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(A) Cardioplegia bag with crystalloid component as provided by pharmacy. (B) Cardioplegia reservoir bag where the 4:1 (crystalloid: blood) components are mixed and recirculated. (C) Stopcock, line, and syringe used to inject bypass circuit blood into the cardioplegia circuit. (D) Cardioplegia roller head.
Source publication
Cardioplegia is an integral and essential method of myocardial protection for patients of all ages requiring cardiac surgery in which the heart must be stopped. Numerous cardioplegia solutions and delivery methods have been developed. The del Nido cardioplegia solution has been in use for 18 years at Boston Children's Hospital. This is a unique fou...
Context in source publication
Citations
... Del Nido Cardioplegia (DNC) is an extracellular myocardial protection fluid that provides up to 90 min of myocardial protection after a single dose at 20 ml/kg [4]. In the early 1990s, Pedro del Nido and his team developed this solution to protect immature myocardial cells [5]. Delivery of del Nido solution was administered in a 1:4 ratio of blood to crystalloid [6]. ...
Objective
Systematic evaluation of the safety of del Nido cardioplegia compared to cold blood cardioplegia in adult cardiac surgery.
Methods
We systematically searched PubMed, EMbase, The Cochrane Library and ClinicalTrials.gov for randomized clinical trials (published by 14 January 2024) comparing del Nido cardioplegia to cold blood cardioplegia in adult. Our main endpoints were myocardial injury markers and clinical outcomes. We assessed pooled data by use of a random-effects model or a fixed-effects model.
Results
A total of 10 studies were identified, incorporating 889 patients who received del Nido cardioplegia and 907 patients who received cold blood cardioplegia. The meta-analysis results showed that compared with the cold blood cardioplegia, the del Nido cardioplegia had less volume of cardioplegia, higher rate of spontaneous rhythm recovery after cross clamp release, lower levels of postoperative cardiac troponin T and creatinine kinase-myocardial band, all of which were statistically significant. However, there was no statistically significant difference in postoperative troponin I and postoperative left ventricular ejection fraction. The clinical outcomes including mechanical ventilation time, intensive care unit stay time, hospital stay time, postoperative stroke, postoperative new-onset atrial fibrillation, postoperative heart failure requiring intra-aortic balloon pump mechanical circulation support, and in-hospital mortality of both are comparable.
Conclusion
Existing evidence suggests that del Nido cardioplegia reduced volume of cardioplegia administration and attempts of defibrillation. The superior postoperative results in CTnT and CK-MB may provide a direction for further research on improvement of the composition of cardioplegia.
Visual Abstract
... (PMC)! Other most sought after JECT articles from PMC, not surprisingly, are two articles on del Nido cardioplegia, one of which was by Dr del Nido himself with his chief perfusionist, Greg Matte; [3,4] and two other articles by our Kiwi anesthesiologist and intensivist colleague, Dr Sidebotham, on troubleshooting ECMO and Hyperlactatemia [5,6]. Also just breaking into the top 10 despite being more recently published is the blood management clinical practice guideline update authored by some of our leading perfusionist colleagues in collaboration with surgeons and anesthesiologists [7]. ...
... For several decades, del Nido cardioplegia solutions have been used in both pediatric and adult cardiac operationsused in pediatric cardiac operations. Cost-effectiveness, single-dose usage without the need for repeated dosing repeated injection until 90 minutes, and shorter pump time are reported as del Nido benefits [6][7][8][9][10] . The time between initial and redosing can cause myocardialThe long time duration between two del Nido injections can cause myocardial impairment due to the risk of myocardial warming and ischemia 11 . ...
