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Wang Z, Xu J, Kang Y, Liu L, Zhang L, Wang D. Early dynamic behavior of lactate in predicting continuous renal replacement therapy after surgery for acute type A aortic dissection. Front Cardiovasc Med 2022; 9:948672. [PMID: 35958404 PMCID: PMC9360317 DOI: 10.3389/fcvm.2022.948672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Accepted: 07/07/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundIt has been well known that hyperlactatemia is an independent risk factor for postoperative mortality in patients who received acute type A aortic dissection (ATAAD) surgery. Some patients may require the assistance of continuous renal replacement therapy (CRRT) for acute postoperative renal deficiency and often associate with increased mortality rate. This study aimed to examine the association between the early dynamic change of lactate levels and postoperative CRRT in ATAAD patients who received surgical repairment.MethodsThis retrospective study included 503 patients who received ATAAD surgeries. Serum lactate levels were measured before operation and at 0, 1, 3, 6, 12, 24 h post intensive care unit (ICU) admission. We examined the association between dynamic changes of lactate and CRRT.ResultsAmong all patients, 19.9% (100 patients) required CRRT. Our data showed that the lactate levels were higher in the CRRT group at all timepoints compared to the non-CRRT group. In a multivariate model, lactate levels at 12 h post ICU admission [odds ratio (OR), 1.362; p = 0.007] was identified as an independent predictor for requiring CRRT. Unsurprisingly, 30-day mortality in the CRRT group (41%) was 8.2 times higher than in the non-CRRT group (5%). To better understand the associations between CRRT and lactate levels, patients in the CRRT group were further stratified into the non-survivor group (n = 41) and survivor group (n = 59) based on the 30-day mortality. Elevated lactate levels measured upon ICU admission (OR, 1.284; p = 0.001) and decreased 24 h lactate clearance (OR, 0.237; p = 0.039) were independent risk factors for 30-day mortality in patients who received CRRT. The area under the curve to predict requirement for CRRT at 6 and 12 h post CICU admission were 0.714 and 0.722, respectively, corresponding to lactate cut-off levels of 4.15 and 2.45 mmol/L.ConclusionThe CRRT is commonly required in patients who received ATAAD surgery and often associated with worse mortality. Early dynamic changes of lactate levels can be used to predict the requirement of postoperative CRRT.
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Affiliation(s)
- Zhigang Wang
- Department of Cardio-Thoracic Surgery, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China
| | - Jingfang Xu
- Department of Nephrology, Nanjing Drum Tower Hospital Clinical College of Nanjing University of Chinese Medicine, Nanjing, China
| | - Yubei Kang
- Department of Cardio-Thoracic Surgery, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China
| | - Ling Liu
- Department of Cardio-Thoracic Surgery, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China
| | - Lifang Zhang
- Department of Psychiatry, The First Affiliated Hospital, Zhengzhou University, Zhengzhou, China
| | - Dongjin Wang
- Department of Cardio-Thoracic Surgery, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, China
- *Correspondence: Dongjin Wang,
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Abstract
Mitochondria are key to the cellular response to energetic demand, but are also vital to reactive oxygen species signaling, calcium hemostasis, and regulation of cell death. Cardiac surgical patients with diabetes, heart failure, advanced age, or cardiomyopathies may have underlying mitochondrial dysfunction or be more sensitive to perioperative mitochondrial injury. Mitochondrial dysfunction, due to ischemia/reperfusion injury and an increased systemic inflammatory response due to exposure to cardiopulmonary bypass and surgical tissue trauma, impacts myocardial contractility and predisposes to arrhythmias. Strategies for perioperative mitochondrial protection and recovery include both well-established cardioprotective protocols and targeted therapies that remain under investigation.
