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Sánchez-Pérez P, Mata A, Torp MK, López-Bernardo E, Heiestad CM, Aronsen JM, Molina-Iracheta A, Jiménez-Borreguero LJ, García-Roves P, Costa ASH, Frezza C, Murphy MP, Stenslokken KO, Cadenas S. Energy substrate metabolism, mitochondrial structure and oxidative stress after cardiac ischemia-reperfusion in mice lacking UCP3. Free Radic Biol Med 2023; 205:244-261. [PMID: 37295539 DOI: 10.1016/j.freeradbiomed.2023.05.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Revised: 04/22/2023] [Accepted: 05/15/2023] [Indexed: 06/12/2023]
Abstract
Myocardial ischemia-reperfusion (IR) injury may result in cardiomyocyte dysfunction. Mitochondria play a critical role in cardiomyocyte recovery after IR injury. The mitochondrial uncoupling protein 3 (UCP3) has been proposed to reduce mitochondrial reactive oxygen species (ROS) production and to facilitate fatty acid oxidation. As both mechanisms might be protective following IR injury, we investigated functional, mitochondrial structural, and metabolic cardiac remodeling in wild-type mice and in mice lacking UCP3 (UCP3-KO) after IR. Results showed that infarct size in isolated perfused hearts subjected to IR ex vivo was larger in adult and old UCP3-KO mice than in equivalent wild-type mice, and was accompanied by higher levels of creatine kinase in the effluent and by more pronounced mitochondrial structural changes. The greater myocardial damage in UCP3-KO hearts was confirmed in vivo after coronary artery occlusion followed by reperfusion. S1QEL, a suppressor of superoxide generation from site IQ in complex I, limited infarct size in UCP3-KO hearts, pointing to exacerbated superoxide production as a possible cause of the damage. Metabolomics analysis of isolated perfused hearts confirmed the reported accumulation of succinate, xanthine and hypoxanthine during ischemia, and a shift to anaerobic glucose utilization, which all recovered upon reoxygenation. The metabolic response to ischemia and IR was similar in UCP3-KO and wild-type hearts, being lipid and energy metabolism the most affected pathways. Fatty acid oxidation and complex I (but not complex II) activity were equally impaired after IR. Overall, our results indicate that UCP3 deficiency promotes enhanced superoxide generation and mitochondrial structural changes that increase the vulnerability of the myocardium to IR injury.
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Affiliation(s)
- Patricia Sánchez-Pérez
- Centro de Biología Molecular "Severo Ochoa" (CSIC/UAM), 28049, Madrid, Spain; Instituto de Investigación Sanitaria Princesa (IIS-IP), 28006, Madrid, Spain
| | - Ana Mata
- Centro de Biología Molecular "Severo Ochoa" (CSIC/UAM), 28049, Madrid, Spain; Instituto de Investigación Sanitaria Princesa (IIS-IP), 28006, Madrid, Spain
| | - May-Kristin Torp
- Centro de Biología Molecular "Severo Ochoa" (CSIC/UAM), 28049, Madrid, Spain; Department of Molecular Medicine, Institute of Basic Medical Sciences, Faculty of Medicine, University of Oslo, PB1110, N-0317, Oslo, Norway
| | - Elia López-Bernardo
- Centro de Biología Molecular "Severo Ochoa" (CSIC/UAM), 28049, Madrid, Spain; Instituto de Investigación Sanitaria Princesa (IIS-IP), 28006, Madrid, Spain
| | - Christina M Heiestad
- Department of Molecular Medicine, Institute of Basic Medical Sciences, Faculty of Medicine, University of Oslo, PB1110, N-0317, Oslo, Norway
| | - Jan Magnus Aronsen
- Department of Molecular Medicine, Institute of Basic Medical Sciences, Faculty of Medicine, University of Oslo, PB1110, N-0317, Oslo, Norway; Bjørknes College, 0456, Oslo, Norway
| | | | - Luis J Jiménez-Borreguero
- Instituto de Investigación Sanitaria Princesa (IIS-IP), 28006, Madrid, Spain; Servicio de Cardiología, Hospital Universitario de La Princesa, 28006, Madrid, Spain; Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, 28029, Madrid, Spain
| | - Pablo García-Roves
- Department of Physiological Sciences, Universitat de Barcelona, 08907, Barcelona, Spain; Nutrition, Metabolism and Gene Therapy Group, Diabetes and Metabolism Program, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), Barcelona, Spain; Centro de Investigación Biomédica en Red Fisiopatología de la Obesidad y la Nutrición (CIBEROBN), Instituto de Salud Carlos III, 28029, Madrid, Spain
| | - Ana S H Costa
- MRC Cancer Unit, University of Cambridge, Hutchison/MRC Research Center, Cambridge Biomedical Campus, Cambridge, CB2 0XZ, UK
| | - Christian Frezza
- MRC Cancer Unit, University of Cambridge, Hutchison/MRC Research Center, Cambridge Biomedical Campus, Cambridge, CB2 0XZ, UK
| | - Michael P Murphy
- MRC Mitochondrial Biology Unit, University of Cambridge, Wellcome Trust/MRC Building, Cambridge, CB2 0XY, UK
| | - Kåre-Olav Stenslokken
- Department of Molecular Medicine, Institute of Basic Medical Sciences, Faculty of Medicine, University of Oslo, PB1110, N-0317, Oslo, Norway
| | - Susana Cadenas
- Centro de Biología Molecular "Severo Ochoa" (CSIC/UAM), 28049, Madrid, Spain; Instituto de Investigación Sanitaria Princesa (IIS-IP), 28006, Madrid, Spain.
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Skeffington KL, Moscarelli M, Abdul-Ghani S, Fiorentino F, Emanueli C, Reeves BC, Punjabi PP, Angelini GD, Suleiman MS. Pathology-related changes in cardiac energy metabolites, inflammatory response and reperfusion injury following cardioplegic arrest in patients undergoing open-heart surgery. Front Cardiovasc Med 2022; 9:911557. [PMID: 35935655 PMCID: PMC9354251 DOI: 10.3389/fcvm.2022.911557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Accepted: 06/29/2022] [Indexed: 11/13/2022] Open
Abstract
Introduction Changes in cardiac metabolites in adult patients undergoing open-heart surgery using ischemic cardioplegic arrest have largely been reported for non-ventricular tissue or diseased left ventricular tissue, with few studies attempting to assess such changes in both ventricular chambers. It is also unknown whether such changes are altered in different pathologies or linked to the degree of reperfusion injury and inflammatory response. The aim of the present work was to address these issues by monitoring myocardial metabolites in both ventricles and to establish whether these changes are linked to reperfusion injury and inflammatory/stress response in patients undergoing surgery using cold blood cardioplegia for either coronary artery bypass graft (CABG, n = 25) or aortic valve replacement (AVR, n = 16). Methods Ventricular biopsies from both left (LV) and right (RV) ventricles were collected before ischemic cardioplegic arrest and 20 min after reperfusion. The biopsies were processed for measuring selected metabolites (adenine nucleotides, purines, and amino acids) using HPLC. Blood markers of cardiac injury (Troponin I, cTnI), inflammation (IL- 6, IL-8, Il-10, and TNFα, measured using Multiplex) and oxidative stress (Myeloperoxidase, MPO) were measured pre- and up to 72 hours post-operatively. Results The CABG group had a significantly shorter ischemic cardioplegic arrest time (38.6 ± 2.3 min) compared to AVR group (63.0 ± 4.9 min, p = 2 x 10-6). Cardiac injury (cTnI release) was similar for both CABG and AVR groups. The inflammatory markers IL-6 and Il-8 were significantly higher in CABG patients compared to AVR patients. Metabolic markers of cardiac ischemic stress were relatively and significantly more altered in the LV of CABG patients. Comparing diabetic and non-diabetic CABG patients shows that only the RV of diabetic patients sustained major ischemic stress during reperfusion and that diabetic patients had a significantly higher inflammatory response. Discussion CABG patients sustain relatively more ischemic stress, systemic inflammatory response and similar injury and oxidative stress compared to AVR patients despite having significantly shorter cross-clamp time. The higher inflammatory response in CABG patients appears to be at least partly driven by a higher incidence of diabetes amongst CABG patients. In addition to pathology, the use of cold blood cardioplegic arrest may underlie these differences.
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Affiliation(s)
- Katie L. Skeffington
- Bristol Heart Institute and Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Marco Moscarelli
- National Heart and Lung Institute, Imperial College, London, United Kingdom
- GVM Care & Research, Anthea Hospital, Bari, Italy
| | - Safa Abdul-Ghani
- Department of Physiology, Faculty of Medicine, Al-Quds University, Jerusalem, Palestine
| | - Francesca Fiorentino
- Nightingale-Saunders Clinical Trials and Epidemiology Unit (King's Clinical Trials Unit), King's College London, London, United Kingdom
| | - Costanza Emanueli
- National Heart and Lung Institute, Imperial College, London, United Kingdom
| | - Barnaby C. Reeves
- Bristol Heart Institute and Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Prakash P. Punjabi
- National Heart and Lung Institute, Imperial College, London, United Kingdom
| | - Gianni D. Angelini
- Bristol Heart Institute and Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - M-Saadeh Suleiman
- Bristol Heart Institute and Bristol Medical School, University of Bristol, Bristol, United Kingdom
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Zhou K, Zhang X, Li D, Song G. Myocardial Protection With Different Cardioplegia in Adult Cardiac Surgery: A Network Meta-Analysis. Heart Lung Circ 2021; 31:420-429. [PMID: 34600812 DOI: 10.1016/j.hlc.2021.09.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 08/05/2021] [Accepted: 09/07/2021] [Indexed: 11/28/2022]
Abstract
AIM Cardioplegia is one of the most studied fields of myocardial protection during cardiac surgery. However, the most effective cardioplegia for protection in adult cardiac surgery remains unknown. METHOD PubMed and other databases were searched and a network meta-analysis with a Bayesian framework was performed. The primary outcomes were the serum concentrations of creatine kinase-myocardial band (CK-MB), cardiac troponin I, and cardiac troponin T (cTnT) at four time points. Several clinical outcomes were evaluated, including low output syndrome, myocardial infarction, and risk of early mortality. All studies that involved crystalloid cardioplegia without reference to St Thomas cardioplegia or histidine-tryptophan-ketoglutarate solution, and if the cardioplegia was used at a temperature between 4°C and 16°C were classified as cold crystalloid (cCCP) or cold blood cBCP cardioplegia. Warm blood cardioplegia (wBCP) was defined as the blood cardioplegia used at a temperature between 32°C and 37°C. RESULTS Forty-seven (47) studies with a total of 4,175 patients were included. Seven (7) cardioplegia solutions were used, including cold CCP or BCP, del Nido solution, histidine-tryptophan-ketoglutaratesolution, St Thomas cardioplegia, wBCP and warm terminal blood cardioplegia (wtBCP). The serum concentrations of CK-MB at 2 hours (mean difference [MD], 213.56; 95% confidence interval [CI], -25.79 to -1.59) and cTnT at 24 hours of wBCP (MD, -1.50; 95% CI, -2.69 to -0.31) were significantly lower than that of cCCP. There were no significant differences in other outcomes of these six cardioplegia solutions, when compared to cCCP. CONCLUSIONS The seven cardioplegia solutions analysed had similar myocardial protective effects after adult cardiac surgery, although wBCP had a lower CK-MB at 2 hours and lower cTnT at 24 hours.
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Affiliation(s)
- Ke Zhou
- Department of Cardiac Surgery, Shengjing Hospital of China Medical University, Shenyang, China
| | - Xintong Zhang
- Department of Ultrasound, Shengjing Hospital of China Medical University, Shenyang, China
| | - Dongyu Li
- Department of Cardiac Surgery, Shengjing Hospital of China Medical University, Shenyang, China
| | - Guang Song
- Department of Ultrasound, Shengjing Hospital of China Medical University, Shenyang, China.
