A clinical trial comparing how well two solutions protect the heart during heart surgery in children

ISRCTN ISRCTN13638147
DOI https://doi.org/10.1186/ISRCTN13638147
EudraCT/CTIS number 2021-001915-10
IRAS number 279068
Secondary identifying numbers CPMS 49735, Grant Codes: CS/20/3/34738, IRAS 279068
Submission date
26/07/2021
Registration date
28/07/2021
Last edited
16/04/2025
Recruitment status
No longer recruiting
Overall study status
Completed
Condition category
Circulatory System
Prospectively registered
Protocol
Statistical analysis plan
Results
Individual participant data
Record updated in last year

Plain English summary of protocol

Background and study aims
This study aims to improve the outcomes of children’s heart surgery so that they recover faster with fewer complications. Children with congenital heart defects often need operations to correct the abnormalities that they were born with. The surgery is complex and usually involves a period of support on a heart-lung machine (cardiopulmonary bypass). This allows the heart to be stopped for a short period of time, using a fluid called cardioplegia solution, whilst the defect is repaired. Inevitably, any surgery puts a strain on the heart and has the potential to cause damage. In this study, we will compare two types of cardioplegia solution used to stop the heart: del Nido, the most commonly used in children in the US, and St Thomas’, currently the standard practice in the UK, to determine which solution protects the heart better, and whether children recover faster and with fewer complications, so that we can improve the outcomes of children’s heart surgery.

Who can participate?
Children aged less than 16 years who are undergoing heart surgery requiring cardioplegia.

What does the study involve?
During the operation, the heart will need to be stopped for a period of time so that the surgeon can repair the heart defect. Being involved in this study will not affect whether the heart needs to be stopped during the operation – the only change will be the type of cardioplegia solution that is used. Both del Nido and St Thomas’ cardioplegia solutions are in routine clinical use in hospitals around the world and have been used in many thousands of children’s heart operations.

What are the possible benefits and risks of participating?
This trial will increase our understanding of which cardioplegia is better in children but there may not be any direct benefit for a child taking part. Whilst some previous studies have suggested that del Nido cardioplegia may better protect children’s hearts during surgery, we do not know if it is beneficial to all children and whether they recover faster with fewer complications - that is why we are conducting this study. We do not know whether being in the study will make your child’s surgery safer, but we are conducting it to understand how to improve the outcomes of children’s heart surgery in the future. Both types of cardioplegia are used routinely for heart surgery in children, del Nido in the US and St Thomas’ in the UK. The operation itself carries a risk, as discussed with the Surgeon and Cardiologist, but being involved in this study causes no additional pain, discomfort, distress or intrusion.

Where is the study run from?
This trial is being coordinated by the DESTINY trial office at Birmingham Clinical Trials Unit (BCTU) and is sponsored by the University of Birmingham (UK).

When is the study starting and how long is it expected to run for?
June 2021 to July 2025

Who is funding the study?
British Heart Foundation

Who is the main contact?
DESTINY trial office, DESTINY@trials.bham.ac.uk

Study website

Contact information

Mr Nigel Drury
Scientific

Department of Paediatric Cardiac Surgery
Birmingham Children’s Hospital
Steelhouse Lane
Birmingham
B4 6NH
United Kingdom

ORCiD logoORCID ID 0000-0001-9012-6683
Phone +44 (0)121 3338731
Email nigel.drury@nhs.net

Study information

Study designInterventional randomized controlled trial
Primary study designInterventional
Secondary study designRandomised controlled trial
Study setting(s)Hospital
Study typeTreatment
Participant information sheet 40206 DESTINY child info sheet v1.0 25Mar2021.pdf
Scientific titledel Nido versus St. Thomas’ blood cardioplegia in the young (DESTINY) trial: a multi-centre randomized controlled trial in children undergoing cardiac surgery
Study acronymDESTINY
Study objectivesIn children undergoing cardiac surgery, the use of del Nido cardioplegia, compared with St. Thomas’ blood cardioplegia, will reduce myocardial injury during surgery
Ethics approval(s)Approved 30/06/2021, West Midlands - Coventry & Warwickshire Research Ethics Committee (The Old Chapel, Royal Standard Place, Nottingham, NG1 6FS, UK; +44 (0)207 104 8009; coventryandwarwick.rec@hra.nhs.uk), ref: 21/WM/0149
Health condition(s) or problem(s) studiedCardiac surgery
InterventionThe trial interventions are either del Nido cardioplegia (experimental arm) or St. Thomas’ blood cardioplegia (control arm). del Nido cardioplegia is administered in a 1:4 blood:crystalloid preparation, given at 4-8°C, with an initial dose of 20ml/kg and subsequent doses every 60-90 minutes if required, at the discretion of the surgeon, as required. St. Thomas’ blood cardioplegia is administered in a 4:1 blood:crystalloid using Harefield Hospital preparation, given at 4-8°C, with an initial dose of 20-30ml/kg, subsequent doses of 15 ml/kg every 20-30 minutes at the discretion of the surgeon, as required.

