Bretschneider (Custodiol®) and St. Thomas 2 Cardioplegia Solution in Mitral Valve Repair via Anterolateral Right Thoracotomy: A Propensity-Modelled Comparison

Abstract

Background Single-dose cardioplegia is preferred in minimal invasive mitral valve surgery to maintain the adjustment of the operative site without change of preset visualization. The aim of our study was to compare two widely used crystalloid cardioplegias Bretschneider (Custodiol®) versus St. Thomas 2 in patients who underwent mitral valve repair via small anterolateral right thoracotomy. Material and Methods From May 2012 until February 2019, 184 isolated mitral valve procedures for mitral valve repair via anterolateral right thoracotomy were performed using Bretschneider (Custodiol®) cardioplegia (n = 123) or St. Thomas (n = 61). Primary efficacy endpoint was peak postoperative high-sensitivity cardiac troponin (hs-cTnT) during hospitalization. Secondary endpoints were peak creatine kinase-muscle brain type (CK-MB) and creatine kinase (CK) as well as safety outcomes. We used inverse probability of treatment weighting (IPTW) in order to adjust for confounding by indication. Results Peak hs-cTnT was higher after use of Bretschneider (Custodiol®) (geometric mean 716 mg/L, 95% confidence interval (CI) 605-847 mg/L) vs. St. Thomas 2 (561 mg/L, CI 467-674 mg/L, p = 0.047). Peak CK-MB (geometric mean after Bretschneider (Custodiol®): 40 μg/L, CI 35-46, St. Thomas 2: 33 μg/L, CI 27-41, p = 0.295) and CK (geometric mean after Bretschneider (Custodiol®): 1370 U/L, CI 1222-1536, St. Thomas 2: 1152 U/L, CI 972-1366, p = 0.037) showed the same pattern. We did not see any difference with respect to postoperative complications between treatment groups after IPTW. Conclusion Use of St. Thomas 2 cardioplegia was associated with lower postoperative peak levels of all cardiac markers that reflect cardiac ischemia such as hs-cTnT, CK, and CK-MB as compared to Bretschneider (Custodiol®) in propensity-weighted treatment groups.

In search of optimal cardioplegia for minimally invasive valve surgery

“…The lack of difference in myocardial damage post-MIVS was shown when comparing DNC to SBC, DNC to St Thomas' cardioplegia and Custodiol to WBC or St Thomas' solution in MIVS. 7,[11][12][13][14][15][16]24 When analysing the results, only Mork et al found a significant difference in TnI, however the group size for Bretschneider's was significantly larger than that of St Thomas's solution in that study. 7 As cardiac arrest is required to perform the procedures in a safe manner, there is always a risk of ischaemic damage.…”

“…7,[11][12][13][14][15][16]24 When analysing the results, only Mork et al found a significant difference in TnI, however the group size for Bretschneider's was significantly larger than that of St Thomas's solution in that study. 7 As cardiac arrest is required to perform the procedures in a safe manner, there is always a risk of ischaemic damage. The notion that the best cardioplegic solution for myocardial protection is yet to be found has been supported in several reviews.…”

“…5,6 Now, minimally invasive cardiac surgery (MICS) techniques have advanced so that the surgery can be performed through a right or left mini-thoracotomy, or via a mini-sternotomy, whereby a small incision is made through the sternum, but does not go the entire length of the sternum. 5,7,8 Whilst not gaining full access to the thoracic cavity by fully separating the sternum can present challenges to a surgical procedure, minimally invasive surgeries produce comparable results to a full sternotomy. These procedures may be preferred to a full sternotomy for enhance patient satisfaction and/or where poor prognostic factors may impair recovery.…”

Single-Dose St. Thomas Versus Custodiol® Cardioplegia for Right Mini-thoracotomy Mitral Valve Surgery

“…Custodiol® is primarily preferred in case of planned prolonged procedures, typically complex MV repair, because a single dose may enable up to 3 h of safe cardiac arrest before redosing. However, concerns have been raised regarding the adequate myocardial protection of the Custodiol® cardioplegia when compared to other crystalloid solutions [23,31]. On the other hand, the administration of the St. Thomas cardioplegia is generally considered safe if repeated every 30 min [32].…”

“…Only few data exist in the literature regarding a direct comparison between Custodiol® and St. Thomas cardioplegia. In a recent study focused on minimally invasive MV operations, the St. Thomas solution was associated with lower postoperative cTn-T peak levels [31]. Interestingly, the authors employed the St. Thomas 2 solution as a single shot, advocating effective and safe myocardial protection up to 2 h of cardioplegic arrest.…”