Talwar Sachin, Chatterjee Sujoy, Sreenivas Vishnubhatla, Makhija Neeti, Kapoor Poonam Malhotra, Choudhary Shiv Kumar, Airan Balram
Department of Cardiothoracic and Vascular Surgery, All India Institute of Medical Sciences, New Delhi, India.
Department of Cardiothoracic and Vascular Surgery, All India Institute of Medical Sciences, New Delhi, India.
J Thorac Cardiovasc Surg. 2019 Mar;157(3):1182-1192.e1. doi: 10.1016/j.jtcvs.2018.09.140. Epub 2018 Nov 27.
We conducted a prospective randomized controlled trial to compare del Nido (DN) and histidine-tryptophan-ketoglutarate (HTK) cardioplegia solution in pediatric patients undergoing intracardiac tetralogy of Fallot repair.
One hundred consecutive patients 12 years of age or younger, undergoing intracardiac repair of tetralogy of Fallot were randomized into DN (n = 50) and HTK (n = 50) groups. Cardioplegia strategy consisted of a single dose of DN (20 mL/kg) or HTK (6 mL/kg/min for 6 minutes). Primary outcome was cardiac index (CI). Secondary outcomes were ventricular arrhythmias post cross-clamp release, time to peripheral rewarming, duration of mechanical ventilation, inotropic score, intensive care unit and hospital stay, and serum levels of troponin-I, interleukin-6, and tumor necrosis factor-α. Ultrastructural changes in the myocardium were assessed.
CI was significantly higher in the DN group compared with the HTK group at 6 (P = .005) and 24 hours (P < .001) after surgery. It was on an average 0.44 L/min/m higher in the DN group at any time point (P = .004). Time for complete cessation of electrical activity was longer in the HTK group (P = .01) and more patients in the HTK group had ventricular arrhythmias post cross-clamp release (P = .03). Duration of mechanical ventilation (P = .006), intensive care unit stay (P = .05), and hospital stay (P < .001) were lower in the DN group. Patients in the DN group had lower troponin I levels 24 hours after cardiopulmonary bypass (P < .001). Electron microscopic studies showed more myocardial edema (P = .02) and myofibrillar disarray (P = .04) in the HTK group along with lower glycogen stores (P = .04). DN cardioplegia was more cost-effective than HTK cardioplegia (P < .001).
DN cardioplegia was associated with better preservation of CI, less duration of mechanical ventilation, shorter intensive care unit and hospital stays, lower inotropic scores, and less release of troponin-I. Electron microscopy showed less myocardial edema and better preservation of the myofibrillar architecture and glycogen stores in the DN group.
我们进行了一项前瞻性随机对照试验，以比较在接受法洛四联症心内修复术的儿科患者中，德尔尼多（DN）和组氨酸 - 色氨酸 - 酮戊二酸（HTK）心脏停搏液的效果。
100例12岁及以下接受法洛四联症心内修复术的连续患者被随机分为DN组（n = 50）和HTK组（n = 50）。心脏停搏策略包括单次剂量的DN（20 mL/kg）或HTK（6 mL/kg/min，持续6分钟）。主要结局指标是心脏指数（CI）。次要结局指标包括夹闭解除后室性心律失常、外周复温时间、机械通气时间、血管活性药物评分、重症监护病房和住院时间，以及肌钙蛋白 - I、白细胞介素 - 6和肿瘤坏死因子 - α的血清水平。评估心肌的超微结构变化。
术后6小时（P = 0.005）和24小时（P < 0.001），DN组的CI显著高于HTK组。在任何时间点，DN组的CI平均比HTK组高0.44 L/min/m²（P = 0.004）。HTK组电活动完全停止的时间更长（P = 0.01），且HTK组更多患者在夹闭解除后出现室性心律失常（P = 0.03）。DN组的机械通气时间（P = 0.006）、重症监护病房住院时间（P = 0.05）和住院时间（P < 0.001）更短。体外循环后24小时，DN组患者的肌钙蛋白I水平更低（P < 0.001）。电子显微镜研究显示，HTK组心肌水肿更严重（P = 0.02）、肌原纤维紊乱更明显（P = 0.04），糖原储备更低（P = 0.04）。DN心脏停搏液比HTK心脏停搏液更具成本效益（P < 0.001）。
DN心脏停搏液与更好地保存CI、更短的机械通气时间、更短的重症监护病房和住院时间、更低的血管活性药物评分以及更少的肌钙蛋白 - I释放相关。电子显微镜显示DN组心肌水肿更少，肌原纤维结构和糖原储备保存更好。
