Del Nido cardioplegia may offer economic advantages over Custodiol during isolated surgical aortic valve replacement, according to a retrospective study from Bogotá, Colombia. Kevin Maldonado-Cañón and colleagues combined clinical records with hospital cost estimates to examine whether lower spending translated into favorable value. Their analysis supports Del Nido as a potentially cost-effective option under the study’s local assumptions, but important differences between the treatment groups prevent a definitive conclusion that the solutions provide equivalent myocardial protection.
Study population and treatment selection
The investigators reviewed 179 adults undergoing isolated surgical aortic valve replacement with cardiopulmonary bypass at Clínica Universitaria Colombia between 2009 and 2023. Fifty-eight received Custodiol, a histidine-tryptophan-ketoglutarate solution, and 121 received Del Nido. Patients with previous cardiac surgery, minimally invasive procedures, use of Plegisol, EuroSCORE above 5%, or less than one year of follow-up were excluded. The results therefore concern a selected surgical population rather than the full spectrum of adult cardiac surgery.
Cardioplegia selection was not randomized. Custodiol was used before Del Nido became available at the institution in 2021, after which Del Nido became the predominant approach. Institutional practice also favored Custodiol in certain patients, including those with heart failure or renal failure. Only 21 operations occurred before 2019, but the partial separation of treatment groups by calendar period remains relevant to interpretation.
Clinical outcomes and statistical adjustment
The primary effectiveness measure was freedom from major adverse cardiac events, or MACE, within 30 days or during the admission. The composite included all-cause mortality, myocardial infarction, stroke, reoperation for bleeding, and low cardiac output syndrome requiring mechanical support. Thirty-day mortality was approximately 1.7% in each group: one death among 58 Custodiol recipients and two among 121 Del Nido recipients. These small numbers provide limited ability to detect a clinically meaningful mortality difference.
To address measured baseline differences, the researchers used inverse probability of treatment weighting. This approach assigns statistical weights based on the probability of receiving each treatment and can improve comparability for included variables. It does not create a randomized trial, add new patients, or eliminate unmeasured confounding. The weighted population is a statistical construct based on the original 179 patients.
After weighting, MACE occurred in 11.3% of the Del Nido group and 6.6% of the Custodiol group, with p = 0.098. Thus, the point estimate favored Custodiol, although the difference did not meet the conventional threshold for statistical significance. A nonsignificant comparison does not establish equivalence or noninferiority. The paper also contains an inconsistency between a reported crude Custodiol event count and its percentage; the adjusted comparison is more useful for understanding the economic model.
What the reported costs represent
The analysis adopted a healthcare payer perspective and included direct inpatient costs. These covered operating room resources, prosthetic valves, medications, intensive care, ward care, and treatment of complications. Hospital resource costs were valued using 2023 data and converted from Colombian pesos using purchasing power parity. Consequently, the reported dollar figures should not be interpreted as current US hospital charges, international procurement quotations, or guaranteed savings at another institution.
Mean total costs were reported as $41,761 for Del Nido and $47,599 for Custodiol, a difference of $5,838 per surgical episode. This corresponds to approximately 12.3% lower total cost relative to the Custodiol amount. The authors separately reported cardioplegia-related costs of $657 and $2,566, respectively, with the costing description including solution components and cannulas. The full hospitalization difference should not be attributed solely to purchasing the cardioplegia solution.
Interpreting cost-effectiveness
The economic comparison involved a trade-off: Del Nido had lower modeled costs, while Custodiol had higher weighted MACE-free survival. Table 3 reported an incremental effectiveness difference of approximately 0.047 and an incremental cost-effectiveness ratio of $123,363 for Custodiol. In this model, that ratio concerns additional MACE-free survival, not a quality-adjusted life-year or a proven survival gain.
The investigators compared their estimates with willingness-to-pay thresholds of approximately $6,947 to $20,841, representing one to three times Colombian gross domestic product per capita. At those selected thresholds, the additional modeled effectiveness with Custodiol did not justify its higher cost, favoring Del Nido. The finding is conditional on the outcome definition, cost inputs, and decision thresholds; it is not a demonstration that Del Nido was simultaneously cheaper and clinically superior.
A probabilistic sensitivity analysis used 10,000 Monte Carlo simulations to vary cost and effectiveness estimates. Del Nido was the cost-effective alternative in 75.5% of simulations at the lower threshold and 72.35% at the higher threshold. These percentages describe the model’s behavior under specified assumptions. They are not the probability that Del Nido is the best treatment for an individual patient, and simulation cannot remove bias from the underlying observational data.
Limitations that matter for perfusion practice
The most striking baseline difference was pre-existing heart failure, present in 43.1% of Custodiol patients and 0.8% of Del Nido patients. Because treatment groups had insufficient overlap for this characteristic, heart failure was excluded from the weighting model. This leaves a major source of structural confounding despite improved balance in other measured variables. Differences in valve prosthesis types and treatment era also complicate attribution of outcomes and total costs to cardioplegia alone.
Additional limitations include the single-center design, small sample, few adverse events, retrospective outcome capture, and short clinical horizon used for the economic endpoint. Applying contemporary prices to resource use across several years adds assumptions. Longer-term quality of life and functional recovery were not incorporated into a quality-adjusted survival model. Findings should not be generalized automatically to high-risk patients, reoperations, combined procedures, prolonged ischemic periods, or pediatric surgery.
Practical relevance and next steps
For perfusion and cardiac surgery programs, this study provides a reason to evaluate local cardioplegia costs alongside consistently measured clinical outcomes. A useful local review would distinguish solution acquisition and preparation costs from the total surgical episode, document why each solution is selected, and account for case mix and institutional protocols. Multicenter prospective comparisons with better treatment overlap would help determine whether the observed economic advantage persists without clinically important differences in outcomes.
The study was supported by the Vice Presidency of Innovation and Scientific Development of Clínica Colsanitas. The authors declared no potential conflicts of interest. Its contribution is a context-specific economic evaluation that raises useful questions about resource allocation while leaving comparative clinical effectiveness uncertain.
Source: Maldonado-Cañón K, Prada Liévano SA, Olaya H, et al. Del Nido cardioplegia is a cost-effective alternative to custodiol for myocardial protection in aortic valve surgery: A real-world study. Perfusion. 2026:1–9. doi:10.1177/02676591261475489.
Attribution: © The Author(s) 2026. This independently written IPA educational summary accompanies the unchanged supplied article. Cover artwork is conceptual.
