The myocardial protection of HTK versus del Nido cardioplegia solutions in neonates with surgeries for transposition of the great arteries : A propensity score matching study_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

LI Cong , YAN Yichen , CHEN Hongtong ,  ZHU Zhongqun

Department of Cardiothoracic Surgery, Shanghai Children’s Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200127, P. R. China;

Corresponding author：

ZHU Zhongqun, Email: zhuzhongqun@scmc.com.cn

Keywords：

Neonates; complete transposition of the great arteries; myocardial protection; HTK; del Nido

DOI：

10.7507/1007-4848.202109064

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Objective To compare and analyze the effect of myocardial protection between HTK and del Nido cardioplegia solutions in neonates with surgeries for transposition of the great arteries. Methods The clinical data of 208 neonates with complete transposition of the great arteries in our institution from 2014 to 2020 were retrospectively analyzed. According to the cardioplegia solutions utilized in the operations, the patients were divided into two groups: a HTK group and a del Nido group. Propensity score matching was conducted to eliminate the biases. The cardiopulmonary bypass time, aortic cross-clamping time, total amount of cardioplegia solutions, transfusion frequency of cardioplegia, ICU stay time, mechanical support time, inotropic score, hospital stay, left ventricular ejection fraction, N-terminal proBNP and troponin I were compared and analyzed between the two groups after matching. Results After 1:1 propensity score matching, a total of 54 patients were analyzed with 27 patients in each group. In the HTK group, there were 22 males and 5 females with a median age of 7.0 (2.0, 11.0) d. In the del Nido group, there were 23 males and 4 females with a median age of 8.0 (3.0, 11.0) d. A total of 3 children died after the surgery: 2 (7.4%) patients in the HTK group and 1 (3.7%) patient in the del Nido group. There was no significant difference in hospital mortality between the two groups (P=1.000). The total amount of cardioplegia solutions in the HTK group was significantly higher than that of del Nido group (P<0.001). Transfusion frequency of cardioplegia in del Nido group was significantly higher than that of the HTK group (P=0.043). There was no significant difference in the postoperative ICU time, mechanical support time, length of hospital stay, inotropic score, left ventricular ejection fraction, N-terminal B-type natriuretic peptide precursor or troponin I between the two groups (P>0.05). Conclusion For neonates with surgeries for complete transposition of the great arteries, HTK cardioplegia solutions can provide effective and safe myocardial protection, which is similar to del Nido cardioplegia solutions.

Citation： LI Cong, YAN Yichen, CHEN Hongtong, ZHU Zhongqun. The myocardial protection of HTK versus del Nido cardioplegia solutions in neonates with surgeries for transposition of the great arteries : A propensity score matching study. Chinese Journal of Clinical Thoracic and Cardiovascular Surgery, 2023, 30(9): 1301-1307. doi: 10.7507/1007-4848.202109064 Copy

