Children's Hospital at Saint Francis Tulsa OK ... - Perfusion.com

Children’s Hospital at Saint Francis 

Tulsa OK 

Extended One Injection 

Cardioplegia in a 22 Kilo Pediatric 

Patient with Custodiol® 

• Hisashi Nikaidoh, M.D. 

• MaryJane Barth, M.D. 

• Jorge Molina, PA-C, CCP

Boston Children’s Hospital 

Boston 

Willie Gieser 

Bob Howe 

Bob LaPierre 

1963-2009

How did I hear about it? 

Custodiol 

Mexico City Perfusion Meeting 50 th yr. 

November 2006

Only for the real sick 

patients? 

Because of 

cost of Custodiol?

Techniques Myocardial 

Perservation 

• Blood vs. Crystaloid 

• Antegrade vs. Retrograde 

• Single Shot vs. Intermittent 

• Cold vs. warm 

• Dosage: Volume vs. time 

• High K+ vs. normal K+ 

• Electromechanical arrest vs. V.Fib 

• Etc., etc. etc…….. Open minded

Cardioplegia: Evidence Based? 

According to the American Heart Association / 

American College of Cardiology guidelines for 

scientific evidence: 

• Myocardial Protection is experience based 

• Class III Evidence: Principle for which there is no 

sufficient scientific evaluation about the usefulness, 

efficacy, or both, of a procedure or treatment, using invitro 

studies and animal studies

Ratios 4:1 & 1:4

History 

Rethinking Cardioplegia Solutions 

• 1961: Dr. Hoelscher – identifies citrate as issue; suggests 

MgCl and procaine 

• 1964: Dr. Bretschneider – develops multi-component 

cardioplegia solution; tweaked & eventually marketed as 

Custodiol HTK 

• 1973: Dr. Gay & Ebert – hypothermic potassium based 

arrest 

• 1976: Dr. Hearse – landmark publication on ideal 

components of cardioplegia; St. Thomas Solution is born 

• 1978: Dr. Buckberg – blood as cardioplegia vehicle; 

intermittent reinfusion; substrate additives

AKA 

• Bretschneider Solution 

• HTK Solution 

Description 

HTK: Histidine – Tryptophan – Ketoglutarate 

A flush and preservation solution used for multi-organ protection 

including heart, liver, kidney, pancreas, and lungs 

Currently awaiting FDA approval as cardioplegia in US 

www.custodiol.com

Custodiol: How It’s Made 

$190 / Liter 

Shelf life: 1 year 

www.custodiol.com

Custodiol: How It Works 

Two Prong Approach 

• Electromechnical Arrest 

–Slight high K+ (9 mEq) to help get initial arrest (.5-1 

min) 

–Electrical inactivity: Via Na equilibration of 

extracellular & intracellular (cytoplasmic) levels 

–Mechanical inactivity: Via virtually non-existent 

calcium content 

• Buffer 

–Histidine: An amino acid buffer that is non toxic, natural, 

temp shift same as neutral point of H2O, pK 6.1 

•Tryptophan: Inhibits histidine entry into the cell 

•Ketoglutarate: Replenishes KREBS cycle / preserves 

ATP

BAGs 

• 0.5 liter(bottle) 

• 1.0 liter 

• 2.0 liters 

• 5.0 liters 

•One year shelf life 

•Storage 2 – 15o C 

•Ready to use

Mission Trip 

Cemesa Hospital: San Pedro Sula, Honduras

Mission Trip Honduras 

1 st Clinical use 

• Echocardiographer stated Custodiol had 

better contraction than Plegisol & Boston 

• Surgeons needed no more explanation 

other than that.

Mission Trip Honduras 

1 st Clinical use 

• Recirculating system 

• As cold as possible 

• No temperature monitoring 

• 1/8 inch i.d. tubing 

• Large bore luers 

• Re-use the conducer 

• Change-out the table line/case

Procedures 

n = 220 (excluding 42 Honduras) 

• VSD 

• Sub AS 

• TAPVR 

• AVR 

• ASD 

• Norwood 

• Ross 

• PAPVR 

• MVReplac 

• MV Repair 

• Pulm. Valve Replac 

• Supra AS 

• Fontan 

• ASO 

• Glenn 

• RVOTO 

• TOF 

• Truncus 

• Atrial Septectomy 

• DORV 

• Translocation 

• Conduit Replacement 

• DKS 

• Pulm. Arterioplasty

Cross-Clamp times 

• 17 minutes – 

mini 

( *Higher incidence fibrillation ? ) 