Introduction: myocardial protection with cardioplegia solution is one of the precautions during coronary bypass grafting surgery (CABG) with cardiopulmonary bypass (CPB) to reduce myocardial damage and ischemia/reperfusion injuries. Unfortunately, the major component of the del Nido cardioplegia solution, Plasma-Lyte A, is unreachable in Iran due to high cost. Therefore, we have utilized lactate Ringer's solution as the base solution for our modified del Nido solution (LR DN). Study design and methods: the present clinical trial was performed on 18-75 year old patients (EF>35%) undergoing CABG with CPB in Imam Hossein hospital Tehran-Iran in 2021. Patients were randomly allocated to LR DN (modified del Nido cardioplegia) and PL DN (standard del Nido cardioplegia solution) groups. Serum level of cardiac troponin I (cTnI) at baseline, declamp, ICU admission, and 24 hours after admission, the type and dosage of inotrope agents, EF, rate of arrhythmia after clamp removal and lactate level were measured and compared between groups. Results: 109 patients were recruited. There were no statistically significant differences between the PL DN cardioplegia and LR DN groups for cardiopulmonary bypass times, cardiac enzymes, transfusion requirements, and arterial blood gases. However, postoperative serum levels of cTnI among patients in the LR DN group was significantly higher than patients of the PL DN group after ICU admission and 24 hours postoperatively. Also, more patients needed epinephrine administration in the operating room in the LR DN group (29.8% vs. 11.5%; p: 0.019 vs. PL DN group). Conclusion: we concluded that standard del Nido cardioplegia solution offers better myocardial protection compared with Ringer's lactate-based del Nido cardioplegia in adult patients undergoing CABG with CPB. We recommend using standard del Nido cardioplegia with a base of Plasma-Lyte A for patients presenting for CABG surgery.
... Since 2003, this solution has also been used effectively in adult cardiac 4 surgery. The solution's efficacy and safety make it a promising option for cardiac surgery in both adult and pediatric populations (7,8). Del Nido cardioplegia has also been proven effective in adult minimal invasive cardiac surgeries and acquired cases (coronary artery bypass, valvular, and combined surgeries)(9-11). ...
Background: The del Nido Cardioplegia Solution is a widely used method for myocardial protection in various settings. However, there is limited evidence of its effectiveness in adult cardiac surgery, and the baseline solution, Plasma Lyte A, is not readily available, leading to the use of alternative baseline solutions. This study aims to investigate the effectiveness of routine del Nido cardioplegia in adult cardiac surgery and the impact of different baseline solutions on myocardial protection and other perioperative outcomes. Methods: This study was a prospective, double-blind randomized parallel group clinical trial conducted at a single tertiary care hospital in Iran. A total of 187 adult patients were evaluated for eligibility, of which 120 met the inclusion criteria for elective isolated CABG surgery. The patients were randomly assigned to three groups, with each group consisting of 40 patients. The control group received normal saline-based routine del Nido cardioplegia, Intervention Group A received ringer lactate-based del Nido cardioplegia, and Intervention Group B received plain ringer-based del Nido cardioplegia. The levels of CK-MB, Troponin T, Troponin I, and lactate were primarily assessed at four different times: after anesthesia induction (Baseline), 2 hours, 12 hours, and 24 hours. Results: Preoperative demographic and clinical characteristics were the same among groups with insignificant differences (p > 0.05). There was no significant difference among groups based on CK-MB, Troponin T, Troponin I, and lactate levels (p=0.078, 0.143, 0.311, and 0.129 respectively). However, there was a significant difference in the time effect of Troponin T and Lactate (p=0.034, p= < 0.001). Conclusion: Normal saline, Ringer lactate, and plain Ringer provide comparable myocardial protection in adult-isolated CABG surgery with modified del Nido cardioplegia. Larger studies are needed to identify the best alternative to Plasma Lyte A while maintaining del Nido Cardioplegia as the control.
... We previously described the relationship between AQP7 and myocardial injury in normothermic global ischemia and elucidated the effects of hyperkalemic cardioplegia with St Thomas' Hospital cardioplegic solution No. 2 (STH2) on patients of various ages with an AQP7 deficiency [17,18]. Del Nido cardioplegia (DNC) has been extensively used in congenital heart surgery for >20 years [19]. It has an electrolyte composition similar to extracellular fluid and is delivered in patients along with fully oxygenated blood in a 4:1 ratio, providing potassium-based myocyte depolarization with concurrent lidocaine sodium channel blockade. ...
... A modified DNC solution [19] (Plasma-Lyte A, 500 mL; 20% D-mannitol, 6.67 mL; MgSO 4 , 6.7 mL; 1 mEq/mL KCl, 10.8 mL; 2% lidocaine, 3.25 mL; 8.4% NaHCO 3 , 5.41 mL; pH 7.8 at 37°C) (Plasma-Lyte A: Y361187, Baxter International Inc., Deerfield, Illinois, USA; D-mannitol: OE018, Yoshindo Inc., Toyama, Japan; MgSO4: MOK78, Otsuka Pharmaceutical Factory, Tokushima, Japan; KCl: MOJ78, Otsuka Pharmaceutical Factory, Tokushima, Japan; lidocaine: 8Z0101, Maruishi Pharmaceutical Co., Ltd., Toyama, Japan; NaHCO3: KIA77, Otsuka Pharmaceutical Factory, Tokushima, Japan) was also prepared daily and filtered through a 5-µm cellulose nitrate filter. ...