Blood samples will be taken at several time-points: before the operation, once the child is asleep under anaesthesia; and at 5 timepoints after the operation, at 3, 6, 9, 12 and 24 hours after surgery.

Following surgery, the child will be transferred to the Paediatric Intensive Care Unit and will be closely monitored. Follow-up in the trial will be until 30 days after the index operation.
Intervention typeProcedure/Surgery
Primary outcome measureReduction in area under the time-concentration curve (AUC) for plasma high-sensitivity troponin-I (μg.h/L) in the first 24 hours after the index aortic cross-clamp release (reperfusion).
Secondary outcome measuresCurrent secondary outcome measures as of 14/03/2024:

1. Low cardiac output syndrome (LCOS) defined as either of the following: Vasoactive Inotrope Score (VIS) ≥15, or major cardiac event (cardiac arrest, ECLS or death) in the first 48 hours after reperfusion
2. Duration of mechanical ventilation (hours), defined as the number of hours from termination of index CPB to extubation
3. Length of postoperative stay on Paediatric Intensive Care (hours), defined as number of hours from admission to PICU from theatre following index procedure to discharge from PICU
4. Maximum VIS by thresholds: ≥10, ≥15 and ≥20 in the first 48 hours after reperfusion
5. Total VIS in the first 4 hours after PICU admission following the index procedure (score)
6. Arterial lactate (mmol/L) in the first 12 hours after reperfusion
7. Omega, determined by [SaO2]/[SaO2-ScvO2] in the first 12 hours after reperfusion
8. Total aortic cross-clamp time (mins) during the index procedure
9. Total volume of cardioplegia given (ml) during the index procedure
10. Need for internal defibrillation during reperfusion during the index procedure
11. Delayed sternal closure, incidence and duration (days) following the index procedure
12. Unplanned reoperation, including chest re-opening on PICU, following the index procedure
13. Need for new renal replacement therapy following the index procedure
14. Lowest estimated glomerular filtration rate (eGFR), calculated using the bedside Schwartz equation and the peak postoperative creatinine on routine monitoring during the first 7 days following the index procedure (ml/min/1.73m²), and according to the paediatric RIFLE categories
15. Length of postoperative stay in the hospital (days), defined as number of days from day of the index procedure to discharge from hospital or death, whichever is sooner
16. 30-day survival following the index procedure

_____

Previous secondary outcome measures:

1. Low cardiac output syndrome (LCOS) defined as either of the following: Vasoactive Inotrope Score (VIS) ≥15, or major cardiac event (cardiac arrest, ECLS or death) in the first 48 hours after reperfusion
2. Duration of mechanical ventilation (hours), defined as the number of hours from termination of index CPB to extubation
3. Length of postoperative stay on Paediatric Intensive Care (hours), defined as number of hours from admission to PICU from theatre following index procedure to discharge from PICU
4. Maximum VIS by thresholds: ≥10, ≥15 and ≥20 in the first 48 hours after reperfusion
5. Total VIS in the first 4 hours after PICU admission following the index procedure (score)
6. Arterial lactate (mmol/L) In the first 12 hours after reperfusion
7. Omega, determined by [SaO2]/[SaO2-ScvO2] in the first 12 hours after reperfusion
8. Total aortic cross-clamp time (mins) during the index procedure
9. Total volume of cardioplegia given (ml) during the index procedure
10. Need for internal defibrillation during reperfusion during the index procedure
11. Delayed sternal closure, incidence and duration (days) following the index procedure
12. Unplanned reoperation, including chest re-opening on PICU, following the index procedure
13. Need for new renal replacement therapy following the index procedure
14. Lowest estimated glomerular filtration rate (eGFR), calculated using the bedside Schwartz equation and the peak postoperative creatinine on routine monitoring during the first 7 days following the index procedure (ml/min/1.73m2), and according to the paediatric RIFLE categories
15. Length of postoperative stay in the hospital (days), defined as number of days from day of the index procedure to discharge from hospital or death, whichever is sooner
16. 30-day survival following the index procedure
Overall study start date26/07/2021
Completion date31/07/2025