• 203 minutes – max 

10 cases ≥100 

100(3), 105, 108, 112, 122, 125, 133, 203

DX Procedure CPB Xclamp 

VSD/PS VSD/PS 86 59 

ASD ASD 40 17 

SubAS SubAS resection 42 26 

AVC AVC repair 118 91 

TruncusArt TruncusArt Repair 127 71 


ASD Primum Repair ASD Primum 72 43 

SV Fontan 101 67 

SV Modify Fontan 64 29 

MR MV repair 105 62 

RV Conduit Stenosis Repl. RV-MPA conduit 85 59 

VSD VSD P Closure 61 35 

RV Conduit Stenosis/ASD Repl. RV-MPA conduit/ASD 130 89 

IAA/VSD/PDS/ASD Repair IAA/VSD/ASD/PDA 127 55 

TOF/ASD TOF/ASD (NTA) 94 71 

ASD Secundum/UnRoCS Patch repair 82 51 

PAPVR PAPVR repair 71 47 

VSD/SubAS VSD Closure/Sub AS resection 61 32 

TGV/VSD/ASD/PDA ASO/VSD/ASD/PDA 133 69 

TAPVR TAPVR/ASD/PDA/ECMO 61 32

AS/AI Ross 178 91 

RVOT Obst/Thrombus SVC RVOT Rep/Thrombectomy 62 59 

RCA anomalous Unroofing of RCA 58 31 

VSD/ASD/PDA VSD/ASD/PDA Repair 74 54 

TOF/ASD/sp Shunt TOF/ASD (NTA) ShuntTD 112 86 

TAPVR mixed TAPVR repair 76 27 

TGV/VSD/ASD/PDA ASO/VSD/ASD/PDA 159 71 


TAPVR infra Repair TAPVR 64 38 

AS/AI AVR 98 72 


ASD ASD P Closure 42 20 

HLHS Norwood 173 66 


MR MV Replacement 171 108 

TOF ASD TOF ASD 181 98 

SV/DILV/LTGV/Dextrocardia Glenn 93 57 

RVOT Obst/postTOF RVOT Rep 57 29 


Coartation/Hypoplastic Ao Ar Patch repair 67 33 

ASD Secundum/TI ASD P Closure/Tricuspid Valvuplasty 50 31


TruncusArt TruncusArt Repair 110 85 

SV LTGV PS RestrASD s/pShunt BT Glenn/AtrialSeptectomy/Lig Shunt/PA Div. 71 27 

TAVPVR/SV/PA/TGA TAPVR repair Central Shunt 95 35 


SV Fontan 70 25 

ASD ASD Closure 28 18 

Conduit stenosis Replacement of Conduit 120 88 

ASD Primum ASD Patch Primum repair 65 54 

TGV/SV/PS/Dextrocardia Shunt/Atrial Septectomy/PA plasty 99 10 

TOF/Hypoplasia Pas RVOT Patch 59 35 

TOF TOF repair 85 69 

TGA/VSD/ASD/PDA ASO/VSD/ASD/PDA 134 86 


RV conduit stenosis Conduit replacement 234 133 

VSD VSD P Closure 42 26 


TGA/ASD/PDA ASO/ASD/PDA 127 86 

SV DKS 144 71 



RV Conduit Stenosis/VSD/ASD Conduit replacement/VSD/ASD 107 67

ASD Primum ASD Primum repair 66 45 




PS/Supra PS Pulmonary Valvotomy/Arterioplast 47 31 

SubAS/Supra AS Repair SubAS/Supra AS 159 96 


TAPVR TAPVR repair 102 59 

ASD ASD repair 52 24 

DORV/ASD/PDA DORV/ASD/PDA repair 69 48 


TGV/VSD/PS/Dextrocardia Translocation 182 103 

RV-MPA conduit stenosis Conduit Replacement 180 78 

DILV/SV/PAB/GLENN DKS/FONTAN 143 95 

PA hypoplasia Pulmonary Arterioplasty/Shunt Revision 77 49 

VSD/ASD VSD P Closure/ ASD -S- Closure 64 43 

AVC/PDA AVC repair/PDA ligation 155 90 

Conduit stenosis Conduit replacement 168 79 

VSD/ASD VSD/ASD repair 59 40 

Pul. Venous Obstruction Repair Pul Ven. Obstruction s/pTAPVR 81 43

DORV/PA RVOT Patch 68 36 

Ebsteins TV repair 165 100 


TGV/Dextrocardia/PDA/ASD ASO/ASD/PDA 150 90 

DORV DORV/ASD repair 110 69 


RVOTO RVOTO repair 59 34 

ASD/PS ASD/PS repair 67 48 

VSD VSD closure 44 31 

MS/MR Mitral Valve Replacement 154 113 

IAA/Ao. Hypoplasia/VSD/ASD IAA repair/Norwood 167 57 

ASD ASD Patch closure 41 23 

VSD/PAPVR/SUB AS VSD Closure/Sub AS/PAPVR repair 156 105 

VSD VSD Closure 72 56 

Tricuspid Atresia Fontan 121 59 

PS s/p ASO RVOT Patch Infundibular resection 112 58 

Tricuspid Valve Insufficiency Tricuspid Valve Repair 53 30 

ASD Primum ASD Primum repair 57 32 


Supra AS Supra AS repair 96 46 

ASD Secundum ASD Patch closure 41 24 

VSD/ASD VSD Patch Cl / ASD S Closure 62 45 

Anom. RCA Repair Anom. RCA 57 36

Supra AS Supra AS repair 382 47 


PS, recurrent, LCA occluded PA arterioplasty, LAD bypass 194 122 


Supra PS Supra PS repair 169 57 

ASD ASD P Closure 42 27 

TAPVR TAPVR 101 54 

ASD ASD 36 20 

VSD/ASD/Sub PS VSD/ASD/Sub PS repair 55 40 

VSD/SubAS VSD/Sub AS repair 66 46 




VSD/ASD/Prematurity VSD/ASD repair 168 73 

PI/ s/p TOF PVR 27mm 87 48 

PAPVR/ASD PAPVR /ASD repair 68 39 

Sub AS Sub AS resection 56 32 

MS/MR Mitral Valve Replacement 141 89 

Peripheral HypoPAs/VSD/PI Pul Arterioplasty/PVR/VSD 242 150 

TOF/PA/MACAP Repair TOF/PA/MACAP 144 96 

PAPVR (Mixed) PAPVR repair 146 94


SV/PA hypoplasia/RVOTO/AVC unbala. RVOTO patch/arterioplasty/takedownshunt 114 67 

