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Salameh S, Guerrelli D, Miller JA, Desai M, Moise N, Yerebakan C, Bruce A, Sinha P, d'Udekem Y, Weinberg SH, Posnack NG. Connecting Transcriptomics with Computational Modeling to Reveal Developmental Adaptations in the Human Pediatric Myocardium. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2024:2024.04.19.589826. [PMID: 38712262 PMCID: PMC11071413 DOI: 10.1101/2024.04.19.589826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/08/2024]
Abstract
Background Nearly 1% or 1.3 million babies are born with congenital heart disease (CHD) globally each year - many of whom will require palliative or corrective heart surgery within the first few years of life. A detailed understanding of cardiac maturation can help to expand our knowledge on cardiac diseases that develop during gestation, identify age-appropriate cardiovascular drug therapies, and inform clinical care decisions related to surgical repair, myocardial preservation, or postoperative management. Yet, to date, our knowledge of the temporal changes that cardiomyocytes undergo during postnatal development is largely limited to animal models. Methods Right atrial tissue samples were collected from n=117 neonatal, infant, and pediatric patients undergoing correct surgery due to (acyanotic) CHD. Patients were stratified into five age groups: neonate (0-30 days), infant (31-364 days), toddler to preschool (1-5 years), school age (6-11 years), and adolescent to young adults (12-32 years). We measured age-dependent adaptations in cardiac gene expression, and used computational modeling to simulate action potential and calcium transients. Results Enrichment of differentially expressed genes (DEG) was explored, revealing age-dependent changes in several key biological processes (cell cycle, cell division, mitosis), cardiac ion channels, and calcium handling genes. Gene-associated changes in ionic currents exhibited both linear trends and sudden shifts across developmental stages, with changes in calcium handling ( I NCX ) and repolarization ( I K1 ) most strongly associated with an age-dependent decrease in the action potential plateau potential and increase in triangulation, respectively. We also note a shift in repolarization reserve, with lower I Kr expression in younger patients, a finding likely tied to the increased amplitude of I Ks triggered by elevated sympathetic activation in pediatric patients. Conclusion This study provides valuable insights into age-dependent changes in human cardiac gene expression and electrophysiology among patients with CHD, shedding light on molecular mechanisms underlying cardiac development and function across different developmental stages.
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Drury NE, van Doorn C, Woolley RL, Amos-Hirst RJ, Bi R, Spencer CM, Morris KP, Montgomerie J, Stickley J, Crucean A, Gill A, Hill M, Weber RJ, Najdekr L, Jankevics A, Southam AD, Lloyd GR, Jaber O, Kassai I, Pelella G, Khan NE, Botha P, Barron DJ, Madhani M, Dunn WB, Ives NJ, Kirchhof P, Jones TJ. Bilateral remote ischemic conditioning in children: A two-center, double-blind, randomized controlled trial in young children undergoing cardiac surgery. JTCVS OPEN 2024; 18:193-208. [PMID: 38690427 PMCID: PMC11056492 DOI: 10.1016/j.xjon.2024.02.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Revised: 01/30/2024] [Accepted: 02/20/2024] [Indexed: 05/02/2024]
Abstract
Objective The study objective was to determine whether adequately delivered bilateral remote ischemic preconditioning is cardioprotective in young children undergoing surgery for 2 common congenital heart defects with or without cyanosis. Methods We performed a prospective, double-blind, randomized controlled trial at 2 centers in the United Kingdom. Children aged 3 to 36 months undergoing tetralogy of Fallot repair or ventricular septal defect closure were randomized 1:1 to receive bilateral preconditioning or sham intervention. Participants were followed up until hospital discharge or 30 days. The primary outcome was area under the curve for high-sensitivity troponin-T in the first 24 hours after surgery, analyzed by intention-to-treat. Right atrial biopsies were obtained in selected participants. Results Between October 2016 and December 2020, 120 eligible children were randomized to receive bilateral preconditioning (n = 60) or sham intervention (n = 60). The primary outcome, area under the curve for high-sensitivity troponin-T, was higher in the preconditioning group (mean: 70.0 ± 50.9 μg/L/h, n = 56) than in controls (mean: 55.6 ± 30.1 μg/L/h, n = 58) (mean difference, 13.2 μg/L/h; 95% CI, 0.5-25.8; P = .04). Subgroup analyses did not show a differential treatment effect by oxygen saturations (pinteraction = .25), but there was evidence of a differential effect by underlying defect (pinteraction = .04). Secondary outcomes and myocardial metabolism, quantified in atrial biopsies, were not different between randomized groups. Conclusions Bilateral remote ischemic preconditioning does not attenuate myocardial injury in children undergoing surgical repair for congenital heart defects, and there was evidence of potential harm in unstented tetralogy of Fallot. The routine use of remote ischemic preconditioning cannot be recommended for myocardial protection during pediatric cardiac surgery.