Background: Aquaporin 7 (AQP7), a member the aquaglyceroporin subgroup of the AQP family, is a water channel that controls transport of glycerol and water in heart tissues. It facilitates the uptake of glycerol, a substrate for cardiac energy production, in cardiomyocytes. St. Thomas' Hospital cardioplegic solution No. 2 has cardio-protective effect even in AQP7-deficient hearts. Here, we aimed to determine whether nicorandil or del Nido cardioplegia (DNC) solution can protect AQP7-deficient hearts. Methods: The hearts of male AQP7 knockout (KO) and wild-type (WT) C57/B6N mice (age >15 weeks) were aerobically perfused using the Langendorff technique, and cardiac function was measured as left ventricular diastolic pressure (LVDP) throughout the study. Troponin T was measured as an indicator of myocardial damage after reperfusion for 60 min. We compared WT and KO controls subjected to 25 min of global ischemia as well as WT and KO groups infused with nicorandil (100 µM) for 10 min followed by 25 min of global ischemia. We also compared WT-DNC and KO-DNC hearts administered with DNC for 2 min followed by 23 min of global ischemia (Study 2). Results: The final recovery rates of LVDP were 20.8 ± 7.0%, 28.1 ± 7.6%, 40.0 ± 8.4%, and 38.7 ± 4.7% in the WT control, KO control, WT nicorandil, and KO nicorandil groups, respectively. The LVDP recovered faster in the hearts treated with DNC and reached a significantly higher plateau in the KO than in the WT hearts. Troponin T values were 2144 ± 493 and 1313 ± 717 in the WT and KO groups, respectively (p = 0.041). Conclusion: The Langendorff perfusion model revealed similar myocardial protective effects of nicorandil in AQP7-deficient mice as in WT mice. AQP7 deficiency did not impair the cardioprotective effects of DNC solution.
... well-known in the medical industry due to its extended duration of cardiac protection, ease of administration, and decreased re-dosing frequency. Yet, few studies have been conducted on its use in adults [3,4,[7][8][9][10][11][12][13][14][15][16][17]. However, due to extended re-dosing intervals achieved with DN and advances in scientific research, it has become appealing for surgeons to extend its use in adults, where it has been reported to provide satisfactory outcomes [7,10,11,18,19]. ...
Background
St. Thomas cardioplegia is commonly administered to adults, yet repeated dosing at brief intervals is required. Del Nido’s cardioplegic solution provides a prolonged duration of safe myocardial arrest, yet it was primarily intended for pediatric cardiac surgery. Recently, there has been an increasing interest in using Del Nido’s in adults; this might be due to its ease of administration and extended re-dosing intervals. This study contrasted Del Nido’s to modified St. Thomas cardioplegia in adults.
Methods
This study was conducted on 200 patients. Troponin-T was the primary outcome within the first 24 and 48 h post-surgery. Cardiopulmonary bypass time, cross-clamp time, intraoperative use of inotropic support, defibrillator and/or intra-aortic balloon were the secondary outcomes of the study.
Results
There was a significant reduction in post-operative Troponin-T levels in the first 24 and 48 h within Del Nido’s group compared to the modified St. Thomas group. The cross-clamp and cardiopulmonary bypass times were also found to be lower within Del Nido’s group.
Conclusion
This study has demonstrated a significant reduction in early postoperative Troponin-T levels as well as operative times favoring Del Nido’s in adults.
... The components of the DN cardioplegic solution effectively provides myocardial protection. Mannitol is effective in scavenging free radicals and reducing edema owing to its hyperosmotic property [17]. With the effect of lidocaine in the solution, the entry of calcium and sodium into the cell decreases. ...
Background
The results of the use of del-Nido(DN) solution using a different method or crystalloid blood cardioplegia in coronary bypass patients were compared. We aimed to investigate the effects on intraoperative and postoperative arrhythmias, arrhythmia durations and early results.
Methods
The study included 175 patients using crystalloid blood cardioplegia (Group 1) and 150 patients using DN solution(Group 2). In the DN group, 75% of the calculated plegia dose was given first. the remaining part was applied by giving from grafts. Intraoperative/postoperative data were compared.
