correlating markers of postoperative myocardial performance with myocardial preservation strategies should be considered.
Cardiac arrest by cardioplegia provides a reproducible and safe method to induce and maintain electromechanical cardiac quiescence. Techniques of intraoperative myocardial protection are constantly ...evolving. For the past three decades, modified Buckberg cardioplegia solution has been used for adult cardiac surgery at the Cleveland Clinic. This formulation serves as the crystalloid component, which is delivered 4:1 with oxygenated patient's blood to crystalloid. Meanwhile, our use of the del Nido cardioplegia solution in adult patients, heretofore primarily used in pediatric cardiac surgical centers, has been increasing over the past several years. Single-dose, cold blood del Nido cardioplegia can be delivered antegrade if the duration of the operation will be limited and if there is no significant coronary artery disease or aortic insufficiency that would limit the distribution of cardioplegia. The addition of del Nido cardioplegia to our cardioplegia armamentarium allows us to customize our myocardial protection strategies for different surgical needs. This article aims to provide information on technical aspects of del Nido cardioplegia in adult cardiac surgery and its use at the Cleveland Clinic in the adult surgical population.
We sought to determine the outcome of suicidal hanging and the impact of targeted temperature management (TTM) on hanging-induced cardiac arrest (CA) through an Eastern Association for the Surgery of ...Trauma (EAST) multicenter retrospective study.
We analyzed hanging patient data and TTM variables from January 1992 to December 2015. Cerebral performance category score of 1 or 2 was considered good neurologic outcome, while cerebral performance category score of 3 or 4 was considered poor outcome. Classification and Regression Trees recursive partitioning was used to develop multivariate predictive models for survival and neurologic outcome.
A total of 692 hanging patients from 17 centers were analyzed for this study. Their overall survival rate was 77%, and the CA survival rate was 28.6%. The CA patients had significantly higher severity of illness and worse outcome than the non-CA patients. Of the 175 CA patients who survived to hospital admission, 81 patients (46.3%) received post-CA TTM. The unadjusted survival of TTM CA patients (24.7% vs 39.4%, p < 0.05) and good neurologic outcome (19.8% vs 37.2%, p < 0.05) were worse than non-TTM CA patients. However, when subgroup analyses were performed between those with an admission Glasgow Coma Scale score of 3 to 8, the differences between TTM and non-TTM CA survival (23.8% vs 30.0%, p = 0.37) and good neurologic outcome (18.8% vs 28.7%, p = 0.14) were not significant. Targeted temperature management implementation and post-CA management varied between the participating centers. Classification and Regression Trees models identified variables predictive of favorable and poor outcome for hanging and TTM patients with excellent accuracy.
Cardiac arrest hanging patients had worse outcome than non-CA patients. Targeted temperature management CA patients had worse unadjusted survival and neurologic outcome than non-TTM patients. These findings may be explained by their higher severity of illness, variable TTM implementation, and differences in post-CA management. Future prospective studies are necessary to ascertain the effect of TTM on hanging outcome and to validate our Classification and Regression Trees models.
Therapeutic study, level IV; prognostic study, level III.
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