Eligibility

Participant type(s)Patient
Age groupChild
Upper age limit16 Years
SexBoth
Target number of participantsPlanned Sample Size: 220; UK Sample Size: 220
Total final enrolment112
Key inclusion criteriaChildren (<16 years) undergoing cardiac surgery on cardiopulmonary bypass with cardioplegic arrest
Key exclusion criteriaCurrent exclusion criteria as of 18/03/2025:

1. Predicted cross-clamp time <30 minutes (e.g. atrial septal defect, atrial septectomy, sub-aortic stenosis) at the discretion of the Consultant surgeon
2. Known contraindication to one of the constituents of either cardioplegia solution (e.g. lidocaine/procaine hypersensitivity/allergy) or its method of delivery, including temperature (e.g. haemoglobinopathy including sickle cell disease, cold agglutinins)
3. Ventricular assist device (VAD) insertion/explant or transplantation
4. Pre-operative inotropic support or extracorporeal life support (ECLS)
5. Previous cardiac surgery with cardioplegic arrest within the last 30 days
6. Previous enrolment in the DESTINY trial
7. Emergency surgery
8. Parent/guardian declines consent
9. Weight at the time of screening >50 kg

_____


Previous exclusion criteria as of 14/03/2024:

1. Predicted cross-clamp time <30 minutes (e.g. atrial septal defect, atrial septectomy, sub-aortic stenosis) at the discretion of the Consultant surgeon
2. Known contraindication to one of the constituents of either cardioplegia solution (e.g. lidocaine/procaine hypersensitivity/allergy) or its method of delivery, including temperature (e.g. haemoglobinopathy including sickle cell disease, cold agglutinins)
3. Ventricular assist device (VAD) insertion/explant or transplantation
4. Pre-operative inotropic support or extracorporeal life support (ECLS)
5. Previous cardiac surgery with cardioplegic arrest within the last 30 days
6. Previous enrolment in the DESTINY trial
7. Emergency surgery
8. Parent/guardian declines consent
9. Weight at the time of surgery >50 kg

_____

Previous exclusion criteria:

1. Predicted cross-clamp time <30 minutes (e.g. atrial septal defect, atrial septectomy, sub-aortic stenosis) at the discretion of the Consultant surgeon
2. Known contraindication to one of the constituents of either cardioplegia solution (e.g. lidocaine/procaine hypersensitivity/allergy) or its method of delivery, including temperature (e.g. haemoglobinopathy including sickle cell disease, cold agglutinins)
3. Ventricular assist device (VAD) insertion/explant or transplantation
4. Pre-operative inotropic support or extracorporeal life support (ECLS)
5. Previous cardiac surgery with cardioplegic arrest within the last 30 days
6. Emergency surgery
7. Parent/guardian declines consent

(added 15/03/2023)
8. Weight at the time of surgery >50 kg
9. Previous enrolment in the DESTINY trial
Date of first enrolment07/02/2022
Date of final enrolment13/03/2025

Locations

Countries of recruitment

  • England
  • United Kingdom

Study participating centres

Birmingham Children’s Hospital
Steelhouse Lane
Birmingham
B4 6NH
United Kingdom
Bristol Royal Hospital for Children
University Hospitals Bristol and Weston NHS Foundation Trust
Upper Mauldin Street
Bristol
BS2 8BJ
United Kingdom
Great Ormond Street Hospital
Great Ormond Street
London
WC1N 3JH
United Kingdom
Leeds General Infirmary (Children's Hospital)
The Leeds Teaching Hospitals NHS Trust
Great George Street
Leeds
LS1 3EX
United Kingdom

Sponsor information

University of Birmingham
University/education

Dr Birgit Whitman
Head of Research Ethics, Governance and Integrity
Research Strategy & Services Division – Research Governance
Ash House
University of Birmingham
Edgbaston
Birmingham
B15 2SQ
England
United Kingdom

Phone +44 (0)121 414 3344
Email researchgovernance@contacts.bham.ac.uk
Website http://www.birmingham.ac.uk/index.aspx
ROR logo "ROR" https://ror.org/03angcq70

Funders

Funder type

Charity

British Heart Foundation
Private sector organisation / Trusts, charities, foundations (both public and private)
Alternative name(s)
the_bhf, The British Heart Foundation, BHF
Location
United Kingdom

Results and Publications

Intention to publish date31/12/2025
Individual participant data (IPD) Intention to shareNo
IPD sharing plan summaryData sharing statement to be made available at a later date
Publication and dissemination planPlanned publication in a high-impact peer-reviewed journal.
IPD sharing planThe current data sharing plans for this study are unknown and will be available at a later date.

