del Nido cardioplegia in adult cardiac surgery - scopes and concerns

Abstract

The convenience offered by a single-dose cardioplegia strategy is the avoidance of interruption of the flow of surgery and, more importantly, a significant reduction in the cross-clamp time. del Nido cardioplegia is an extracellular cardioplegic solution which serves these purposes and has been used successfully in pediatric cardiac surgery. The subsequent extrapolation of its use in adult cardiac surgery has returned encouraging results, as evidenced by recent literature. The use of del Nido cardioplegia in adults has been reported to shorten the cross-clamp time, cardiopulmonary bypass time and overall operating time. Intraoperative peak glucose value and insulin requirement have also been reported to be lower with del Nido cardioplegia, which can have prognostic significance. There have been reports of lesser incidence of atrial fibrillation and the number of defibrillations required with use of this technique. However, some unique concerns still remain. The lack of prospective randomized trials, the trend of elevation in CKMB (as reported by one study) and the need for a protocol-based approach to its use in adults are to be given due consideration while adopting its use in adults. This review attempts to have an overview on del Nido cardioplegia, its advantages, the recent studies comparing it with conventional cardioplegia techniques and the potential areas of concern with its use in adult cardiac surgery.

Transitioning to Del Nido cardioplegia for all-comers: the next switching gear?

“…The total Del Nido cardioplegia volume given was one third of the volume of cold blood cardioplegia but did not translate into fewer transfusions such as reported by Kim et al [9]. It is possible that the reduction in cardioplegia volume in combination with the more physiologic nature of the cardioplegic solution may contribute to myocardial protection by reducing myocardial edema [24]. This is reported with the use of microplegia solutions [25].…”

Modified whole blood microplegia in high‐risk patients

“…Benefits of the del Nido formula include blocking of calcium flux into the intracellular compartment, reduction of energy expenditure, scavenging of hydrogen ions, preservation of high energy phosphates, and facilitation of anaerobic glycolysis . Recent studies have described the expansion of its use in adult cardiac surgery . Mick et al (2015) presented the outcomes with del Nido cardioplegia and compared them with those of Buckberg blood cardioplegia in adult patients undergoing valve surgery.…”

“…Mick et al (2015) presented the outcomes with del Nido cardioplegia and compared them with those of Buckberg blood cardioplegia in adult patients undergoing valve surgery. The authors concluded that del Nido cardioplegia was a safe myocardial protection strategy for use in patients who required isolated aortic and mitral valve surgery . Similarly, Mick et al (2015) presented their results on the use of del Nido cardioplegia in adult cardiac surgery patients who required CABG or CABG/valve surgeries and compared them with use of whole blood cold cardioplegia solution.…”

“…The authors concluded that del Nido cardioplegia was associated with comparable clinical outcomes compared with cold blood cardioplegia in patients who had CABG or valve/CABG surgeries. The del Nido solution was described as 1:4 crystalloid to blood solution and previous studies have reported the use of this formula in adult cardiac surgery patients. We modified the del Nido cardioplegia solution by removing the crystalloid portion and utilizing the Quest MPS2, MPS for delivery of what we called “whole blood microplegia.” There is a scarcity of studies reporting the use of whole blood microplegia in adult cardiac surgery .…”

The del Nido cardioplegia in adult cardiac surgery: reinventing myocardial protection?

“…The del Nido cardioplegia (DNC) was conceived and introduced for pediatric cardiac surgery at the University of Pittsburgh in the early 1990s (1). The solution is based on Plasma-Lyte A, which has an electrolyte milieu similar to extracellular fluid, with the addition of mannitol, magnesium sulfate, sodium bicarbonate, potassium chloride (26 mEq), and lidocaine (2). This solution is calcium free.…”