1.	Allen BS, Barth MJ, Ilbawi MN. Pediatric myocardial protection: An overview. Semin Thorac Cardiovasc Surg, 2001, 13(1): 56-72.
2.	Helmers MR, Atluri P. Commentary: One and done: The case for single-dose del Nido cardioplegia. J Thorac Cardiovasc Surg, 2020, 160(5): 1203-1204.
3.	Ibrahim MF, Venn GE, Young CP, et al. A clinical comparative study between crystalloid and blood-based St Thomas' hospital cardioplegic solution. Eur J Cardiothorac Surg, 1999, 15(1): 75-83.
4.	Williams WG, Rebeyka IM, Tibshirani RJ, et al. Warm induction blood cardioplegia in the infant. A technique to avoid rapid cooling myocardial contracture. J Thorac Cardiovasc Surg, 1990, 100(6): 896-901.
5.	Talwar S, Chatterjee S, Sreenivas V, et al. Comparison of del Nido and histidine-tryptophan-ketoglutarate cardioplegia solutions in pediatric patients undergoing open heart surgery: A prospective randomized clinical trial. J Thorac Cardiovasc Surg, 2019, 157(3): 1182-1192.
6.	Wang ZH, An Y, Du MC, et al. Clinical assessment of histidine-tryptophan-ketoglutarate solution and modified St. Thomas' solution in pediatric cardiac surgery of Tetralogy of Fallot. Artif Organs, 2017, 41(5): 470-475.
7.	Su Z, Liu Y, Zhang H. Adaptive cardiac metabolism under chronic hypoxia: Mechanism and clinical implications. Front Cell Dev Biol, 2021, 9: 625524.
8.	Turkoz R. Myocardial protection in pediatric cardiac surgery. Artif Organs, 2013, 37(1): 16-20.
9.	Silverman NA, Kohler J, Levitsky S, et al. Chronic hypoxemia depresses global ventricular function and predisposes to the depletion of high-energy phosphates during cardioplegic arrest: Implications for surgical repair of cyanotic congenital heart defects. Ann Thorac Surg, 1984, 37(4): 304-308.
10.	Pérez-Andreu J, Fernández-Doblas J, Sao Avilés A, et al. Myocardial protection in the arterial switch operation: Custodiol versus cold blood cardioplegia. Interact Cardiovasc Thorac Surg, 2020, 30(1): 136-143.
11.	Ferguson ZG, Yarborough DE, Jarvis BL, et al. Evidence-based medicine and myocardial protection: Where is the evidence? Perfusion, 2015, 30(5): 415-422.
12.	Chen Y, Liu J, Li S, et al. Which is the better option during neonatal cardiopulmonary bypass: HTK solution or cold blood cardioplegia? ASAIO J, 2013, 59(1): 69-74.
13.	Liu J, Feng Z, Zhao J, et al. The myocardial protection of HTK cardioplegic solution on the long-term ischemic period in pediatric heart surgery. ASAIO J, 2008, 54(5): 470-473.
14.	Turner II, Ruzmetov M, Niu J, et al. Scavenging right atrial Bretschneider histidine-tryptophan-ketoglutarate cardioplegia: Impact on hyponatremia and seizures in pediatric cardiac surgery patients. J Thorac Cardiovasc Surg, 2021, 162(1): 228-237.
15.	del Nido PJ. Myocardial protection and cardiopulmonary bypass in neonates and infants. Ann Thorac Surg, 1997, 64(3): 878-879.
16.	Gambardella I, Gaudino MFL, Antoniou GA, et al. Single- versus multidose cardioplegia in adult cardiac surgery patients: A meta-analysis. J Thorac Cardiovasc Surg, 2020, 160(5): 1195-1202.
17.	Matte GS, del Nido PJ. History and use of del Nido cardioplegia solution at Boston Children's Hospital. J Extra Corpor Technol, 2012, 44(3): 98-103.
18.	Kronon M, Bolling KS, Allen BS, et al. The relationship between calcium and magnesium in pediatric myocardial protection. J Thorac Cardiovasc Surg, 1997, 114(6): 1010-1019.
19.	Kronon MT, Allen BS, Hernan J, et al. Superiority of magnesium cardioplegia in neonatal myocardial protection. Ann Thorac Surg, 1999, 68(6): 2285-2291.
20.	Kronon MT, Allen BS, Bolling KS, et al. The role of cardioplegia induction temperature and amino acid enrichment in neonatal myocardial protection. Ann Thorac Surg, 2000, 70(3): 756-764.
21.	Suominen PK, Keski-Nisula J, Tynkkynen P, et al. The effect of tepid amino acid-enriched induction cardioplegia on the outcome of infants undergoing cardiac surgery. Perfusion, 2012, 27(4): 338-344.
22.	Temizturk Z, Azboy D, Uysal A. The effects of amino acids enriched Del Nido cardioplegia on myocardial leucocyte accumulation and ventricular functions in patients undergoing coronary artery bypass grafting surgery. Heart Surg Forum, 2021, 24(1): E038-E047.