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Dimagli A, Sinha S, Caputo M, Angelini GD, Benedetto U. Trend in morbidity and mortality in surgical aortic valve replacement: a retrospective, observational, single-centre study. Interact Cardiovasc Thorac Surg 2021; 31:796-802. [PMID: 33150396 DOI: 10.1093/icvts/ivaa189] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2020] [Revised: 07/06/2020] [Accepted: 07/28/2020] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Continuous improvement in the management of patients undergoing surgical aortic valve replacement (SAVR) may have considerably enhanced surgical outcomes including in-hospital mortality and perioperative complications. We aimed to analyse in-hospital mortality and morbidity trends in patients undergoing SAVR in a single centre to provide insights for future benchmarking for transcatheter aortic valve implantation indications. METHODS This was a retrospective study of prospectively collected data from patients undergoing either isolated SAVR or combined with coronary artery bypass grafting (CABG) at the Bristol Heart Institute, UK, from January 2000 to December 2017. Baseline characteristics were extracted and analysed across 3 different eras (2000-2005, 2006-2011 and 2012-2017). Risk-adjusted time trend was obtained from univariate and multivariate logistic regression including all baseline characteristics. RESULTS A total of 2719 patients (63.2%) underwent isolated SAVR, and 1581 (36.8%) underwent combined CABG and SAVR during the study period. For patients undergoing SAVR, in-hospital mortality decreased from 2.9% in 2000-2005 to 0.7% in 2012-2017 (risk-adjusted time trend 0.0001). Hospital mortality in patients aged 75-79 and ≥80 years decreased from 5.6% and 5.3% to 0.4% and 2.2%, respectively. Mortality after combined SAVR and CABG did not significantly decrease (from 3.9% in 2000-2005 to 3.5% in 2012-2017; risk-adjusted time trend = 0.62). However, in patients aged ≥80 years, index hospitalization mortality showed a decreasing non-significant trend from 9.8% to 4.8%. CONCLUSIONS Our findings support the hypothesis that mortality and morbidity rates following SAVR have significantly improved over the years, including for patients at high risk.
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Affiliation(s)
| | - Shubhra Sinha
- Bristol Heart Institute, University of Bristol, Bristol, UK
| | - Massimo Caputo
- Bristol Heart Institute, University of Bristol, Bristol, UK
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Kot TKM, Chan JSK, Froghi S, Lau DHH, Morgan K, Magni F, Harky A. Warm versus cold cardioplegia in cardiac surgery: A meta-analysis with trial sequential analysis. JTCVS OPEN 2021; 6:161-190. [PMID: 36003589 PMCID: PMC9390447 DOI: 10.1016/j.xjon.2021.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 03/17/2021] [Indexed: 11/16/2022]
Affiliation(s)
- Thompson Ka Ming Kot
- Faculty of Medicine, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong
- Department of Anaesthesia and Intensive Care, Prince of Wales Hospital, Shatin, New Territories, Hong Kong
| | - Jeffrey Shi Kai Chan
- Faculty of Medicine, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong
- Division of Cardiology, Department of Medicine and Therapeutics, Prince of Wales Hospital, Hong Kong
| | - Saied Froghi
- Division of Surgery and Interventional Sciences, Royal Free Hospital, University College London, London, United Kingdom
| | - Dawnie Ho Hei Lau
- Faculty of Medicine, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong
- Division of Cardiology, Department of Medicine and Therapeutics, Prince of Wales Hospital, Hong Kong
| | - Kara Morgan
- Department of Cardiology, Manchester Royal Infirmary, Manchester, United Kingdom
- Faculty of Biology, Medicine & Health, Division of Pharmacy & Optometry, School of Health Sciences, The University of Manchester, Manchester, United Kingdom
| | - Francesco Magni
- Faculty of Medicine, University College London, London, United Kingdom
- Address for reprints: Francesco Magni, University College London Medical School, London, United Kingdom.
| | - Amer Harky
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
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An acute estrogen receptor agonist enhances protective effects of cardioplegia in hearts from aging male and female mice. Exp Gerontol 2020; 141:111093. [DOI: 10.1016/j.exger.2020.111093] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 09/08/2020] [Accepted: 09/11/2020] [Indexed: 01/01/2023]
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James TM, Nores M, Rousou JA, Lin N, Stamou SC. Warm Blood Cardioplegia for Myocardial Protection: Concepts and Controversies. Tex Heart Inst J 2020; 47:108-116. [PMID: 32603472 DOI: 10.14503/thij-18-6909] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Warm blood cardioplegia has been an established cardioplegic method since the 1990s, yet it remains controversial in regard to myocardial protection. This review will describe the physiologic and technical concepts behind warm blood cardioplegia, as well as outline the current basic and clinical research that evaluates its usefulness. Controversies regarding this technique will also be reviewed. A long history of experimental data indicates that warm blood cardioplegia is safe and effective and thus suitable myocardial protection during cardiopulmonary bypass surgeries.
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Affiliation(s)
- Taylor M James
- Graduate Medical Education MD/MPH Program, University of Miami Miller School of Medicine, Miami, Florida 33130
| | - Marcos Nores
- Department of Cardiothoracic Surgery, JFK Medical Center, Atlantis, Florida 33462
| | - John A Rousou
- Department of Cardiothoracic Surgery, Baystate Medical Center, Springfield, Massachusetts 01199
| | - Nicole Lin
- Graduate Medical Education MD/MPH Program, University of Miami Miller School of Medicine, Miami, Florida 33130
| | - Sotiris C Stamou
- Department of Cardiothoracic Surgery, JFK Medical Center, Atlantis, Florida 33462
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Ghimire A, Bisset ES, Howlett SE. Ischemia and reperfusion injury following cardioplegic arrest is attenuated by age and testosterone deficiency in male but not female mice. Biol Sex Differ 2019; 10:42. [PMID: 31443710 PMCID: PMC6708213 DOI: 10.1186/s13293-019-0256-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Accepted: 08/12/2019] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Cardiovascular disease increases with age in both sexes. Treatment can require cardiac surgery, where the hearts are pre-treated with protective cardioplegic solution before ischemia and reperfusion (I/R). While endogenous estrogen is beneficial in I/R, whether testosterone is involved is uncertain and whether age modifies responses to I/R is unclear. We investigated sex- and age-specific differences in I/R injury in the hearts pre-treated with clinically relevant cardioplegic solution. METHODS The hearts were isolated from young (6-9 months) and old (20-28 months) mice of both sexes and perfused (Langendorff) with Krebs-Henseleit buffer (15 min, 37 °C), followed by St. Thomas' two cardioplegia (6 min, 6-7 °C), global ischemia (90 min, 23-24 °C), and reperfusion (30 min, 37 °C). The hearts were perfused with triphenyltetrazolium chloride to quantify infarct area. Testosterone's role was investigated in gonadectomized (GDX, 6-9 months) male mice; serum testosterone and estradiol were measured with ELISA assays. RESULTS Left ventricular developed pressure (LVDP) recovered to 67.3 ± 7.4% in the old compared to 21.8 ± 9.2% in the young male hearts (p < 0.05). Similar results were seen for rates of pressure development (+dP/dt) and decay (-dP/dt). Infarct areas were smaller in the old male hearts (16.6 ± 1.6%) than in the younger hearts (55.8 ± 1.2%, p < 0.05). By contrast, the hearts from young and old females exhibited a similar post-ischemic functional recovery and no age-dependent difference in infarcts. There was a sex difference in the young group, where ventricular function (LVDP, +dP/dt, -dP/dt) recovered better and infarcts were smaller in females than males. Estradiol levels were highest in young females. Testosterone was high in young males but low in females and old males, which suggested beneficial effects of low testosterone. Indeed, the hearts from GDX males exhibited much better recovery of LVDP in reperfusion than that from intact males (values were 64.4 ± 7.5 % vs. 21.8 ± 9.2%; p < 0.05). The GDX hearts also had smaller infarcts than the hearts from intact males (p < 0.05). CONCLUSIONS Although age had no effect on susceptibility to I/R injury after cardioplegic arrest in females, it actually protected against injury in older males. Our findings indicate that low testosterone may be protective against I/R injury following cardioplegic arrest in older males.
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Affiliation(s)
- Anjali Ghimire
- Department of Pharmacology, Dalhousie University, Sir Charles Tupper Medical Building, 5850 College Street, PO Box 15000, Halifax, Nova Scotia B3H 4R2 Canada
| | - Elise S. Bisset
- Department of Pharmacology, Dalhousie University, Sir Charles Tupper Medical Building, 5850 College Street, PO Box 15000, Halifax, Nova Scotia B3H 4R2 Canada
| | - Susan E. Howlett
- Department of Pharmacology, Dalhousie University, Sir Charles Tupper Medical Building, 5850 College Street, PO Box 15000, Halifax, Nova Scotia B3H 4R2 Canada
- Department of Medicine (Geriatric Medicine), Dalhousie University, Halifax, Nova Scotia Canada
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Saclı H, Kara I, Diler MS, Percin B, Turan AI, Kırali K. The Relationship between the Use of Cold and Isothermic Blood Cardioplegia Solution for Myocardial Protection during Cardiopulmonary Bypass and the Ischemia-Reperfusion Injury. Ann Thorac Cardiovasc Surg 2019; 25:296-303. [PMID: 31308305 PMCID: PMC6923728 DOI: 10.5761/atcs.oa.18-00293] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
PURPOSE In this study, we aimed to assess myocardial protection and ischemia-reperfusion injury in patients undergoing open heart surgery with isothermic blood cardioplegia (IBC) or hypothermic blood cardioplegia (HBC). MATERIALS AND METHODS A total of 48 patients who underwent isolated coronary artery bypass grafting or isolated mitral valve surgery between March 2017 and October 2017 were evaluated as randomized prospective study. Study groups (HBC: Group 1, IBC: Group 2) were compared in terms of interleukin 6 (IL-6), IL-8, IL-10, and complement factor 3a (C3a) levels, metabolic parameters, creatine kinase-muscle/brain (CK-MB) and high-sensitivity Troponin I (hsTn-I), and clinical outcomes. RESULTS Comparison of the markers of ischemia-reperfusion injury showed significantly higher levels of the proinflammatory cytokine IL-6 in the early postoperative period as well as IL-8, in Group 2 (p <0.001), whereas the anti-inflammatory cytokine IL-10 was significantly higher during the X1 time period (p = 0.11) in Group 2, and subsequently it was higher in Group 1. Using myocardial temperature probes, the target myocardial temperatures were measured in the patients undergoing open heart surgery with different routes of cardioplegia, and significant differences were noted (p = 0.000). CONCLUSION HBC for open heart surgery is associated with less myocardial injury and intraoperative and postoperative morbidity, indicating superior myocardial protection versus IBC.
