Comparison of modified Del Nido and Custodiol® cardioplegia in minimally invasive mitral valve surgery.

OBJECTIVES: In this study, we evaluated if modified Del Nido cardioplegia delivers comparable cardiac protection in comparison to Custodiol® in patients undergoing isolated minimally invasive mitral valve repair. METHODS: From January 2018 to October 2021, all patients undergoing non-emergent isolated minimally invasive mitral valve repair were included in this study. The cardioplegia was chosen at the surgeons' discretion. The primary end points of this study were peak postoperative cardiac enzyme levels. Secondary end points were in-hospital mortality, hospital stay, occurrence of cardiac arrhythmias, pacemaker implantations, postoperative lactate and sodium levels and postoperative incidence of renal failure requiring dialysis. RESULTS: A total of 355 patients were included in this study. The mean age of patients was 57. After propensity score matching, a total of 156 pairs were identified. There was no difference in cross-clamp time between both groups. Postoperative creatine kinase levels were higher in patients receiving Custodiol on the 1st and 2nd postoperative days. Creatine kinase isoenzyme MB levels were higher in patients receiving Custodiol on the 2nd postoperative day (0.5 ± 0.2 vs 0.4 ± 0.1 µmol/l s; P < 0.001). Postoperative Troponin T concentrations were similar between both groups. Maximum lactate concentrations were higher in patients receiving Custodiol on the day of surgery (2.4 ± 1.9 vs 2.0 ± 1.1 mmol/l; P = 0.04). The overall hospital stay was longer in patients receiving Del Nido cardioplegia (10.6 ± 3.2 vs 8 ± 4.1 days; P < 0.01). CONCLUSIONS: Modified Del Nido cardioplegia based on Ionosteril® solution offers equivalent protection compared to Custodiol for isolated minimally invasive mitral valve repair.

Comparison of lactated Ringer's solution and Plasma-Lyte A as a base solution for del Nido cardioplegia: a prospective randomized trial.

OBJECTIVES: The use of del Nido cardioplegia has been increasing in popularity for adult cardiac surgery. However, the base solution, Plasma-Lyte A, is not always available in many countries. This prospective randomized controlled trial evaluated myocardial preservation and clinical outcomes when using lactated Ringer's solution (LRS) compared to Plasma-Lyte A as a base solution for del Nido cardioplegia. METHODS: Adult patients undergoing first-time elective cardiac surgery for acquired heart disease, including isolated coronary artery bypass grafting, isolated valve surgery, combined valve surgery or concomitant coronary artery bypass grafting and valve surgery were randomized to receive either LRS (n = 100) or Plasma-Lyte A (n = 100). RESULTS: There were no significant differences between the 2 groups in terms of age, comorbidities, Society of Thoracic Surgeons risk score and type of procedures. The primary outcome, postoperative troponin-T at 24 h, was similar in both groups (0.482 vs 0.524 ng/ml; P = 0.464). Other cardiac markers were also similar at all time points. The LRS group had a lower pH (7.228 vs 7.246; P = 0.005) and higher calcium levels (0.908 vs 0.358 mmol/l; P < 0.001) in the delivered cardioplegia, but there were no significant differences in clinical outcomes, such as ventricular fibrillation, left ventricular ejection fraction, inotrope/vasopressor requirement, intra-aortic balloon pump support, intensive care unit stay, hospital stay, atrial fibrillation, red cell transfusion and complications. CONCLUSIONS: The results suggest that LRS can be used as an alternative to Plasma-Lyte A as the base solution for del Nido cardioplegia, with similar myocardial preservation and clinical outcomes.

Myocardial protection in cardiac surgery-hindsight from the 2020s.

Myocardial protection and specifically cardioplegia have been extensively investigated in the beginnings of cardiac surgery. After cardiopulmonary bypass had become routine, more and more cardiac operations were possible, requiring reliable and reproducible protection for times of blood flow interruptions to the most energy-demanding organ of the body. The concepts of hypothermia and cardioplegia evolved as tools to extend cardiac ischaemia tolerance to a degree considered safe for the required operation. A plethora of different solutions and delivery techniques were developed achieving remarkable outcomes with cross-clamp times of up to 120 min and more. With the beginning of the new millennium, interest in myocardial protection research declined and, as a consequence, conventional cardiac surgery is currently performed using myocardial protection strategies that have not changed in decades. However, the context, in which cardiac surgery is currently performed, has changed during this time. Patients are now older and suffer from more comorbidities and, thus, other organs move more and more into the centre of risk assessment. Yet, systemic effects of cardioplegic solutions have never been in the focus of attention. They say hindsight is always 20-20. We therefore review the biochemical principles of ischaemia, reperfusion and cardioplegic extension of ischaemia tolerance and address the concepts of myocardial protection with 'hindsight from the 2020s'. In light of rising patient risk profiles, minimizing surgical trauma and improving perioperative morbidity management becomes key today. For cardioplegia, this means accounting not only for cardiac, but also for systemic effects of cardioplegic solutions.