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Akt is a critical node of acute myocardial insulin resistance and cardiac dysfunction after cardiopulmonary bypass. Life Sci 2019; 234:116734. [PMID: 31394126 DOI: 10.1016/j.lfs.2019.116734] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2019] [Revised: 08/04/2019] [Accepted: 08/04/2019] [Indexed: 10/26/2022]
Abstract
AIMS Acute myocardial insulin resistance is an independent risk factor for patients who undergo cardiac surgery with cardiopulmonary bypass (CPB). However, the underlying mechanism of insulin resistance during CPB has not been fully investigated. MATERIALS AND METHODS To explore the role of myocardial insulin resistance on the cardiac function and its underlying mechanism, CPB operation and pharmacological intervention were applied in mini pigs, and myocardial insulin signaling, glucose uptake, ATP production and cardiac function were examined. KEY FINDINGS Our data showed that CPB elicited not only hyperglycemia and hyperinsulinemia, but also inactivated Akt, and impaired the transposition of membrane glucose transporter-4 (GLUT-4), reduced glucose uptake and ATP production in the myocardium as well, which in turn was accompanied with cardiac dysfunction. Meanwhile, linear correlations were established among reduced myocardial glucose uptake, ATP production, and depressed cardiac systolic or diastolic function. Reactivation of Akt by SC79, an Akt agonist, partially alleviated myocardial insulin resistance and restored post CPB cardiac function via augmenting myocardial glucose uptake and ATP production. SIGNIFICANCE These findings revealed that acute myocardial insulin resistance due to inactivation of Akt played a key role in cardiac dysfunction post CPB via suppressing glucose metabolism related energy supply.
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Pendino JC, Hess L, Beltrame S, Castillo GAE, Trujillo J. Oxygen saturation and lactate concentration gradient from the right atrium to the pulmonary artery in the immediate postoperative following cardiac surgery with extracorporeal circulation. Rev Bras Ter Intensiva 2017; 29:287-292. [PMID: 28876405 PMCID: PMC5632970 DOI: 10.5935/0103-507x.20170042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Accepted: 05/27/2017] [Indexed: 11/28/2022] Open
Abstract
Objective This prospective study aimed to characterize the changes in blood lactate
concentration and blood oxygen saturation in patients during the immediate
postoperative period of cardiac surgery with extracorporeal circulation. Methods Blood samples were collected from 35 patients in a rapid and random order
from the arterial line and from the proximal and distal port of a pulmonary
artery catheter. Results The results showed no statistically significant differences between the blood
oxygen saturation in the right atrium (72% ± 0.11%) and the blood
oxygen saturation in the pulmonary artery (71% ± 0.08%). The blood
lactate concentration in the right atrium was 1.7mmol/L ± 0.5mmol/L,
and the blood lactate concentration in the pulmonary artery was 1.6mmol/L
± 0.5mmol/L (p < 0.0005). Conclusion The difference between the blood lactate concentration in the right atrium
and the blood lactate concentration in the pulmonary artery might be a
consequence of the low blood lactate concentration in the blood from the
coronary sinus, as it constitutes an important substrate for the myocardium
during this period. The lack of differences between the blood oxygen
saturation in the right atrium and the percentage of blood oxygen saturation
in the pulmonary artery suggests a lower oxygen extraction by the myocardium
given a lower oxygen consumption.
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Affiliation(s)
- Juan Carlos Pendino
- Unidad de Terapia Intensiva, Hospital Provincial del Centenario - Rosário, Argentina.,Facultad de Ciências Médicas, Universidad Nacional de Rosario - Rosário, Argentina
| | - Leonardo Hess
- CIMA-Profisio, Facultad de Ciências Médicas, Universidad Nacional de Rosario - Rosário, Argentina
| | - Sergio Beltrame
- Servicio de Cirugía Cardíaca, Hospital IDCSalud - Albacete, España
| | | | - John Trujillo
- Servicio de Cirugía Cardíaca, Hospital IDCSalud - Albacete, España
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Park SJ, Kim SP, Kim JB, Jung SH, Choo SJ, Chung CH, Lee JW. Blood lactate level during extracorporeal life support as a surrogate marker for survival. J Thorac Cardiovasc Surg 2014; 148:714-20. [DOI: 10.1016/j.jtcvs.2014.02.078] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2013] [Revised: 01/30/2014] [Accepted: 02/26/2014] [Indexed: 11/30/2022]
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High lactate levels are predictors of major complications after cardiac surgery. J Thorac Cardiovasc Surg 2013; 146:455-60. [DOI: 10.1016/j.jtcvs.2013.02.003] [Citation(s) in RCA: 98] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2012] [Revised: 12/13/2012] [Accepted: 02/08/2013] [Indexed: 11/20/2022]
