Understanding Del Nido Cardioplegia in Adult Cardiac Surgery
Del Nido cardioplegia, a crystalloid-based myocardial protection solution developed in the 1990s for pediatric cardiac surgery, is now widely used in adult procedures. This comprehensive narrative review by Najmuddin et al. (2025) evaluates Del Nido’s efficacy, comparing it with conventional blood-based cardioplegia in coronary artery bypass grafting (CABG), valve surgeries, and complex cardiac operations.
Historical Background and Development
Cardioplegia has evolved significantly since its inception in the 1950s. Initially met with skepticism due to myocardial complications, modifications eventually led to the adoption of safer, more effective solutions. Del Nido cardioplegia emerged as a single-dose strategy to prolong myocardial arrest while minimizing ischemia-reperfusion injury, especially beneficial in surgeries requiring longer arrest times.
Mechanism of Action and Composition
Del Nido cardioplegia functions by inducing a depolarized arrest through high potassium content, while lidocaine and magnesium act synergistically to prevent intracellular calcium overload—a major cause of reperfusion injury. Its composition includes PlasmaLyte-A, potassium chloride, sodium bicarbonate, lidocaine, mannitol, and magnesium sulfate. The solution is typically mixed in a 1:4 blood-to-crystalloid ratio.
Clinical Efficacy and Comparative Benefits
Del Nido cardioplegia shows several clinical advantages over traditional solutions:
- Longer Arrest Duration: A single dose can last up to 90 minutes, reducing the need for repeated dosing.
- Shorter Cross-Clamp and Bypass Times: Due to fewer interruptions, procedures are more streamlined.
- Reduced Myocardial Injury: Studies report lower postoperative levels of troponin and CK-MB.
- Lower Transfusion Needs: Crystalloid composition minimizes hemodilution, decreasing the need for blood products.
- Improved Recovery: Antiarrhythmic properties of lidocaine contribute to better postoperative rhythm control.
Global Adoption and Research
Since its first adult use in 2003, Del Nido cardioplegia has gained global acceptance. Institutions across the U.S., India, and Europe report positive outcomes. Numerous studies support its safety and efficacy, with some highlighting superiority in myocardial protection, especially in high-risk or elderly populations.
Special Considerations and Modified Applications
Variants like tepid Del Nido and modified versions for heart transplantation have also shown promising results. Some studies explored substituting PlasmaLyte-A with Ringer’s lactate, maintaining clinical outcomes. Its potential use in patients with cold agglutinins and asanguinous applications highlight its versatility.
Limitations and Controversies
Not all findings are conclusive. Some studies show no significant difference in biomarkers or operative times compared to traditional cardioplegia. Concerns also exist around its use in complex multi-vessel CABG cases, where uneven distribution may require additional dosing.
Conclusion
Del Nido cardioplegia offers a compelling alternative to conventional blood cardioplegia in adult cardiac surgery. It balances ease of use, myocardial protection, and cost-efficiency. While further randomized trials are necessary to standardize protocols, existing evidence strongly supports its broader adoption.
