Inflammatory cytokine response and cardiac troponin I changes in cardiopulmonary bypass using two cardioplegia solutions;del Nido and modified St. Thomas’: a randomized controlled trial

Abstract

Background:

Long intervals of del Nido (DN) solution administration, 90 minutes, may result in rewarming of the myocardial tissue and elevate metabolic demand and hypoxia. This will potentially increase inflammatory response due to ischemia-reperfusion injury. We conducted this study to compare the inflammatory response between patients receiving DN and multi-dose St Thomas’ cardioplegia solution (MST) in cardiopulmonary bypass (CPB) surgery for the correction of tetralogy of Fallot (TF).

Methods:

Fifty-nine pediatric patients undergoing TF total correction surgery were randomly assigned into two groups: DN and MST. The patients’ demographic data, blood chemistry parameters, hemodynamics and other clinical variables were recorded. TNF-a, IL-6, IL-8, IL-10 and cTnI were measured after anesthesia induction (before skin incision), immediately after cross-clamp removal and 24 hours after admission to the intensive care unit (ICU).

Results:

Thirty-two patients of a mean age of 28.0±16.4 months received DN and 27 patients of a mean age of 24.2±15.9 months received MST. Perioperative clinical parameters were not significantly different between the two groups. Cytokine levels for all patients were significantly increased after surgery. Inter-group comparisons of cytokine levels demonstrated no significant differences in TNF-α, IL-6 and IL-8 cytokines levels. IL-10 level showed a moderately significant increase in the MST group compared to the DN group after surgery (2.94±0.9 vs. 2.46±0.61 log10 pg/mL, respectively; p=0.039). Postoperative lactate level was significantly different between two groups (2.475±1.29 vs 1.63±0.82 mg/dL in DN and MST groups, respectively; p=0.007). CTnI levels increased after surgery and remained constant until 24 hours after surgery. Significant differences between the MST and DN groups, at all times, were not detected.

Conclusions:

The anti-inflammatory cytokine response in the MST group is significantly better than in the DN group. This may be due to shorter intervals of the MST cardioplegia solution administration, which prevents rewarming of the myocardium, increased metabolic demand and hypoxia. Decreasing the intervals of DN administration may improve its cardioprotective properties.

Keywords

cardiopulmonary bypass cardioplegia del Nido solution inflammation myocardial damage

Get full access to this article

View all access options for this article.

References

Lawton

JS.

50th Anniversary Landmark Commentary on Gay WA. Potassium-induced cardioplegia. Ann Thorac Surg 1975; 20: 95–100. Ann Thorac Surg 2015; 99: 1120–1121.

Usta

Renovanz

Mustafi

. Human cardiac tissue in a microperfusion chamber simulating extracorporeal circulation–ischemia and apoptosis studies. J Cardiothorac Surg 2010; 5: 3–15.

Ibrahim

Refaat

AA.

Long-term outcome after coronary artery bypass grafting in patients with left ventricular dysfunction: does the type of cardioplegia matter?

Interact Cardiovasc Thorac Surg 2008; 7: 498.

Kim

Park

. Association between the neutrophil/lymphocyte ratio and acute kidney injury after cardiovascular surgery: a retrospective observational study. Medicine (Baltimore) 2015; 94: e1867.

Pearse

Wijeysundera

DN.

Steroids for cardiac surgery: has the story finally ended?

Lancet 2015; 386: 1215–1216.

Floh

Manlhiot

Redington

. Insulin resistance and inflammation are a cause of hyperglycemia after pediatric cardiopulmonary bypass surgery. J Thorac Cardiovasc Surg 2015; 150: 498–504 e491.

Corral-Velez

Lopez-Delgado

Betancur-Zambrano

. The inflammatory response in cardiac surgery: an overview of the pathophysiology and clinical implications. Inflamm Allergy Drug Targets 2015; 13: 367–370.

Mahle

Matthews

Kanter

. Inflammatory response after neonatal cardiac surgery and its relationship to clinical outcomes. Ann Thorac Surg 2014; 97: 950–956.