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Rapp-Kesek D, Stridsberg M, Andersson LG, Berne C, Karlsson T. Insulin resistance after cardiopulmonary bypass in the elderly patient. SCAND CARDIOVASC J 2009; 41:102-8. [PMID: 17454835 DOI: 10.1080/14017430601050355] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVES Preoperative carbohydrate administration attenuates insulin resistance. We studied effects of preoperative oral carbohydrate loading in elderly patients undergoing coronary artery bypass grafting. DESIGN Eighteen patients were assigned either to get a carbohydrate drink or to be controls. Perioperatively, glucose was administered. A gastric emptying test was performed. Glucose and insulin concentrations were measured. Levels of glucose, insulin and stress hormones were studied pre-, per- and postoperatively. RESULTS AND DISCUSSION Preoperative carbohydrate loading did not affect stress hormones. Gastric residual after the carbohydrate drink was 11+/-3% (mean+/-SEM). Glucose concentration was lower before anaesthesia induction in the carbohydrate group, possibly due to increased insulin release. Insulin levels differed at baseline, induction and day six. All patients returned to baseline on day six. CONCLUSIONS The study group was insulin resistant on postoperative day one and two. The effects were explainable by the traumatic stress response. No adverse effect was noted from the carbohydrate drink. If glucose is administered intravenously during surgery, there is no obvious advantage of preoperative carbohydrate loading on insulin resistance or stress hormone response.
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Affiliation(s)
- Doris Rapp-Kesek
- Department of Surgical Sciences, Section of Anaesthesiology and Intensive Care, University Hospital, Uppsala, Sweden.
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Pöling J, Leptien A, Klaus S, Rees W, Kraatz E, Wiebe K, Bahlmann L. Analysis of the myocardial metabolism by microdialysis during open beating heart surgery. SCAND CARDIOVASC J 2009; 41:114-9. [PMID: 17454837 DOI: 10.1080/14017430601091706] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVES Microdialysis allows the in vivo biochemical analysis of interstitial fluids. Our aim was to reveal in vivo reliable data of the myocardium during open beating heart surgery. DESIGN In ten patients undergoing routine beating coronary artery bypass grafting a microdialysis catheter was inserted into the left ventricle. Measurements were performed up to 45 min after anastomosis. Data were retrospectively compared with standard on-pump procedures. RESULTS The myocardial lactate remained stable during anastomosis, followed by a significant decrease of lactate after revascularisation. Myocardial glucose levels showed a slight decrease, followed by a significant increase after revascularisation. Myocardial purines showed a slight increase during anastomosis, followed by a sharp decrease during reperfusion period. CONCLUSIONS In contrast to on-pump procedures myocardial lactate and purines showed less increasing trend during the ischemic period, while myocardial glucose remained stable as a sign of preserved tissue blood flow. Myocardial microdialysis showed different values compared to the elective on-pump CABG and previous animal studies. This technique allows bedside monitoring of biochemical changes, suggesting its possible role as a clinical monitoring tool.
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Affiliation(s)
- Jochen Pöling
- Department of Cardiac Surgery, Schüchtermann-Klinik Bad Rothenfelde, Germany.
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Turer AT, Stevens RD, Bain JR, Muehlbauer MJ, van der Westhuizen J, Mathew JP, Schwinn DA, Glower DD, Newgard CB, Podgoreanu MV. Metabolomic profiling reveals distinct patterns of myocardial substrate use in humans with coronary artery disease or left ventricular dysfunction during surgical ischemia/reperfusion. Circulation 2009; 119:1736-46. [PMID: 19307475 DOI: 10.1161/circulationaha.108.816116] [Citation(s) in RCA: 118] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Human myocardial metabolism has been incompletely characterized in the setting of surgical cardioplegic arrest and ischemia/reperfusion. Furthermore, the effect of preexisting ventricular state on ischemia-induced metabolic derangements has not been established. METHODS AND RESULTS We applied a mass spectrometry-based platform to profile 63 intermediary metabolites in serial paired peripheral arterial and coronary sinus blood effluents obtained from 37 patients undergoing cardiac surgery, stratified by presence of coronary artery disease and left ventricular dysfunction. The myocardium was a net user of a number of fuel substrates before ischemia, with significant differences between patients with and without coronary artery disease. After reperfusion, significantly lower extraction ratios of most substrates were found, as well as significant release of 2 specific acylcarnitine species, acetylcarnitine and 3-hydroxybutyryl-carnitine. These changes were especially evident in patients with impaired ventricular function, who exhibited profound limitations in extraction of all forms of metabolic fuels. Principal component analysis highlighted several metabolic groupings as potentially important in the postoperative clinical course. CONCLUSIONS The preexisting ventricular state is associated with significant differences in myocardial fuel uptake at baseline and after ischemia/reperfusion. The dysfunctional ventricle is characterized by global suppression of metabolic fuel uptake and limited myocardial metabolic reserve and flexibility after global ischemia/reperfusion stress in the setting of cardiac surgery. Altered metabolic profiles after ischemia/reperfusion are associated with postoperative hemodynamic course and suggest a role for perioperative metabolic monitoring and targeted optimization in cardiac surgical patients.
