Stephanie Mick MDStephanie Mick MDCleveland Clinic
Upper hemisternotomy Thoracotomy BasedUpper hemisternotomy
AVR
Ascending Aorta
Thoracotomy Based
• Anterior– AVR
Ascending Aorta
MVr
– AVR
• Lateral– Thoracotomy Mitral/Tricuspid– Thoracotomy Mitral/Tricuspid
surgery
– Robotically assisted surgery
• Limited working space, at times with limited exposure• Limited working space, at times with limited exposure
• Repeated doses of antegrade or retrogradecardioplegia can be associated with challenges
Antegrade DeliveryAntegrade Delivery
• Direct ostial antegrade cardioplegia administrationfollowing aortotomyfollowing aortotomy
– Interrupts flow of operation
– Risk of coronary ostial injury/dissection– Risk of coronary ostial injury/dissection
• Repeated antegrade delivery during mitral cases requireschange of retraction
• Repeated antegrade delivery during mitral cases requireschange of retraction
– Interrupts flow of operation
– Changes of exposure– Changes of exposure
RetrogradeRetrograde
• Conventional retrograde cardioplegiacannulacannula
– Can be difficult to place
– Risk of coronary sinus perforation– Risk of coronary sinus perforation
• Percutaneous retrograde cardioplegiacannula:
• Percutaneous retrograde cardioplegiacannula:
– Reliance on anesthesia
– Can be time consuming or difficult– Can be time consuming or difficult
– $$$
• One shot cardioplegia• One shot cardioplegia
– Potassium based depolarization with concurrentlidocaine sodium channel blockadelidocaine sodium channel blockade
• Additional additives for free radical scavenging, calciumchannel blockade and bufferingchannel blockade and buffering
• Good for >60 minutes• Good for >60 minutes
• Originally used in pediatric cases• Originally used in pediatric cases
• Potentially ideal solution to overcome the challenges• Potentially ideal solution to overcome the challengeslisted previously
• One shot antegrade• One shot antegrade– No need for retrograde administration (assuming no AI)
• Decreased operative interruptionsDecreased operative interruptions
• Desire to simplify minimally invasive cases wasoriginal impetus for the initiation of DNS at CCF,starting August of 2012starting August of 2012
Buckberg– 1 : 4 Crystal : Blood ratio
del Nido
– 4 : 1 Crystal : Blood ratio1 : 4 Crystal : Blood ratio
– Glucose based
– Dose q 15 min
– KCl
– 4 : 1 Crystal : Blood ratio
– Non-glucose based
– Dose q 90-180 min– KCl
– Additives
THAM
– Dose q 90-180 min
– KCl
– Additives: LidocaineTHAM
Glutamate
Aspartate
– Additives: Lidocaine
Mannitol
MagnesiumAspartate
Antegrade & RetrogradeMagnesium
BicarbonateAntegradeAntegrade(unless significant AI)
• Adults undergoing isolated valve surgery from8/2012 to 9/2013 receiving del Nido solution8/2012 to 9/2013 receiving del Nido solution(DNS) compared to Buckberg cardioplegia (BC)
• 90% of these cases were minimally invasive• 90% of these cases were minimally invasive
– Upper hemisternotomy AVRs
– Thoracotomy, robotic and upper hemisternotomy– Thoracotomy, robotic and upper hemisternotomyMV repairs
No mortality difference: 0 mortality in all groupsNo mortality difference: 0 mortality in all groups
No differences from standard multidosecardioplegia:cardioplegia:
• Postoperative LVEF by echo
• Inotrope/pressor requirementInotrope/pressor requirement
• Volume of resuscitative fluid
• CPB nadir hematocrit
• Blood transfusions
• Postoperative atrial fibrillation
Buckberg Del Nido
Time savings in mini AVRs (upper hemis):Time savings in mini AVRs (upper hemis):Cross clampCPB timeCPB timeTotal OR time
DNS – non glucose-based solutionDNS – non glucose-based solution
Lower peak CPB glucose, reduced need forLower peak CPB glucose, reduced need forpostoperative insulin drips
Costs• Price per bag:Price per bag:
