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Published on: August 6, 2015
Evaluation of Myocardial Protection in Prolonged Aortic Cross-Clamp Times: Del Nido and HTK Cardioplegia in Adult
Murat Yücel1, Emre Demir Benli1, Kemal Eşref Erdoğan1,2
1Department of Cardiovascular Surgery, Ankara Bilkent City Hospital, Ankara 06800, Turkey.
Insights
For adult cardiac surgery with long aortic cross-clamp (ACC) times, histidine-tryptophan-ketoglutarate (HTK) cardioplegia may offer better myocardial protection than Del Nido (DN) cardioplegia. ACC duration is a key predictor of adverse outcomes, suggesting individualized cardioplegia selection.
Area of Science:
- Cardiology
- Cardiac Surgery
- Cardioplegia Solutions
Background:
- Effective myocardial protection is crucial for cardiac surgery outcomes.
- Comparative efficacy of Del Nido (DN) and histidine-tryptophan-ketoglutarate (HTK) cardioplegia for prolonged aortic cross-clamp (ACC) times in adults is unclear.
Purpose of the Study:
- To compare the efficacy and safety of DN and HTK cardioplegia for myocardial protection during prolonged ACC times in adult cardiac surgery.
- To define clinically relevant thresholds for ACC duration and cardioplegia efficacy.
Main Methods:
- Retrospective study of 320 adult patients undergoing cardiac surgery with ACC ≥ 90 min.
- 1:1 propensity score matching comparing DN (n=160) and HTK (n=160) groups.
- Analysis of clinical and biochemical outcomes, including troponin I, CK-MB, lactate, low cardiac output syndrome (LCOS), and mechanical circulatory support needs.
Main Results:
- HTK associated with lower troponin I and less intra-aortic balloon pump (IABP) use at ACC times >180 min.
- DN group had lower cardioplegia volume and transfusion requirements.
- Prolonged ACC duration independently predicted LCOS, VIS >15, IABP requirement, and early mortality.
Conclusions:
- Aortic cross-clamp duration is a strong predictor of adverse outcomes in adult cardiac surgery.
- HTK cardioplegia may offer superior myocardial protection during long ACC durations, while DN is effective for shorter procedures.
- Individualizing cardioplegia choice based on ACC duration is recommended, with further prospective studies needed.
Abstract:
Background and Objectives: Effective myocardial protection is essential for successful cardiac surgery outcomes, especially in complex and prolonged procedures. To this end, Del Nido (DN) and histidine-tryptophan-ketoglutarate (HTK) cardioplegia solutions are widely used; however, their comparative efficacy in adult surgeries with prolonged aortic cross-clamp (ACC) times remains unclear. This study aimed to compare the efficacy and safety of DN and HTK for myocardial protection during prolonged ACC times in adult cardiac surgery and to define clinically relevant thresholds. Materials and Methods: This retrospective study included a total of 320 adult patients who underwent cardiac surgery under cardiopulmonary bypass (CPB) with an aortic cross-clamp time ≥ 90 min. Data were collected from the medical records of elective adult cardiac surgery cases performed at a single center between 2019 and 2025. Patients were categorized into two groups based on the type of cardioplegia received: Del Nido (n = 160) and HTK (n = 160). The groups were compared using 1:1 propensity score matching. Clinical and biochemical outcomes-including troponin I (TnI), CK-MB, lactate levels, incidence of low cardiac output syndrome (LCOS), and need for mechanical circulatory support-were analyzed between the two cardioplegia groups. Subgroup analyses were performed according to ACC duration (90-120, 120-150, 150-180 and >180 min). The predictive threshold of ACC duration for each complication was determined by ROC analysis, followed by the analysis of independent predictors of each endpoint by multivariate logistic regression. Results: Intraoperative cardioplegia volume and transfusion requirements were lower in the DN group (p < 0.05). HTK was associated with lower TnI levels and less intra-aortic balloon pump (IABP) requirement at ACC times exceeding 180 min. Markers of myocardial injury were lower in patients with an ACC duration of 120-150 min in favor of HTK. The propensity for ventricular fibrillation after ACC was significantly lower in the DN group. Significantly lower postoperative sodium levels were observed in the HTK group. Prolonged ACC duration was an independent risk factor for LCOS (odds ratio [OR]: 1.023, p < 0.001), VIS > 15 (OR, 1.015; p < 0.001), IABP requirement (OR: 1.020, p = 0.002), and early mortality (OR: 1.016, p = 0.048). Postoperative ejection fraction (EF), troponin I, and CK-MB levels were associated with the development of LCOS and a VIS > 15. Furthermore, according to ROC analysis, HTK cardioplegia was able to tolerate ACC for up to a longer duration in terms of certain complications, suggesting a higher physiological tolerance to ischemia. Conclusions: ACC duration is a strong predictor of major adverse outcomes in adult cardiac surgeries. Although DN cardioplegia is effective and economically advantageous for shorter procedures, HTK may provide superior myocardial protection in operations with long ACC duration. This study supports the need to individualize cardioplegia choice according to ACC duration. Further prospective studies are needed to establish standard dosing protocols and to optimize cardioplegia selection according to surgical duration and complexity.