[Efficacy and short-term outcomes of myocardial protection using single-dose histidine-tryptophan-ketoglutarate cardioplegia during aortic root surgery with different duration of myocardial ischemia].

Objective: To explore the efficacy of myocardial protection with single-dose histidine-tryptophan-ketoglutarate (HTK) cardioplegia during aortic root operation, and the correlation between short-term clinical outcomes and duration of myocardial ischemia. Methods: The data of clinical cases undergoing myocardial protection with single-dose HTK cardioplegia during aortic root operation from January 2018 to December 2022 were retrospectively reviewed. Patients were divided into conventional HTK cardioplegia group (<3 h) and prolonged HTK cardioplegia group (≥3 h) according to duration of intraoperative myocardial ischemia. A 1∶1 propensity score matching was performed and the correlations between duration of myocardial ischemia and postoperative short-term outcomes (30-day mortality, readmission, mechanical circulation support and renal insufficiency) were analyzed. Results: A total of 282 patients were included in the final analysis, with 210 cases in the conventional HTK cardioplegia group and 72 cases inthe prolonged HTK cardioplegia group before matching. After matching, there were 64 cases (53 males and 11 females) in the conventional HTK cardioplegia group, with a mean age of (49.4±14.2) years. The prolonged HTK cardioplegia group had 64 cases (55 males and 9 females), with a mean age of (50.5±12.3) years. Higher sensitivity troponin [12 h: 10.1 (4.6, 18.7) µg/Lvs 4.1(2.2, 8.6) µg/L, P=0.002; 24 h: 7.7 (4.5, 19.0) µg/L vs 4.8 (2.2, 11.9) µg/L, P=0.025] and creatine kinase isoenzyme[12 h: 46.3 (28.1, 62.4) µg/L vs 20.7(14.1, 32.9) µg/L, P<0.001; 24 h: 26.3(13.4, 49.2) µg/L vs 14.5 (10.1, 33.5)µg/L, P=0.011] after surgery was detected in prolonged HTK cardioplegia group. Comparisons of other primary and secondary endpoint events showed no significant differences between the two groups (all P>0.05). Multivariate binary logistic regression showed that duration of myocardial ischemia had no significant effect on postoperative 30-day mortality (OR=1.255, 95%CI: 0.500-3.148, P=0.629), 30-day readmission (OR=0.378, 95%CI: 0.069-2.065, P=0.261) and mechanical circulation support (OR=0.991, 95%CI: 0.331-2.970, P=0.998). Conclusion: During aortic root surgery, single-dose HTK cardioplegia may provide satisfactory myocardial protection, and there was no significant correlation between duration of myocardial ischemia and short-term clinical outcomes.

Comparison of Single-Dose Cardioplegia in Valvular Heart Surgery: Lactated Ringer's-Based del Nido vs. Histidine-Tryptophan-Ketoglutarate Cardioplegia Solution.

INTRODUCTION: This study evaluated myocardial protection and clinical outcomes when using lactated Ringer's solution as the base solution for del Nido cardioplegia compared with histidine-tryptophan-ketoglutarate (HTK) solution in valvular surgery. METHODS: From January 2017 to May 2018, 71 adult patients who underwent valvular surgery with del Nido cardioplegia (n=37) or HTK cardioplegia (n=34) were retrospectively analyzed. RESULTS: Patients' characteristics were comparable between groups. Postoperative peak troponin T levels were similar. The del Nido group had a decreased incidence of ventricular fibrillation after aortic cross-clamp removal (13.51 vs. 55.88%; P<0.001), lower total volume of cardioplegia administered (1,000 [1,000, 1,250] vs. 1,800 [1,500, 2,000] mL; P<0.001), shorter hospital stay (6 [5, 8] vs. 7 [6, 10] days; P=0.03), and less postoperative red cell transfusion (34.29 vs. 61.11%; P=0.024). There is no difference in aortic cross-clamping time, postoperative change in left ventricular ejection fraction, intensive care unit stay, duration of inotropic support, new onset of atrial fibrillation, in-hospital mortality, complications, and three-year overall survival rate. CONCLUSION: Lactated Ringer's-based del Nido cardioplegia can be safely used for valvular surgery with acceptable clinical outcomes compared to HTK cardioplegia.