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Affiliation(s)
- Aslan T Turer
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Box 31297, Erwin Rd, Durham, NC 27710, USA.
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Deja MA, Malinowski M, Gołba KS, Kajor M, Lebda-Wyborny T, Hudziak D, Domaradzki W, Szurlej D, Bończyk A, Biernat J, Woś S. Diazoxide protects myocardial mitochondria, metabolism, and function during cardiac surgery: a double-blind randomized feasibility study of diazoxide-supplemented cardioplegia. J Thorac Cardiovasc Surg 2009; 137:997-1004, 1004e1-2. [PMID: 19327530 DOI: 10.1016/j.jtcvs.2008.08.068] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2008] [Revised: 08/06/2008] [Accepted: 08/27/2008] [Indexed: 10/21/2022]
Abstract
OBJECTIVES The study was designed to assess whether diazoxide-mediated cardioprotection might be used in human subjects during cardiac surgery. METHODS Forty patients undergoing coronary artery bypass grafting were randomized to receive intermittent warm blood antegrade cardioplegia supplemented with either diazoxide (100 micromol/L) or placebo (n = 20 in each group). Mitochondria were assessed before and after ischemia and reperfusion in myocardial biopsy specimens. Myocardial oxygen and glucose and lactic acid extraction ratios were measured before ischemia and in the first 20 minutes of reperfusion. Hemodynamic data were collected, and troponin I, creatine kinase-MB, and N-terminal prohormone brain natriuretic peptide levels were measured. All outcomes were analyzed by using mixed-effects modeling for repeated measures. RESULTS No deaths, strokes, or infarcts were observed. Patients received, on average, 36.2 +/- 1.2 mg of diazoxide and 37.3 +/- 1.9 mg of placebo (P = .6). Diazoxide added to cardioplegia prevented mitochondrial swelling (8899 +/- 474 vs 9273 +/- 688 pixels before and after the procedure, respectively; P = .6) compared with that seen in the placebo group (8474 +/- 163 vs 11,357 +/- 759 pixels, P = .004). No oxygen debt was observed in the diazoxide group. Glucose consumption and lactic acid production returned to preischemic values faster in the diazoxide group. The following hemodynamic parameters differed between the diazoxide and placebo groups, respectively, in the postoperative period: cardiac index, 3.0 +/- 0.09 versus 2.6 +/- 0.09 L . min(-1) . m(-2) (P = .002); left cardiac work index, 2.81 +/- 0.07 versus 2.31 +/- 0.07 kg/m(2) (P < .001); oxygen delivery index, 420 +/- 14 versus 377 +/- 13 mL . min(-1) . m(-2) (P = .03); and oxygen extraction ratio, 29.3% +/- 1.1% versus 32.6% +/- 1.1% (P = .02). Postoperative myocardial enzyme levels did not differ, but N-terminal prohormone brain natriuretic peptide levels were lower in the diazoxide group (120 +/- 27 vs 192 +/- 29 pg/mL, P = .04). CONCLUSIONS Supplementing blood cardioplegia with diazoxide is safe and improves myocardial protection during cardiac surgery, possibly through its influence on the mitochondria.
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Affiliation(s)
- Marek A Deja
- Second Department of Cardiac Surgery, Medical University of Silesia, Katowice, Poland.
