Del Nido cardioplegia versus blood cardioplegia in adult aortic root surgery

Objective: Del Nido cardioplegia solution offers prolonged cardiac protection with single-dose administration; this is particularly interesting for aortic root surgery. However, there is a scarcity of data supporting its safety in adults undergoing complex cardiac surgery, such as aortic root repair. We hypothesized that del Nido cardioplegia solution and blood cardioplegia solution provide equivalent safety during aortic root surgery. Methods: Between January 2015 and June 2018, 283 consecutive patients undergoing the Ross procedure (204) and valve-sparing operation (79) with del Nido cardioplegia solution or blood cardioplegia solution were 1:1 propensity matched (110 aortic root surgery), and outcomes were compared. Clinical patient characteristics and data were extracted from our local database for valve-sparing operations and for Ross procedures. Results: Preoperative characteristics were similar between del Nido cardioplegia solution and blood cardioplegia solution after propensity matching (mean age, 48.6 +/- 1.5 years). Median postoperative creatine kinase MB isotype did not differ between del Nido cardioplegia solution and blood cardioplegia solution (48.9 [14.9-300] mu g/L vs 51.2 [12.4-116] mu g/L for blood cardioplegia solution [P = .1]), but there was a trend toward higher troponin T levels with del Nido cardioplegia solution (748 [221-5834] ng/L vs 710 [212-3332] ng/L for blood cardioplegia solution [P = .07]). In patients with myocardial ischemia longer than 180 minutes, median creatine kinase MB isotype was higher in del Nido cardioplegia solution (75.1 [59.3-300] mu g/L than in blood cardioplegia solution 60.5 [16.5-116] mu g/L [P = .01]). Aortic crossclamp and cardiopulmonary bypass times were shorter with del Nido cardioplegia solution (163 +/- 5 vs 181 +/- 5 minutes, P = .01 and 145 +/- 4 vs 161 +/- 4 minutes, respectively, P = .006). Return to spontaneous rhythm was more frequent in the del Nido cardioplegia solution group (52% [29/55] vs 27% [15/55], P = .006). There was no difference in inotropic or vasoactive agent use (P = .8). Postoperative left ventricle ejection fraction was similar (0.54 +/- 0.09 vs 0.55 +/- 0.08 for del Nido cardioplegia solution and blood cardioplegia solution, respectively; P = .4). There was no difference between groups for perioperative mortality and postoperative complications. Conclusions: Del Nido cardioplegia solution can be used as an alternative to blood cardioplegia solution in adults undergoing complex aortic root surgery, providing comparable clinical outcomes and improved surgical workflow. However, del Nido cardioplegia solution seems to be associated with increased myocardial injury, especially with extended myocardial ischemic times, but this finding did not translate into adverse clinical events. Caution is warranted in adopting this cardioplegic solution in aortic interventions requiring long ischemic times, and further study is required to establish its exact role in complex cardiac surgery.