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Affiliation(s)
- Hakan Saclı
- Faculty of Medicine, Department of Cardiovascular Surgery, Sakarya University, Adapazarı, Turkey
| | - Ibrahim Kara
- Faculty of Medicine, Department of Cardiovascular Surgery, Sakarya University, Adapazarı, Turkey
| | - Mevriye Serpil Diler
- Department of Cardiovascular Surgery, Sakarya University Education and Research Hospital, Adapazarı, Turkey
| | - Bilal Percin
- Department of Cardiovascular Surgery, Sakarya University Education and Research Hospital, Adapazarı, Turkey
| | - Ahmet Ilksoy Turan
- Department of Cardiovascular Surgery, Sakarya University Education and Research Hospital, Adapazarı, Turkey
| | - Kaan Kırali
- Faculty of Medicine, Department of Cardiovascular Surgery, Sakarya University, Adapazarı, Turkey
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Hoyer A, Kiefer P, Borger M. Cardioplegia and myocardial protection: time for a reassessment? J Thorac Dis 2019; 11:E76-E78. [PMID: 31285915 DOI: 10.21037/jtd.2019.05.08] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Alexandro Hoyer
- Department of Cardiac Surgery, Heart Center of University of Leipzig, Leipzig, Germany
| | - Philipp Kiefer
- Department of Cardiac Surgery, Heart Center of University of Leipzig, Leipzig, Germany
| | - Michael Borger
- Department of Cardiac Surgery, Heart Center of University of Leipzig, Leipzig, Germany
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Tevaearai Stahel HT, Do PD, Klaus JB, Gahl B, Locca D, Göber V, Carrel TP. Clinical Relevance of Troponin T Profile Following Cardiac Surgery. Front Cardiovasc Med 2018; 5:182. [PMID: 30619889 PMCID: PMC6301188 DOI: 10.3389/fcvm.2018.00182] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Accepted: 12/03/2018] [Indexed: 11/13/2022] Open
Abstract
Background: Peak post-operative cardiac troponin T (cTnT) independently predicts mid- and long-term outcome of cardiac surgery patients. A few studies however have reported two peaks of cTnT over the first 48–72 h following myocardial reperfusion. The aim of the current study was to better understand underlying reasons of these different cTnT profiles and their possible relevance in terms of clinical outcome. Methods: All consecutive adult cardiac surgical procedures performed with an extra-corporeal circulation during a >6 years period were retrospectively evaluated. Patients with a myocardial infarction (MI) < 8 days were excluded. cTnT profile of patients with at least one value ≥1 ng/mL value were categorized according to the time occurrence of the peak value. Univariable and multivariable analysis were performed to identify factors influencing early vs. late increase of cTnT values, and to verify the correlation of early vs. late increase with clinical outcome. Results: Data of 5,146 patients were retrieved from our prospectively managed registry. From 953 with at least one cTnT value ≥1 ng/mL, peak occurred ≤ 6 h (n = 22), >6 to ≤ 12 h (n = 366), >12 to ≤ 18 h (n = 176), >18 to ≤ 24 h (171), >24 h (218). Age (OR: 1.023; CI: 1.016–1.030) and isolated CABG (OR: 1.779; CI: 1.114–2.839) were independent predictors of a late increase of cTnT over a limit of 1 ng/ml (p < 0.05), whereas isolated valve procedures (OR: 0.685; CI: 0.471–0.998) and cross-clamp duration (OR: 0.993; CI: 0.990–0.997) independently predicted an early elevation (p < 0.05). Delayed elevation as opposed to early elevation correlated with a higher rate of post-operative complications including MI (19.8 vs. 7.2%), new renal insufficiency (16.3 vs. 6.7%), MACCE (32.0 vs. 15.5%), or death (7.4 vs. 4.4%). Conclusion: Profile of cTnT elevation following cardiac surgery depends on patients' intrinsic factors, type of surgery and duration of cross-clamp time. Delayed increase is of higher clinically relevance than prompt post-operative elevation.
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Affiliation(s)
- Hendrik T Tevaearai Stahel
- Department of Cardiovascular Surgery, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Peter D Do
- Department of Cardiovascular Surgery, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Jeremias Bendicht Klaus
- Institute of Radiology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Brigitta Gahl
- Department of Cardiovascular Surgery, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Didier Locca
- Department of Cardiology, Barts Heart Center, Barts Health NHS Trust, London, United Kingdom.,William Harvey Institute, Queen Mary University London, United Kingdom
| | - Volkhard Göber
- Department of Cardiovascular Surgery, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Thierry P Carrel
- Department of Cardiovascular Surgery, Bern University Hospital and University of Bern, Bern, Switzerland
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Rogers CA, Capoun R, Scott LJ, Taylor J, Jain A, Angelini GD, Narayan P, Suleiman MS, Sarkar K, Ascione R. Shortening cardioplegic arrest time in patients undergoing combined coronary and valve surgery: results from a multicentre randomized controlled trial: the SCAT trial. Eur J Cardiothorac Surg 2018; 52:288-296. [PMID: 28444178 PMCID: PMC5848808 DOI: 10.1093/ejcts/ezx087] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Accepted: 02/26/2017] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Combined coronary artery bypass grafting and valve surgery requires a prolonged period of cardioplegic arrest (CA) predisposing to myocardial injury and postoperative cardiac-specific complications. The aim of this trial was to reduce the CA time in patients undergoing combined coronary artery bypass grafting and valve surgery and assess if this was associated with less myocardial injury and related complications. METHODS Participants were randomized to (i) coronary artery bypass grafting performed on the beating heart with cardiopulmonary bypass support followed by CA for the valve procedure (hybrid) or (ii) both procedures under CA (conventional). To assess complications related to myocardial injury, we used the composite of death, myocardial infarction, arrhythmia, need for pacing or inotropes for >12 h. To assess myocardial injury, we used serial plasma troponin T and markers of metabolic stress in myocardial biopsies. RESULTS Hundred and sixty patients (80 hybrid and 80 conventional) were randomized. Mean age was 66.5 years and 74% were male. Valve procedures included aortic (61.8%) and mitral (33.1%) alone or in combination (5.1%). CA time was 16% lower in the hybrid group [median 98 vs 89 min, geometric mean ratio (GMR) 0.84, 95% confidence interval (CI) 0.77-0.93, P = 0.0004]. Complications related to myocardial injury occurred in 131/160 patients (64/80 conventional, 67/80 hybrid), odds ratio 1.24, 95% CI 0.54-2.86, P = 0.61. Release of troponin T was similar between groups (GMR 1.04, 95% CI 0.87-1.24, P = 0.68). Adenosine monophosphate was 28% lower in the hybrid group (GMR 0.72, 95% CI 0.51-1.02, P = 0.056). CONCLUSIONS The hybrid procedure reduced the CA time but myocardial injury outcomes were not superior to conventional approach. TRIAL REGISTRATION ISRCTN65770930.
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Affiliation(s)
- Chris A Rogers
- Clinical Trials and Evaluation Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Radek Capoun
- Bristol Heart Institute, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Lauren J Scott
- Clinical Trials and Evaluation Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Jodi Taylor
- Clinical Trials and Evaluation Unit, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Anil Jain
- SAL Hospital and Medical Institute, Ahmedabad, India
| | - Gianni D Angelini
- Bristol Heart Institute, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Pradeep Narayan
- Rabindranath Tagore International Institute of Cardiac Sciences (RTIICS), Kolkata, India
| | - M-Saadeh Suleiman
- Bristol Heart Institute, School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Kunal Sarkar
- Rabindranath Tagore International Institute of Cardiac Sciences (RTIICS), Kolkata, India
| | - Raimondo Ascione
- Bristol Heart Institute, School of Clinical Sciences, University of Bristol, Bristol, UK
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Nardi P, Vacirca SR, Russo M, Colella DF, Bassano C, Scafuri A, Pellegrino A, Melino G, Ruvolo G. Cold crystalloid versus warm blood cardioplegia in patients undergoing aortic valve replacement. J Thorac Dis 2018; 10:1490-1499. [PMID: 29707299 DOI: 10.21037/jtd.2018.03.67] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Myocardial protection techniques during cardiac arrest have been extensively investigated in the clinical setting of coronary revascularization. Fewer studies have been carried out of patients affected by left ventricular hypertrophy, where the choice of type and temperature of cardioplegia remain controversial. We have retrospectively investigated myocardial injury and short-term outcome in patients undergoing aortic valve replacement plus or minus coronary artery bypass grafting with using cold crystalloid cardioplegia (CCC) or warm blood cardioplegia (WBC). Methods From January 2015 to October 2016, 191 consecutive patients underwent aortic valve replacement plus or minus coronary artery bypass grafting in normothermic cardiopulmonary bypass. Cardiac arrest was obtained with use of intermittent antegrade CCC group (n=32) or WBC group (n=159), according with the choice of the surgeon. Results As compared with WBC group, in CCC group creatine-kinase-MB (CK-MB), cardiac troponin I (cTnI), aspartate aminotransferase (AST) release, and their peak levels, were lower during each time points of evaluation, with the greater statistically significant difference at time 0 (P<0.05, for all comparisons). A time 0, CK-MB/CK ratio >10% was 5.9% in CCC group versus 7.8% in WBC group (P<0.0001). At time 0 CK-MB/CK ratio >10% in patients undergoing isolated aortic valve replacement was 6.0% in CCC group versus 8.0% in WBC group (P<0.01). No any difference was found in perioperative myocardial infarction (0% versus 3.8%), postoperative (PO) major complications (15.6% versus 16.4%), in-hospital mortality (3.1% versus 1.3%). Conclusions In aortic valve surgery a significant decrease of myocardial enzymes release is observed in favor of CCC, but this difference does not translate into different clinical outcome. However, this study suggests that in presence of cardiac surgical conditions associated with significant left ventricular hypertrophy, i.e., the aortic valve disease, a better myocardial protection can be achieved with the use of a cold rather than a warm cardioplegia. Therefore, CCC can be still safely used.
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Affiliation(s)
- Paolo Nardi
- Division of Cardiac Surgery, Faculty of Medicine and Surgery, Tor Vergata University, Rome, Italy
| | - Sara R Vacirca
- Division of Cardiac Surgery, Faculty of Medicine and Surgery, Tor Vergata University, Rome, Italy
| | - Marco Russo
- Division of Cardiac Surgery, Faculty of Medicine and Surgery, Tor Vergata University, Rome, Italy
| | - Dionisio F Colella
- Division of Anesthesiology, Faculty of Medicine and Surgery, Tor Vergata University, Rome, Italy
| | - Carlo Bassano
- Division of Cardiac Surgery, Faculty of Medicine and Surgery, Tor Vergata University, Rome, Italy
| | - Antonio Scafuri
- Division of Cardiac Surgery, Faculty of Medicine and Surgery, Tor Vergata University, Rome, Italy
| | - Antonio Pellegrino
- Division of Cardiac Surgery, Faculty of Medicine and Surgery, Tor Vergata University, Rome, Italy
| | - Gerry Melino
- Department of Experimental Medicine and Surgery, Faculty of Medicine and Surgery, Tor Vergata University, Rome, Italy
| | - Giovanni Ruvolo
- Division of Cardiac Surgery, Faculty of Medicine and Surgery, Tor Vergata University, Rome, Italy
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Warm blood cardioplegia versus cold crystalloid cardioplegia for myocardial protection during coronary artery bypass grafting surgery. Cell Death Discov 2018. [PMID: 29531820 PMCID: PMC5841304 DOI: 10.1038/s41420-018-0031-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
We retrospectively analyzed early results of coronary artery bypass grafting (CABG) surgery using two different types of cardioplegia for myocardial protection: antegrade intermittent warm blood or cold crystalloid cardioplegia. From January 2015 to October 2016, 330 consecutive patients underwent isolated on-pump CABG. Cardiac arrest was obtained with use of warm blood cardioplegia (WBC group, n = 297) or cold crystalloid cardioplegia (CCC group, n = 33), according to the choice of the surgeon. Euroscore II and preoperative characteristics were similar in both groups, except for the creatinine clearance, slightly lower in WBC group (77.33 ± 27.86 mL/min versus 88.77 ± 51.02 mL/min) (P < 0.05). Complete revascularization was achieved in both groups. In-hospital mortality was 2.0% (n = 6) in WBC group, absent in CCC group. The required mean number of cardioplegia’s doses per patient was higher in WBC group (2.3 ± 0.8) versus CCC group (2.0 ± 0.7) (P = 0.045), despite a lower number of distal coronary artery anastomoses (2.7 ± 0.8 versus 3.2 ± 0.9) (P = 0.0001). Cardiopulmonary and aortic cross-clamp times were similar in both groups. The incidence of perioperative myocardial infarction (WBC group 3.4% versus CCC group 3.0%) and low cardiac output syndrome (4.4% versus 3.0%) were similar in both groups. As compared with WBC group, in CCC group CK-MB/CK ratio >10% was lower during each time points of evaluation, with a statistical significant difference at time 0 (4% ± 1.6% versus 5% ± 2.5%) (P = 0.021). In presence of complete revascularization, despite the value of CK-MB/CK ratio >10% was less in the CCC group, clinical results were not affected by both types of cardioplegia adopted to myocardial protection. As compared with cold crystalloid, warm blood cardioplegia requires a shorter interval of administration to achieve better myocardial protection.
