Document Type : Original Article(s)


1 Associate Professor, Department of Cardiac Surgery, School of Medicine AND Cardiac Rehabilitation Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran

2 Assistant Professor, Department of Cardiac Surgery, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran


BACKGROUND: Cardioplegia is one of the main post-operative cardiac protective factors widely used in recent decades in the form of crystalloid (St. Thomas) and bloody solutions [del Nido (DN)]. The purpose of this study was to compare the effect of a crystalloid cardioplegic agent (St. Thomas) with that of a bloody cardioplegic agent (DN) in pediatric cardiac surgery among children with Tetralogy of Fallot (TOF).METHODS: This study was performed on 60 children with TOF, who were candidates for heart repair surgery. The participants were randomly divided into two groups of crystalloid cardioplegic agent and bloody cardioplegic agent. Operative outcomes such as required time for onset of heart arrest, duration of returning to normal heart rhythm, and cardiopulmonary bypass (CPB) time, and operative complications were compared between the two groups.RESULTS: The duration of returning to normal heart rhythm (50.43 ± 10.93 seconds vs. 43.03 ± 16.35 seconds; P = 0.044) and duration of inotropy (80.40 ± 27.14 hours vs. 63.20 ± 26.91 hours; P = 0.017) were significantly higher in the DN group compared to the St. Thomas group. However, there were no significant differences between the two groups in terms of heart arrest time, cross-clamp time, CPB time, supplementary lasix‎ time, duration of intubation, and intensive care unit (ICU) and hospital length of stay (LOS) (P > 0.050).CONCLUSION: The use of St. Thomas cardioplegic solution was more effective in reducing the duration of returning to normal heart rhythm and inotropy compared with DN cardioplegic agent, and a single dose of these two cardioplegic agents can keep the mean cardiac arrest duration within the range of 50-70 minutes. It seems that the use of St. Thomas cardioplegic solution can be suggested in pediatric heart surgery. 