Oxygen Nanocarriers for Improving Cardioplegic Solution Performance: Physico-Chemical Characterization.

Nanocarriers for oxygen delivery have been the focus of extensive research to ameliorate the therapeutic effects of current anti-cancer treatments and in the organ transplant field. In the latter application, the use of oxygenated cardioplegic solution (CS) during cardiac arrest is certainly beneficial, and fully oxygenated crystalloid solutions may be excellent means of myocardial protection, albeit for a limited time. Therefore, to overcome this drawback, oxygenated nanosponges (NSs) that can store and slowly release oxygen over a controlled period have been chosen as nanocarriers to enhance the functionality of cardioplegic solutions. Different components can be used to prepare nanocarrier formulations for saturated oxygen delivery, and these include native α-cyclodextrin (αCD), αcyclodextrin-based nanosponges (αCD-NSs), native cyclic nigerosyl-nigerose (CNN), and cyclic nigerosyl-nigerose-based nanosponges (CNN-NSs). Oxygen release kinetics varied depending on the nanocarrier used, demonstrating higher oxygen release after 24 h for NSs than the native αCD and CNN. CNN-NSs presented the highest oxygen concentration (8.57 mg/L) in the National Institutes of Health (NIH) CS recorded at 37 °C for 12 h. The NSs retained more oxygen at 1.30 g/L than 0.13 g/L. These nanocarriers have considerable versatility and the ability to store oxygen and prolong the amount of time that the heart remains in hypothermic CS. The physicochemical characterization presents a promising oxygen-carrier formulation that can prolong the release of oxygen at low temperatures. This can make the nanocarriers suitable for the storage of hearts during the explant and transport procedure.

The role of Del Nido Cardioplegia in reducing postoperative atrial fibrillation after cardiac surgery in patients with impaired cardiac function.

BACKGROUND: Postoperative atrial fibrillation (POAF) occurs in 20% to 40% of patients who underwent cardiac surgery and can compromise the postoperative course, especially in those with reduced left ventricular ejection fraction. The most common causes are related to surgical trauma and the high variations in volemic and electrolyte balance in the postoperative period. OBJECTIVES: As cardioplegic solutions can significantly impact both these factors, the study aimed to assess the role of Del Nido (DN) cardioplegia on the onset of POAF. METHODS: A retrospective single-center analysis was carried out on 93 patients undergoing coronary artery bypass graft surgery where cardioplegia was used. The patients were divided into two groups according to the cardioplegic solution (Cold Blood vs Del Nido), and perioperative outcomes were compared. RESULTS: POAF occurred in 21.5% of patients; the patients treated with cold blood cardioplegia (CBC) showed a 3-times higher rate of POAF compared to the DN group (OR: 3.44; 95% CI: 1.1 to 10.5; p = 0.029). The CBC group showed higher serum potassium levels both after the cross-clamp removal (p<0.001), at the ICU admission (p = 0.007), and during the first 3 postoperative days (p = 0.009). The defibrillation rate at cross-clamp removal (p = 0.003), the dose of postoperative epinephrine (p<0.001), and the peak of serum troponin (p = 0.01), were lower in the DN Group. CONCLUSION: DN cardioplegia showed significantly reduced POAF rates after cardiac surgery by acting on the electrolyte balance, myocardial protection and on the need for postoperative inotropic support.

Myocardial Protection in Isolated Coronary Artery Bypass Grafting: Del Nido versus Blood Cardioplegia.