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15
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Comentale G, Giordano R, Palma G. Comparison of the different cardioplegic strategies in cardiac valves surgery: who wins the "arm-wrestling"? J Thorac Dis 2018; 10:714-717. [PMID: 29607140 DOI: 10.21037/jtd.2018.01.133] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Giuseppe Comentale
- Adult and Pediatric Cardiac Surgery, Department of Advanced Biomedical Sciences, University of Naples "Federico II", Naples, Italy
| | - Raffaele Giordano
- Adult and Pediatric Cardiac Surgery, Department of Advanced Biomedical Sciences, University of Naples "Federico II", Naples, Italy
| | - Gaetano Palma
- Adult and Pediatric Cardiac Surgery, Department of Advanced Biomedical Sciences, University of Naples "Federico II", Naples, Italy
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Preservation of Myocardial Perfusion and Function by Keeping Hypertrophied Heart Empty and Beating for Valve Surgery: An In Vivo MR Study of Pig Hearts. BIOMED RESEARCH INTERNATIONAL 2017; 2017:4107587. [PMID: 28409155 PMCID: PMC5376923 DOI: 10.1155/2017/4107587] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Revised: 12/13/2016] [Accepted: 12/29/2016] [Indexed: 11/17/2022]
Abstract
Objectives. Normothermic hyperkalemic cardioplegia arrest (NHCA) may not effectively preserve hypertrophied myocardium during open-heart surgery. Normothermic normokalemic beating perfusion (NNBP), keeping hearts empty-beating, was utilized as an alternative to evaluate its cardioprotective role. Materials and Methods. Twelve hypertrophied pig hearts at 58.6 ± 7.2 days after ascending aorta banding underwent NNBP and NHCA, respectively. Near infrared myocardial perfusion imaging with indocyanine green (ICG) was conducted to assess myocardial perfusion. Left ventricular (LV) contractile function was assessed by cine MRI. TUNEL staining and western blotting for caspase-3 cleavage and cardiac troponin I (cTnI) degradation were conducted in LV tissue samples. Results. Ascending aortic diameter was reduced by 52.7% ± 0.4% at approximately fifty-eight days after banding. LV wall thickness was significantly higher in aorta banding than in sham operation. Myocardial blood flow reflected by maximum ICG absorbance value was markedly higher in NNBP than in NHCA. The amount of apoptotic cardiomyocyte was significantly lower in NNBP than in NHCA. NNBP alleviated caspase-3 cleavage and cTnI degradation associated with NHCA. NNBP displayed a substantially increased postoperative ejection fraction relative to NHCA. Conclusions. NNBP was better than NHCA in enhancing myocardial perfusion, inhibiting cardiomyocyte apoptosis, and preserving LV contractile function for hypertrophied hearts.
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18
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Ellis L, Murphy GJ, Culliford L, Dreyer L, Clayton G, Downes R, Nicholson E, Stoica S, Reeves BC, Rogers CA. The Effect of Patient-Specific Cerebral Oxygenation Monitoring on Postoperative Cognitive Function: A Multicenter Randomized Controlled Trial. JMIR Res Protoc 2015; 4:e137. [PMID: 26685289 PMCID: PMC4704972 DOI: 10.2196/resprot.4562] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2015] [Accepted: 08/15/2015] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Indices of global tissue oxygen delivery and utilization such as mixed venous oxygen saturation, serum lactate concentration, and arterial hematocrit are commonly used to determine the adequacy of tissue oxygenation during cardiopulmonary bypass (CPB). However, these global measures may not accurately reflect regional tissue oxygenation and ischemic organ injury remains a common and serious complication of CPB. Near-infrared spectroscopy (NIRS) is a noninvasive technology that measures regional tissue oxygenation. NIRS may be used alongside global measures to optimize regional perfusion and reduce organ injury. It may also be used as an indicator of the need for red blood cell transfusion in the presence of anemia and tissue hypoxia. However, the clinical benefits of using NIRS remain unclear and there is a lack of high-quality evidence demonstrating its efficacy and cost effectiveness. OBJECTIVE The aim of the patient-specific cerebral oxygenation monitoring as part of an algorithm to reduce transfusion during heart valve surgery (PASPORT) trial is to determine whether the addition of NIRS to CPB management algorithms can prevent cognitive decline, postoperative organ injury, unnecessary transfusion, and reduce health care costs. METHODS Adults aged 16 years or older undergoing valve or combined coronary artery bypass graft and valve surgery at one of three UK cardiac centers (Bristol, Hull, or Leicester) are randomly allocated in a 1:1 ratio to either a standard algorithm for optimizing tissue oxygenation during CPB that includes a fixed transfusion threshold, or a patient-specific algorithm that incorporates cerebral NIRS monitoring and a restrictive red blood cell transfusion threshold. Allocation concealment, Internet-based randomization stratified by operation type and recruiting center, and blinding of patients, ICU and ward care staff, and outcome assessors reduce the risk of bias. The primary outcomes are cognitive function 3 months after surgery and infectious complications during the first 3 months after surgery. Secondary outcomes include measures of inflammation, organ injury, and volumes of blood transfused. The cost effectiveness of the NIRS-based algorithm is described in terms of a cost-effectiveness acceptability curve. The trial tests the superiority of the patient-specific algorithm versus standard care. A sample size of 200 patients was chosen to detect a small to moderate target difference with 80% power and 5% significance (two tailed). RESULTS Over 4 years, 208 patients have been successfully randomized and have been followed up for a 3-month period. Results are to be reported in 2015. CONCLUSIONS This study provides high-quality evidence, both valid and widely applicable, to determine whether the use of NIRS monitoring as part of a patient-specific management algorithm improves clinical outcomes and is cost effective. TRIAL REGISTRATION International Standard Randomized Controlled Trial Number (ISRCTN): 23557269; http://www.isrctn.com/ISRCTN23557269 (Archived by Webcite at http://www.webcitation.org/6buyrbj64).
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Affiliation(s)
- Lucy Ellis
- Clinical Trials & Evaluation Unit, University of Bristol, Bristol, United Kingdom
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19
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Rogers CA, Bryan AJ, Nash R, Suleiman MS, Baos S, Plummer Z, Hillier J, Davies I, Downes R, Nicholson E, Reeves BC, Angelini GD. Propofol cardioplegia: A single-center, placebo-controlled, randomized controlled trial. J Thorac Cardiovasc Surg 2015; 150:1610-9.e13. [DOI: 10.1016/j.jtcvs.2015.06.044] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2015] [Revised: 05/28/2015] [Accepted: 06/20/2015] [Indexed: 12/09/2022]
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20
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Zakkar M, Ascione R, James AF, Angelini GD, Suleiman MS. Inflammation, oxidative stress and postoperative atrial fibrillation in cardiac surgery. Pharmacol Ther 2015; 154:13-20. [PMID: 26116810 DOI: 10.1016/j.pharmthera.2015.06.009] [Citation(s) in RCA: 134] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Accepted: 06/18/2015] [Indexed: 01/24/2023]
Abstract
Postoperative atrial fibrillation (POAF) is a common complication of cardiac surgery that occurs in up to 60% of patients. POAF is associated with increased risk of cardiovascular mortality, stroke and other arrhythmias that can impact on early and long term clinical outcomes and health economics. Many factors such as disease-induced cardiac remodelling, operative trauma, changes in atrial pressure and chemical stimulation and reflex sympathetic/parasympathetic activation have been implicated in the development of POAF. There is mounting evidence to support a major role for inflammation and oxidative stress in the pathogenesis of POAF. Both are consequences of using cardiopulmonary bypass and reperfusion following ischaemic cardioplegic arrest. Subsequently, several anti-inflammatory and antioxidant drugs have been tested in an attempt to reduce the incidence of POAF. However, prevention remains suboptimal and thus far none of the tested drugs has provided sufficient efficacy to be widely introduced in clinical practice. A better understanding of the cellular and molecular mechanisms responsible for the onset and persistence of POAF is needed to develop more effective prediction and interventions.
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Affiliation(s)
- M Zakkar
- Bristol Heart Institute, University of Bristol, Level 7, Bristol Royal Infirmary, Upper Maudlin Street, Bristol BS2 8HW, UK
| | - R Ascione
- Bristol Heart Institute, University of Bristol, Level 7, Bristol Royal Infirmary, Upper Maudlin Street, Bristol BS2 8HW, UK
| | - A F James
- School of Physiology & Pharmacology, University of Bristol, Medical Sciences Building, University Walk, Bristol, BS8 1TD, UK
| | - G D Angelini
- Bristol Heart Institute, University of Bristol, Level 7, Bristol Royal Infirmary, Upper Maudlin Street, Bristol BS2 8HW, UK
| | - M S Suleiman
- Bristol Heart Institute, University of Bristol, Level 7, Bristol Royal Infirmary, Upper Maudlin Street, Bristol BS2 8HW, UK.
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21
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El Zayat A, Refaat A, Sobhy E, Farouk A. Can restrictive filling pattern on dobutamine stress echocardiography predict recovery of left ventricular systolic function after valve replacement in patients with low flow-low gradient aortic stenosis? Egypt Heart J 2015. [DOI: 10.1016/j.ehj.2014.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Endothelial Injury Associated with Cold or Warm Blood Cardioplegia during Coronary Artery Bypass Graft Surgery. BIOMED RESEARCH INTERNATIONAL 2015; 2015:256905. [PMID: 26090394 PMCID: PMC4452219 DOI: 10.1155/2015/256905] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/19/2014] [Accepted: 01/13/2015] [Indexed: 11/17/2022]
Abstract
The aim of this investigation was to analyze the impact of intermittent cold blood cardioplegia (ICC) and intermittent warm blood cardioplegia (IWC) on endothelial injury in patients referred to elective on-pump coronary artery bypass graft (CABG) surgery. Patients undergoing CABG procedures were randomized to either ICC or IWC. Myocardial injury was assessed by CK-MB and cardiac troponin T (cTnT). Endothelial injury was quantified by circulating endothelial cells (CECs), von Willebrand factor (vWF), and soluble thrombomodulin (sTM). Perioperative myocardial injury (PMI) and major adverse cardiac events (MACE) were recorded. Demographic data and preoperative risk profile of included patients (ICC: n = 32, IWC: n = 36) were comparable. No deaths, PMI, or MACE were observed. Levels of CK-MB and cTnT did not show intergroup differences. Concentrations of CECs peaked at 6 h postoperatively with significantly higher values for IWC-patients at 1 h (ICC: 10.1 ± 3.9/mL; IWC: 18.4 ± 4.1/mL; P = 0.012) and 6 h (ICC: 19.3 ± 6.2/mL; IWC: 29.2 ± 6.7/mL; P < 0.001). Concentrations of vWF (ICC: 178.4 ± 73.2 U/dL; IWC: 258.2 ± 89.7 U/dL; P < 0.001) and sTM (ICC: 3.2 ± 2.1 ng/mL; IWC: 5.2 ± 2.4 ng/mL; P = 0.011) were significantly elevated in IWC-group at 1 h postoperatively. This study shows that the use of IWC is associated with a higher extent of endothelial injury compared to ICC without differences in clinical endpoints.
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Liu S, Liu Z, Li L, Liu P, Liu H. Keeping the heart empty and beating: an alternative technique to preserve hypertrophied hearts during valvular surgery. J Cardiothorac Surg 2015; 10:71. [PMID: 25968233 PMCID: PMC4434573 DOI: 10.1186/s13019-015-0273-2] [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: 12/23/2014] [Accepted: 05/01/2015] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION To determine whether keeping the heart empty and beating is an effective technique to preserve hypertrophied pig hearts, and to investigate the underlying mechanism. METHODS Ten Bama Miniature pigs with hypertrophied hearts were divided into 2 groups (n = 5 in each group). One group underwent normothermic normokalemic simultaneous perfusion (NNSP). The other group was subjected to normothermic hypermokalemic simultaneous perfusion (NHSP) and used as controls. Cardiac contractive function, myocardial energy metabolism and myocardial perfusion were assessed using magnetic resonance imaging. Western blot analysis was carried out to determine the expression of Troponin I (cTnI), Troponin T (cTnT), SM-MHC, Casapase-3 and PARP4. TUNEL assay was used to detect apoptotic cardiomyocytes. RESULTS Keeping the heart empty and beating with NNSP improved the preservation of contractile function in comparison with cardioplegic arrest using NHSP. No significant differences existed in the effects of NNSP and NHSP in maintaining myocardial energy metabolism. 13 % perfusion defects areas were found in one heart in the NHSP group, whereas none was found in all other hearts in both groups. The expressions of cTnI, cTnT, Casapase-3 and PARP4 in NHSP group were abundantly increased compared to NNSP group as measured by Western blotting. Conversely, the expression of SM-MHC in NHSP group was reduced compared with NNSP group. The number of TUNEL positive nuclei per mm(2) area was significantly increased in NHSP group compared with NNSP group. CONCLUSIONS Keeping the heart beating with NNSP is an alternative technique to preserve hypertrophied hearts during valvular surgery.