TOF/PA/s/pshunt TOF/Monocup/repair CorMatrix/TD shunt 147 93 

ALCAPA ReImplant Anom L C A 84 61 

DORV/SubPS/RVOTO DORV/SUB PS/RVOTO repair 152 97 

SV/DORV/s/p DKS Glenn Takedown shunt 46 

VSD/ASD/Sub PS VSD/ASD/Sub PS repair 83 49 


Supra AS/Supra PS/PFO Repair Supra AS/ Supra PS/ PFO 111 84 

PAPVR/ASD Repair PAPVR/ASD 51 34 

VSD/ASD VSD/ASD 62 40 

HypoPlastic Ao Arch/Coarct Aortoplasty CorMatrix 106 70 

Anom. RCA Unroofing of RCA 53 29 



SV DILV LTGV DKS Glenn 112 67 

HLHS Glenn 58 


TGV/VSD/PS/ASD Ao. Root Translocation/ ASD 200 105 

ALCAPA Repair ALCAPA 128 84 

RV-MPA conduit stenosis Replacement of Conduit 102 49



Coarct/PA Stenosis/Small MV/AV Coarct repair patch/ PA plasty 110 48 

VSD/ASD/TI VSD/ASD/Tricupsid Valve repair 71 49 

Tricuspid Atresia Fontan 57 

MR/TR/VSD MV/TV/VSD repair 152 112 

SV/NonConful Pas/Dextro/TGA Sano 8mm, Pul Arterioplasty/Septectomy 248 64 

PA/SV/Nonconful Pas Central AP shunt/Pul Arterioplasty 74 

TOF/Tracheal Stenosis TOF repair 146 89 

RPA to Ao/ASD/s/p RPA banding Reimplant RPA/Deband/ASD closure 130 63 

SV/ s/p Fontan/Glenn Div. MPA/ Takedown Fenestration 176 57 


AVC/Common Atrium AVC/Common Atrium repair 107 72 


PI s/p Pul Valvotomy Pul Valve Implantation 94 38 

VSD/PS/PFO VSD /ASD/SubPS repair 111 80 



ASD Secundum ASD P Closure 68 24 

AI/AS Aortoplasty CorMatrix 146 100 

AS/AI Aortoplasty CorMatrix 87 52

SV/PS Glenn/AtrialSeptectomy/PA Div. 88 54 



AI/SubAS Ao Valve Repair/Sub AS resection 83 67 

VSD/AS/AI VSD closure/Ao Valvotomy 72 47 


AVR Root with AS/AI AVR Root Replacement 190 127 

TAPVR, supra ASD TAPVR Supra repair/ ASD closure 62 34 


Ascending Aorta Dilatation Marfans Ascending Ao Rt Replacement 193 132 

AVC/PDA AVC repair/PDA ligation 135 87 


ASD/PDA ASD / PDA closure 45 21 

Conduit stenosis/VSD/ASD/Sub PS Conduit Replac/VSD/ASD/Sub PS resection 187 108 


Anom. RCA Repair Anom. RCA 54 34 

ALCAPA Rep ALCAPA 146 69 

SV/ s/p PAB Bilat/bi-directional Glenns 104 69 

VSD/PDA VSD/PDA closure 97 59 



Supra AS Supra AS repair 88 51

Cases 

One Injection Antegrade 

3 o--- 4 o C 

Conducer Recirculation System 

• Neonates 

• Toddlers 

• Others 

40 ml/kg 

35 ml/kg 

25-30 ml/kg 

• Adults size 1000--1800 ml

Table Line 

Large-bore luers 

Pressure drop 100mmHg-48 inches-30%Hct-30 o C 

• 1/8 -----460 ml/min 

• 5/32 ------760 ml/min 

• 3/16 ------1300 ml/min

Temperature o C 

• Recirculating system 

• As cold as possible 

• No temperature monitoring 

• 1/8 inch i.d. tubing 

• Large bore luers

Case Report: Diagnosis 

• Newborn TGV/ASD/PDA 

• s/p ASO/PDA division - 11/02 

• s/p ECMO, PO exploratory x 3 