INTRODUCTION: Our study aimed to examine the impacts of blood cardioplegia (BC) and del Nido cardioplegia (DNC) solutions - which we used in isolated coronary artery bypass grafting (CABG) - on early mortality and major adverse events (MAE). METHODS: We retrospectively analyzed 329 consecutive patients who underwent CABG in our clinic between January 2016 and January 2020. Myocardial infarction, reoperation, cardiac tamponade, stroke, renal failure, extracorporeal membrane oxygenation requirement, and cardiopulmonary resuscitation were defined as MAE. The group in which DNC was used was Group D (181 [55%] patients), and the group in which BC was used was Group B (141 [45%] patients). RESULTS: No statistically significant difference was determined between the groups regarding age, weight, body surface area, gender, or European System for Cardiac Operative Risk Evaluation score (P=0.615, P=0.560, P=0.934, P=0.365, P=0.955, respectively). Although there was no statistically significant difference between the groups in terms of aortic cross-clamping time (P=0.712), cardiopulmonary bypass duration was longer in Group B (P=0.001). Even though the incidence of stroke was higher in Group B (P=0.030), no statistically significant difference was observed between the groups regarding total incidence of MAE, mortality, mechanical ventilation time, length of stay in the intensive care unit, or length of hospital stay (P=0.153, P=0.130, P=0.689, P=0.710, P=0.613, respectively). CONCLUSION: We found no significant difference in MAE, mortality, duration of mechanical ventilation, intensive care unit stay, or hospital stay between the DNC and BC groups. We believe that both solutions can be used safely for cardiac protection in the adult patient population.

The impact of del Nido cardioplegia solution on blood morphology parameters.

BACKGROUND: Crystalloid cardioplegic solutions are believed to reduce hemoglobin significantly and increase the transfusion rate. However, recent reports indicate that the del Nido cardioplegia may preserve blood morphology parameters. METHODS: In "The del Nido versus cold blood cardioplegia in aortic valve Replacement" trial patients undergoing aortic valve replacement were randomized into the del Nido (DN) or cold blood cardioplegia (CB) group. For the subanalysis, patients who underwent blood transfusions were excluded from the study. Red blood cell (RBC) count, hemoglobin, white blood cell (WBC) count and platelet (PLT) count were measured before the surgery, 24-, 48-, and 96 hours postoperatively. Furthermore, percental variation in first-last measure was compared in groups. In addition, indexed normalized ratio (INR) and activated partial thromboplastin time (aPTT) were compared preoperatively and 24 hours after the surgery. RESULTS: Eighteen (24%) patients from the del Nido group and 22 (29.3%) patients from the CB group received blood product transfusions (p = 0.560) and were excluded from further analysis. As such, 57 patients remained in DN group and 53 patients remained in CB group. No difference was found in RBC, hemoglobin, WBC, and platelet count in time intervals. Percental variation in first-last measure revealed higher fall in RBC (p = 0.0024) and hemoglobin (p = 0.0028) in the CB group. No difference was shown in preoperative and 24-hour postoperative INR and aPTT. CONCLUSIONS: The del Nido cardioplegia does not decrease blood morphology parameters when compared to cold blood cardioplegia and may be used alternatively regardless of bleeding and coagulopathy risk.

Network meta-analysis comparing blood cardioplegia, Del Nido cardioplegia and custodiol cardioplegia in minimally invasive cardiac surgery.

INTRODUCTION: Minimally invasive cardiac surgery has been evolving, with the intention of reducing surgical trauma, improve cosmesis and patient satisfaction. Single dose, crystalloid cardioplegia such as Del Nido cardioplegia and Custoidol solution have been increasingly used to reduce the interruption from repeating cardioplegia dosing to minimise the cardiopulmonary bypass and cross clamp time. However, the best cardioplegia for myocardial protection in adult minimally invasive cardiac surgery remains controversial. We aimed to conduct a meta-analysis to analyse the current evidence in the literature. METHOD: A systematic review and meta-analysis was performed following the updated 2020 PRISMA guideline. Articles published in the five major electronic databases up 1st of April 2021 were identified and reviewed. The primary outcome was in-hospital or 30-day mortality. Traditional pairwise and Bayesian network meta-analyses were conducted. RESULTS: Nine articles were included in this study. The use of Del Nido cardioplegia was associated with a lower volume of cardioplegia used (Del Nido vs Blood, 1105.62 mL+/-123.47 vs 2569.46 mL+/-1515.52, p<0.001), cardiopulmonary bypass (Del Nido vs Custoidol vs Blood: 91.67+/-14.78 vs 138.05 +/- 21.30 vs 119.38+/-26.91 minutes, p<0.001) and cross-clamp time (Del Nido vs Custoidol vs Blood: 74.99+/-18.55 vs 82.01 +/- 17.28 vs 93.66+/-8.88 minutes, p < 0.001). No differences were observed in the incidence of in-hospital/30-day mortality rate, new onset of atrial fibrillation and stroke. Ranking analysis showed the Custoidol solution has the highest probability to be the first ranked cardioplegia. CONCLUSION: No differences were found between blood and crystalloid cardioplegia in adult minimally invasive cardiac surgery in several clinical outcomes. The cardioplegia of choice in minimally invasive cardiac surgery remains the surgeons' decision and preference.