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Affiliation(s)
- Nigel E. Drury
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom
- Department of Paediatric Cardiac Surgery, Birmingham Children's Hospital, Birmingham, United Kingdom
| | - Carin van Doorn
- Department of Congenital Cardiac Surgery, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Rebecca L. Woolley
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, United Kingdom
- Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom
| | - Rebecca J. Amos-Hirst
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, United Kingdom
- Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom
| | - Rehana Bi
- Department of Paediatric Cardiac Surgery, Birmingham Children's Hospital, Birmingham, United Kingdom
| | - Collette M. Spencer
- Department of Congenital Cardiac Surgery, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Kevin P. Morris
- Department of Paediatric Intensive Care, Birmingham Children's Hospital, Birmingham, United Kingdom
| | - James Montgomerie
- Department of Paediatric Cardiac Anesthesia, Birmingham Children's Hospital, Birmingham, United Kingdom
| | - John Stickley
- Department of Paediatric Cardiac Surgery, Birmingham Children's Hospital, Birmingham, United Kingdom
| | - Adrian Crucean
- Department of Paediatric Cardiac Surgery, Birmingham Children's Hospital, Birmingham, United Kingdom
| | - Alicia Gill
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, United Kingdom
- Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom
| | - Matt Hill
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, United Kingdom
- Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom
| | - Ralf J.M. Weber
- Phenome Centre Birmingham, School of Biosciences, University of Birmingham, Birmingham, United Kingdom
| | - Lukas Najdekr
- Phenome Centre Birmingham, School of Biosciences, University of Birmingham, Birmingham, United Kingdom
| | - Andris Jankevics
- Phenome Centre Birmingham, School of Biosciences, University of Birmingham, Birmingham, United Kingdom
| | - Andrew D. Southam
- Phenome Centre Birmingham, School of Biosciences, University of Birmingham, Birmingham, United Kingdom
| | - Gavin R. Lloyd
- Phenome Centre Birmingham, School of Biosciences, University of Birmingham, Birmingham, United Kingdom
| | - Osama Jaber
- Department of Congenital Cardiac Surgery, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Imre Kassai
- Department of Congenital Cardiac Surgery, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Giuseppe Pelella
- Department of Congenital Cardiac Surgery, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Natasha E. Khan
- Department of Paediatric Cardiac Surgery, Birmingham Children's Hospital, Birmingham, United Kingdom
| | - Phil Botha
- Department of Paediatric Cardiac Surgery, Birmingham Children's Hospital, Birmingham, United Kingdom
| | - David J. Barron
- Division of Cardiovascular Surgery, Hospital for Sick Children, Toronto, Canada
- Department of Surgery, University of Toronto, Toronto, Canada
| | - Melanie Madhani
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Warwick B. Dunn
- Phenome Centre Birmingham, School of Biosciences, University of Birmingham, Birmingham, United Kingdom
- Department of Biochemistry and Systems Biology, Institute of Systems, Molecular, and Integrative Biology, University of Liverpool, Liverpool, United Kingdom
| | - Natalie J. Ives
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, United Kingdom
- Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom
| | - Paulus Kirchhof
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom
- Department of Cardiology, University Heart and Vascular Centre, UKE Hamburg, Hamburg, Germany
- German Centre for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Timothy J. Jones
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom
- Department of Paediatric Cardiac Surgery, Birmingham Children's Hospital, Birmingham, United Kingdom
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Drury NE. Myocardial protection in paediatric cardiac surgery: building an evidence-based strategy. Ann R Coll Surg Engl 2024; 106:277-282. [PMID: 37249560 PMCID: PMC10904256 DOI: 10.1308/rcsann.2023.0004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/24/2023] [Indexed: 05/31/2023] Open
Abstract
Cardioplegia is fundamental to the surgical repair of congenital heart defects by protecting the heart against ischaemia/reperfusion injury, characterised by low cardiac output and troponin release in the early postoperative period. The immature myocardium exhibits structural, physiological and metabolic differences from the adult heart, with a greater sensitivity to calcium overload-mediated injury during reperfusion. Del Nido cardioplegia was designed specifically to protect the immature heart, is widely used in North America and may provide better myocardial protection in children; however, it has not been commercially available in the UK, where most centres use St Thomas' blood cardioplegia. There are no phase 3 clinical trials in children to support one solution over another and this lack of evidence, combined with variations in practice, suggests the presence of clinical equipoise. The best cardioplegia solution for use in children, and the impact of age and other clinical factors remain unknown. In this Hunterian lecture, I propose an evidence-based strategy to improve myocardial protection during cardiac surgery in children through: (1) conducting multicentre clinical trials of established techniques; (2) improving our knowledge of ischaemia/reperfusion injury in the setting of cardioplegic arrest; (3) applying this to drive innovation, moving beyond current cardioplegia solutions; (4) empowering personalised medicine, through combining clinical and genomic data, including ethnic diversity; and (5) understanding the impact of cardioplegic arrest on the late outcomes that matter to patients and their families.