Appachi

Mossad

Mee

. Perioperative serum interleukins in neonates with hypoplastic left-heart syndrome and transposition of the great arteries. J Cardiothorac Vasc Anesth 2007; 21: 184–190.

10.

Allan

Newburger

McGrath

. The relationship between inflammatory activation and clinical outcome after infant cardiopulmonary bypass. Anesth Analg 2010; 111: 1244–1251.

11.

Varan

Tokel

Mercan

. Systemic inflammatory response related to cardiopulmonary bypass and its modification by methyl prednisolone: high dose versus low dose. Pediatr Cardiol 2002; 23: 437–441.

12.

Jacob

Kallikourdis

Sellke

. Is blood cardioplegia superior to crystalloid cardioplegia? Interact Cardiovasc Thorac Surg 2008; 7: 491–498.

13.

Matte

del Nido

PJ.

History and use of del Nido cardioplegia solution at Boston Children’s Hospital. J Extra Corpor Technol 2012; 44: 98–103.

14.

Kim

Ball

Grady

. Use of del Nido cardioplegia for adult cardiac surgery at the Cleveland Clinic: perfusion implications. J Extra Corpor Technol 2014; 46: 317–323.

15.

Jynge

Hearse

Feuvray

. The St. Thomas’ hospital cardioplegic solution: a characterization in two species. Scand J Thorac Cardiovasc Surg Suppl 1981; 30: 1–28.

16.

Caputo

Mokhtari

Miceli

. Controlled reoxygenation during cardiopulmonary bypass decreases markers of organ damage, inflammation, and oxidative stress in single-ventricle patients undergoing pediatric heart surgery. J Thorac Cardiovasc Surg 2014; 148: 792–801 e798; discussion 800–801.

17.

Landis

Brown

Fitzgerald

. (2014) Attenuating the systemic inflammatory response to adult cardiopulmonary bypass: a critical review of the evidence base. J Extra Corpor Technol 2014; 46: 197–211.

18.

Miklaszewska

Korohoda

Zachwieja

. Serum interleukin 6 levels as an early marker of acute kidney injury on children after cardiac surgery. Adv Clin Exp Med 2013; 22: 377–386.

19.

Sorabella

Akashi

Yerebakan

. Myocardial protection using del Nido cardioplegia solution in adult reoperative aortic valve surgery. J Card Surg 2014; 29: 445–449.

20.

Charette

Gerrah

Quaegebeur

. Single dose myocardial protection technique utilizing del Nido cardioplegia solution during congenital heart surgery procedures. Perfusion 2012; 27: 98–103.

21.

Ota

Yerebakan

Neely

. Short-term outcomes in adult cardiac surgery in the use of del Nido cardioplegia solution. Perfusion 2016; 31: 27–33.

22.

Yerebakan

Sorabella

Najjar

. Del Nido Cardioplegia can be safely administered in high-risk coronary artery bypass grafting surgery after acute myocardial infarction: a propensity matched comparison. J Cardiothorac Surg 2014; 9: 141.

23.

Mick

Robich

Houghtaling

. del Nido versus Buckberg cardioplegia in adult isolated valve surgery. J Thorac Cardiovasc Surg 2015; 149: 626–634; discussion 634–626.

24.

Kim

Jeong

Moon

. Sufficient myocardial protection of del Nido cardioplegia regardless of ventricular mass and myocardial ischemic time in adult cardiac surgical patients. J Thorac Dis 2016; 8: 2004–2010.

25.

Wittnich

Belanger

Bandali

KS.

Newborn hearts are at greater ‘metabolic risk’ during global ischemia–advantages of continuous coronary washout. Can J Cardiol 2007; 23: 195–200.

26.

Govindapillai

Hancock Friesen

O’Blenes

. Protecting the aged heart during cardiac surgery: single-dose del Nido cardioplegia is superior to multi-dose del Nido cardioplegia in isolated rat hearts. Perfusion 2016; 31: 135–142.