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11
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Zuurbier CJ, Van Wezel HB. Glucose-insulin therapy, plasma substrate levels and cardiac recovery after cardiac ischemic events. Cardiovasc Drugs Ther 2008; 22:125-31. [PMID: 18266096 PMCID: PMC2329728 DOI: 10.1007/s10557-008-6087-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2008] [Accepted: 01/17/2008] [Indexed: 01/04/2023]
Abstract
Introduction The potential usefulness of glucose-insulin therapy relies to a large extent on the premise that it prevents hyperglycemia and hyperlipidemia following cardiac ischemic events. Methods In this review we evaluate the literature concerning plasma glucose and free fatty acids levels during and following cardiac ischemic events. Results The data indicate that hyperlipidemia and hyperglycemia most likely occur during acute coronary ischemic syndromes in the conscious state (e.g. acute myocardial infarction) and less so during reperfusion following CABG reperfusion. This is in accordance with observations that glucose-insulin therapy during early reperfusion post CABG may actually cause hypolipidemia, because substantial hyperlipidemia does not appear to occur during that stage of cardiac surgery. Discussion Considering recent data indicating that hypolipidemia may be detrimental for cardiac function, we propose that free fatty acid levels during reperfusion post CABG with the adjunct glucose-insulin therapy need to be closely monitored. Conclusion From a clinical point of view, a strategy directed at monitoring and thereafter maintaining plasma substrate levels in the normal range for both glucose (4–6 mM) and FFA (0.2–0.6 mM) as well as stimulation of glucose oxidation, promises to be the most optimal metabolic reperfusion treatment following cardiac ischemic episodes. Future (preclinical and subsequently clinical) investigations are required to investigate whether the combination of glucose-insulin therapy with concomitant lipid administration may be beneficial in the setting of reperfusion post CABG.
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Affiliation(s)
- C J Zuurbier
- Department of Anesthesiology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
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Zuurbier CJ, Hoek FJ, van Dijk J, Abeling NG, Meijers JCM, Levels JHM, de Jonge E, de Mol BA, Van Wezel HB. Perioperative hyperinsulinaemic normoglycaemic clamp causes hypolipidaemia after coronary artery surgery. Br J Anaesth 2008; 100:442-50. [PMID: 18305079 DOI: 10.1093/bja/aen018] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Glucose-insulin-potassium (GIK) administration is advocated on the premise of preventing hyperglycaemia and hyperlipidaemia during reperfusion after cardiac interventions. Current research has focused on hyperglycaemia, largely ignoring lipids, or other substrates. The present study examines lipids and other substrates during and after on-pump coronary artery bypass grafting and how they are affected by a hyperinsulinaemic normoglycaemic clamp. METHODS Forty-four patients were randomized to a control group (n=21) or to a GIK group (n=23) receiving a hyperinsulinaemic normoglycaemic clamp during 26 h. Plasma levels of free fatty acid (FFA), total and lipoprotein (VLDL, HDL, and LDL)-triglycerides (TG), ketone bodies, and lactate were determined. RESULTS In the control group, mean FFA peaked at 0.76 (sem 0.05) mmol litre(-1) at early reperfusion and decreased to 0.3-0.5 mmol litre(-1) during the remaining part of the study. GIK decreased FFA levels to 0.38 (0.05) mmol litre(-1) at early reperfusion, and to low concentrations of 0.10 (0.01) mmol litre(-1) during the hyperinsulinaemic clamp. GIK reduced the area under the curve (AUC) for FFA by 75% and for TG by 53%. The reduction in total TG was reflected by a reduction in the VLDL (-54% AUC) and HDL (-42% AUC) fraction, but not in the LDL fraction. GIK prevented the increase in ketone bodies after reperfusion (-44 to -47% AUC), but was without effect on lactate levels. CONCLUSIONS Mild hyperlipidaemia was only observed during early reperfusion (before heparin reversal) and the hyperinsulinaemic normoglycaemic clamp actually resulted in hypolipidaemia during the largest part of reperfusion after cardiac surgery.
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Affiliation(s)
- C J Zuurbier
- Department of Anaesthesiology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands.