  1. Kotani Y, Tweddell J, Gruber P, Pizarro C, Austin EH 3rd, Woods RK, et al. Current cardioplegia practice in pediatric cardiac surgery: A North American multiinstitutional survey. Ann Thorac Surg 2013; 96(3): 923-9.
  2. Cooley DA, Reul GJ, Wukasch DC. Ischemic contracture of the heart: "stone heart". Am J Cardiol 1972; 29(4): 575-7.
  3. Yamamoto H, Yamamoto F. Myocardial protection in cardiac surgery: A historical review from the beginning to the current topics. Gen Thorac Cardiovasc Surg 2013; 61(9): 485-96.
  4. Kouchoukos NT, Blackstone EH, Hanley FL, Kirklin JK. Kirklin/Barratt-Boyes Cardiac Surgery E-Book. Philadelphia, PA: Elsevier Health Sciences; 2012.
  5. Feindel CM, Tait GA, Wilson GJ, Klement P, MacGregor DC. Multidose blood versus crystalloid cardioplegia. Comparison by quantitative assessment of irreversible myocardial injury. J Thorac Cardiovasc Surg 1984; 87(4): 585-95.
  6. Fallouh HB, Kentish JC, Chambers DJ. Targeting for cardioplegia: Arresting agents and their safety. Curr Opin Pharmacol 2009; 9(2): 220-6.
  7. Buckberg GD. Antegrade/retrograde blood cardioplegia to ensure cardioplegic distribution: Operative techniques and objectives. J Card Surg 1989; 4(3): 216-38.
  8. Jonas RA. Myocardial protection. In: Jonas R, Editor. Comprehensive Surgical Management of Congenital Heart Disease. Boca Raton, FL: CRC Press; 2004. p. 175-84.
  9. Buel ST, Striker CW, O'Brien JE. del Nido versus St. Thomas cardioplegia solutions: A single-center retrospective analysis of post cross-clamp defibrillation rates. J Extra Corpor Technol 2016; 48(2): 67-70.
  10. Liu J, Feng Z, Zhao J, Li B, Long C. The myocardial protection of HTK cardioplegic solution on the long-term ischemic period in pediatric heart surgery. ASAIO J 2008; 54(5): 470-3.
  11. Charette K, Gerrah R, Quaegebeur J, Chen J, Riley D, Mongero L, et al. Single dose myocardial protection technique utilizing del Nido cardioplegia solution during congenital heart surgery procedures. Perfusion 2012; 27(2): 98-103.
  12. Mimic B, Ilic S, Vulicevic I, Milovanovic V, Tomic D, Mimic A, et al. Comparison of high glucose concentration blood and crystalloid cardioplegia in paediatric cardiac surgery: A randomized clinical trial. Interact Cardiovasc Thorac Surg 2016; 22(5): 553-60.
  13. Fazelifar S, Bigdelian H. Effect of esmolol on myocardial protection in pediatrics congenital heart defects. Adv Biomed Res 2015; 4: 246.
  14. Kim K, Ball C, Grady P, Mick S. Use of del nido cardioplegia for adult cardiac surgery at the cleveland clinic: Perfusion implications. J Extra Corpor Technol 2014; 46(4): 317-23.
  15. Mishra P, Jadhav RB, Mohapatra CK, Khandekar J, Raut C, Ammannaya GK, et al. Comparison of del Nido cardioplegia and St. Thomas Hospital solution-two types of cardioplegia in adult cardiac surgery. Kardiochir Torakochirurgia Pol 2016; 13(4): 295-9.
  16. Gorjipour F, Dehaki MG, Totonchi Z, Hajimiresmaiel SJ, Azarfarin R, Pazoki-Toroudi H, et al. Inflammatory cytokine response and cardiac troponin I changes in cardiopulmonary bypass using two cardioplegia solutions; del Nido and modified St. Thomas':A randomized controlled trial. Perfusion 2017; 32(5): 394-402.
  17. Matte GS, del Nido PJ. History and use of del Nido cardioplegia solution at Boston Children's Hospital. J Extra Corpor Technol 2012; 44(3): 98-103.
  18. Sorabella RA, Akashi H, Yerebakan H, Najjar M, Mannan A, Williams MR, et al. Myocardial protection using del nido cardioplegia solution in adult reoperative aortic valve surgery. J Card Surg 2014; 29(4): 445-9.
  19. O'Brien JD, Howlett SE, Burton HJ, O'Blenes SB, Litz DS, Friesen CL. Pediatric cardioplegia strategy results in enhanced calcium metabolism and lower serum troponin T. Ann Thorac Surg 2009; 87(5): 1517-23.
  20. Talwar S, Bhoje A, Sreenivas V, Makhija N, Aarav S, Choudhary SK, et al. Comparison of del Nido and St Thomas Cardioplegia Solutions in Pediatric Patients: A Prospective Randomized Clinical Trial. Semin Thorac Cardiovasc Surg 2017; 29(3): 366-74.
  21. Suleiman MS, Hancock M, Shukla R, Rajakaruna C, Angelini GD. Cardioplegic strategies to protect the hypertrophic heart during cardiac surgery. Perfusion 2011; 26(Suppl 1): 48-56.
  22. Valooran GJ, Nair SK, Chandrasekharan K, Simon R, Dominic C. del Nido cardioplegia in adult cardiac surgery - scopes and concerns. Perfusion 2016; 31(1): 6-14.
  23. Tsukube T, McCully JD, Federman M, Krukenkamp IB, Levitsky S. Developmental differences in cytosolic calcium accumulation associated with surgically induced global ischemia: Optimization of cardioplegic protection and mechanism of action. J Thorac Cardiovasc Surg 1996; 112(1): 175-84.
  24. O'Blenes SB, Friesen CH, Ali A, Howlett S. Protecting the aged heart during cardiac surgery: The potential benefits of del Nido cardioplegia. J Thorac Cardiovasc Surg 2011; 141(3): 762-70.
  25. Kim JS, Jeong JH, Moon SJ, Ahn H, Hwang HY. Sufficient myocardial protection of del Nido cardioplegia regardless of ventricular mass and myocardial ischemic time in adult cardiac surgical patients. J Thorac Dis 2016; 8(8): 2004-10.
  26. Pourmoghadam KK, Ruzmetov M, O'Brien MC, Piggott KD, Plancher G, Narasimhulu SS, et al. Comparing del Nido and Conventional Cardioplegia in Infants and Neonates in Congenital Heart Surgery. Ann Thorac Surg 2017; 103(5): 1550-6.
  27. Ramanathan R, Parrish DW, Armour TK, Brinster DR. Use of del Nido Cardioplegia in Adult Cardiac Surgery. Thorac Cardiovasc Surg 2015; 63(7): 624-7.
  28. Smigla G, Jaquiss R, Walczak R, Bonadonna D, Kaemmer D, Schwimer C, et al. Assessing the safety of del Nido cardioplegia solution in adult congenital cases. Perfusion 2014; 29(6): 554-8.
  29. Mick SL, Robich MP, Houghtaling PL, Gillinov AM, Soltesz EG, Johnston DR, et al. del Nido versus Buckberg cardioplegia in adult isolated valve surgery. J Thorac Cardiovasc Surg 2015; 149(2): 626-34.
  30. Ota T, Yerebakan H, Neely RC, Mongero L, George I, Takayama H, et al. Short-term outcomes in adult cardiac surgery in the use of del Nido cardioplegia solution. Perfusion 2016; 31(1): 27-33.
  31. Yerebakan H, Sorabella RA, Najjar M, Castillero E, Mongero L, Beck J, et al. Del Nido Cardioplegia can be safely administered in high-risk coronary artery bypass grafting surgery after acute myocardial infarction: A propensity matched comparison. J Cardiothorac Surg 2014; 9: 141.