Eastern Cardiothoracic Surgical Society

Del Nido Cardioplegia Simplifies Myocardial Protection Strategy for Minimally Invasive Aortic Valve Replacement
Michael S. Koeckert, Deane E. Smith, Thomas Beaulieu, Patrick F. Vining, Didier F. Loulmet, Elias A. Zias, Mathew R. Williams, Aubrey C. Galloway, Eugene A. Grossi, NYU Langone Medical Center, New York, NY

OBJECTIVE: The longer dosing interval afforded by Del Nido cardioplegia (DNC) may simplify myocardial protection strategies. We analyzed the impact and safety of DNC in patients undergoing minimally invasive aortic valve replacement (MIAVR).

METHODS: Institutional use of DNC began in May 2013; we analyzed all isolated MIAVR replacements during this transition (5/2013-6/2015), excluding re-operative sternotomy patients. The approach was hemi-median sternotomy in all patients. Prospectively collected local and STS database data were utilized. Patients were divided into two cohorts, those who received 4:1 crystalloid:blood DNC solution and those in whom standard 1:4 Buckberg-based cardioplegia (BC) was used. One-to-one propensity case matching of DNC to BC was performed based on standard risk factors and differences between groups were analyzed using chi-square and non-parametric methods.

RESULTS: MIAVR was performed in 181 patients; DNC was used in 59 and BC in 122. Case matching resulted in 59 patients per cohort. DNC was associated with reduced re-dosing (5/59 (8.5%) vs 39/59 (61.0%), p<0.001) and less total cardioplegia volume (1290ml 347ml vs 2284ml 828ml, p<0.001). Antegrade cardioplegia alone was used in 89.8% (53/59) of DNC patients versus 33.9% (20/59) of BC patients (p<0.001). Median bypass and aortic cross-clamp times were similar. Clinical outcomes were similar with respect to post-operative hematocrit, transfusion requirements, need for inotropic/pressor support, duration of ICU stay, re-intubation, length of stay, new onset atrial fibrillation, and mortality. The table contains demographics, cardioplegia delivery methods and results.

CONCLUSIONS: DNC usage markedly simplifies cardioplegia strategy for MIAVR. Patient safety was not compromised with this technique.

Table SA15-1 – Select Demographic, Intraoperative and Outcomes Data

Case Matched Patients BC (n=59) DNC (n=59) p value
Age (years) 68.4 10.8 69.1 11.8 0.746
STS Mortality (range) 1.44 % (0.43 - 7.01) 1.54 % (0.35 – 7.50) 0.629
Severe AI 8 (13.6%) 13 (22.0%) 0.336
Antegrade Cardioplegia Only 20 (33.9%) 53 (89.8%) <0.001
# of Cardioplegia Injections 2.1 1.1 1.1 0.5 <0.001
Cardioplegia Volume (ml) 2284   828 1290    347 <0.001
pRBC Use (units) 0.46    1.24 0.81    2.41 0.316
Cross-clamp time (min) 56.6 11.8 58.1    17.7 0.591
>24h Inotropes 3 (5.1%) 9 (15.3%) 0.125