• s/p Supra aortic & pulmonary 

arterioplasty – 11/03 

• s/p bilateral PA stents - 2004 

• LV & RV hypertension 

• Supra AS 

• Supra PS 

• Infra PS

Patient 

• 21.9 Kilos 

• 119.5 cm 

• 0.85 m 2 

• 2.4 l/m 2 2.0 l/min

Perfusion Equip 

• AV loop – 1/4 x 3/8 

• Boot – 3/8 

• RX 15 

• Sorin DHF0.2 

• X-coating tubing 

• Recirculating Plegia Conducer System 

• S3 Heart Lung Machine 

• 3T Heater Cooler 208volt

Cannulas 

• Aortic Cannula 14 french DLP 77144 

• SVC Venous 90 o metal tip 18 french DLP CB67318 

• IVC Venous 90 o metal tip 20 french DLP CB67320 

• Ventricular (rupv) vent 16 french DLP 12016 

• Cardioplegia needle 16 gauge DLP 10016

Perfusion 

• CPB -----------273” 

• Cross Clamp-----203” 

• Cardioplegia dose-30ml/kg-660ml 

• Rectal temp. ----20.5 o C 

• No transfusion

Procedure 

“Painful” 

• Contregra RVOT reconst 20mm 

conduit RVOT to MPA (Supra/Infra) 

• (Hemashield ) 

• CorMatrix patch augmentation ascend 

aorta- base non/coronary cusp to 

innominate artery (Hemashield )

Hospitalization 

• August 10 Surgery 4pm(Tuesday) 

• August 12 Extubated 7am 

• August 12 Dopamine/Milrinone dc’d 

• August 17 CTs, wires, A-line dc’d 

• August 17 Transferred to floor 

• August 18 Discharged (Wednesday) 

Meds Lasix 20mg PO bid, OTC pain meds

After Cardioplegia Injection 

Low Sodium 

CUFNS or 3%NS 

(Seattle) 

Hemodilution 

Hemoconcentration

My Surgeons say 

• Focus on defect 

• No ischemic times concerns 

• With electrical activity we 

cool down a few more 

degrees

Colette Calame 

c.calame@att.net 

OKC 

• Tried it on her pediatric 

patients & switched 

• Then converted the four adult 

surgeons – Valves & complex 

redos


c.calame@att.net 

OKC---Adults 

• Max Aortic X-Clamp 5” 23” 

with 3 injections 

• Max Single Aortic X-Clamp 2”


OKC 

No difference if surgeons are 

quick, fast & speedy

Hisashi Nikaicoh, M.D. 

Pediatric Cardiac Surgery 

Childrens Hospital at Saint Francis-Tulsa 

CMC-Dallas 78-08 

Children’s Memorial Hospital-Chicago

Timothy H. Trotter, MD, FACS, FCCP 

Section of Thoracic and Cardiovascular Surgery 

University of Oklahoma 

“I'd leave the mechanics to the people 

paying the bill. The short version is that it 

works and changes the procedure from 

being half myocardial protection and 

half doing the operation you came to do 

to simply doing the operation. Tell them 

to get the lead out and simply start using 

it -- how hard is it to run in 1700ml of 

crystalloid? “

Children's Hospital at Saint Francis Tulsa OK ... - Perfusion.com

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