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Affiliation(s)
- Shangdian Liu
- Department of Cardiovascular Surgery, the First Affiliated Hospital of Harbin Medical University, 23 Youzheng Road, Harbin, Heilongjiang, 150001, China.
| | - Zonghong Liu
- Department of Cardiovascular Surgery, the First Affiliated Hospital of Harbin Medical University, 23 Youzheng Road, Harbin, Heilongjiang, 150001, China.
| | - Lulu Li
- Department of Magnetic Resonance Imaging (MRI), the First Affiliated Hospital of Harbin Medical University, Harbin, China.
| | - Pengfei Liu
- Department of Magnetic Resonance Imaging (MRI), the First Affiliated Hospital of Harbin Medical University, Harbin, China.
| | - Hongyu Liu
- Department of Cardiovascular Surgery, the First Affiliated Hospital of Harbin Medical University, 23 Youzheng Road, Harbin, Heilongjiang, 150001, China.
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Fiorentino F, Angelini GD, Suleiman MS, Rahman A, Anderson J, Bryan AJ, Culliford LA, Moscarelli M, Punjabi PP, Reeves BC. Investigating the effect of remote ischaemic preconditioning on biomarkers of stress and injury-related signalling in patients having isolated coronary artery bypass grafting or aortic valve replacement using cardiopulmonary bypass: study protocol for a randomized controlled trial. Trials 2015; 16:181. [PMID: 25899533 PMCID: PMC4425928 DOI: 10.1186/s13063-015-0696-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2014] [Accepted: 03/30/2015] [Indexed: 01/14/2023] Open
Abstract
Background Ischaemia-reperfusion injury occurs during heart surgery that uses cardiopulmonary bypass (CPB) and cardioplegic arrest. It is hypothesised that remote ischaemic preconditioning (RIPC) protects the heart against such injury. Despite the numerous studies investigating the protective effects of RIPC, there is still uncertainty about the interpretation of the findings as well as conflicting results between studies. The objective of this trial is to investigate the cardioprotective effect of RIPC in patients having coronary artery bypass grafting (CABG) or aortic valve replacement surgery. This will be achieved by estimating the effect of the intervention in the two groups of pathologies and by investigating the signalling mechanisms that may underpin the cardioprotective effect. Methods/Design A two-centre randomised controlled trial will be used to investigate the effects of RIPC in two pathologies: patients having isolated CABG and those having aortic valve replacement surgery (AVR) with CPB. Participants will be randomised to RIPC or control (sham RIPC), stratified by surgical stratum. The intervention will be delivered by a research nurse. Data will be collected by a research nurse blinded to the intervention. The patient and the theatre staff are also blinded to the allocation. Markers of myocardial injury and inflammation will be measured in myocardial biopsies and in blood samples at different times. Discussion This trial is designed to investigate whether RIPC will reduce myocardial injury and inflammation following heart surgery and whether there is a difference in effect between participants having CABG or AVR. This trial is a unique opportunity to study the mechanisms associated with RIPC using human myocardial tissue and blood, and to relate these to the extent of myocardial injury/protection. Trial registration Current Controlled Trials ISRCTN33084113 (25 March 2013). Electronic supplementary material The online version of this article (doi:10.1186/s13063-015-0696-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Francesca Fiorentino
- National Heart and Lung Institute, Cardiothoracic Surgery Department, Imperial College London, Du Cane Road, W12 0NN, London, UK.
| | - Gianni D Angelini
- National Heart and Lung Institute, Cardiothoracic Surgery Department, Imperial College London, Du Cane Road, W12 0NN, London, UK. .,Bristol Heart Institute, University of Bristol, Bristol Royal Infirmary, Marlborough Street, BS2 8HW, Bristol, UK.
| | - M-Saadeh Suleiman
- Bristol Heart Institute, University of Bristol, Bristol Royal Infirmary, Marlborough Street, BS2 8HW, Bristol, UK.
| | - Alima Rahman
- National Heart and Lung Institute, Cardiothoracic Surgery Department, Imperial College London, Du Cane Road, W12 0NN, London, UK.
| | - Jon Anderson
- National Heart and Lung Institute, Cardiothoracic Surgery Department, Imperial College London, Du Cane Road, W12 0NN, London, UK.
| | - Alan J Bryan
- Bristol Heart Institute, University of Bristol, Bristol Royal Infirmary, Marlborough Street, BS2 8HW, Bristol, UK.
| | - Lucy A Culliford
- Bristol Heart Institute, University of Bristol, Bristol Royal Infirmary, Marlborough Street, BS2 8HW, Bristol, UK.
| | - Marco Moscarelli
- National Heart and Lung Institute, Cardiothoracic Surgery Department, Imperial College London, Du Cane Road, W12 0NN, London, UK.
| | - Prakash P Punjabi
- National Heart and Lung Institute, Cardiothoracic Surgery Department, Imperial College London, Du Cane Road, W12 0NN, London, UK.
| | - Barnaby C Reeves
- Bristol Heart Institute, University of Bristol, Bristol Royal Infirmary, Marlborough Street, BS2 8HW, Bristol, UK.
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Plummer ZE, Baos S, Rogers CA, Suleiman MS, Bryan AJ, Angelini GD, Hillier J, Downes R, Nicholson E, Reeves BC. The effects of propofol cardioplegia on blood and myocardial biomarkers of stress and injury in patients with isolated coronary artery bypass grafting or aortic valve replacement using cardiopulmonary bypass: protocol for a single-center randomized controlled trial. JMIR Res Protoc 2014; 3:e35. [PMID: 25004932 PMCID: PMC4115261 DOI: 10.2196/resprot.3353] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2014] [Accepted: 06/09/2014] [Indexed: 11/21/2022] Open
Abstract
Background Despite improved myocardial protection strategies, cardioplegic arrest and ischemia still result in reperfusion injury. We have previously published a study describing the effects of propofol (an anesthetic agent commonly used in cardiac surgery) on metabolic stress, cardiac function, and injury in a clinically relevant animal model. We concluded that cardioplegia supplementation with propofol at a concentration relevant to the human clinical setting resulted in improved hemodynamic function, reduced oxidative stress, and reduced reperfusion injury when compared to standard cardioplegia. Objective The Propofol cardioplegia for Myocardial Protection Trial (ProMPT) aims to translate the successful animal intervention to the human clinical setting. We aim to test the hypothesis that supplementation of the cardioplegic solution with propofol will be cardioprotective for patients undergoing isolated coronary artery bypass graft or aortic valve replacement surgery with cardiopulmonary bypass. Methods The trial is a single-center, placebo-controlled, randomized trial with blinding of participants, health care staff, and the research team. Patients aged between 18 and 80 years undergoing nonemergency isolated coronary artery bypass graft or aortic valve replacement surgery with cardiopulmonary bypass at the Bristol Heart Institute are being invited to participate. Participants are randomly assigned in a 1:1 ratio to either cardioplegia supplementation with propofol (intervention) or cardioplegia supplementation with intralipid (placebo) using a secure, concealed, Internet-based randomization system. Randomization is stratified by operation type and minimized by diabetes mellitus status. Biomarkers of cardiac injury and metabolism are being assessed to investigate any cardioprotection conferred. The primary outcome is myocardial injury, studied by measuring myocardial troponin T. The trial is designed to test hypotheses about the superiority of the intervention within each surgical stratum. The sample size of 96 participants has been chosen to achieve 80% power to detect standardized differences of 0.5 at a significance level of 5% (2-tailed) assuming equal numbers in each surgical stratum. Results A total of 96 patients have been successfully recruited over a 2-year period. Results are to be published in late 2014. Conclusions Designing a practicable method for delivering a potentially protective dose of propofol to the heart during cardiac surgery was challenging. If our approach confirms the potential of propofol to reduce damage during cardiac surgery, we plan to design a larger multicenter trial to detect differences in clinical outcomes. Trial Registration International Standard Randomized Controlled Trial Number (ISRCTN): 84968882; http://www.controlled-trials.com/ISRCTN84968882/ProMPT (Archived by WebCite at http://www.webcitation.org/6Qi8A51BS).
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Affiliation(s)
- Zoe E Plummer
- Clinical Trials and Evaluation Unit, University of Bristol, Bristol, United Kingdom
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Lindman BR, Pibarot P, Arnold SV, Suri RM, McAndrew TC, Maniar HS, Zajarias A, Kodali S, Kirtane AJ, Thourani VH, Tuzcu EM, Svensson LG, Waksman R, Smith CR, Leon MB. Transcatheter versus surgical aortic valve replacement in patients with diabetes and severe aortic stenosis at high risk for surgery: an analysis of the PARTNER Trial (Placement of Aortic Transcatheter Valve). J Am Coll Cardiol 2013; 63:1090-9. [PMID: 24291272 DOI: 10.1016/j.jacc.2013.10.057] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2013] [Revised: 10/11/2013] [Accepted: 10/17/2013] [Indexed: 01/15/2023]
Abstract
OBJECTIVES The goal of this study was to determine whether a less-invasive approach to aortic valve replacement (AVR) improves clinical outcomes in diabetic patients with aortic stenosis (AS). BACKGROUND Diabetes is associated with increased morbidity and mortality after surgical AVR for AS. METHODS Among treated patients with severe symptomatic AS at high risk for surgery in the PARTNER (Placement of Aortic Transcatheter Valve) trial, we examined outcomes stratified according to diabetes status of patients randomly assigned to receive transcatheter or surgical AVR. The primary outcome was all-cause mortality at 1 year. RESULTS Among 657 patients enrolled in PARTNER who underwent treatment, there were 275 patients with diabetes (145 transcatheter, 130 surgical). There was a significant interaction between diabetes and treatment group for 1-year all-cause mortality (p = 0.048). Among diabetic patients, all-cause mortality at 1 year was 18.0% in the transcatheter group and 27.4% in the surgical group (hazard ratio: 0.60 [95% confidence interval: 0.36 to 0.99]; p = 0.04). Results were consistent among patients treated via transfemoral or transapical routes. In contrast, among nondiabetic patients, there was no significant difference in all-cause mortality at 1 year (p = 0.48). Among diabetic patients, the 1-year rates of stroke were similar between treatment groups (3.5% transcatheter vs. 3.5% surgery; p = 0.88), but the rate of renal failure requiring dialysis >30 days was lower in the transcatheter group (0% vs. 6.1%; p = 0.003). CONCLUSIONS Among patients with diabetes and severe symptomatic AS at high risk for surgery, this post-hoc stratified analysis of the PARTNER trial suggests there is a survival benefit, no increase in stroke, and less renal failure from treatment with transcatheter AVR compared with surgical AVR. (The PARTNER Trial: Placement of AoRTic TraNscathetER Valve Trial; NCT00530894).
