• 1950s Whole body hypothermia

(Bigelow, Swan, Ross, Lewis)

• 1960s Topical myocardial hypothermia
with aortic cross clamp
(Shumway)
• 1972 Hyperpolarizing solution
(Bretschneider, Kirsch)
• 1970 Warm aortic cross clamping (Cooley)

Cardioplegia • 1973 Chemical arrest/hypothermia

(Gay & Ebert)

History • 1976 Hypothermia, potassium, glucose,

calcium ( Hearse)
• 1978 4:1 blood with warm reperfusion
(Buckberg)
• 1978 Retrograde cardiopleiga (Solorzano)
• 1989 Warm continuous cardioplegia (Panos)
• 1991 Warm continuous retrograde (Salerno)
• 1999 Microplegia (Califiore, Weisel)
• 2003 Single dose cardioplegia (del Nido)
• 2005 Potassium channel openers (Dobson)
 Cardioplegia solution
• Blood cardioplegia
- Buckberg better oxygen delivery and
buffering capacity, physiological
- St’Thomas osmotic pressure and
(Extracellular cardioplegia) antioxidant capability
Y Fang, C Long, S Lou, Y Guan and Z Fu ,Perfusion 2015, Vol. 30(7) 529-536

• Crystalloid cardioplagia prolong clamp time

- Custodiol-HTK higher costs and the associated
hemodilution, hyponatremia
(Intracellular cardioplegia)
George Jose Valooran, et al. Perfusion 2016, Vol. 31(1) 6-14
 In the early 1990s, Dr. Pedro
del Nido and his team at the
University of Pittsburgh
developed a cardioplegia
solution to address the specific
needs of immature myocardium
in neonate and pediatric cardiac
surgery

“del Nido Cardioplegia”

Prashant Mishra et al
Kardiochirurgia i Torakochirurgia Polska 2016; 13 (4): 295-299
del Nido Cardioplegia
• Plasma-Lyte A
• Mannitol
• Magnesium sulfate
• Sodium Bicarbonate
• Potassium Chloride
• Lidocaine
• Patient Blood Additive
del Nido Cardioplegia
• Plasma-Lyte A

Base Solution of Plasma-Lyte A

Sodium 140 mEq/L

Potassium 5 mEq/L

Magnesium 3 mEq/L

Chloride 98 mEq/L
Acetate 27 mEq/L

Gluconate 23 mEq/L

pH 7.4

osmolarity 294 mmol/L

• No calcium in the base solution

• Not available in Thailand
del Nido Cardioplegia

• Mannitol

• Hyperosmotic
• Scavenge free radicals
• Reduce myocardial cell swelling
del Nido Cardioplegia

• Magnesium sulfate

• Calcium channel blocker

• Improve ventricular recovery
• Combination with lidocaine affords superior
preservation of LV function
del Nido Cardioplegia

• Sodium Bicarbonate

• Buffering solution to scavenge excess

hydrogen ions
• Maintaining intracellular pH
del Nido Cardioplegia

• Potassium Chloride

The potassium level in del Nido cardioplegia is 26 mEq/L

del Nido Cardioplegia

• Sodium channel blocker and is a frequently used

antiarrhythmic
• Prevents the calcium overload at periods of prolonged
ischemia and reperfusion
• Reduces the release of troponin I
• Increases the refractory period
• Negative effects of a hyperkalemia

• Lidocaine
del Nido Cardioplegia

• Preserve myocardial metabolism and function

• Provides buffering

• Improve coronary perfusion during cardioplegia delivery

• Less metabolic ischemic stress and reperfusion injury

• Patient Blood Additive

del Nido Cardioplegia

Components of del Nido solution

Plasma-lyte A 1000 ml
20% Mannitol 16.3 ml
50% Magnesium Sulfate 4 ml
8.4% Sodium Bicarbonate 13 ml
Potassium Chloride (2mEq/ml) 13 ml
1% Lidocaine 13 ml
del Nido Cardioplegia

• 1 : 4 blood : crystalloid
• Single dose
• 20 ml/kg cardioplegia dose over 1–2 minutes
• System pressure 100–200 mmHg
• Flow rate of 10–20 ml/kg/min
• Temperature 8-12 oC
• Repeat only if clamp time > 90 min / activity
 Del Nido cardioplegia in
Maharaj Nakorn Chiang Mai Hospital
• Classical del Nido • Modified del Nido microplegia
Maharaj Nakorn Chiang Mai Hospital
Classical del Nido Cardioplegia Protocol

• The circuit
Maharaj Nakorn Chiang Mai Hospital
Classical del Nido Cardioplegia Protocol

