Steph ani eph ani Mi M ck i MD Cleveland Clinic

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1 Stephanie Mick MD Stephanie Mick MD Cleveland Clinic

2 Upper hemisternotomy AVR Ascending Aorta MVr Thoracotomy Based Anterior AVR Lateral Thoracotomy Mitral/Tricuspid surgery Robotically assisted surgery

3 Limited working space, at times with limited exposure Repeated doses of antegrade or retrograde cardioplegia can be associated with challenges

4 Antegrade Delivery Direct ostial antegrade cardioplegia administration following aortotomy Interrupts flow of operation Risk of coronary ostial injury/dissection Repeated antegrade delivery during mitral cases requires change of retraction Interrupts flow of operation Changes of exposure

5 Retrograde Conventional retrograde cardioplegia cannula Can be difficult to place Risk of coronary sinus perforation Percutaneous retrograde cardioplegia cannula: Reliance on anesthesia Can be time consuming or difficult $$$

6 One shot cardioplegia Potassium based depolarization with concurrent lidocaine sodium channel blockade Additional additives for free radical scavenging, calcium channel blockade and buffering Good for >60 minutes Originally used in pediatric cases

7 Potentially ideal solution to overcome the challenges listed previously One shot antegrade No need for retrograde administration (assuming no AI) Decreased operative interruptions Desire to simplify minimally invasive cases was original impetus for the initiation of DNS at CCF, starting August of 2012

8 Buckberg 1 : 4 Crystal : Blood ratio Glucose based Dose q 15 min KCl Additives THAM Glutamate Aspartate Antegrade & Retrograde del Nido 4 : 1 Crystal : Blood ratio Non-glucose based Dose q min KCl Additives: Lidocaine Mannitol Magnesium Bicarbonate Antegrade (unless significant AI)

9 Adults undergoing isolated valve surgery from 8/2012 to 9/2013 receiving del Nido solution (DNS) compared to Buckberg cardioplegia (BC) 90% of these cases were minimally invasive Upper hemisternotomy AVRs Thoracotomy, robotic and upper hemisternotomy Thoracotomy, robotic and upper hemisternotomy MV repairs

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12 No mortality difference: 0 mortality in all groups

13 No differences from standard multidose cardioplegia: Postoperative LVEF by echo Inotrope/pressor requirement Volume of resuscitative fluid CPB nadir hematocrit Blood transfusions Postoperative atrial fibrillation

14 Buckberg Del Nido Time savings in mini AVRs (upper hemis): Cross clamp CPB time Total OR time

15 DNS non glucose-based solution Lower peak CPB glucose, reduced need for Lower peak CPB glucose, reduced need for postoperative insulin drips

16 Costs Price per bag: DNS: ~$29 BC: ~$75 Price per operation: DNS: ~$ DNS BC: ~$ BC Other $$$ Savings Equipment costs Retrograde cardioplegia Tubing Savings Per Operation: $220/open case ~$1,190 per robotic case Lower usage of insulin drips 150 $ Cardioplegia Price per Case DNS BC

17 46 upper hemisternotomy AVRs vs 21 blood cardioplegia Similar findings with respect to insulin drips, other outcomes Significant difference (p 0.004) in ventricular fibrillation after cross clamp removal (lower in DNS group)

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19 100 consecutive isolated CABGs with DN (antegrade only) compared to BC (antegrade and retrograde), propensity matched No difference in inotropic support, Troponin, mortality, atrial fibrillation or postop EF Ann Thorac Surg 2016;101:

20 Retrospective review , single center 88 patients post acute myocardial infarction undergoing CABG 40 patients receiving whole blood cardioplegia propensity matched and compared with 40 patients receiving del Nido cardioplegia J Card Surg 2014, 9:141

21 Single antegrade dose cardioplegia in most del Nido patients vs multidose antegrade and retrograde cardioplegia in most patients in whole blood group Mean CPB and crossclamp times shorter in del Nido group No difference in mortality, postop inotropic support, IABP requirement, transfusion rate or length of stay between groups J Card Surg 2014, 9:141

22 Retrospective review , single center 113 reoperative AVRs 61 blood cardioplegia (46% prior CABG), 52 del Nido (38% prior CABG) 46 propensity matched pairs compared J Card Surg 2014; 29:445-9

23 No differences in mortality, crossclamp, bypass time, transfusion requirement, ventilator time, any postoperative complication, ICU or hospital length of stay Total and retrograde cardioplegia dose lower in del Nido group J Card Surg 2014; 29:445-9

24 Success of one shot cardioplegia relies on Adequate delivery We do not use DNS in patients with CAD Challenge of patients with AI Uncertain antegrade delivery Excellent venous drainage Rewarms heart, elevated venous pressure tends to washout cardioplegia May be difficult to assess in some minimally invasive approaches Adjunctive cooling may be useful

25 Literature is evolving but is all retrospective Guidance for Broader Applications is wanting: Optimal dosing? Redosing? Adjunctive cooling? Modifications? 4:1 blood to crystalloid ratio? Further investigation is required Randomized trial is warranted

26 Del Nido cardoplegia appears to be safe in some forms of adult cardiac surgery although evidence is not conclusive More efficient, less costly, fewer glucose perturbations Further investigation is required

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