1. Allen BS, Barth MJ, Ilbawi MN. Pediatric myocardial protection: An overview. Semin Thorac Cardiovasc Surg, 2001, 13(1): 56-72.
2. Helmers MR, Atluri P. Commentary: One and done: The case for single-dose del Nido cardioplegia. J Thorac Cardiovasc Surg, 2020, 160(5): 1203-1204.
3. Ibrahim MF, Venn GE, Young CP, et al. A clinical comparative study between crystalloid and blood-based St Thomas' hospital cardioplegic solution. Eur J Cardiothorac Surg, 1999, 15(1): 75-83.
4. Williams WG, Rebeyka IM, Tibshirani RJ, et al. Warm induction blood cardioplegia in the infant. A technique to avoid rapid cooling myocardial contracture. J Thorac Cardiovasc Surg, 1990, 100(6): 896-901.
5. Talwar S, Chatterjee S, Sreenivas V, et al. Comparison of del Nido and histidine-tryptophan-ketoglutarate cardioplegia solutions in pediatric patients undergoing open heart surgery: A prospective randomized clinical trial. J Thorac Cardiovasc Surg, 2019, 157(3): 1182-1192.
6. Wang ZH, An Y, Du MC, et al. Clinical assessment of histidine-tryptophan-ketoglutarate solution and modified St. Thomas' solution in pediatric cardiac surgery of Tetralogy of Fallot. Artif Organs, 2017, 41(5): 470-475.
7. Su Z, Liu Y, Zhang H. Adaptive cardiac metabolism under chronic hypoxia: Mechanism and clinical implications. Front Cell Dev Biol, 2021, 9: 625524.
8. Turkoz R. Myocardial protection in pediatric cardiac surgery. Artif Organs, 2013, 37(1): 16-20.
9. Silverman NA, Kohler J, Levitsky S, et al. Chronic hypoxemia depresses global ventricular function and predisposes to the depletion of high-energy phosphates during cardioplegic arrest: Implications for surgical repair of cyanotic congenital heart defects. Ann Thorac Surg, 1984, 37(4): 304-308.
10. Pérez-Andreu J, Fernández-Doblas J, Sao Avilés A, et al. Myocardial protection in the arterial switch operation: Custodiol versus cold blood cardioplegia. Interact Cardiovasc Thorac Surg, 2020, 30(1): 136-143.
11. Ferguson ZG, Yarborough DE, Jarvis BL, et al. Evidence-based medicine and myocardial protection: Where is the evidence? Perfusion, 2015, 30(5): 415-422.
12. Chen Y, Liu J, Li S, et al. Which is the better option during neonatal cardiopulmonary bypass: HTK solution or cold blood cardioplegia? ASAIO J, 2013, 59(1): 69-74.
13. Liu J, Feng Z, Zhao J, et al. The myocardial protection of HTK cardioplegic solution on the long-term ischemic period in pediatric heart surgery. ASAIO J, 2008, 54(5): 470-473.
14. Turner II, Ruzmetov M, Niu J, et al. Scavenging right atrial Bretschneider histidine-tryptophan-ketoglutarate cardioplegia: Impact on hyponatremia and seizures in pediatric cardiac surgery patients. J Thorac Cardiovasc Surg, 2021, 162(1): 228-237.
15. del Nido PJ. Myocardial protection and cardiopulmonary bypass in neonates and infants. Ann Thorac Surg, 1997, 64(3): 878-879.
16. Gambardella I, Gaudino MFL, Antoniou GA, et al. Single- versus multidose cardioplegia in adult cardiac surgery patients: A meta-analysis. J Thorac Cardiovasc Surg, 2020, 160(5): 1195-1202.
17. Matte GS, del Nido PJ. History and use of del Nido cardioplegia solution at Boston Children's Hospital. J Extra Corpor Technol, 2012, 44(3): 98-103.
18. Kronon M, Bolling KS, Allen BS, et al. The relationship between calcium and magnesium in pediatric myocardial protection. J Thorac Cardiovasc Surg, 1997, 114(6): 1010-1019.
19. Kronon MT, Allen BS, Hernan J, et al. Superiority of magnesium cardioplegia in neonatal myocardial protection. Ann Thorac Surg, 1999, 68(6): 2285-2291.
20. Kronon MT, Allen BS, Bolling KS, et al. The role of cardioplegia induction temperature and amino acid enrichment in neonatal myocardial protection. Ann Thorac Surg, 2000, 70(3): 756-764.
21. Suominen PK, Keski-Nisula J, Tynkkynen P, et al. The effect of tepid amino acid-enriched induction cardioplegia on the outcome of infants undergoing cardiac surgery. Perfusion, 2012, 27(4): 338-344.
22. Temizturk Z, Azboy D, Uysal A. The effects of amino acids enriched Del Nido cardioplegia on myocardial leucocyte accumulation and ventricular functions in patients undergoing coronary artery bypass grafting surgery. Heart Surg Forum, 2021, 24(1): E038-E047.

Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

The myocardial protection of HTK versus del Nido cardioplegia solutions in neonates with surgeries for transposition of the great arteries : A propensity score matching study

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