Cardioplegia delivery during aortic root reconstruction may also offer an opportunity to inspect surgical hemostasis. In a retrospective cohort of 103 patients undergoing Bentall procedures, initial del Nido cardioplegia followed by intermittent blood cardioplegia was associated with less postoperative drainage and fewer re-explorations for bleeding than a conventional double-dose del Nido strategy. The study supports further investigation, but does not establish that the hybrid technique caused these improvements.
Why combine myocardial protection and hemostatic assessment?
The Bentall procedure replaces the aortic root with a valved conduit and requires reimplantation of the coronary buttons. Bleeding from reconstructed root and coronary suture lines can be difficult to address after surgical exposure changes. Arslan and colleagues evaluated a strategy that uses cardioplegia delivery to pressurize the reconstructed root while the surgeon can still directly assess these sites.
The proposed benefit extends beyond myocardial protection: pressurization may reveal small leaks earlier. That mechanism remains an explanation offered by the authors, rather than a measured mediator of the postoperative outcomes.
Study population and comparison
The single-center study reviewed consecutive Bentall operations at Adana City Training and Research Hospital in Türkiye between January 2015 and December 2021. Of 112 patients, 103 met eligibility criteria. The analysis included elective aortic aneurysm surgery and emergency surgery for acute type A dissection, while excluding concomitant total or hemiarch replacement, major preoperative neurological deficits and incomplete records.
Forty-six patients received conventional double-dose del Nido cardioplegia and 57 received the modified hybrid strategy. Treatment was selected according to surgeon preference rather than random allocation. Each of the three primary surgeons used both strategies, and both were used throughout the study period; neither observation eliminates residual confounding.
Reported baseline characteristics, bypass duration and cross-clamp duration were similar. Cardiopulmonary bypass times were approximately 167 minutes in both groups. Mean cross-clamp times were 137.9 minutes with conventional treatment and 130.7 minutes with hybrid treatment, without a statistically significant difference.
What the hybrid strategy involved
Both groups began with antegrade del Nido cardioplegia. In the conventional group, a second dose was routinely given after 75 minutes of cross-clamping, with additional doses every 60 minutes when needed. The hybrid group instead received blood cardioplegia at defined stages of root reconstruction.
After the left coronary button was completed, cardioplegia delivered through a needle cannula in the cross-clamped conduit pressurized the reconstructed root so the team could inspect the left coronary button and proximal valve-graft suture lines. The unreimplanted right coronary ostium received separate selective cardioplegia. After right coronary button reimplantation, another graft-delivered dose preceded distal graft reconstruction.
The supplemental blood cardioplegia was tepid, at 24–28°C. This was a staged reconstruction strategy, rather than simply a terminal warm blood dose immediately before unclamping. The paper describes its institutional del Nido mixture as a 1:4 crystalloid-to-blood ratio; that detail is important when considering applicability and should not be silently interpreted as a different mixture. The published protocol is a study description, not a universal dosing recommendation.
Less drainage and fewer re-explorations
Median 24-hour drainage was 450 mL (interquartile range 350–550) with hybrid treatment and 550 mL (400–650) with conventional treatment, a 100 mL difference in group medians (P = 0.005).
Re-exploration for bleeding occurred in 2 of 57 hybrid patients (3.5%) and 9 of 46 conventional patients (19.6%; P = 0.011). The authors reported an unadjusted odds ratio of 0.15, with a 95% confidence interval of 0.03–0.73. The observed absolute difference was 16.1 percentage points, but it came from only 11 events and cannot be treated as a proven treatment effect.
Blood product requirements did not differ significantly. Median red cell transfusion was 3 units in both groups (P = 0.112), and median fresh frozen plasma transfusion was 2 units in both groups (P = 0.339). Platelet transfusion also showed no significant difference (P = 0.147). The bleeding findings therefore did not translate into a demonstrated reduction in transfusion exposure in this cohort.
Recovery and mortality outcomes
Mechanical ventilation duration, ICU stay and hospital stay did not differ significantly. In-hospital mortality was 3.5% in the hybrid group and 4.3% in the conventional group (P = 1.000). With so few deaths, the study could not establish equivalence or exclude clinically important differences.
The team reported consistent perioperative anticoagulation, protamine reversal, antifibrinolytic treatment and routine topical fibrin sealant use across groups. Viscoelastic testing was not routinely used. These institutional conditions help define the setting in which the association was observed.
Limitations that affect interpretation
The retrospective, nonrandomized design and single-center population limit causal inference and generalizability. Similar measured baseline characteristics do not establish that the groups were comparable on all factors affecting bleeding. With only 11 re-explorations, the investigators avoided extensive multivariable modeling and propensity-based balancing, leaving important potential confounding unresolved.
Re-exploration decisions reflected overall clinical assessment and surgical team consensus rather than a fully standardized objective threshold. Patient-level chest-tube configurations were insufficiently documented for reliable comparison, which could affect interpretation of drainage volume. Operative reports also did not systematically record the additional hemostatic sutures placed during pressurization, so the proposed mechanism could not be directly tested.
Patients undergoing arch reconstruction were excluded, and an exploratory elective-only subgroup analysis does not establish a definitive subgroup benefit. Larger prospective multicenter studies with standardized hemostatic assessment and systematic recording of surgical corrections are needed.
Relevance for perfusion teams
The study highlights how the timing, route and temperature of cardioplegia can intersect with surgical workflow. Its practical research message is the value of coordinating myocardial protection with inspection of reconstructed root suture lines. It does not establish superior myocardial protection, a mortality advantage or a broadly applicable replacement for existing cardioplegia protocols.
Source: Arslan AS, Karaca S, Özsöyler İ. A Modified Hybrid Cardioplegia Strategy Associated with Reduced Postoperative Bleeding and Re-Exploration Following Bentall Procedures: A Retrospective Single-Center Observational Study. Journal of Cardiovascular Development and Disease. 2026;13:353. doi:10.3390/jcdd13080353.
Funding and disclosures: The authors report no external funding and no conflicts of interest. The original article is open access under the Creative Commons Attribution (CC BY) license.