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Pöling J, Rees W, Klaus S, Bahlmann L, Hübner N, Heringlake M, Mantovani V, Warnecke H. Functional Recovery of Chronic Ischemic Myocardium after Surgical Revascularization Correlates with Magnitude of Oxidative Metabolism. Cardiology 2007; 110:174-81. [DOI: 10.1159/000111927] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2006] [Accepted: 04/22/2007] [Indexed: 11/19/2022]
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van der Vusse GJ, van Bilsen M. Free Fatty acids and postischemic myocardial function. Semin Cardiothorac Vasc Anesth 2007; 10:231-5. [PMID: 16959757 DOI: 10.1177/1089253206291319] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
This review highlights the changes in fatty acid homeostasis in the postischemic heart. The impact of restoration of flow (reperfusion) after an ischemic episode on both structural fatty acids (ie, incorporated in phospholipids, the building blocks of cellular membranes) and fatty acids, serving as energy donors by mitochondrial oxidation, are discussed. Attempts to interfere with cardiac fatty acid homeostasis to prevent loss of cardiac function or to restore cardiac performance after reperfusion is also discussed.
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Affiliation(s)
- Ger J van der Vusse
- Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, The Netherlands.
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Amark K, Berggren H, Björk K, Ekroth A, Ekroth R, Nilsson K, Sunnegårdh J. Myocardial Metabolism is Better Preserved After Blood Cardioplegia in Infants. Ann Thorac Surg 2006; 82:172-8. [PMID: 16798209 DOI: 10.1016/j.athoracsur.2006.01.093] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2005] [Revised: 01/22/2006] [Accepted: 01/26/2006] [Indexed: 10/24/2022]
Abstract
BACKGROUND We have previously reported improved hemodynamic function after blood cardioplegia in comparison with crystalloid cardioplegia. Furthermore, lactate was released from the heart after crystalloid cardioplegia but not after blood cardioplegia. The purpose of this study was to determine whether the difference in substrate metabolism between the two cardioplegia methods was restricted to lactate, or whether the difference in metabolic derangement was more extensive. METHODS Thirty consecutive infants with complete atrioventricular septal defects were included in this prospective, randomized, controlled study. Arterial and coronary sinus blood concentrations of substrates and amino acids were measured after weaning from bypass. RESULTS After crystalloid cardioplegia, there was a myocardial uptake of glutamate (p = 0.003), leucine (p = 0.03), lysine (p = 0.003), and beta-hydroxybutyrate (p = 0.004), whereas lactate was released (p = 0.03). After blood cardioplegia, there was a myocardial uptake of free fatty acids (p = 0.01) but no uptake of amino acids and no release of lactate. CONCLUSIONS There are differences in myocardial substrate metabolism between blood cardioplegia and crystalloid cardioplegia, which involve carbohydrates and amino acids. The differences may include lipids but our data in this respect are not conclusive.
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Affiliation(s)
- Kerstin Amark
- Department of Pediatrics, The Queen Silvia Children's Hospital, Göteborg, Sweden.
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Lorenz RA, Lorenz RM, Codd JE. Perioperative blood glucose control during adult coronary artery bypass surgery. AORN J 2005; 81:126-44, 147-50; quiz 151-4. [PMID: 15693687 DOI: 10.1016/s0001-2092(06)60066-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Coronary artery bypass graft (CABG) procedures are among the most frequently performed surgical procedures in the United States. People with cardiovascular disease who also have diabetes have a greater risk of poor outcomes after CABG procedures than patients who do not have diabetes. This literature review examines current information regarding perioperative blood glucose (BG) control. It emphasizes BG control in adults during the hypothermic period of cardiopulmonary bypass. Hyperglycemia, not the diagnosis of diabetes, significantly increases the risk of adverse clinical outcomes, longer hospitalizations, and increased health care costs.
