Practical Technique

Perfusion
2024, Vol. 0(0) 1–4
A hardshell reservoir technique for administering © The Author(s) 2024
Article reuse guidelines:
del Nido cardioplegia sagepub.com/journals-permissions
DOI: 10.1177/02676591241260859
journals.sagepub.com/home/prf

Giuseppe Comentale,  Alessandra Notarnicola, Ilaria Ruffo,

Paola Bianca Pisco, Anna Milione, Antonio Pacciolla,
Anna Damiano, Concetta Calanni and Emanuele Pilato

Abstract
Introduction: The use of del Nido cardioplegia has increased in the adult cardiac surgery population. Centers have adopted
the formula with a variety of circuit systems. This report includes our set up for delivering 1:4 (blood: crystalloid) del Nido
cardioplegia.
Materials and Methods: A homemade circuit for cardioplegia administration was built with a pediatric reservoir, a roller
pump, a coil cooler, a 3/16-inch circuit to administer and recycle cardioplegia, and two ¼-inch tubes to collect the patient’s
blood.
Technique: The circuit allows the perfusionist to collect the blood directly from the cardiopulmonary bypass arterial limb of
the circuit, to precisely mix it with the crystalloid component of the del Nido cardioplegia solution already in the reservoir,
and to administer the final solution under strictly controlled parameters.
Summary: We present a circuit design that can accurately measure and administer del Nido cardioplegia through the use of a
roller pump and a pediatric reservoir. It simplifies and enhances the accuracy and efficiency of cardioplegic administration in
our practice.