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Salameh S, Ogueri V, Posnack NG. Adapting to a new environment: postnatal maturation of the human cardiomyocyte. J Physiol 2023; 601:2593-2619. [PMID: 37031380 PMCID: PMC10775138 DOI: 10.1113/jp283792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 03/16/2023] [Indexed: 04/10/2023] Open
Abstract
The postnatal mammalian heart undergoes remarkable developmental changes, which are stimulated by the transition from the intrauterine to extrauterine environment. With birth, increased oxygen levels promote metabolic, structural and biophysical maturation of cardiomyocytes, resulting in mature muscle with increased efficiency, contractility and electrical conduction. In this Topical Review article, we highlight key studies that inform our current understanding of human cardiomyocyte maturation. Collectively, these studies suggest that human atrial and ventricular myocytes evolve quickly within the first year but might not reach a fully mature adult phenotype until nearly the first decade of life. However, it is important to note that fetal, neonatal and paediatric cardiac physiology studies are hindered by a number of limitations, including the scarcity of human tissue, small sample size and a heavy reliance on diseased tissue samples, often without age-matched healthy controls. Future developmental studies are warranted to expand our understanding of normal cardiac physiology/pathophysiology and inform age-appropriate treatment strategies for cardiac disease.
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Affiliation(s)
- Shatha Salameh
- Department of Pharmacology & Physiology, George Washington University, Washington, DC, USA
- Sheikh Zayed Institute for Pediatric Surgical Innovation, Children’s National Hospital, Washington, DC, USA
| | - Vanessa Ogueri
- Children’s National Heart Institute, Children’s National Hospital, Washington, DC, USA
| | - Nikki Gillum Posnack
- Department of Pharmacology & Physiology, George Washington University, Washington, DC, USA
- Sheikh Zayed Institute for Pediatric Surgical Innovation, Children’s National Hospital, Washington, DC, USA
- Children’s National Heart Institute, Children’s National Hospital, Washington, DC, USA
- Department of Pediatrics, George Washington University, Washington, DC, USA
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Skeffington KL, Mohamed Ahmed E, Rapetto F, Chanoit G, Bond AR, Vardeu A, Ghorbel MT, Suleiman MS, Caputo M. The effect of cardioplegic supplementation with sildenafil on cardiac energetics in a piglet model of cardiopulmonary bypass and cardioplegic arrest with warm or cold cardioplegia. Front Cardiovasc Med 2023; 10:1194645. [PMID: 37351284 PMCID: PMC10282544 DOI: 10.3389/fcvm.2023.1194645] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 05/17/2023] [Indexed: 06/24/2023] Open
Abstract
Cardioplegic cardioprotection strategies used during paediatric open-heart surgery remain suboptimal. Sildenafil, a phosphodiesterase 5 (PDE-5) inhibitor, has been shown to be cardioprotective against ischemia/reperfusion injury in a variety of experimental models and this study therefore tested the efficacy of supplementation of cardioplegia with sildenafil in a piglet model of cardiopulmonary bypass and arrest, using both cold and warm cardioplegia protocols. Piglets were anaesthetized and placed on coronary pulmonary bypass (CPB), the aorta cross-clamped and the hearts arrested for 60 min with cardioplegia with or without sildenafil (10 nM). Twenty minutes after removal of cross clamp (reperfusion), attempts were made to wean the pigs from CPB. Termination was carried out after 60 min reperfusion. Throughout the protocol blood and left ventricular tissue samples were taken for analysis of selected metabolites (using HPLC) and troponin I. In both the cold and warm cardioplegia protocols there was evidence that sildenafil supplementation resulted in faster recovery of ATP levels, improved energy charge (a measure of metabolic flux) and altered release of hypoxanthine and inosine, two purine catabolites. There was no effect on troponin release within the studied short timeframe. In conclusion, sildenafil supplementation of cardioplegia resulted in improved cardiac energetics in a translational animal model of paediatric CPB surgery.