One-shot cardioplegia for minimally invasive mitral valve repair-a comparison of del Nido and Bretschneider Histidine-Tryptophan-Ketoglutarate solutions.

BACKGROUND: Minimally invasive procedures are demanding in terms of cardioprotection. In many leading centres Bretschneider HTK solution is used for mitral valve surgery. The study was designed to provide comparison of the del Nido and Bretschneider HTK protocol. METHODS: Patients who underwent minimally invasive mitral valve repair for primary mitral regurgitation and received single delivery of either del Nido (Group 1) or Bretschneider HTK cardioplegia (Group 2) were matched on basis of age, gender and length of the cross-clamp time. The groups were compared in terms of major adverse cardiac and cerebrovascular events (death, myocardial infarction, stroke), high sensitivity troponin T (hs-TnT) and creatine kinase- MB isoenzyme (CK-MB) release at 12 h and 24 h following the surgery, incidence of low cardiac output syndrome (LCOS), postoperative arrhythmia, transfusions and postoperative renal function. RESULTS: Case control matching selected 38 pairs of patients. None of patients died, nor suffered from myocardial infarction or stroke. Troponin values did not differ at 12 h (median: 281.0 pg/mL vs 313.0 pg/mL; p = .38) and 24 h (median: 261.0 pg/mL vs 299.0 pg/mL; p = .54), as well as CK-MB at 12 h (median: 25.0 ng/mL vs 29.0 ng/mL; p = .31) and 24 h (median: 11.0 ng/mL versus 9.6 ng/mL; p = .46). Difference in occurrence of LCOS was insignificant (2 vs 7; 5.2% vs 18.4%; p =.15). No difference was shown in incidence of postoperative arrhythmia, transfusions and renal function. CONCLUSIONS: Del Nido cardioplegia can be used safely as an alternative for Bretschneider HTK for minimally invasive mitral valve surgery.

Del Nido cardioplegia for myocardial protection in adult cardiac surgery: a systematic review and update meta-analysis.

OBJECTIVE: Although the application of del Nido cardioplegia solution (DNC) in adult cardiac surgery is accumulating, the feasibility and safety of this myocardial protection strategy in adults remains controversial. We aimed to update our previous meta-analysis to determine the myocardial protective effect of DNC versus conventional cardioplegia (CC) in adult cardiac surgery. METHODS: A comprehensive literature search was performed using PubMed, EMBASE, the Cochrane Library, and International Clinical Trials Registry Platform databases through November 2020. RESULTS: Thirty-seven observational studies and four randomized controlled trials (RCTs) including 21,779 patients were identified. The DNC group was associated with decreased postoperative cardiac enzymes [troponin T (cTnT) and creatine kinase-MB (CK-MB)] [standardized mean differences (SMD): -0.59, 95% confidence interval (CI): -0.99 to -0.19, p = 0.004], cardiopulmonary bypass (CPB) time (MD: -9.31, 95% CI: -13.10 to -5.51, p < 0.00001), aortic cross-clamp (ACC) time (MD: -7.20, 95% CI: -10.31 to -4.09, p < 0.00001), and cardioplegia volume (SMD: -1.95, 95% CI: -2.46 to -1.44, p < 0.00001). Intraoperative defibrillation requirement was less in the DNC group [relative risk (RR): 0.50, 95% CI: 0.33 to 0.75, p = 0.0007]. The pooled analysis revealed no significant difference in operative mortality among the patients assigned to DNC and those undergoing CC. CONCLUSION: In adult cardiac surgery, compared to CC, myocardial protection used with DNC yield similar or better short-term clinical outcomes. More high-quality trials and RCTs reflecting long-term follow-up morbidity and mortality are required in the future to confirm these findings.

Cold modified Del Nido cardioplegia in adults undergoing elective cardiac coronary surgery.

INTRODUCTION: The cardioplegic solution of Kirklin (Kn) is frequently used in adult cardiosurgical patients. It requires reinfusion at short intervals, which causes further difficulty during surgery and the quality of myocardial protection is often called into question.