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Affiliation(s)
- Brian R Lindman
- Washington University School of Medicine, St. Louis, Missouri.
| | - Philippe Pibarot
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | | | | | | | - Hersh S Maniar
- Washington University School of Medicine, St. Louis, Missouri
| | - Alan Zajarias
- Washington University School of Medicine, St. Louis, Missouri
| | - Susheel Kodali
- Cardiovascular Research Foundation, New York, New York; Columbia University Medical Center/New York Presbyterian Hospital, New York, New York
| | - Ajay J Kirtane
- Cardiovascular Research Foundation, New York, New York; Columbia University Medical Center/New York Presbyterian Hospital, New York, New York
| | | | | | | | - Ron Waksman
- MedStar Washington Hospital Center, Washington, DC
| | - Craig R Smith
- Columbia University Medical Center/New York Presbyterian Hospital, New York, New York
| | - Martin B Leon
- Cardiovascular Research Foundation, New York, New York; Columbia University Medical Center/New York Presbyterian Hospital, New York, New York
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Abah U, Garfjeld Roberts P, Ishaq M, De Silva R. Is cold or warm blood cardioplegia superior for myocardial protection? Interact Cardiovasc Thorac Surg 2012; 14:848-55. [PMID: 22402501 DOI: 10.1093/icvts/ivs069] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether the use of warm or cold blood cardioplegia has superior myocardial protection. More than 192 papers were found using the reported search, of which 20 represented the best evidence to answer the clinical question. The authors, journal, date, country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. A good breadth of high-level evidence addressing this clinical dilemma is available, including a recent meta-analysis and multiple large randomized clinical trials. Yet despite this level of evidence, no clear significant clinical benefit has been demonstrated by warm or cold blood cardioplegia. This suggests that neither method is significantly superior and that both provide similar efficacy of myocardial protection. The meta-analysis, including 41 randomized control trials (5879 patients in total), concluded that although a lower cardiac enzyme release and improved postoperative cardiac index was demonstrated in the warm cardioplegia group, this benefit was not reflected in clinical outcomes, which were similar in both groups. This theme of benefit in biochemical markers, physiological metrics and non-fatal postoperative events in the warm cardioplegia group ran throughout the literature, in particular the 'Warm Heart investigators' who conducted a randomized trial of 1732 patients, demonstrated a reduction in postoperative low output syndrome (6.1 versus 9.3%, P = 0.01) in the warm cardioplegia group, but no significant drop in 30-day all-cause mortality (1.4 versus 2.5%, P = 0.12). However, their later follow-up indicates non-fatal postoperative events predict reduced late survival, independent of cardioplegia. A minority of studies suggested a benefit of cold cardioplegia over warm in particular patient subgroups: One group conducted a retrospective study of 520 patients who required prolonged aortic cross-clamp times, results demonstrated less myocardial damage and reduced postoperative cardiac mortality and morbidity in the cold group. The clinical bottom line is that warm and cold cardioplegia result in similar short-term mortality. However, large studies have shown that warm cardioplegia reduces adverse post-operative events; the significance of which is unclear.
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Affiliation(s)
- Udo Abah
- Department of Cardiothoracic Surgery, John Radcliffe Hospital, Oxford, UK.
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Elghobary T, Ali IM, Ahmad AF. Operative Myocardial Protection in Patients with Left Ventricular Hypertrophy: The Role of Systemic Hypothermia. Open J Cardiovasc Surg 2011; 4:1-4. [PMID: 26949335 PMCID: PMC4767134 DOI: 10.4137/ojcs.s6937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVES Myocardial hypertrophy represents a great challenge in cardiac surgery. Several strategies have been described to protect the hypertrophied myocardium during cardiopulmonary bypass, and aortic clamping, yet the ideal strategy has not been identified. This study investigates the use of moderate systemic hypothermia (MSH) as an adjuvant method to protect the hypertrophied myocardium in patients undergoing aortic valve replacement (AVR). METHODS Twenty eight patients undergoing AVR were divided into two groups, (Group I) received continuous cold 5-8 °C retrograde blood cardioplegia (CRBC) and their body temperature was cooled down to 23-26 °C. (Group II) also received CRBC but their body temperature was kept at 32-34 °C. RESULTS No operative morality (30 days) was noted in both groups. Postoperative reduction in ejection fraction (EF) was seen in nine patients of group I and in twelve patients of group II (P < 0.05). The need for multiple inotropes was more in group II (eight patients) than in group I (two patients) (P < 0.001). IABP was needed in three patients of group II and non in group I (P < 0.01). CONCLUSION Moderate systemic hypothermia might have a role in protecting hypertrophied myocardium in patients undergoing AVR.
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Affiliation(s)
- Tamer Elghobary
- Dalhousie University and QEII Health Science Center, Halifax, Nova Scotia, Canada
| | - Idris M Ali
- Dalhousie University and QEII Health Science Center, Halifax, Nova Scotia, Canada
| | - Ahmad F Ahmad
- Dalhousie University and QEII Health Science Center, Halifax, Nova Scotia, Canada
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Salhiyyah K, Raja SG, Akeela H, Pepper J, Amrani M. Beating heart continuous coronary perfusion for valve surgery: what next for clinical trials? Future Cardiol 2010; 6:845-58. [DOI: 10.2217/fca.10.102] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Prior to the introduction of cardioplegia, beating heart continuous coronary perfusion (BHCCP) was the only available method of myocardial protection. Currently, cardiac surgery on cardiopulmonary bypass with cardioplegic arrest is the gold standard strategy. Cardioplegic arrest provides an easier and safer way to operate on a still heart. It enables the performance of a broader range of cardiac procedures, and avoids the potential difficulties of continuous perfusion on a beating heart. Despite the overall effectiveness and safety of cardioplegia, some adverse effects remain, mainly due to the insult of ischemia, which results in ischemic reperfusion injury. As a result BHCCP has seen a revival as an alternative to cardioplegia for performing complex valvular surgery. Increasing experience reporting safety and efficacy of BHCCP is being published. However, despite the reported advantages, current available evidence validating safety and efficacy of BHCCP is controversial. This article provides an overview of BHCCP highlighting the current best available evidence supporting this strategy, concerns, controversies and potential areas for further research.
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Affiliation(s)
| | - Shahzad G Raja
- Department of Cardiothoracic Surgery, Harefield Hospital, Royal Brompton & Harefield NHS Trust, Hill End Road, Harefield, London, UB9 6JH, UK
| | - Hiba Akeela
- Department of Cardiothoracic Surgery, Harefield Hospital, Royal Brompton & Harefield NHS Trust, Hill End Road, Harefield, London, UB9 6JH, UK
| | - John Pepper
- Department of Cardiothoracic Surgery, Harefield Hospital, Royal Brompton & Harefield NHS Trust, Hill End Road, Harefield, London, UB9 6JH, UK
| | - Mohamed Amrani
- Department of Cardiothoracic Surgery, Harefield Hospital, Royal Brompton & Harefield NHS Trust, Hill End Road, Harefield, London, UB9 6JH, UK
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Licker M, Cikirikcioglu M, Inan C, Cartier V, Kalangos A, Theologou T, Cassina T, Diaper J. Preoperative diastolic function predicts the onset of left ventricular dysfunction following aortic valve replacement in high-risk patients with aortic stenosis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2010; 14:R101. [PMID: 20525242 PMCID: PMC2911741 DOI: 10.1186/cc9040] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/01/2009] [Revised: 11/20/2009] [Accepted: 06/03/2010] [Indexed: 11/10/2022]
Abstract
INTRODUCTION Left ventricular (LV) dysfunction frequently occurs after cardiac surgery, requiring inotropic treatment and/or mechanical circulatory support. In this study, we aimed to identify clinical, surgical and echocardiographic factors that are associated with LV dysfunction during weaning from cardiopulmonary bypass (CPB) in high-risk patients undergoing valve replacement for aortic stenosis. METHODS Perioperative data were prospectively collected in 108 surgical candidates with an expected operative mortality >or=9%. All anesthetic and surgical techniques were standardized. Reduced LV systolic function was defined by an ejection fraction <40%. Diastolic function of the LV was assessed using standard Doppler-derived parameters, tissue Doppler Imaging (TDI) and transmitral flow propagation velocity (Vp). RESULTS Doppler-derived pulmonary flow indices and TDI could not be obtained in 14 patients. In the remaining 94 patients, poor systolic LV was documented in 14% (n = 12) and diastolic dysfunction in 84% of patients (n = 89), all of whom had Vp <50 cm/s. During weaning from CPB, 38 patients (40%) required inotropic and/or mechanical circulatory support. By multivariate regression analysis, we identified three independent predictors of LV systolic dysfunction: age (Odds ratio [OR] = 1.11; 95% confidence interval (CI), 1.01 to 1.22), aortic clamping time (OR = 1.04; 95% CI, 1.00 to 1.08) and Vp (OR = 0.65; 95% CI, 0.52 to 0.81). Among echocardiographic measurements, Vp was found to be superior in terms of prognostic value and reliability. The best cut-off value for Vp to predict LV dysfunction was 40 cm/s (sensitivity of 72% and specificity 94%). Patients who experienced LV dysfunction presented higher in-hospital mortality (18.4% vs. 3.6% in patients without LV dysfunction, P = 0.044) and an increased incidence of serious cardiac events (81.6 vs. 28.6%, P < 0.001). CONCLUSIONS This study provides the first evidence that, besides advanced age and prolonged myocardial ischemic time, LV diastolic dysfunction characterized by Vp <or= 40 cm/sec identifies patients who will require cardiovascular support following valve replacement for aortic stenosis.
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Affiliation(s)
- Marc Licker
- Faculty of Medicine, University of Geneva, Department of Anaesthesiology, University Hospital, CH-1211 Geneva 14, Switzerland
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Macedo FIB, Carvalho EM, Hassan M, Ricci M, Gologorsky E, Salerno TA. Beating Heart Valve Surgery in Patients with Low Left Ventricular Ejection Fraction. J Card Surg 2010; 25:267-71. [DOI: 10.1111/j.1540-8191.2010.01000.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Ho JK, Liakopoulos OJ, Crowley R, Yezbick AB, Sanchez E, Shivkumar K, Mahajan A. In vivo detection of myocardial ischemia in pigs using visible light spectroscopy. Anesth Analg 2009; 108:1185-92. [PMID: 19299784 DOI: 10.1213/ane.0b013e3181951a65] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Monitoring tissue oxygenation (StO(2)) by visible light spectroscopy (VLS) can identify tissue ischemia, but its feasibility for detecting myocardial ischemia is not known. We hypothesized that VLS can reliably detect changes in myocardial StO(2) in pigs subjected to acute regional or global myocardial ischemia. METHODS In 11 pigs, regional myocardial ischemia was created by ligation of left anterior descending artery (LAD). Myocardial StO(2) was determined from the ischemic and nonischemic left ventricular (LV) regions and compared to coronary venous saturations. Myocardial function was assessed by echocardiography. In six pigs, LV-StO(2) was measured during cardiopulmonary bypass (CPB), after cardioplegic cardiac arrest, and during CPB with inadequate myocardial protection. Additionally, right ventricular (RV)- and LV-StO(2) were assessed during acute RV pressure overload from pulmonary artery (PA) banding. RESULTS StO(2) baselines in pigs undergoing LAD occlusion were similar in the ischemic and nonischemic myocardium (70% +/- 8% vs 74% +/- 5%). After LAD ligation, StO(2) rapidly declined (30 s: 59% +/- 8%; 1 min:50 +/- 9; 5 min:42% +/- 4%; P < 0.05) in the ischemic myocardium. Decreases in StO(2) correlated with coronary venous saturations (r = 0.88) and were associated with myocardial dysfunction. In pigs undergoing CPB, LV-StO(2) remained unchanged with initiation of CPB or after cardioplegic cardiac arrest, but LV ischemia was detected by StO(2) after aortic cross-clamp without adequate myocardial protection. Similarly, PA banding resulted in a profound decrease of RV-StO(2) from 69% +/- 6% to 52% +/- 7% (P < 0.05) with recovery after PA release. CONCLUSIONS VLS is a reliable method of detecting alterations in myocardial StO(2) and can be a useful monitor for rapid identification of myocardial ischemia.