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Bortone F, Mazzoni M, Repossini A, Campolo J, Ceriani R, Devoto E, Parolini M, De Maria R, Arena V, Parodi O. Myocardial lactate metabolism in relation to preoperative regional wall motion and to early functional recovery after coronary revascularization. J Cardiothorac Vasc Anesth 2003; 17:478-85. [PMID: 12968236 DOI: 10.1016/s1053-0770(03)00153-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To evaluate myocardial lactate metabolism as a marker of functional status after surgical coronary revascularization. DESIGN Single-center, prospective, cohort study. SETTING Tertiary care teaching hospital. PARTICIPANTS Fifty patients with stable angina, ejection fraction >0.40, undergoing coronary artery bypass surgery for multiple-vessel disease. MEASUREMENTS AND MAIN RESULTS Before (T1) and 30 minutes (T2) after coronary artery bypass grafting, the authors simultaneously sampled blood from artery and coronary sinus to determine myocardial lactate dynamics and performed transesophageal echocardiography (TEE) to assess segmental wall motion. Wall motion score index (WMSI) was calculated with an online/offline comparison. At T2, WMSI improved from 1.40 +/- 0.31 to 1.17 +/- 0.23 (p = 0.0001). Preoperatively, 2 patterns of lactate balance were found: 39 patients were lactate extractors (17% +/- 10%) and 11 were lactate producers (-11% +/- 11%). At T2, lactate metabolism was shifted towards a pattern opposite to the baseline: delta lactate extraction was -8% +/- 16% in extractors at T1 versus 7% +/- 9% in producers at T1 (p = 0.003). Changes in WMSI were not correlated with changes in lactate utilization. No single preoperative variable predicted postoperative WMSI or its changes from baseline. Cardiopulmonary bypass (CPB) time was the only significant predictor of postoperative lactate extraction by multivariate regression (r = -0.46, p = 0.001): at T2, patients in the highest CPB time quartile showed frank lactate production (-6% +/- 13%) when compared with those in the lowest quartile (15% +/- 11%, p = 0.005). However, postoperative WMSI was similar in different CPB time groups. CONCLUSIONS Myocardial lactate metabolism pattern is not associated with functional status before and early after successful coronary revascularization. CPB time was the only significant predictor of postoperative lactate extraction. Measurement of lactate does not appear to be a valuable tool to assess the coupling of myocardial regional function and metabolism in the setting of coronary artery surgery and mild-to-moderate functional impairment.
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Affiliation(s)
- Franco Bortone
- Department of Anesthesia and Cardiac Surgery, Humanitas Gavazzeni, Bergamo, Italy
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Kennergren C, Mantovani V, Strindberg L, Berglin E, Hamberger A, Lonnroth P. Myocardial interstitial glucose and lactate before, during, and after cardioplegic heart arrest. Am J Physiol Endocrinol Metab 2003; 284:E788-94. [PMID: 12388141 DOI: 10.1152/ajpendo.00522.2001] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The interstitial fluid of the human myocardium was monitored in 13 patients undergoing aortic valve and/or bypass surgery before, during, and after hypothermic potassium cardioplegia. The regulation of glucose and lactate was studied after sampling with microdialysis. The following questions were addressed. 1). Is the rate of transcapillary diffusion the limiting step for myocardial uptake of glucose before or after cardioplegia? 2). Does cold potassium cardioplegia induce a critical deprivation of glucose and/or accumulation of lactate in the myocardium? Before cardioplegia, interstitial glucose was approximately 50% of the plasma level (P < 0.001). Interstitial glucose decreased significantly immediately after induction of cardioplegia and remained low (1.25 +/- 0.25 mM) throughout cardioplegia. It was restored to precardioplegic levels 1 h after release of the aortic clamp. Interstitial glucose then decreased again at 25 and 35 h postoperatively to the levels observed during cardioplegia. Interstitial lactate decreased immediately after induction of cardioplegia but returned to basal level during the clamping period. At 25 and 35 h, interstitial lactate was significantly lower than before and during cardioplegia. Glucose transport over the capillary endothelium is considered rate limiting for its uptake in the working heart but not during cold potassium cardioplegia despite the glucose deprivation following perfusion of glucose-free cardioplegic solution. Lactate accumulated during cardioplegia but never reached exceedingly high interstitial levels. We conclude that microdialysis provides information that may be relevant for myocardial protection during open-heart surgery.
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Affiliation(s)
- Charles Kennergren
- Departments of Heart and Lung Medicine, University of Göteborg, SE-413 45, Goteborg, Sweden.