Keywords
del Nido cardioplegia, cardioplegia circuit, cardioplegia

Introduction measure as infusion bags are not graduated, especially in

del Nido cardioplegia has gained popularity in adult
cardiac surgery as many authors reported its advantages
in coronary artery bypass, valves, aortic, and redo
surgeries1–3; however, many questions still remain un-
answered, especially concerning the redosing strategy.4
Cardioplegia circuit design also varies among adult
cardiac surgery practices with some utilizing traditional
single-pass systems and others utilizing recirculating
systems.5
In its original protocol for adult patients (>70 kg), del
Nido cardioplegia has to be mixed with the patient’s own
blood in a 1:4 (blood:crystalloid) ratio (5). Our program
protocol formerly included mixing 1L of the crystalloid
component with 250 mL of patient arterial blood off of
the surgical field. This final cardioplegia mixture was
then injected into the coronary artery through a pressure
infusion bag. That system usually did not allow the
precise assessment of the infusion pressure and makes
the exact amount of cardioplegia to mix more difficult to
patients weighing less than 70 kg or during redosing
procedures. Additionally, the collection of blood to
manually add to the cardioplegia bags increases the risk
of bloodstream infections.
Our updated technique includes a homemade
circuit design for cardioplegia infusion that uses a
pediatric reservoir and a roller pump to collect blood
from the arterial limb of the cardiopulmonary bypass
(CPB), recirculate and mix the final solution, and
administer it.
Division of Cardiac Surgery, Department of Advanced Biomedical
Sciences, University of Naples “Federico II”, Naples, Italy
Corresponding author:
Giuseppe Comentale, Division of Cardiac Surgery, Department of
Advanced Biomedical Sciences, Azienda Ospedaliera Universitaria
“Federico II”, Via S. Pansini n°5, Naples 80131, Italy.
Email: giuseppe.comentale1990@gmail.com
2 Perfusion 0(0)
Materials and methods
This homemade circuit design for adult cardioplegia
delivery has been derived from the pediatric cardiac
surgery experience in our center. It was made up of a
Pediatric Reservoir (Inspire, LivaNova, Italy), a roller
pump, a coil cooler, a 3/16-inch circuit to administer
and recycle cardioplegia, and two ¼-inch tubes to collect
the patient’s blood (Figure 1). The 1/4-inch tube from
the oxygenator is connected to the top of the car-
dioplegia reservoir where there is the line by which del
Nido solution flows from the manufacturer bag into the
reservoir. At the bottom, a 1/4-inch line comes out,
passes into the roller pump and the coil cooler, and ends
in a switch that splits the circuit into two lines: one line is
used to recycle the cardioplegia to the reservoir and the
other is used to administer cardioplegia to the patient.
Technique
Before the start of CPB, a perfusionist fills the pediatric
reservoir with 1000 mL of del Nido solution (its com-
position and administration protocol was that provided
by the manufacturer:1000 mL of Plasma-Lyte A solu-
tion, 3,25 gr of Sodium Mannitol, 2 gr of Magnesium
Sulphate, 12,3 mEq of Sodium Bicarbonate, 29,3 mEq of
Potassium chloride and 130 mg of 2% Lidocaine) and
starts to recycle it through the coil cooler to maintain its
temperature at 4°C and to fill the whole circuit. At the
completion of priming, the pediatric reservoir will have
approximately 800 mL of del Nido solution. Some
minutes after CPB is started, the clamp on the 1/4-inch
line that goes out from the arterial inflow lines is
Figure 1. Schematic representation of the homemade cardioplegic infusion circuit.
removed and the perfusionist adds 250 mL of the pa-
tient’s blood to the pediatric reservoir, obtaining a total
amount of 1050 mL of del Nido Cardioplegia; this
ensures a good mixture with the circuit. If there is a need
to add bank blood to the prime, while rare, this avoids
having citrate in the cardioplegia solution. After that, the
3/16-inch line that goes to the patient remains closed
and the perfusionist recycles the cardioplegia by acti-
vating the roller pump and removing the clamp of the
recycle line to mix the final solution (Figure 2); the
volume of 250 mL of patient’s blood, indeed, is necessary
to preserve the 1:4 ratio as the volume of crystalloid
component that fills the whole circuit is 1000 mL. When
the surgeon is ready to administer the solution, the
cardioplegia circuit recirculation is clamped and the
cardioplegia flows into the 3/16-inch line towards the
patient, monitoring the cardioplegia circuit pressure for
a typical target value of 80-100 mmHg. For patients
heavier than 70 kg, it is almost always necessary to
administer 1000 mL of the final solution,5 leaving 50 mL
in the reservoir to not fully empty it in case of need for a
second dose.
Discussion
One of the main limitations about the use of del Nido
cardioplegia in adult cardiac surgery is the loss of high-
volume data especially regarding its re-dosing strategy
and a well-standardized population.6,7 Many surgeons
re-dose this cardioplegia between 60 and 90 min with
250 or 500 mL of the original “first dose”8 but many
concerns have been raised about the negative effect of a
high dose of lidocaine. Chung et al. recently proposed a
Comentale et al.
Figure 2. Real picture of pediatric reservoir and circuit used for
del Nido cardioplegia infusion.
novel “reverse” ratio for del Nido cardioplegia redosing
where the blood part is much more represented com-
pared to the del Nido Solution in a 4:1 ratio, justifying
this strategy to avoid the detrimental effects of lidocaine
excess on cardiac inotropy and on peripheral vasodi-
latation.9 All these scenarios, however, require a well-
balanced mixing of a small amount of the patient’s blood
with del Nido solution which can be very difficult to
perform using the commonly used infusion bags; the
need to physically remove the blood from the CPB by a
syringe and to add to the final solution could increase
the risk of infection. Our technique creates a “closed”
circuit that not only allows for easier preparation of the
final solution but even makes the administration much
more precise; in this way, redosing is faster and more
controlled as the reservoir acts like a “mixer” where is
prepared the perfect ratio that has been planned. The
pediatric reservoir, in addition, allows even to use it to
quickly change the cardioplegic strategy in case of the
need for a second cross-clamp which many authors
suggested to shift on conventional blood cardioplegia.6
Our circuit is essentially the same as the original
circuit reported by del Nido5 or similar to the Kole
cardioplegia chamber; however, we have elected to
control recirculation at the perfusionist’s side of the
circuit using a hardshell reservoir instead of a bag. A
3
concern about this circuit could be related to the slightly
higher costs compared to a simple circuit made up of
infusion bags but in our opinion, this difference is very
negligible compared to the costs of the whole operation.
The costs of the pediatric reservoir, however, could be
even balanced by those of the disposable cooler that
circuits with infusion bags require.
Conclusion
We created a recirculating del Nido cardioplegia circuit
for adult cardiac surgery. This setup is easy for the
surgeon and perfusionist to control and allows for
precise delivery during initial dosing and redosing, as
needed.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
Ethical statement
Ethical approval
IRB approval was not necessary.
Informed consent
Informed consent was obtained.
ORCID iD
Giuseppe Comentale  https://orcid.org/0000-0003-3176-
5391
References
1. Ad N, Holmes SD, Massimiano PS, et al. The use of del
Nido cardioplegia in adult cardiac surgery: a prospective
randomized trial. J Thorac Cardiovasc Surg 2018; 155:
1011–1018. DOI: 10.1016/j.jtcvs.2017.09.146.
2. Sanetra K, Gerber W, Shrestha R, et al. The del Nido
versus cold blood cardioplegia in aortic valve replace-
ment: a randomized trial. J Thorac Cardiovasc Surg
2020; 159: 2275–2283.e1. DOI: 10.1016/j.jtcvs.2019.05.
083.
3. Comentale G, Pilato E. Safety of del Nido cardioplegia
during frozen elephant trunk procedure: A case report of
first experience in complex aortic surgery. Perfusion 2023;
39(4): 833–835. DOI: 10.1177/02676591231157202.
4 Perfusion 0(0)
4. Waterford SD, Ad N. Del Nido cardioplegia: questions and
(some) answers. J Thorac Cardiovasc Surg 2023; 165(3):
1104–1108. DOI: 10.1016/j.jtcvs.2021.11.053.
5. Matte GS, del Nido PJ. History and use of del Nido car-
dioplegia solution at Boston Children’s Hospital. J Extra
Corpor Technol. 2012; 44(3): 98–103. Erratum in: J Extra
Corpor Technol. 2013 Dec;45(4):262.
6. Likosky DS, Wu X, Fitzgerald DC, et al. Evaluating
Changes in del Nido Cardioplegia Practices in Adult
Cardiac Surgery. J Extra Corpor Technol 2020; 52(3):
173–181. DOI: 10.1182/ject-2000014.
7. Hawkins RB, Stewart JW, Wu X, et al. del Nido versus
blood cardioplegia in cardiac surgery: A multicenter
analysis of over 40,000 patients. J Thorac Cardiovasc Surg.
2023. DOI: 10.1016/j.jtcvs.2023.09.057, In press.
8. Waterford SD, Ad N. Del Nido cardioplegia: questions and
(some) answers. J Thorac Cardiovasc Surg 2023; 165(3):
1104–1108. DOI: 10.1016/j.jtcvs.2021.11.053.
9. Chung MM, Erwin WC, Ning Y, et al. A novel dosing
strategy of del Nido cardioplegia in aortic surgery.
JTCVS Open 2022; 10: 39–61. DOI: 10.1016/j.xjon.2022.
04.028.