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Affiliation(s)
- Jonathan K Ho
- Department of Anesthesiology, David Geffen School of Medicine, University of California, Los Angeles, California 90095, USA
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Godet G, Bernard M, Ben Ayed S. [Cardiac biomarkers for diagnosis of myocardial infarction]. ACTA ACUST UNITED AC 2009; 28:321-31. [PMID: 19304448 DOI: 10.1016/j.annfar.2009.01.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2008] [Accepted: 01/14/2009] [Indexed: 11/29/2022]
Abstract
Diagnosis of postoperative myocardial infarction is often difficult, based on tools with a low sensitivity (clinical symptoms, EKG), or with a low specifity (old biomarkers, echocardiographic abnormalities) or inadequate for clinical practice (scintigraphy). Since 1995, clinicians may use more cardiospecific markers (troponin) allowing to modify strategy for postoperative myocardial infarction diagnosis. The aim of this review is to resume such an attitude.
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Affiliation(s)
- G Godet
- Département d'anesthésie et réanimation 2, hôpital Pontchaillou, 2, rue Henri-Le-Guilloux, 35033 Rennes cedex, France.
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Influencia del sexo en el pronóstico perioperatorio de pacientes sometidos a sustitución valvular por estenosis aórtica severa. Rev Esp Cardiol 2009. [DOI: 10.1016/s0300-8932(09)70018-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Influence of Concentric Left Ventricular Remodeling on Early Mortality After Aortic Valve Replacement. Ann Thorac Surg 2008; 85:2030-9. [DOI: 10.1016/j.athoracsur.2008.02.075] [Citation(s) in RCA: 97] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2007] [Revised: 02/19/2008] [Accepted: 02/25/2008] [Indexed: 01/19/2023]
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Ascione R, Suleiman SM, Angelini GD. Retrograde hot-shot cardioplegia in patients with left ventricular hypertrophy undergoing aortic valve replacement. Ann Thorac Surg 2008; 85:454-8. [PMID: 18222241 DOI: 10.1016/j.athoracsur.2007.08.039] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2007] [Revised: 08/15/2007] [Accepted: 08/21/2007] [Indexed: 11/16/2022]
Abstract
BACKGROUND Intermittent antegrade cold-blood cardioplegia followed by terminal warm-blood cardioplegic reperfusion or hot-shot is reported to reduce myocardial injury in the setting of coronary surgery. The efficacy of this cardioplegic technique in patients with left ventricular hypertrophy secondary to aortic stenosis remains uncertain. METHODS Thirty-six patients with left ventricular hypertrophy undergoing aortic valve replacement were prospectively randomized to cold-blood cardioplegia either alone (cold-blood cardioplegia group) or with retrograde hot-shot (hot-shot group). Reperfusion injury was assessed by measuring myocardial levels of adenosine triphosphate and lactate in left and right ventricular biopsies taken 5 minutes after institution of cardiopulmonary bypass and 20 minutes after removal of cross-clamp using high-performance liquid chromatography and enzymatic techniques. Myocardial injury was assessed by serial release of troponin I up to 48 hours postoperatively. Overall clinical outcome was prospectively collected. RESULTS Baseline and intraoperative characteristics were similar between groups. In the hot-shot group, there were no significant changes in the myocardial concentration of adenosine triphosphate and lactate in both left and right ventricular biopsies after reperfusion. In the cold-blood cardioplegia group, there was a trend to a fall in adenosine triphosphate levels in the left and right ventricular biopsies after reperfusion, but this reached statistical significance only in the right ventricle. Troponin I release was raised in both groups at 4 and 12 hours after surgery (p < 0.05), but did not reach levels of myocardial infarction. CONCLUSIONS The terminal retrograde hot-shot reperfusion does not add any extra benefit to antegrade cold-blood cardioplegia in preventing myocardial injury in patients with left ventricular hypertrophy undergoing aortic valve replacement. Nevertheless, it appears to reduce ischemic stress in the right ventricle. There was no difference in clinical outcome between groups.
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Affiliation(s)
- Raimondo Ascione
- Bristol Heart Institute, University of Bristol, Bristol, United Kingdom.
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Salerno TA, Panos AL, Tian G, Deslauriers R, Calcaterra D, Ricci M. Surgery for cardiac valves and aortic root without cardioplegic arrest ("beating heart"): experience with a new method of myocardial perfusion. J Card Surg 2008; 22:459-64. [PMID: 18039204 DOI: 10.1111/j.1540-8191.2007.00448.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Simultaneous antegrade/retrograde warm blood perfusion with a beating heart has not been previously reported as a mean of protecting hypertrophied hearts in cardiac valve and aortic root surgeries. Similarly, beating heart mitral valve surgery via the trans-septal approach with the aorta unclamped, is a novel technique. We, herein, report a series of 346 patients with a variety of cardiac pathologies who were operated upon utilizing a new modality of myocardial perfusion. Among this group of patients, there were 55 patients who were diagnosed with endocarditis of one or more valves. These patients were excluded from this series of patients. Mean age was 59 +/- 12, and there were 196 (67.3%) males and 95 (32.7%) females. There were six aortic root procedures, 90 mitral valve replacements (MVR), 46 mitral valve repairs, 20 MVR+ coronary artery bypass grafting (CABG), 28 tricuspid valve repairs, 106 aortic valve replacements (AVR), 17 AVR+CABG, and 8 AVR/MVR. Crude mortality for the group was 20 of 291 (6.8%). Intra-aortic balloon pump utilization at time of weaning from cardiopulmonary bypass was 6/291 (2.06%), and re-operation for bleeding was needed in 12 of 291 (4.1%) patients. Postoperative stroke occurred in 4 of 291 (1.3%) patients. In these patients, the clinical diagnosis of stroke was made prior to surgery. This initial experience with this new method of myocardial perfusion indicates that results are at least comparable, if not superior, to conventional techniques utilizing intermittent cold blood cardioplegia.
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Affiliation(s)
- Tomas A Salerno
- Division of Cardiothoracic Surgery, University of Miami, Miller School of Medicine, Jackson Memorial Hospital, Miami, Florida, USA.
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Ascione R, Culliford L, Rogers C, Wild J, Narajan P, Angelini G. Mechanical Heart Valves in Septuagenarians. J Card Surg 2008; 23:8-16. [DOI: 10.1111/j.1540-8191.2007.00504.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Suleiman MS, Zacharowski K, Angelini GD. Inflammatory response and cardioprotection during open-heart surgery: the importance of anaesthetics. Br J Pharmacol 2007; 153:21-33. [PMID: 17952108 DOI: 10.1038/sj.bjp.0707526] [Citation(s) in RCA: 105] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Open-heart surgery triggers an inflammatory response that is largely the result of surgical trauma, cardiopulmonary bypass, and organ reperfusion injury (e.g. heart). The heart sustains injury triggered by ischaemia and reperfusion and also as a result of the effects of systemic inflammatory mediators. In addition, the heart itself is a source of inflammatory mediators and reactive oxygen species that are likely to contribute to the impairment of cardiac pump function. Formulating strategies to protect the heart during open heart surgery by attenuating reperfusion injury and systemic inflammatory response is essential to reduce morbidity. Although many anaesthetic drugs have cardioprotective actions, the diversity of the proposed mechanisms for protection (e.g. attenuating Ca(2+) overload, anti-inflammatory and antioxidant effects, pre- and post-conditioning-like protection) may have contributed to the slow adoption of anaesthetics as cardioprotective agents during open heart surgery. Clinical trials have suggested at least some cardioprotective effects of volatile anaesthetics. Whether these benefits are relevant in terms of morbidity and mortality is unclear and needs further investigation. This review describes the main mediators of myocardial injury during open heart surgery, explores available evidence of anaesthetics induced cardioprotection and addresses the efforts made to translate bench work into clinical practice.
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Affiliation(s)
- M-S Suleiman
- Bristol Heart Institute and Department of Anaesthesia, Faculty of Medicine and Dentistry, Bristol Royal Infirmary, University of Bristol, Bristol, UK.
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Wang J, Liu H, Salerno TA, Xiang B, Li G, Gruwel M, Jackson M, Manley D, Tomanek B, Deslauriers R, Tian G. Does normothermic normokalemic simultaneous antegrade/retrograde perfusion improve myocardial oxygenation and energy metabolism for hypertrophied hearts? Ann Thorac Surg 2007; 83:1751-8. [PMID: 17462393 DOI: 10.1016/j.athoracsur.2007.01.026] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2006] [Revised: 01/13/2007] [Accepted: 01/15/2007] [Indexed: 10/23/2022]
Abstract
BACKGROUND Beating-heart valve surgery appears to be a promising technique for protection of hypertrophied hearts. Normothermic normokalemic simultaneous antegrade/retrograde perfusion (NNSP) may improve myocardial perfusion. However, its effects on myocardial oxygenation and energy metabolism remain unclear. The present study was to determine whether NNSP improved myocardial oxygenation and energy metabolism of hypertrophied hearts relative to normothermic normokalemic antegrade perfusion (NNAP). METHODS Twelve hypertrophied pig hearts underwent a protocol consisting of three 20-minute perfusion episodes (10 minutes NNAP and 10 minutes NNSP in a random order) with each conducted at a different blood flow in the left anterior descending coronary artery (LAD [100%, 50%, and 20% of its initial control]). Myocardial oxygenation was assessed using near-infrared spectroscopic imaging. Myocardial energy metabolism was monitored using localized phosphorus-31 magnetic resonance spectroscopy. RESULTS With 100% LAD flow, both NNAP and NNSP maintained myocardial oxygenation, adenosine triphosphate, phosphocreatine, and inorganic phosphate at normal levels. When LAD flow was reduced to 50% of its control level, NNSP resulted in a small but significant decrease in myocardial oxygenation and phosphocreatine, whereas those measurements did not change significantly during NNAP. With LAD flow further reduced to 20% of its control level, both NNAP and NNSP caused a substantial decrease in myocardial oxygenation, adenosine triphosphate, and phosphocreatine with an increase in inorganic phosphate. However, the changes were significantly greater during NNSP than during NNAP. CONCLUSIONS Normothermic normokalemic simultaneous antegrade/retrograde perfusion did not improve, but slightly impaired myocardial oxygenation and energy metabolism of beating hypertrophied hearts relative to NNAP. Therefore, NNSP for protection of beating hypertrophied hearts during valve surgery should be used with extra caution.
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Affiliation(s)
- Jian Wang
- Institute for Biodiagnostics, National Research Council, Winnipeg, Manitoba, Canada
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Licker M, Sierra J, Kalangos A, Panos A, Diaper J, Ellenberger C. Cardioprotective effects of acute normovolemic hemodilution in patients with severe aortic stenosis undergoing valve replacement. Transfusion 2007; 47:341-50. [PMID: 17302782 DOI: 10.1111/j.1537-2995.2007.01111.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND After acute normovolemic hemodilution (ANH), improvement of the rheologic conditions may contribute to optimize tissue oxygen delivery and attenuate ischemia-reperfusion injuries. It was hypothesized that ANH would confer additional cardioprotection in patients with ventricular hypertrophy undergoing open heart surgery. STUDY DESIGN AND METHODS This study was a randomized controlled trial. Forty patients scheduled for elective aortic valve replacement were randomly assigned to a control group (standard care) or an ANH group (target hematocrit level of 28%). All patients were managed with standard myocardial preservation techniques (cold blood cardioplegia, anesthetic preconditioning). The outcome measures included the release of myocardial enzymes, perioperative hemodynamic changes, the need for pharmacologic cardiovascular support, and cardiac complications. RESULTS In the ANH group, the postoperative release of troponin I (mean peak plasma concentrations, 1.7 ng/mL; 95% confidence interval, 1.4-2.1 ng/mL) and myocardial fraction of creatine kinase (22 U/L; range, 18-24 U/L) was significantly lower than in the control group (3.6 [range, 3.0-4.2] ng/mL and 45 [range, 39-51] U/L, respectively). In addition, requirement for inotropic support was significantly lower and fewer hemodiluted patients presented adverse cardiac events. After ANH, there was a significant decrease in heart rate (-11 +/- 6%) and rate-pressure product (-16 +/- 8%) until the aortic cross-clamping time and, at the end of surgery, the circulating levels of erythropoietin (EPO) were higher than in control patients (13.6 +/- 4.2 mUI/mL vs. 7.3 +/- 2.4 mUI/mL; p < 0.05). CONCLUSIONS Besides conventional cardiac preservation techniques, preoperative ANH further attenuates myocardial injuries. Optimization of preischemic myocardial oxygen delivery and/or consumption and the postconditioning effects of endogenous EPO are potential mechanisms for ANH-induced cardioprotection.
