Single-Shot Cold Histidine-Tryptophan-Ketoglutarate Cardioplegia for Long Aortic Cross-Clamping Durations in Neonates

Objective: More than 30% of European pediatric cardiac surgery centers use single-dose cold histidine-tryptophan-ketoglutarate cardioplegia (Custodiol; Dr Franz Kohler Chemie GmbH, Bensheim, Germany). In neonates with transposition of the great arteries, arterial switch surgery (ASO) implies aortic division, and it is unknown whether repeated ostial cannulation causes intimal insult and affects long-term results, and therefore, single-dose Custodiol is appealing. The present study investigated the association among myocardial no-flow duration, postoperative troponins, and postoperative outcomes in neonates undergoing ASO with Custodiol cardioplegia. Design: Retrospective analysis of the association among myocardial no-flow duration, postoperative troponin release (concentration magnitude x measurement duration within 48 h), and outcomes using stratification according to coronary anatomy and attending surgeon. Setting: Single-institutional, tertiary pediatric cardiac surgery unit of a university hospital. Participants: The study comprised 101 neonates undergoing ASO. Interventions: None. Measurements and Main Results: The mean age of patients was 6.1 +/- 5.4 days, the cardiopulmonary bypass duration was 108.7 +/- 54.1 minutes, the temperature during cross-clamping was 31.1 degrees C +/- 1.7 degrees C, the duration of mechanical ventilation was 4 (3-6) days, the length of intensive care unit stay was 7 (5-8) days, delayed sternal closure occurred in 32 (31.7%) patients, and no patients died. The myocardial no-flow duration averaged 62.3 +/- 14.6 minutes and was linked with both troponin release (p = 0.04) and low cardiac output syndrome, as assessed by the requirement for delayed sternal closure (p = 0.03), regardless of cardiopulmonary bypass duration and temperature. Eighty-two percent of the patients with myocardial no-flow duration >74 minutes necessitated delayed sternal closure. Conclusions: Single-dose Custodiol may be inadequate for prolonged cross-clamping durations without myocardial perfusion in neonates. (C) 2019 Elsevier Inc. All rights reserved.