J. L. Liao1,2, M. D. Price2, S. Y. Green2, H. Amarasekara2, J. S. Coselli2, S. A. LeMaire2, O. Preventza2 1Indiana University School Of Medicine,Indianapolis, IN, USA 2Baylor College Of Medicine,Cardiothoracic Surgery,Houston, TX, USA
Introduction: Currently, many cardioplegic solutions exist for myocardial protection during open cardiac operations. del Nido cardioplegia differs from others in that it includes lidocaine, which limits sodium influx in order to produce a depolarizing cardiac arrest. It also generally necessitates fewer doses, sometimes only one, during an operation. Although del Nido is commonly used in pediatric patients, its efficacy in adults is less well established. Recent literature has described promising results in adults undergoing coronary artery bypass. However, the outcomes of using del Nido in proximal aortic surgery—which generally involve substantially longer periods of cardiac ischemia—are not well described. The aim of our study was to characterize early outcomes of patients who underwent proximal aortic surgery with del Nido cardioplegia.
Methods: We retrospectively reviewed data from 59 consecutive patients (mean age 61±15 y; male [n=37, 63%]) who underwent proximal aortic surgery and received del Nido cardioplegia between July 2016 and July 2017. In most cases, an initial dose of approximately 1000 mL was administered, followed by 300-400 mL every 20-30 min. 34 (58%) patients had an aneurysm without dissection, 21 (36%) had DeBakey Type I dissection, and 4 (7%) had Type II dissection. 6 (10%) patients had heritable thoracic aortic disease. 14 (24%) had total arch replacement and 35 (59%) had hemiarch replacement. Concomitant procedures included coronary artery bypass (n=4, 7%) and repair/replacement of the aortic valve (n=33, 56%), aortic root (n=22, 37%), mitral valve (n=1, 2%), and tricuspid valve (n=2, 3%). Hypothermic circulatory arrest (median duration 37 min, 22-55 IQR) and antegrade cerebral perfusion (median duration 34 min, 22-55 IQR) were used in 51 (86%) patients. The median cardiopulmonary bypass and cardiac ischemic times were 140 min (118-176 IQR) and 110 min (87-129 IQR), respectively.
Results: There were 3 (5%) operative deaths. Only 3 (5%) patients required intraoperative defibrillation, and 2 (3%) required intra-aortic balloon pump. 41 (70%) patients required inotropic support immediately postoperatively, but only 9 (15%) required it beyond 24 hours. Of these 9, 3 died—2 due to multiple organ failure and 1 due to stroke—5 recovered completely with no reduction in left ventricular (LV) function, and 1 recovered with mild reduction in LV function. No patients developed myocardial infarction. Stroke occurred in 2 (3%) patients (both persistent). Other postoperative complications included renal dysfunction (n=8, 14%) and renal failure requiring hemodialysis (transient [n=4, 7%]; persistent [n=2, 3%]).
Conclusions: As the use of del Nido cardioplegia becomes more common in adult cardiac cases, it becomes increasingly important to obtain outcomes data. Based on our study, the use of del Nido appears to provide satisfactory myocardial protection in complex proximal aortic cases that tend towards long ischemic times.