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van Wezel HB, Jong SWMD. Clinical Use of Glucose-Insulin-Potassium in Cardiac Surgery andAcute Myocardial Infarction: An Overview. Semin Cardiothorac Vasc Anesth 2003. [DOI: 10.1177/108925320300700114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Harry B. van Wezel
- Department of Anesthesiology, Academic Medical Center, Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
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Zuurbier C. Postischemic Myocardial Metabolism. Semin Cardiothorac Vasc Anesth 2003. [DOI: 10.1177/108925320300700112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- C.J. Zuurbier
- Department of Anesthesiology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105AZ, The Netherlands
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van Wezel HB, de Jong SWM. Glucose, Free Fatty Acids, and Insulin Following Acute Myocardial Ischemia. Intensive Care Med 2003. [DOI: 10.1007/978-1-4757-5548-0_40] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Ganushchak YM, Maessen JG, de Jong DS. The oxygen debt during routine cardiac surgery: illusion or reality? Perfusion 2002; 17:167-73. [PMID: 12017383 DOI: 10.1191/0267659102pf561oa] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Patients undergoing cardiac surgery with the use of cardiopulmonary bypass (CPB) are often thought to have tissue hypoxia and intraoperative oxygen debt accumulation despite the lack of sufficient data to support this assumption. METHODS AND RESULTS Oxygen uptake and related parameters, including the plasma lactate and pyruvate concentrations, were studied during the perioperative period in a group of 15 consecutive patients who underwent coronary artery bypass graft surgery. The actual oxygen uptake (VO2) and delivery (DO2) were compared with the individual expected (computed) oxygen transport values. The mean values of DO2 and VO2 were in the range of the expected values. Our results demonstrate a leading role for body temperature in perioperative changes of oxygen consumption rate (r2=0.65, p<0.001). Plasma lactate and pyruvate did not exceed the physiological range in any patient. However, with initiation of CPB, the lactate to pyruvate (LA/PVA) ratio increased (from 9.87 +/- 2.43 at T1 to 12.08 +/- 1.51 at T2, p<0.05). The mean value of the LA/ PVA ratio was elevated during surgery. Later, upon lowering of the plasma lactate concentration in the postoperative period, the LA/PVA ratio decreased to normal values. Without any other evidence of hypoxia, this increase in the LA/PVA ratio could be explained by washout of lactate from previously hypoperfused tissues and intraoperative decrease of lactate clearance. CONCLUSION Systemic oxygenation was not impaired during CPB, or during 18 h after surgery in the studied group of patients.
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Affiliation(s)
- Y M Ganushchak
- Department of Extra Corporeal Circulation, University Hospital Maastricht, The Netherlands.
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Elvenes OP, Korvald C, Irtun O, Larsen T, Sørlie D. Both glucose-insulin-potassium and glutamine in warm blood cardioplegia increase the rates of myocardial glucose and free fatty acid oxidation. SCAND CARDIOVASC J 2002; 36:19-26. [PMID: 12018762 DOI: 10.1080/140174302317282348] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
OBJECTIVE We wanted to assess the effect of glucose-insulin-potassium (GIK) and glutamine on the oxidative metabolism during and after prolonged warm continuous blood cardioplegia (WB). DESIGN WB was given to 21 pigs divided into three equally sized groups: WB (control), WB and GIK, or WB and glutamine. Oxidation rates of radiolabeled glucose (14C) and free fatty acid (FFA) (3H) were assessed before, during, and at 30 and 60 min after 3 h of cardiac arrest with WB. RESULTS During standstill the substrate oxidation dropped markedly (<60%), glucose oxidation was highest in the WB + GIK group (p < 0.05) and FFA oxidation highest in the WB + glutamine group (NS). During recovery the GIK group had an elevated glucose oxidation (47 and 40% vs WB at 30 and 60 min recovery, respectively -p < 0.05). Following 30 min recovery the addition of GIK suppressed FFA oxidation some 60%. Glutamine increased the oxidation of both glucose (30%) and FFA (150%) following 60 min recovery (p < 0.05). During the whole recovery phase the relative FFA oxidation was significantly lowered in the GIK group. There were no differences between the groups regarding arterial levels or uptake of substrates, except for a higher myocardial oxygen consumption (MVO2) during cardioplegia in the glutamine group. All the hearts performed similarly. CONCLUSION Addition of GIK or glutamine to the well-perfused and oxygenated heart during WB led to a postcardioplegic increase in oxidative metabolism and MVO2. GIK resulted in a significant metabolic shift from FFA to glucose.
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Affiliation(s)
- Odd Petter Elvenes
- Department of Cardiothoracic and Vascular Surgery, School of Medicine, University of Tromsø, Norway.
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