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