Neuroprotective Effects of a Cardioplegic Combination (Adenosine, Lidocaine, and Magnesium) in an Ischemic Stroke Model.

Adenosine, lidocaine, and magnesium (ALM) are clinically available cardioplegic solutions. We examined the effects of low-dose ALM on ischemic stroke in cell and animal models. Cobalt chloride (CoCl2)-treated SH-SY5Y cells were used as a surrogate model to mimic oxygen-glucose deprivation conditions. The cells were incubated with different dilutions of ALM authentic solution (1.0 mM adenosine, 2.0 mM lidocaine, and5 mM MgSO4 in Earle's balanced salt solution). At a concentration of 2.5%, ALM significantly reduced CoCl2-induced cell loss. This protective effect persisted even when ALM was administered 1 h after the insult. We used transient middle cerebral artery occlusion to investigate the therapeutic effects of ALM in vivo. Rats were randomly assigned to two groups-the experimental (ALM) and control (saline) groups-and infusion was administered during the ischemia for 1 h. The infarction area was significantly reduced in the ALM group compared with the control group (5.0% ± 2.0% vs. 23.5% ± 5.5%, p = 0.013). Neurological deficits were reduced in the ALM group compared with the control group (modified Longa score: 0 [0-1] vs. 2 [1-2], p = 0.047). This neuroprotective effect was substantiated by a reduction in the levels of various neuronal injury markers in plasma. These results demonstrate the neuroprotective effects of ALM and may provide a new therapeutic strategy for ischemic stroke.

Assessing sex-based differences in postsurgical clinical outcomes after use of del Nido cardioplegia.

OBJECTIVES: del Nido cardioplegia is used to pharmacologically arrest the heart during cardiac surgery and decrease reperfusion- and ischaemia-related myocardial injury. Studies have demonstrated the physiological differences between male and female hearts, potentially related to cardiac size or myocyte calcium handling; we aimed to assess for between-sex differences in clinical outcomes after receipt of del Nido cardioplegia. METHODS: Patients who underwent coronary artery bypass or coronary artery bypass graft/valve surgery at our institution using del Nido cardioplegia (January 2014 to December 2019) were included (n = 2118). Clinical data were collected retrospectively. After the creation of a propensity-matched cohort (n = 1252), multivariable logistic regression was used to analyse binary postoperative outcomes, and a Gamma model was used for a continuous postoperative outcome. Our primary end-point was a composite end-point comprised of 30-day mortality and/or need for a post-bypass mechanical support device. RESULTS: The final cohort included 459 females and 793 males (matched up to 1:2, all standardized mean differences <0.1). Multivariable logistic regression showed that biological sex was not associated with the composite primary end-point (odds ratio = 0.898, P = 0.779). A Gamma model indicated that there were no sex-related differences in vasoactive-inotropic scores reflecting vasopressor and inotrope usage at the time of patient operating room exit (exp[est] = 1.394, P = 0.189). CONCLUSIONS: Our findings showed no significant between-sex differences in clinical outcomes after receiving del Nido cardioplegia, suggesting adequate myocardial protection as currently administered. Further research is warranted to elicit if there are sex-based differences between cardioplegic solutions. IRB APPROVAL DATE (PROTOCOL NUMBER): 26 May 2021 (AAAR8359).

Impact of the Cardioplegia Interval on Myocardial Protection Using the Modified St. Thomas Solution in Minimally Invasive Mitral Valve Surgery: A Double-Center Study.

It has been reported that a single-dose cardioplegia interval is useful, but the safe interval doses are not clear. We aimed to investigate the impact of the cardioplegia interval on myocardial protection using the modified St. Thomas solution. We included consecutive isolated minimally invasive mitral valvuloplasty procedures (n = 229) performed at a hospital and medical center from January 2014 to December 2020. We compared postoperative peak creatine kinase MB and creatine kinase levels and other indicators between the short (Group S, n = 135; maximum myocardial protection interval <60 minutes) and long (Group L, n = 94; maximum myocardial protection interval ≥60 minutes) interval groups. Propensity score matching was used to adjust for confounders between the two groups. After propensity score matching, Groups S and L contained 47 patients each. Groups S and L did not differ significantly in peak creatine kinase MB (45.8 ± 26.3 IU/L and 41.5 ± 27.9 IU/L, respectively; p = .441) and creatine kinase levels (1,133 ± 567 IU/L and 1,100 ± 916 IU/L, respectively; p = .837) after admission to the intensive care unit on the day of surgery based on propensity score matching. In multivariate analysis, a cardioplegia dosing interval ≥60 minutes was not significantly associated with the maximum creatine kinase MB level after admission to the intensive care unit on the day of surgery (p = .354; 95% confidence interval: -1.67 to 4.65). Using the antegrade modified St. Thomas solution, the long interval dose method is useful and safe in minimally invasive mitral valvuloplasty.

