Del Nido Cardioplegia: Elixir of Choice for Pediatric Myocardial Protection.

I think we’re going to be really talking about Del Nido today, because of its observed effectiveness. It kind of went viral. A lot of surgeons wound up leaving Boston and going through other centers and taking it with them and it sort of spread like a little virus and other surgeons wanted this single-dose cardioplegia. The idea of operating uninterrupted sounds pretty appealing. Like Bob (Groom) mentioned—let’s see here, if I could—yeah, I’m going to just go out here. I’ve been using this—well, we’ve (Children’s Health Dallas) been using this solution, excuse me, at our institution for about 10 years on over 3700 congenital surgeries. You know, we do pediatric and adult congenital procedures and we use a solution for everything. We were recently assigned three stars in the Society of Thoracic Surgeons (STS) based on the mortality risk models. Only 6 of 116 centers were assigned that rating and though I don’t think cardioplegia is the reason you get a high rating, I think to get really good results you do need to protect the myocardium. And when I asked around on the six centers and they were well represented on microplegia, custodial, Del Nido. It was across the board, so there was no inconsistency there. We’ve been using this solution for so long and presenting it at these meetings, we constantly get asked what’s your protocol, what’s your cardioplegic circuit, because we have this mini (cardioplegia) circuit. If you were at the myocardial workshop you got to see that, and we recently published our experience with the solution a couple of years back in JECT. I’m going to start off with just a real quick overview in just pediatric myocardial protection, and then we’ll get into the Del Nido part of the talk. First, I think most of you know that cardioplegia is just a part of myocardial protection. When we most often talk about myocardial protection we talk about cardioplegia, but myocardial protection is really anything that reduces metabolic demands in activity. Cardioplegia prolongs the tolerance to ischemia. Excuse me. I’m doing two things at once here and I’m not doing a good job of that. All right. When you look at all of these techniques that everyone uses, it’s kind of crazy. They’re all across the board. There’s really no consistency and it’s really a mess. There’s a lot of conflicting techniques and some are actually literally the opposite of each other. I know I remember being a student and going on clinical rotations and we had surgeons going cold, continuous, and warm. It really was like working with a bunch of bartenders with their own little cocktail. If you really think about it, cardioplegia actually is quite literally almost a cocktail. Maybe your surgeons like a Sazerac style cardioplegia, but you know, we used to do beer and alcohol during these sessions in here a long time ago. I don’t know why they stopped doing that, but alcohol was a very important part of these talks. Let’s see here: to even complicate it even further is now you have these differences of the immature heart. As the myocardium develops the myocites and myofibrils elongate, the number of mitochondria increases, and it’s responsible for adenosine triphosphate (ATP), of course, and also, the structure and amount of sarcoplasmic reticulum change, which, you know, is responsible for calcium management. For the physiologic differences, basically, it can be broken down into how the myocardium manages a calcium energy consuming processes, and we’ll keep this in mind later in the presentation when we talk about the different formulations. If you could actually address these differences in the anatomy and physiology, it would be a great way to create a very special, specific cardioplegia for a very specific subgroup of patients. But, unfortunately, it’s actually unclear when the transition happens from immature to mature. You don’t really know, so to actually tailor a cardioplegia for a pediatric patient is actually Address correspondence to: Richard M. Ginther, Jr., CCP, FPP, UT Southwestern Medical Center, Children's Health Dallas, 1935 Medical District Drive, Dallas, TX 75235. E-mail: [email protected]