Components of del Nido solution

Acetar Ringer’s solution 1000 ml
20% Mannitol 15 ml
50% Magnesium Sulfate 4 ml
7.5% Sodium Bicarbonate 15 ml
Potassium Chloride (2mEq/ml) 10 ml
2% Lidocaine 6 ml
Maharaj Nakorn Chiang Mai Hospital
Classical del Nido Cardioplegia Protocol
• Delivery
- 1 : 4 blood : crystalloid
- Antegrade
- 20 ml/kg cardioplegia dose over 1–2 minutes
- Flow rate of 10–20 ml/kg/min
- System pressure 80-150 mmHg
- Temperature 8-12 oC
 JECT. 2006;38:14–21
The Journal of The American Society of Extra-Corporeal Technology
Maharaj Nakorn Chiang Mai Hospital
Modified del Nido Microplegia Protocol
• The circuit
Maharaj Nakorn Chiang Mai Hospital
Modified del Nido Microplegia Protocol
• Dose

Components of del Nido solution

20% Mannitol 15 ml
50% Magnesium Sulfate 4 ml
7.5% Sodium Bicarbonate 15 ml
Potassium Chloride (2mEq/ml) 10 ml
2% Lidocaine 6 ml
Total 50 ml
1 ml = KCl 0.4 mEq
Maharaj Nakorn Chiang Mai Hospital
Modified del Nido Microplegia Protocol
• Delivery
- 20 ml/kg cardioplegia dose over 1–2 minutes
- Antegrade
- Flow rate of 10–20 ml/kg/min
- System pressure 80–150 mmHg
- Temperature 8-12 oC
- Rate syringe pump

1000 ml KCl 26 mEq

Flow 100 ml/min KCl 2.6 mEq ÷ 0.4 mEq = 6.5 ml
Rate syringe pump 6.5 ml x 60 min = 390 ml/hr
 Result
Components of del Nido solution
Components Classical del Nido Cardioplegia Modified del Nido Microplegia
20% Mannitol 15 ml 15 ml
50% Magnesium Sulfate 4 ml 4 ml
8.4% Sodium Bicarbonate 15 ml 15 ml
Potassium Chloride (2mEq/ml) 10 ml 10 ml
2% Lidocaine 6 ml 6 ml
Base solution Acetar 1000 ml -

Patient characteristics
Characteristics Classical del Nido Cardioplegia Modified del Nido Microplegia
(n = 38) (n = 107)
Age (years), mean (SD) 2.93 (±3.06) 3.66 (±4.21)
Gender, n (%)
Male 18 (47.37%) 43 (40.19%)
Female 20 (52.63%) 64 (59.81%)
Height (cm), mean (SD) 83.06 (±25.07) 90.46 (±29.62)
Weight (kg), mean (SD) 10.64 (±7.02) 14.65 (±13.03)
Result
Type of operations
Type of operations Classical del Nido Cardioplegia Modified del Nido Microplegia
(n = 38) (n = 107)
VSD closure 10 71
ASD closure - 8
VSD, ASD closure 1 12
ASD closure, MV repair 1 5
ASD, explore PA - 1
VSD closure, RVOT reconstruction 2 1
VSD, TV repair - 2
AVSD repair, MV repair, PV - 2
valvulotomy
VSD closure, DORV repair, RVOT plasty - 1
RVOT reconstruction - 1
TV repair - 1
MV repair - 1
MVR 1 -
Total correction 11 1
Glenn operation 1 -
Fontan operation 1 -
Myectomy , MV repair 1 -
Cortriatrium repair 1 -
Fistula closure 1 -
Truncus arteriosus 2 -
Tumor removal 1 -
Yasui operation 1 -
Arterial switch operation 1 -
TAPVR repair 1 -
Hemitruncus operation 1 -
 Result
Intraoperative outcomes
Variable Classical del Nido Cardioplegia Modified del Nido Microplegia
(n = 38) (n = 107)
Total cardioplegic volume use, mean (SD) 260.13 (±265.69) 18.57 (±14.74)
Aortic cross clamp time, mean (SD) 68.08 (±39.96) 60.78 (±24.91)
Total bypass time, mean (SD) 108.79 (±54.47) 90.84 (±28.36)
Defibrillation after aortic cross clamp 3 (7.89%) 5 (4.67%)
removal, n (%)

Postoperative outcomes
Variable Classical del Nido Cardioplegia Modified del Nido Microplegia
(n = 38) (n = 107)
ICU stay (day), mean (SD) 2.83 (±3.45) 1.39 (±0.85)
Hospital stay (day), mean (SD) 13.8 (±9.44) 8.40 (±8.31)
Acute kidney injury, n (%) 2 (5.26%) -
Respiratory complication, n (%) 1 (2.63%) 1 (0.93%)
Stroke, n (%) - -
Insertion ECMO, n (%) 2 (5.26%) -
Mortality, n (%) 1 (2.63%) -
 Modifications of del Nido
• Reduced hemodilution and myocardial edema

• Better microvascular preservation

• Reduced hemoconcentration and blood usage

• Less cost, less morbidity