Network meta-analysis comparing blood cardioplegia, Del Nido cardioplegia and custodiol cardioplegia in minimally invasive cardiac surgery

Introduction Minimally invasive cardiac surgery has been evolving, with the intention of reducing surgical trauma, improve cosmesis and patient satisfaction. Single dose, crystalloid cardioplegia such as Del Nido cardioplegia and Custoidol solution have been increasingly used to reduce the interruption from repeating cardioplegia dosing to minimise the cardiopulmonary bypass and cross clamp time. However, the best cardioplegia for myocardial protection in adult minimally invasive cardiac surgery remains controversial. We aimed to conduct a meta-analysis to analyse the current evidence in the literature. Method A systematic review and meta-analysis was performed following the updated 2020 PRISMA guideline. Articles published in the five major electronic databases up 1st of April 2021 were identified and reviewed. The primary outcome was in-hospital or 30-day mortality. Traditional pairwise and Bayesian network meta-analyses were conducted. Results Nine articles were included in this study. The use of Del Nido cardioplegia was associated with a lower volume of cardioplegia used (Del Nido vs Blood, 1105.62 mL+/-123.47 vs 2569.46 mL+/-1515.52, p<0.001), cardiopulmonary bypass (Del Nido vs Custoidol vs Blood: 91.67+/−14.78 vs 138.05 +/− 21.30 vs 119.38+/−26.91 minutes, p<0.001) and cross-clamp time (Del Nido vs Custoidol vs Blood: 74.99+/−18.55 vs 82.01 +/− 17.28 vs 93.66+/−8.88 minutes, p < 0.001). No differences were observed in the incidence of in-hospital/30-day mortality rate, new onset of atrial fibrillation and stroke. Ranking analysis showed the Custoidol solution has the highest probability to be the first ranked cardioplegia. Conclusion No differences were found between blood and crystalloid cardioplegia in adult minimally invasive cardiac surgery in several clinical outcomes. The cardioplegia of choice in minimally invasive cardiac surgery remains the surgeons’ decision and preference.