Results
There was no significant difference between the groups in terms of demographic characteristics. Preop troponin level was similar.(p = 0.190) However, there was a statistical difference between the postoperative 6th hour.(p = 0.001) There was no difference in troponin values at the postoperative 24th hour. (p = 0.631) Spontaneous rhythm occurred at the cardiopulmonary by pass (CPB) weaning stage in most of the patients in Group 2 (95.3%). Although the need for temporary pacing was less in Group 2, it was not significant.(p = 0.282) No patient required permanent pacing. CPB duration, cross clamp times and intraoperative glucose levels, intensive care follow-up times and hospitalization times were found to be shorter in Group 2. Although the postoperative atrial fibrillation frequency was similar (p = 0.261), the time to return to sinus was lower in Group 2.(p = 0.001).
Conclusion
The use of DN cardioplegia solution provides significant positive contributions to avoid arrhythmias compared to crystalloid blood cardioplegia. DN solution applied with this method may contribute to reducing the anxieties associated with its use in isolated coronary artery bypass surgery.
... Mannitol, sodium bicarbonate, magnesium sulfate, potassium chloride, and lidocaine are also added. Oxygenated patient whole blood is then added to complete the solution [12]. ...
Background: Cardioplegia solutions are used to protect the myocardium from ischemic injury caused by cardiopulmonary bypass and various types of cardioplegia solutions have been introduced for cardiac surgery. In this study, we aimed to compare the effects of del Nido cardioplegia and microplegia, which were mostly used in our clinic for intraoperative and postoperative processes among patients who underwent elective mitral valve replacement. As a result, the comparison could be performed in a specific patient group without additional valvular or coronary disease, and cardioplegia distribution could be achieved more efficiently. Methods: Between 2018 and 2023, a total of 120 patients who underwent elective mitral valve replacement via sternotomy with del Nido cardioplegia or microplegia were included in the study. Patients were divided into two groups; group 1 (del Nido, n = 64) and group 2 (microplegia, n = 56). Preoperative characteristics, intraoperative and postoperative early clinical data as primary outcomes, and postoperative mortality rates and intensive care costs as secondary outcomes were compared statistically. Results: There were no statistically significant differences in terms of preoperative characteristics between the two groups. Duration of cross clamp differences between group 1 versus group 2 (45 ± 16 vs. 57 ± 19 min), cardiopulmonary bypass (56 ± 17 vs. 65 ± 21 min), intensive care length of stay (18.04 ± 7.41 vs. 22.37 ± 6.86 h), requirement of intraoperative defibrillation (n = 5 vs. n = 13), and intensive care costs were found to be statistically significantly lower in del Nido group. Conclusion: Either del Nido or microplegia solutions can be used safely in mitral valve replacement operations, however, del Nido cardioplegia has some advantages over intraoperative processes, such as lowering the cross clamp and cardiopulmonary bypass time. Furthermore, patients who received del Nido cardioplegia had shorter intensive care stay and required less intraoperative defibrillation compared with the microplegia group. Therefore, less exposure to anesthesia, the prevention of infection due to shortened operation duration, and greater cost-effectiveness can be achieved by using del Nido cardioplegia instead of microplegia.
... Del Nido cardioplegia differs from conventional cardioplegia in several ways: it counteracts the negative effects of hyperkalemia by reducing the potassium concentration and adding the sodium channel blocker Lidocaine which increases the refractory period of the cardiac myocyte [3] and prolongs the period of arrest because it remains in adequate concentrations to continually affect the myocardium. Sodium channel blockade also polarizes the cell membrane to some degree, preventing intracellular sodium and calcium accumulation and allowing for reduction in energy consumption [2,4,5]. In addition, magnesium, a natural calcium channel blocker, also reduces the intracellular accumulation of calcium preventing diastolic stiffness from interfering from myocardial recovery. ...
... The type of cardioplegia, conventional vs. del Nido was based on the surgeon's preference. Our del Nido formulation differs from the classical del Nido composition [4] which used a base solution of Plasma-Lyte A (Baxter Healthcare Corporation, Deerfield, IL) to which the cardioplegic additives were added and then this crystalloid component was mixed with blood in a ratio of four parts crystalloid to one part oxygenated whole blood. Our approach was to add the cardioplegic additives (whether conventional cardioplegia or del Nido) directly to the patient's whole blood rather than in a crystalloid base (Fig. 2). ...
Background
del Nido cardioplegia (DN) has been shown to be safe in adult patients undergoing isolated coronary artery bypass grafting with normal left ventricular ejection fraction. We sought to determine whether it was also safe in adult patients with diminished left ventricular function.
