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Efficacy of Single-Dose Del Nido Cardioplegia Beyond 90 Minutes in Adult Cardiac Surgery
Murat Yücel1, Emrah Uğuz2, Kemal Eşref Erdoğan2
1Department of Cardiovascular Surgery, Ankara Bilkent City Hospital, 06800 Ankara, Türkiye.
Insights
Del Nido cardioplegia offers myocardial protection up to 90 minutes. Prolonged ischemia (>90 min) shows increased myocardial injury and instability, necessitating tailored strategies for extended cardiac surgeries.
Area of Science:
- Cardiovascular Surgery
- Cardiothoracic Anesthesia
Background:
- Del Nido (DN) cardioplegia is a standard myocardial protection strategy in cardiac surgery.
- Its efficacy and safety during prolonged aortic cross-clamp (ACC) times remain incompletely understood.
Purpose of the Study:
- To evaluate the impact of prolonged ischemia on myocardial protection using Del Nido cardioplegia.
- To compare clinical outcomes and biochemical markers between patients with shorter (60-90 min) and longer (>90 min) ACC durations.
Main Methods:
- Retrospective analysis of 471 adult cardiac surgery patients undergoing cardiopulmonary bypass (CPB).
- Patients stratified into two groups based on ACC duration: 60-90 min (Group A) and >90 min (Group B).
- Comparison of perioperative characteristics, clinical outcomes, and biochemical markers (troponin I, lactate).
Main Results:
- Group B (prolonged ischemia) showed significantly higher postoperative troponin I and lactate levels, indicating myocardial and metabolic stress.
- Elevated defibrillation requirements and vasoactive inotropic score (VIS) in Group B suggested compromised electrical stability and hemodynamics.
- No significant differences in long-term outcomes like mortality, low cardiac output syndrome (LCOS), or multiple organ dysfunction syndrome (MODS) were observed between groups.
Conclusions:
- Del Nido cardioplegia's myocardial protection efficacy decreases with ACC durations exceeding 90 minutes.
- Prolonged ischemia is associated with increased myocardial injury and hemodynamic instability.
- Optimized redosing protocols and perioperative management are crucial for complex cardiac surgeries with extended ischemia times.
Abstract:
Background: Del Nido (DN) cardioplegia is widely used in cardiac surgery for its efficacy in providing myocardial protection for up to 90 min with a single dose. However, its safety and efficacy during prolonged ischemia remain unclear. Methods: This retrospective study analyzed 471 patients who underwent cardiac surgery with CPB between January 2019 and September 2024. Patients were divided into two groups: ACC durations of 60-90 min (Group A, n = 240) and >90 min (Group B, n = 231). The perioperative characteristics, clinical outcomes, and biochemical markers were compared to evaluate the impact of prolonged ischemia. Results: Patients in Group B exhibited significantly higher postoperative troponin I and lactate levels at 4 h post-CPB, suggesting increased myocardial and metabolic stress. Lactate levels normalized within 24 h, indicating transient myocardial dysfunction. Defibrillation requirements and vasoactive inotropic score (VIS) were also significantly elevated in Group B, reflecting compromised myocardial electrical stability and hemodynamic challenges. However, the long-term outcomes such as mortality, LCOS, and MODS showed no significant differences between the groups. Conclusions: While DN cardioplegia provides sufficient myocardial protection for ACC durations within 90 min, its efficacy diminishes during prolonged ischemia, as evidenced by increased myocardial injury and hemodynamic instability. Tailored strategies, including standardized redosing protocols and enhanced perioperative management, are essential for optimizing outcomes in complex surgeries with extended ischemia times. Further prospective studies are needed to refine these protocols and assess alternative solutions for myocardial protection.
