Blood Versus Crystalloid Cardioplegia in Pediatric Cardiac Surgery: A Systematic Review and Meta-analysis

Abstract

The benefit of blood cardioplegia (BCP) compared to crystalloid cardioplegia (CCP) is still debatable. Our aim was to systematically review and synthesize all available evidence on the use of BCP and CCP to assess if any modality provides superior outcomes in pediatric cardiac surgery. A systematic literature search of the PubMed and Cochrane databases was performed with respect to the PRISMA statement (end-of-search date: January 30th, 2017). We extracted data on study design, demographics, cardioplegia regimens, and perioperative outcomes as well as relevant biochemical markers, namely cardiac troponin I (cTnI), lactate, and ATP levels at baseline, after reperfusion and postoperatively at 1, 4, 12, and 24 h as applicable. Data were appropriately pooled using random and mixed effects models. Our systematic review includes 56 studies reporting on a total of 7711 pediatric patients. A meta-analysis of the 10 eligible studies directly comparing BCP (n = 416) to CCP (n = 281) was also performed. There was no significant difference between the two groups with regard to cTnI and Lac at any measured time point, ATP levels after reperfusion, length of intensive care unit stay (WMD: -0.08, 95% CI -1.52 to 1.36), length of hospital stay (WMD: 0.13, 95% CI -0.85 to 1.12), and 30-day mortality (OR 1.11, 95% CI 0.43-2.88). Only cTnI levels at 4 h postoperatively were significantly lower with BCP (WMD: -1.62, 95% CI -2.07 to -1.18). Based on the available data, neither cardioplegia modality seems to be superior in terms of clinical outcomes, ischemia severity, and overall functional recovery.

Custodiol (Histidine-Tryptophan-Ketoglutarate) versus Modified St. Thomas Cold Crystalloid Cardioplegia: Short-term Results

“…7,8 In our results, the cardiopulmonary bypass time in Group A is 99.4±8.46, and in Group B is 95.6±12.27.The mean cross clamp time in Group A is 72.2±89.36, and in Group B was 68±12.58 showing no statistical difference compared to different studies. 7,9 The mean ICU stay in our results in Group A is 1.28±0.46 and at the same time in Group B it is 1.72±0.61 with p-value 0.006. We found that the mean length of MV in custodial group is 4.64±0.86 and in crystalloid cardioplegia group it is 7.04±0.84 with p-value 0.000 showing a remarkable statistical difference between the two groups suggesting the superiority of HTK solution over the crystalloid cardioplegia which was similar to different studies.…”

Cardioplegia in paediatric cardiac surgery: a systematic review of randomized controlled trials

“…They concluded that there was no evidence of improvement in myocardial injury or clinical outcomes but were limited by the small number of patients and variability in age, preoperative cyanosis and techniques used. Similarly, Mylonas et al [18] recently identified many nonrandomized or retrospective studies on paediatric cardioplegia but few RCTs, a finding that is commonplace throughout the global paediatric cardiac surgery literature. In a recent systematic review of RCTs published since 2000, we identified few latephase clinical trials; most were small, single-centre studies of low value, uncertain quality and at risk of systematic bias [19].…”

Adding Blood to St Thomas Solution Does Not Improve Mortality in Pediatric Cardiac Surgery: A Meta-analysis of a Homogenous Population

“…Two relatively recent meta-analyses (5,24) comparing blood and non-blood cardioplegia in pediatric cardiac surgery found no difference in clinical outcomes following the use of either strategy. Of particular interest to us was that Mylonas et al found no difference in 30day mortality (5). Fang et al examined metabolic markers of myocardial protection, length of postoperative ventilation and length of intensive care unit (ICU) stay; they found that these outcomes were essentially the same irrespective of strategy used (18).…”

“…In comparing clinical outcomes between blood and nonblood cardioplegia, most randomized clinical trials have been on adult patients; pediatric trials are few (2). Some systematic reviews with meta-analyses have been conducted; however, the populations included have been significantly heterogeneous (5). Meta-analysis is a powerful and useful tool when correctly applied; elemental to proper application is the analysis of populations that are as homogenous as possible (6).…”