Methods
All patients with preoperative left ventricular ejection fraction ≤ 40% undergoing isolated coronary artery bypass grafting between 1/1/2019 and 7/10/2022 were retrospectively analyzed. Off-pump and beating heart cases were excluded. Patients were divided by surgeon preference between conventional cardioplegia (CCP) and DN. Baseline and intraoperative characteristics and short-term postoperative outcomes were compared.
Results
Six surgeons performed 829 isolated coronary artery bypass operations during the study. Two-hundred seventy-two met study criteria. Three surgeons used exclusively CCP for the duration of the study, two used exclusively DN and one switched from CCP to DN mid-way through. Group totals were: CCP n = 181 and DN n = 91. There were no significant differences in baseline characteristics including mean left ventricular ejection fraction (CCP 32.5 ± 7.4% vs. DN 33.4 ± 7.29%, p = 0.939). Other than a significant decrease in bypass time for DN (113.20 ± 37.2 vs. 122.43 ± 34.3 min, p = 0.043) there were no intergroup differences in urgency, number of grafts, ischemic time or incidence of blood transfusion. Postoperative outcomes between CCP and DN were similar including incidence of atrial fibrillation (12.2% vs. 8.8%, p = 0.403), intensive care length of stay (3.7 ± 2.3 vs. 4.3 ± 3.7 days, p = 0.886), total length of stay (5.7 ± 3.7 vs. 6.3 ± 4.4 days, p = 0.922) and 30-day mortality (3.85% vs. 1.10%, p = 0.205).
Conclusion
Compared to conventional cardioplegia, del Nido cardioplegia provides equivalent short-term outcomes in patients with low left ventricular ejection fraction undergoing isolated coronary artery bypass grafting.
... Other characteristics of del Nido solution are the reduced Ca 2+ content and the addition of a depolarizing agent, lidocaine. [1] Kirklin's solution is a well-studied crystalloid cardioplegia, administered repeatedly at short intervals during surgery. An increase in myocardial acidosis between cardioplegic doses has been observed adversely affecting the postoperative outcome. ...
... Cardioplegic solutions play a key role in protecting the heart from myocardial damage during cardiosurgical intervention. The DN solution is successfully used in pediatric cardiac surgery [1,4] ; however, its use in cardiac surgery in adults was only recently described [3][4][5][6] . In this study, we present our experience with MDN cardioplegia in patients undergoing isolated CABG and compare it with a group of patients who received Kn cardioplegia. ...
... Георги Стоицев 1 , Веселин Гаврилов 2 , Валя Горановска 1 , Георги Манчев 1 , Васил Гегусков 1,3 1 ...
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.
Aim : To demonstrate whether the modified cardioplegia of del Nido (MDN) with a longer period of cardiac arrest provides sufficiently effective and reliable myocardial protection when compared to the classic cardioplegia of Kirklin we use in our institution.
Materials and methods : This ambispective clinical-epidemiological study was conducted in the Department of Heart Surgery at St Anna University Hospital in Sofia between January 2017 and September 2021. Using a random number generator, а hundred and twenty patients were selected and divided into two cohorts of 60 patients each. After further data processing, an additional five patients dropped out of the Kirklin group due to a ‘beating heart’ operative technique. As a result, the groups were divided as follows: 1) intermittent cardioplegia Kirklin (Kn, n=55) used in patients between January 2017 and June 2019, and 2) modified del Nido cardioplegia (MDN, n=60) used from June 2019 to September 2021.
Results : In this study, we present our experience with MDN cardioplegia in patients undergoing isolated CABG and compare it with a group of patients who received Kn cardioplegia. The difference in cross-clamp and CPB times is due to the individual qualities and experience of surgeons. When using MDN, the longer intraoperative times not only showed no deterioration in postoperative results, did not increase the need of using an additional dose of cardioplegia, but also did not materialize in a statistically significant difference. The MDN cardioplegia showed significantly less usage of inotropic support ( p <0.001) and IABP ( p =0.029). Creatinine phosphokinase MB fraction when patients are admitted to intensive care was significantly less in the Kirklin group ( p =0.045).
Conclusions : Results suggest that the routine use of modified cardioplegic protection of del Nido in adult patients may be safe, leads to comparable clinical outcomes and could accelerate the surgical process. The reduced incidence in intra- and postoperative complications like DC shocks, arrhythmia, myocardial infarction, multiorgan failure and in-hospital mortality should be further studied, as it may imply superiority of myocardial protection with the modified solution.