DNS: ~$29BC: ~$75
• Price per operation:DNS: ~$29
BC: ~$225
250 DNS
Cardioplegia Price per Case
BC: ~$225
Other $$$ Savings• Equipment costs
150$$
200DNSBC
• Equipment costsRetrograde cardioplegiaTubingSavings Per Operation:$220/open case
0
$$100
50$220/open case~$1,190 per robotic case
• Lower usage of insulin drips
0
DNSDNS BCBC
• 46 upper hemisternotomy AVRs vs 21 blood cardioplegia• 46 upper hemisternotomy AVRs vs 21 blood cardioplegia
• Similar findings with respect to insulin drips, otheroutcomesoutcomes
• Significant difference (p 0.004) in ventricular fibrillationafter cross clamp removal (lower in DNS group)after cross clamp removal (lower in DNS group)
• 100 consecutive isolated CABGs with DN (antegradeonly) compared to BC (antegrade and retrograde),propensity matchedpropensity matched
• No difference in inotropic support, Troponin, mortality,• No difference in inotropic support, Troponin, mortality,atrial fibrillation or postop EF
Ann Thorac Surg 2016;101:2237-42
• Retrospective review 2010-2012, single center
• 88 patients post acute myocardial infarction undergoing CABG• 88 patients post acute myocardial infarction undergoing CABG
• 40 patients receiving whole blood cardioplegia propensity matchedand compared with 40 patients receiving del Nido cardioplegia
J Card Surg 2014, 9:141
40 patients receiving whole blood cardioplegia propensity matchedand compared with 40 patients receiving del Nido cardioplegia
• Single antegrade dose cardioplegia in most del Nido patients vsmultidose antegrade and retrograde cardioplegia in mostmultidose antegrade and retrograde cardioplegia in mostpatients in whole blood group
• Mean CPB and crossclamp times shorter in del Nido group• Mean CPB and crossclamp times shorter in del Nido group
• No difference in mortality, postop inotropic support, IABPrequirement, transfusion rate or length of stay between groups
J Card Surg 2014, 9:141
requirement, transfusion rate or length of stay between groups
Retrospective review 2010-2012, single centerRetrospective review 2010-2012, single center
113 reoperative AVRs
61 blood cardioplegia (46% prior CABG), 52 del Nido (38% prior CABG)
J Card Surg 2014; 29:445-9
46 propensity matched pairs compared
No differences in mortality, crossclamp, bypass time, transfusionrequirement, ventilator time, any postoperative complication, ICU orhospital length of stayhospital length of stay
Total and retrograde cardioplegia dose lower in del Nido group
J Card Surg 2014; 29:445-9
• Success of one shot cardioplegia relies on
– Adequate delivery– Adequate delivery• We do not use DNS in patients with CAD• Challenge of patients with AI
– Uncertain antegrade delivery– Uncertain antegrade delivery
– Excellent venous drainage• Rewarms heart, elevated venous pressure tends to washout• Rewarms heart, elevated venous pressure tends to washout
cardioplegia• May be difficult to assess in some minimally invasive approaches• Adjunctive cooling may be useful• Adjunctive cooling may be useful
Literature is evolving but is all retrospectiveLiterature is evolving but is all retrospective
Guidance for Broader Applications is wanting:Guidance for Broader Applications is wanting:– Optimal dosing?
– Redosing? Adjunctive cooling?– Redosing? Adjunctive cooling?
– Modifications?• 4:1 blood to crystalloid ratio? Further investigation is
requiredrequired
Randomized trial is warrantedRandomized trial is warranted
• Del Nido cardoplegia appears to be safe in• Del Nido cardoplegia appears to be safe insome forms of adult cardiac surgery althoughevidence is not conclusiveevidence is not conclusive
• More efficient, less costly, fewer glucose• More efficient, less costly, fewer glucoseperturbations
• Further investigation is required