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Affiliation(s)
- Marc Licker
- Department of Anesthesiology, Pharmacology and Surgical Intensive Care, University Hospital of Geneva, Geneva, Switzerland.
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Wang J, Liu H, Xiang B, Li G, Gruwel M, Jackson M, Tomanek B, Salerno TA, Deslauriers R, Tian G. Keeping the heart empty and beating improves preservation of hypertrophied hearts for valve surgery. J Thorac Cardiovasc Surg 2006; 132:1314-20. [PMID: 17140949 DOI: 10.1016/j.jtcvs.2006.07.010] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2006] [Revised: 07/06/2006] [Accepted: 07/13/2006] [Indexed: 11/21/2022]
Abstract
OBJECTIVE This study was designed to determine whether keeping the heart empty and beating improved myocardial fluid homeostasis and energy metabolism of hypertrophied pig hearts in comparison with cardioplegic arrest. METHODS Twenty piglets underwent a 8-weeks (corrected) ascending aortic banding to induce left ventricular hypertrophy. Isolated hypertrophied hearts were divided into 4 groups (n = 5 in each group). Two groups underwent normothermic normokalemic simultaneous perfusion. The other 2 groups were subjected to normothermic hyperkalemic simultaneous perfusion and used as controls. Intramyocardial hydrostatic pressure was monitored with a microtip pressure transducer. Volumes of intracellular and extracellular compartments and myocardial energy metabolism were monitored by using phosphorus 31 magnetic resonance spectroscopy. RESULTS Normothermic normokalemic simultaneous perfusion (NNSP) maintained intramyocardial hydrostatic pressure at a significantly lower level (13.0 +/- 0.6 mm Hg) compared with normothermic hyperkalemic simultaneous perfusion (NHSP) (23.3 +/- 1.2 mm Hg) during a 90-minute preservation. NNSP maintained the normal volume of the intracellular compartment throughout the preservation period, whereas NHSP caused significant enlargement (to 123% +/- 6% of its normal volume) of the intracellular compartment. Expansion of the extracellular compartment during preservation was significantly less in the NNSP group (124% +/- 6%) than in the NHSP group (152% +/- 7%). NNSP maintained normal levels of phosphocreatine and adenosine triphosphate until coronary perfusion flow was reduced to 50% of the initial control level. No decrease in energy metabolites was observed in the NHSP group even when coronary perfusion flow was reduced to 10% of the initial control level. CONCLUSIONS Keeping the heart empty and beating improves myocardial fluid homeostasis for hypertrophied hearts relative to cardioplegic arrest. Its ability to maintain energy metabolism depends on the degree of coronary stenosis. This technique may be a promising protective strategy for hypertrophied hearts.
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Affiliation(s)
- Jian Wang
- Institute for Biodiagnostics, National Research Council, Winnipeg, Manitoba, Canada
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Ricci M, Salerno TA. Cardiopulmonary bypass without ischemic arrest: a myocardial protection strategy for high-risk patients requiring urgent CABG. J Card Surg 2006; 21:498-9. [PMID: 16948770 DOI: 10.1111/j.1540-8191.2006.00255.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Marco Ricci
- University of Miami, Miller School of Medicine, Jackson Memorial Hospital, Miami, FL, USA
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King N, Lin H, McGivan JD, Suleiman MS. Expression and activity of the glutamate transporter EAAT2 in cardiac hypertrophy: implications for ischaemia reperfusion injury. Pflugers Arch 2006; 452:674-82. [PMID: 16718509 DOI: 10.1007/s00424-006-0096-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2006] [Revised: 04/05/2006] [Accepted: 04/19/2006] [Indexed: 11/26/2022]
Abstract
The expression and activity of the glutamate transporter, excitatory amino acid transporter 2 (EAAT2), in cardiac hypertrophy were investigated with respect to glutamate's potential as a cardioprotective agent. Sarcolemmal vesicles (SV) isolated from hypertrophic hearts of male spontaneously hypertensive rats (SHR) or normotrophic hearts from age-matched male Wistar Kyoto rats (WKY) were used to measure the relative level of EAAT2 expression by Western blotting and the initial rate of 0-0.3 mM L-[(14)C]glutamate uptake. The effects of 20-min global normothermic ischaemia +/-0.5 mM glutamate on cardiac function were measured in isolated working SHR/WKY hearts. In a separate series of hearts, glutamate, lactate and ATP levels were measured. Both the level of EAAT2 expression and the V (max) for sodium-dependent L-[(14)C]glutamate uptake were significantly greater in SHR SV compared to WKY SV. The reperfusion cardiac output (CO) of SHR hearts was significantly worse than that of the WKY hearts (24.3+/-2.2 ml/min vs 39.8+/-3.3 ml/min, n=7/9+/-SE, p<0.01). The addition of 0.5 mM L-glutamate improved the SHR reperfusion CO to 45.2+/-5 ml/min, (n=6+/-SE, p<0.01) but had no effect on WKYs (46.2+/-3.8 ml/min, n=6+/-SE). SHR with 0.5 mM L-glutamate had higher glutamate levels at the start of ischaemia, plus higher glutamate and ATP levels at the end of ischaemia compared to any other group. These results suggest that increased glutamate transporter expression and activity in the SHR hearts helped facilitate glutamate entry into the SHR cardiomyocytes leading to improved myocardial metabolism during ischaemia and better functional recovery on reperfusion.
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Affiliation(s)
- Nicola King
- Bristol Heart Institute, Department of Clinical Science at South Bristol, University of Bristol, Bristol Royal Infirmary, Bristol BS2 8HW, UK.
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Hirose H, Gill IS, Lytle BW. Redo-aortic valve replacement after previous bilateral internal thoracic artery bypass grafting. Ann Thorac Surg 2004; 78:782-5. [PMID: 15336991 DOI: 10.1016/j.athoracsur.2004.02.035] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/10/2004] [Indexed: 11/16/2022]
Abstract
BACKGROUND Aortic valve replacement (AVR) after coronary artery bypass using bilateral internal thoracic arteries (ITAs) is a challenge. Management of these patent grafts and myocardial protection are important issues. Moreover the risk and outcome of these complex operations have not been clearly defined. METHODS Eighteen consecutive patients (all male) who exhibited previous bilateral ITA grafts underwent subsequent AVR surgery from 1990-2001 at the Cleveland Clinic Foundation. Their medical records were retrospectively analyzed. RESULTS At the time of reoperation, the mean age of the patients was 67 +/- 6.4 years and 33 out of 36 (92%) ITAs were patent. The interval between previous coronary bypass and aortic valve surgery was 10.3 +/- 5.3 years. All patients underwent redo-median sternotomy with aortic cannulation in 12 patients (67%) and femoral or axillary artery cannulation in 6 patients (33%). The patent ITAs were clamped during aortic cross-clamping in 15 patients. In 3 patients the ITAs were not dissected. These 3 patients underwent deep hypothermic arrest for myocardial protection. Concomitant coronary revascularization was performed in 8 patients (44%). There were no hospital deaths. One stroke occurred but there were no other major complications. Average intubation time was 23.1 +/- 27.1 hours, intensive care unit stay was 2.3 +/- 3.1 days, and postoperative hospital stay was 10.3 +/- 7.6 days. CONCLUSIONS Reoperative aortic valve surgery in the patients with patent bilateral ITA grafts can be performed safely.
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Affiliation(s)
- Hitoshi Hirose
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic Foundation, Cleveland, Ohio 44109-1998, USA.
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King N, Lin H, McGivan JD, Suleiman MS. Aspartate transporter expression and activity in hypertrophic rat heart and ischaemia-reperfusion injury. J Physiol 2004; 556:849-58. [PMID: 14766933 PMCID: PMC1664986 DOI: 10.1113/jphysiol.2004.060616] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
This study's rationale was that the expression and activity of aspartate transporters in hypertrophied hearts might be different from normal hearts, which could affect the use of aspartate in myocardial protection of hypertrophied hearts. mRNA expression of system X(ag)(-) transporters in hearts from normal (Wistar Kyoto) and hypertrophied (spontaneously hypertensive rat) rats was investigated by RT-PCR. EAAT3 protein expression in isolated cells and vesicles from normal and hypertrophied hearts was investigated by Western blotting. The same vesicles were also used to measure aspartate uptake. The effects of 0.5 mmol l(-1) aspartate supplementation on cardiac performance during ischaemia-reperfusion were investigated in isolated and perfused hearts. Both normal and hypertrophied hearts expressed EAAT1 and EAAT3 mRNA. EAAT3 protein expression was significantly greater in cells and vesicles from hypertrophied hearts compared to normal hearts. The velocity (V(max)) of aspartate uptake was faster at 24.4 +/- 2.2 pmol mg(-1) s(-1) in vesicles from hypertrophied hearts compared to 8.2 +/- 0.8 pmol mg(-1) s(-1) (P < 0.001, t test, n= 6, means +/-s.e.m.) in normal heart vesicles. The affinity (K(m)) was similar for both preparations. When recoveries were matched, 0.5 mmol l(-1) aspartate addition reduced reperfusion injury and increased functional recovery of hypertrophied hearts but not normal hearts. This was associated with a greater preservation of ATP, glutamate and glutamine and less lactate production during ischaemia in aspartate-treated hypertrophied hearts compared to all other experimental groups. These results suggest that increased aspartate transporter expression and activity in hypertrophy helps facilitate aspartate entry into hypertrophied cardiomyocytes, which in turn leads to improved myocardial protection.
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Affiliation(s)
- Nicola King
- Bristol Heart Institute, University of Bristol, Bristol Royal Infirmary, Bristol BS2 8HW, UK.
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Lotto AA, Ascione R, Caputo M, Bryan AJ, Angelini GD, Suleiman MS. Myocardial protection with intermittent cold blood during aortic valve operation: antegrade versus retrograde delivery. Ann Thorac Surg 2003; 76:1227-33; discussion 1233. [PMID: 14530016 DOI: 10.1016/s0003-4975(03)00840-3] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND Intermittent antegrade cold blood cardioplegia is superior to warm blood cardioplegia in patients who have aortic valve operation. This study compared the cardioprotective efficacy of intermittent antegrade and retrograde cold blood cardioplegia with emphasis on metabolic stress in the left and right ventricles. METHODS Thirty-nine patients who had elective aortic valve replacement were prospectively randomly selected to receive intermittent antegrade or retrograde cold blood cardioplegia. Left and right ventricular biopsies were collected 5 minutes after institution of cardiopulmonary bypass and 20 minutes after cross-clamp removal and were used to determine metabolic changes. Metabolites (adenine nucleotides, amino acids, and lactate) were measured using high-powered liquid chromatography and enzymatic techniques. Serial measurement of troponin I release was also used as a marker of myocardial injury. RESULTS Preoperative characteristics were similar between groups. There was no in-hospital mortality, and no differences were observed in postoperative complications. Preischemic concentration of taurine was significantly higher in left ventricular biopsies, whereas adenosine triphosphate tended to be lower in the left ventricle. At reperfusion adenosine triphosphate levels were significantly lower than preischemic levels in right but not left ventricles irrespective of the route of delivery. The alanine-glutamate ratio was significantly elevated in both ventricles. Myocardial injury as assessed by troponin I release was also significantly increased in both groups. CONCLUSIONS Retrograde and antegrade intermittent cold blood cardioplegic techniques are associated with suboptimal myocardial protection. Metabolic stress was more pronounced in the right than the left ventricle irrespective of the cardioplegic route of delivery used.
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Affiliation(s)
- Attilio A Lotto
- Bristol Heart Institute, University of Bristol, Bristol, United Kingdom
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