What are the differences between Buckberg (cardioplegia) solution, microplegia, and Del Nido (cardioplegia) solution?

From the Guidelines

For most adult cardiac surgeries, Buckberg (4:1 blood cardioplegia) is recommended as the standard approach due to its excellent myocardial protection and widespread familiarity among surgical teams. Buckberg cardioplegia consists of a blood-based solution mixed in a 4:1 ratio with a crystalloid component containing potassium (typically 20-30 mEq/L), magnesium, and buffers. It requires repeated doses every 15-20 minutes during cross-clamp time. Microplegia is a modified blood cardioplegia that uses a much smaller crystalloid component (typically 50-60 mL/L of blood), allowing for less hemodilution while still delivering potassium and other additives. Del Nido cardioplegia is a single-dose solution that contains blood and crystalloid in a 1:4 ratio with additives including lidocaine, magnesium, and potassium, providing myocardial protection for up to 90 minutes without redosing.

Key Considerations

• The choice between these solutions should be based on specific surgical needs, with Buckberg offering reliable protection with frequent redosing, microplegia providing similar protection with less hemodilution, and del Nido offering extended protection with a single dose at the cost of more crystalloid volume.
• According to the 2022 guidelines on enhanced recovery after cardiac surgery under cardiopulmonary bypass or off-pump 1, no technique or type of cardioplegia showed any superiority compared to another in terms of clinical endpoints (mortality, neurological complications, atrial fibrillation, myocardial injury reflected by an enzyme elevation).
• The 2019 EACTS/EACTA guidelines on cardiopulmonary bypass in adult cardiac surgery 1 suggest that the use of blood cardioplegia solutions should be considered as the preferred strategy in patients with anaemia, low BSA and chronic kidney disease or patients undergoing complex procedures to reduce haemodilution and the risk of subsequent complications including AKI, bleeding and the need for transfusions perioperatively.

Clinical Implications

• The decision to use Buckberg, microplegia, or del Nido cardioplegia should be individualized based on the patient's specific needs and the surgical team's expertise.
• The use of del Nido cardioplegia may be advantageous in minimally invasive procedures, congenital cases, and situations where repeated cardioplegia administration is challenging, as it provides extended protection with a single dose 1.
• However, the choice of cardioplegia solution should always prioritize the patient's safety and the potential risks and benefits associated with each option, as highlighted in the guidelines 1.

From the Research

Buckberg vs Microplegia vs Del Nido Cardioplegia

• The del Nido cardioplegia solution has been compared to Buckberg cardioplegia in several studies, with results showing that del Nido cardioplegia may be a feasible alternative to conventional Buckberg cardioplegia 2.
• A study comparing del Nido and Buckberg cardioplegia in adult isolated valve surgery found that del Nido solution can be used safely and effectively as an alternative to Buckberg solution, with lower insulin requirements and potential time and cost savings 3.
• In terms of microplegia, a study comparing del Nido cardioplegia and microplegia in patients undergoing elective mitral valve replacement found that del Nido cardioplegia had some advantages over microplegia, including shorter cross-clamp and cardiopulmonary bypass times, and lower intensive care costs 4.
• The use of del Nido cardioplegia in adult cardiac surgery has also been evaluated in a prospective randomized trial, which found that del Nido cardioplegia may be safe and result in comparable clinical outcomes to whole blood cardioplegia, with a trend towards superior myocardial protection 5.
• Key differences between del Nido, Buckberg, and microplegia cardioplegia solutions include their composition and the way they are administered, with del Nido cardioplegia being a non-glucose-based, single-dose solution 6.
• Overall, the choice of cardioplegia solution depends on the specific surgical needs and patient population, and del Nido cardioplegia may be a useful alternative to Buckberg and microplegia cardioplegia in certain situations 2, 3, 4, 5.