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Randomized Controlled Trial
. 2023 Apr 3;63(4):ezad041.
doi: 10.1093/ejcts/ezad041.

Warm versus cold blood cardioplegia in paediatric congenital heart surgery: a randomized trial

Serban Stoica  1 , Helena J M Smartt  2   3 , Rachael Heys  2   3 , Karen Sheehan  1   3 , Terrie Walker-Smith  2   3 , Andrew Parry  1 , Richard Beringer  1 , Iakovos Ttofi  1 , Rebecca Evans  2   3 , Lucy Dabner  2   3 , Mohamed T Ghorbel  4 , William Lansdowne  1 , Barnaby C Reeves  2   3 , Gianni D Angelini  3   4 , Chris A Rogers  2   3 , Massimo Caputo  1   4
Affiliations
Randomized Controlled Trial

Warm versus cold blood cardioplegia in paediatric congenital heart surgery: a randomized trial

Serban Stoica et al. Eur J Cardiothorac Surg. .

Abstract

Objectives: Intermittent cold blood cardioplegia is commonly used in children, whereas intermittent warm blood cardioplegia is widely used in adults. We aimed to compare clinical and biochemical outcomes with these 2 methods.

Methods: A single-centre, randomized controlled trial was conducted to compare the effectiveness of warm (≥34°C) versus cold (4-6°C) antegrade cardioplegia in children. The primary outcome was cardiac troponin T over the 1st 48 postoperative hours. Intensive care teams were blinded to group allocation. Outcomes were compared by intention-to-treat using linear mixed-effects, logistic or Cox regression.

Results: 97 participants with median age of 1.2 years were randomized (49 to warm, 48 to cold cardioplegia); 59 participants (61%) had a risk-adjusted congenital heart surgery score of 3 or above. There were no deaths and 92 participants were followed to 3-months. Troponin release was similar in both groups [geometric mean ratio 1.07; 95% confidence interval (CI) 0.79-1.44; P = 0.66], as were other cardiac function measures (echocardiography, arterial and venous blood gases, vasoactive-inotrope score, arrhythmias). Intensive care stay was on average 14.6 h longer in the warm group (hazard ratio 0.52; 95% CI 0.34-0.79; P = 0.003), with a trend towards longer overall hospital stays (hazard ratio 0.66; 95% CI 0.43-1.02; P = 0.060) compared with the cold group. This could be related to more unplanned reoperations on bypass in the warm group compared to cold group (3 vs 1).

Conclusions: Warm blood cardioplegia is a safe and reproducible technique but does not provide superior myocardial protection in paediatric heart surgery.

Keywords: Cardiac surgery; Cardioplegia temperature; Cardiopulmonary bypass; Clinical trials; Paediatrics; Randomized.

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Figures

Figure 1:
Figure 1:
(A) Primary outcome: cardiac troponin T concentrations over time. Geometric mean and 95% CI of cardiac troponin T level at each time point and GMR for the effect of IWBC versus ICBC on cardiac troponin T release (95% CI). Data from 95 patients (46 allocated ICBC, 49 allocated IWBC) contributed to the analysis (missing baseline was imputed for 1 patient allocated ICBC). (B) Secondary outcomes. CI: confidence interval; CVS: central venous saturation; GMR: geometric mean ratio; HR: hazard ratio; ICBC: intermittent cold blood cardioplegia; IWBC: intermittent warm blood cardioplegia; LV: left ventricular; MD: mean difference; OR: odds ratio; PICU: paediatric intensive care unit; RV: right ventricular; VIS: vasoactive-inotropic score; XC: cross-clamp.
Figure 2:
Figure 2:
Blood gas levels over time. Geometric mean and 95% CI at each time point and GMR and 95% CI for the effect of IWBC versus ICBC on lactate (A). Arithmetic mean ± standard deviation at each time point and MD and 95% CI for the effect of IWBC versus ICBC on base excess (B) and pH (C). CI: confidence interval; GMR: geometric mean ratio; ICBC: intermittent cold blood cardioplegia; IWBC: intermittent warm blood cardioplegia; MD: mean difference; XC: cross-clamp.
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References

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