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

Drury, Nigel E; Yim, Ivan; Patel, Akshay J.; Oswald, Nicola; Chong, Cher‐Rin; Stickley, John; Jones, Timothy J.

doi:10.1093/icvts/ivy199

Cited by 21 publications

(30 citation statements)

References 29 publications

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“…However, the studies have been limited to a retrospective comparison of 1400 patients who underwent cardiac surgery using IWBC with 950 patients treated with intermittent cold-bloodcardioplegia (ICBC) 10 ; and a small single centre randomisedcontrolled trial (RCT) which compared cold crystalloid cardioplegia with IWBC. 11 We would like to take this a step further and provide evidence to support the use of one type of cardioplegia 12 by investigating the effects of warm versus CBC on clinical and biochemical outcomes after paediatric congenital heart surgery.…”

Section: Strengths and Limitations Of This Studymentioning

confidence: 99%

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Intermittent antegrade warm-blood versus cold-blood cardioplegia in children undergoing open heart surgery: a protocol for a randomised controlled study (Thermic-3)

et al. 2020

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IntroductionSurgical repair of congenital heart defects often requires the use of cardiopulmonary bypass (CPB) and cardioplegic arrest. Cardioplegia is used during cardiac surgery requiring CPB to keep the heart still and to reduce myocardial damage as a result of ischaemia–reperfusion injury. Cold cardioplegia is the prevalent method of myocardial protection in paediatric patients; however, warm cardioplegia is used as part of usual care throughout the UK in adults. We aim to provide evidence to support the use of warm versus cold blood cardioplegia on clinical and biochemical outcomes during and after paediatric congenital heart surgery.Methods and analysisWe are conducting a single-centre randomised controlled trial in paediatric patients undergoing operations requiring CPB and cardioplegic arrest at the Bristol Royal Hospital for Children. We will randomise participants in a 1:1 ratio to receive either ‘cold-blood cardioplegia’ or ‘warm-blood cardioplegia’. The primary outcome will be the difference between groups with respect to Troponin T levels over the first 48 postoperative hours. Secondary outcomes will include measures of cardiac function; renal function; cerebral function; arrythmias during and postoperative hours; postoperative blood loss in the first 12 hours; vasoactive-inotrope score in the first 48 hours; intubation time; chest and wound infections; time from return from theatre until fit for discharge; length of postoperative hospital stay; all-cause mortality to 3 months postoperative; myocardial injury at the molecular and cellular level.Ethics and disseminationThis trial has been approved by the London – Central Research Ethics Committee. Findings will be disseminated to the academic community through peer-reviewed publications and presentation at national and international meetings. Patients will be informed of the results through patient organisations and newsletters to participants.Trial registration numberISRCTN13467772; Pre-results.

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Section: Strengths and Limitations Of This Studymentioning

confidence: 99%

“…We would like to take this a step further and provide evidence to support the use of one type of cardioplegia 12 by investigating the effects of warm versus CBC on clinical and biochemical outcomes after paediatric congenital heart surgery.…”

Section: Introductionmentioning

confidence: 99%

Intermittent antegrade warm-blood versus cold-blood cardioplegia in children undergoing open heart surgery: a protocol for a randomised controlled study (Thermic-3)

et al. 2020

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“… 8 9 Postoperative elevation of circulating troponin is a biomarker of myocardial injury and has been shown to strongly correlate with clinical outcomes including level of inotropic support, duration of ventilation, ventricular dysfunction and early death 5 10 ; consequently, it is the most common primary outcome measure in clinical trials of cardioprotection in children. 11 Myocardial protection therefore is a key determinant of heart function and outcome following cardiac surgery.…”

Section: Introductionmentioning

confidence: 99%

Bilateral Remote Ischaemic Conditioning in Children (BRICC) trial: protocol for a two-centre, double-blind, randomised controlled trial in young children undergoing cardiac surgery

Drury

Woolley

et al. 2020

BMJ Open

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IntroductionMyocardial protection against ischaemic-reperfusion injury is a key determinant of heart function and outcome following cardiac surgery in children. However, with current strategies, myocardial injury occurs routinely following aortic cross-clamping, as demonstrated by the ubiquitous rise in circulating troponin. Remote ischaemic preconditioning, the application of brief, non-lethal cycles of ischaemia and reperfusion to a distant organ or tissue, is a simple, low-risk and readily available technique which may improve myocardial protection. The Bilateral Remote Ischaemic Conditioning in Children (BRICC) trial will assess whether remote ischaemic preconditioning, applied to both lower limbs immediately prior to surgery, reduces myocardial injury in cyanotic and acyanotic young children.Methods and analysisThe BRICC trial is a two-centre, double-blind, randomised controlled trial recruiting up to 120 young children (age 3 months to 3 years) undergoing primary repair of tetralogy of Fallot or surgical closure of an isolated ventricular septal defect. Participants will be randomised in a 1:1 ratio to either bilateral remote ischaemic preconditioning (3×5 min cycles) or sham immediately prior to surgery, with follow-up until discharge from hospital or 30 days, whichever is sooner. The primary outcome is reduction in area under the time-concentration curve for high-sensitivity (hs) troponin-T release in the first 24 hours after aortic cross-clamp release. Secondary outcome measures include peak hs-troponin-T, vasoactive inotrope score, arterial lactate and central venous oxygen saturations in the first 12 hours, and lengths of stay in the paediatric intensive care unit and the hospital.Ethics and disseminationThe trial was approved by the West Midlands-Solihull National Health Service Research Ethics Committee (16/WM/0309) on 5 August 2016. Findings will be disseminated to the academic community through peer-reviewed publications and presentation at national and international meetings. Parents will be informed of the results through a newsletter in conjunction with a local charity.Trial registration numberNCT12923441.

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“…9 This may be driven by a lack of evidence to support one technique over another; the paediatric cardiac surgery literature contains no late phase, randomised, controlled trials and there is a need for high-quality evidence to guide practice and improve outcomes. 10 We, therefore, conducted a survey to establish the current cardioplegia practice in paediatric cardiac surgery in the UK & Ireland and the willingness of surgeons to randomise patients to different solutions within the context of a multi-centre, randomised, controlled trial.…”

Section: Introductionmentioning

confidence: 99%

Cardioplegia practice in paediatric cardiac surgery: a UK & Ireland survey

Drury

Horsburgh

et al. 2018

Perfusion

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This survey demonstrates heterogeneity in cardioplegia practice. Whilst most surgeons use blood cardioplegia, there is variation in type, temperature, topical cooling, dosing and intervals. Combined with a lack of evidence from late phase trials, our findings support the presence of clinical equipoise. Surgeons are willing to change practice, suggesting that a pragmatic, multi-centre, randomised, controlled trial of cardioplegia in children is feasible.

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

Abstract: CRD42017080205.

Cited by 21 publications

References 29 publications

Intermittent antegrade warm-blood versus cold-blood cardioplegia in children undergoing open heart surgery: a protocol for a randomised controlled study (Thermic-3)

Intermittent antegrade warm-blood versus cold-blood cardioplegia in children undergoing open heart surgery: a protocol for a randomised controlled study (Thermic-3)

Bilateral Remote Ischaemic Conditioning in Children (BRICC) trial: protocol for a two-centre, double-blind, randomised controlled trial in young children undergoing cardiac surgery

Cardioplegia practice in paediatric cardiac surgery: a UK & Ireland survey

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