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Pragliola et al. Vessel Plus 2019;3:22 I http://dx.doi.org/10.20517/2574-1209.2019.003 Page 7 of 9

Comments and Conclusion
Understandably Lazar put forward a few questions about the use of the DNC in high-risk cases with low
[14]
EF%, high Euroscore or high Pulmonary Artery Pressures; adult patients in whom the solution has not been
extensively tested.

We do not have a definite answer to these questions. In our Centre the DNC quickly took over the IWBC
to be the standard solution in use . Over the last 1000 consecutive cases in 2017-2018 we could propensity
[33]
score match 102 pairs including two groups with a high Euroscore II (mean ESII 10) and one with low EF
(EF 30%) in whom the DNC provided sufficient protection without major differences with the IWBC and
allowed the surgeon to focus on the his surgical workflow (data in press). There are not clear guidelines
on cardioplegic solutions and the debate whether it should be warm or cold, blood or asanguineous,
antegrade or retrograde, intermittent, single shot or continuous flooded the surgical literature. Clearly the
perfect myocardial protection is the result of a complex interaction of the surgical team with the procedure
performed, the patient characteristics, the cardioplegic solution and the technique of delivery. This is coming
from practice, consistence and excellence as certainly occurred in all the centres where the DNC was adopted
routinely in adult cases.

A large randomized superiority trial enrolling only high risk cases will be difficult to complete and poses
several potential problems : some ethical and some very practical. To date, as a result, there are not similar
trials registered in the Clinical Trials website.

In conclusion, there is sufficient evidence to engage with the single shot DNC in all the routine cases either
valvular or coronary, especially in minimally invasive procedures. Whether this will expand into the
moderate and high risk cases will depend from the surgical team preferences.

DECLARATIONS
Authors’ contributions
Made substantial contributions to conception and design of the study: Pragliola C, Hassan E
Performed data analysis and interpretation: Pragliola C, Hassan E, Al Gharni KD
Performed data acquisition, as well as provided administrative, technical, and material support: Alfonso JJT,
Al Hossan A, Al Otaibi K, Al Khalaf A.

Availability of data and materials
Not applicable.

Financial support and sponsorship
None

Conflicts of interest
All authors declare that there are no conflicts of interest.

Ethical approval and consent to participate
Not applicable.

Consent for publication
Not applicable.