Study outputs

Output type Details Date created Date added Peer reviewed? Patient-facing?
Participant information sheet Child
version 1.0
25/03/2021 28/07/2021 No Yes
Participant information sheet Parent
version 1.1a
06/07/2021 28/07/2021 No Yes
Participant information sheet Parent
version 1.1b
06/07/2021 28/07/2021 No Yes
Protocol file version 1.0 26/05/2021 28/07/2021 No No
HRA research summary 28/06/2023 No No
Participant information sheet Parent
version 3.0a
05/10/2023 14/03/2024 No Yes
Participant information sheet Parent
version 3.0b
05/10/2023 14/03/2024 No Yes
Participant information sheet Parent
version 2.0a
27/08/2021 14/03/2024 No Yes
Participant information sheet Parent
version 2.0b
27/08/2021 14/03/2024 No Yes
Protocol file version 2.0 19/08/2021 14/03/2024 No No
Protocol file version 3.0 22/08/2022 14/03/2024 No No
Protocol file version 4.0 25/10/2023 14/03/2024 No No
Protocol file version 5.0 14/02/2025 18/03/2025 No No
Protocol article 14/04/2025 16/04/2025 Yes No

Additional files

40206 DESTINY protocol v1.0 26May2021.pdf
40206 DESTINY child info sheet v1.0 25Mar2021.pdf
Child
40206 DESTINY parent info sheet v1.1a 06Jul2021.pdf
Parent
40206 DESTINY parent info sheet v1.1b 06Jul2021.pdf
Parent
ISRCTN13638147 DESTINY parent info sheet v3.0a 05Oct2023.pdf
Parent
ISRCTN13638147 DESTINY parent info sheet v3.0b 05Oct2023.pdf
Parent
ISRCTN13638147 DESTINY parent info sheet v2.0a 27Aug21.pdf
Parent
ISRCTN13638147 DESTINY parent info sheet v2.0b 27Aug21.pdf
Parent
ISRCTN13638147 DESTINY protocol v2.0 19Aug21.pdf
ISRCTN13638147 DESTINY protocol v3.0 22Aug22.pdf
ISRCTN13638147 DESTINY protocol v4.0 25Oct2023.pdf
ISRCTN13638147_PROTOCOL_V5.0_14Feb25.pdf

Editorial Notes

16/04/2025: Publication reference added.
18/03/2025: The following changes were made to the study record:
1. Protocol uploaded.
2. The recruitment end date was changed from 31/03/2025 to 13/03/2025.
3. Total final enrolment added.
4. Sponsor details and exclusion criteria updated.
28/08/2024: The overall end date was changed from 30/06/2025 to 31/07/2025.
27/08/2024: The following changes were made to the trial record:
1. The overall end date was changed from 25/07/2024 to 30/06/2025.
2. The recruitment end date was changed from 30/04/2024 to 31/03/2025.
3. The plain English summary was updated to reflect these changes.
14/03/2024: The following changes were made to the trial record:
1. The participant information sheets (2.0a, 2.0b, 3.0a, 3.0b) were uploaded as additional files.
2. The secondary outcome measures were changed.
3. The study website was added.
4. The exclusion criteria were changed.
5. The recruitment end date was changed from 31/05/2024 to 30/04/2024.
6. The intention to publish date was changed from 31/12/2024 to 31/12/2025.
7. Uploaded protocols v2.0, v3.0, v4.0 (not peer-reviewed) as additional files.
15/03/2023: The following changes were made to the trial record:
1. The overall start date was changed from 30/06/2021 to 26/07/2021.
2. The overall end date was changed from 31/12/2023 to 25/07/2024.
3. The recruitment start date was changed from 15/01/2022 to 07/02/2022.
4. The recruitment end date was changed from 14/07/2023 to 31/05/2024.
5. The exclusion criteria were changed.
6. The plain English summary was updated to reflect these changes.
29/12/2021: The following changes have been made:
1. The recruitment start date has been changed from 01/11/2021 to 15/01/2022.
2. The recruitment end date has been changed from 30/04/2023 to 14/07/2023.
21/09/2021: The following changes were made to the trial record:
1. The recruitment end date was changed from 31/03/2023 to 30/04/2023.
2. The recruitment start date was changed from 01/09/2021 to 01/11/2021.
28/07/2021: The protocol and participant information sheets were uploaded as additional files.
26/07/2021: Trial's existence confirmed by the NIHR.