Histidine-tryptophan-ketoglutarate solution versus multidose cardioplegia for myocardial protection in cardiac surgeries: a systematic review and meta-analysis.

BACKGROUND: Surgical procedures in the heart requires protection of the heart from ischemia-reperfusion injury. Cardioplegia is the primary myocardial protective method in use. Histidine-tryptophan-ketoglutarate (HTK) solution is an intracellular cardioplegic solution that was initially used to preserve organs for transplantation. METHODS: A systematic electronic search was conducted in July 2021, in four databases; PubMed, Scopus, Web of Science, and Cochrane Library for eligible randomized controlled trials. The results were screened and the eligible trials were identified. Thereafter, the relevant data were extracted and pooled as mean difference or risk ratio, and 95% confidence interval in an inverse variance method using RevMan software. RESULTS: This review included 12 trials (n = 1327). HTK solution has resulted significantly in shorter intensive care unit stay (MD = - 0.09; 95% CI [- 0.15, - 0.03], p = 0.006), and shorter hospital stay (MD = - 0.51; 95% CI [- 0.71, - 0.31], p < 0.00001). Moreover, the patients who received the HTK solution had significantly lower levels of creatine kinase (after 4-7 h (MD = - 157.52; 95% CI [- 272.31, - 42.19], p = 0.007), and 24 h (MD = - 136.62; 95% CI [- 267.20, - 6.05], p = 0.04)), as well as creatine kinase muscle brain band (after 44-48 h (MD = - 3.35; 95% CI [- 5.69, - 1.02], p = 0.005)). CONCLUSION: HTK solution had the same efficacy and safety as other cardioplegic solutions in most of the clinical parameters. Furthermore, the solution showed superiority in fastening the recovery and protecting the myocardium at the biochemical level. HTK solution provides longer myocardial protection; therefore, it limits surgical interruption. HTK solution can be used as an alternative to the currently used cardioplegic solutions.

Oral application of levosimendan before ischaemia/reperfusion with or without cardioplegic arrest in rats.

OBJECTIVES: Clinical studies have indicated minor beneficial effects of the calcium sensitizer levosimendan on clinical outcomes in patients undergoing cardiac surgery. Here, the influence of levosimendan administered 24 h before cardiac arrest on myocardial function was examined in rat hearts perfused in a Langendorff model. METHODS: Levosimendan (Levo group) or NaCl (control group) was administered to 53 rats via drinking water 24 h prior to mounting excised hearts on a Langendorff apparatus. Cardiac arrest with or without cardioplegia was induced in both groups; another set of hearts was perfused continuously. During 90-min reperfusion at 36°C, functional parameters were measured and normalized to baseline values. Troponin I was quantified in coronary sinus effluent, and the functionality of isolated cardiomyocytes was studied. RESULTS: Oral application of levosimendan showed therapeutic efficacy. Baseline values were similar in the Levo and NaCl groups except for coronary flow. After ischaemia and reperfusion, Levo hearts did not recover better than NaCl hearts {left ventricular derived pressure: 63 [standard deviation (SD): 36.2] vs 46 (SD: 41.8)% baseline; P = 0.386}, In hearts exposed to cardioplegia, functional recovery only slightly differed in the Levo and NaCl groups [left ventricular derived pressure: 69.96 (SD: 12.7) vs 51.89 (SD: 28.1)% baseline; P = 0.09]. Cell shortening of cardiomyocytes isolated from hearts exposed to ischaemia or perfusion was better in Levo groups [cell shortening: 7.65 (SD: 1.95) %; 7.8 (SD: 1.79)% vs 6.28 (SD: 1.67)%; 6.5 (SD: 1.87)%, P < 0.001]; this benefit was absent in cardioplegia-treated hearts. CONCLUSIONS: Levosimendan applied orally before ischaemia/reperfusion improves functional recovery, but this effect is only moderate when cardioplegia is included. Differences between hearts exposed to cardioplegia or to global ischaemia may indicate why levosimendan-related beneficial effects do not directly translate into better clinical outcome.