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Affiliation(s)
- Katie L. Skeffington
- Bristol Heart Institute, University of Bristol, Research Floor Level 7, Bristol Royal Infirmary, Bristol, United Kingdom
| | | | - Filippo Rapetto
- Department of Cardiac Surgery, Bristol Royal Infirmary, Bristol, United Kingdom
| | - Guillaume Chanoit
- Langford Vets, University of Bristol, Langford, Bristol, United Kingdom
| | - Andrew R. Bond
- Bristol Heart Institute, University of Bristol, Research Floor Level 7, Bristol Royal Infirmary, Bristol, United Kingdom
| | - Antonella Vardeu
- Bristol Heart Institute, University of Bristol, Research Floor Level 7, Bristol Royal Infirmary, Bristol, United Kingdom
| | - Mohamed T. Ghorbel
- Bristol Heart Institute, University of Bristol, Research Floor Level 7, Bristol Royal Infirmary, Bristol, United Kingdom
| | - M-Saadeh Suleiman
- Bristol Heart Institute, University of Bristol, Research Floor Level 7, Bristol Royal Infirmary, Bristol, United Kingdom
| | - Massimo Caputo
- Bristol Heart Institute, University of Bristol, Research Floor Level 7, Bristol Royal Infirmary, Bristol, United Kingdom
- Department of Cardiac Surgery, Bristol Royal Infirmary, Bristol, United Kingdom
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Early postnatal metabolic profile in neonates with critical CHDs. Cardiol Young 2023; 33:349-353. [PMID: 36193679 DOI: 10.1017/s1047951122003134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Cyanotic CHD is a life-threatening condition that presents with low oxygen saturation in the newborn period. Hypoxemia might cause alterations in the metabolic pathways. In the present study, we aimed to evaluate the early postnatal amino acid and carnitine/acylcarnitine profiles of newborn infants with cyanotic CHD. METHODS A single centre case-control study was conducted. Twenty-seven patients with cyanotic CHD and 54 healthy newborn controls were enrolled. As part of the neonatal screening programme, results of amino acid and carnitine/acylcarnitine were recorded and compared between groups. RESULTS Twenty-seven neonates with cyanotic CHD and 54 healthy newborns as controls were enrolled in the study. Cyanotic CHD neonates had higher levels of alanine, phenylalanine, leucine/isoleucine, citrulline, ornithine, C5, C5-OH; but lower levels of C3, C10, C12, C14, C14:1, C16, C16.1, C18, C5-DC, C6-DC, C16-OH, C16:1-OH when compared with the healthy controls. CONCLUSION This study showed that there are differences between patients with cyanotic CHD and healthy controls in terms of postnatal amino acid and carnitine/acylcarnitine profiles.
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Cardioplegia in Open Heart Surgery: Age Matters. J Clin Med 2023; 12:jcm12041698. [PMID: 36836232 PMCID: PMC9958799 DOI: 10.3390/jcm12041698] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 01/31/2023] [Accepted: 02/02/2023] [Indexed: 02/23/2023] Open
Abstract
INTRODUCTION Cardioplegia is a pharmacological approach essential for the protection of the heart from ischemia-reperfusion (I-R) injury. Over the years, numerous cardioplegic solutions have been developed, with each cardioplegic approach having its advantages and disadvantages. Cardioplegic solutions can be divided into crystalloid and blood cardioplegic solutions, and an experienced surgeon chooses the type of solution based on the individual needs of patients in order to provide optimal heart protection. Importantly, the pediatric immature myocardium is structurally, physiologically, and metabolically different from the adult heart, and consequently its needs to achieve cardioplegic arrest strongly differ. Therefore, the present review aimed to provide a summary of the cardioplegic solutions available to pediatric patients with a special focus on emphasizing differences in heart injury after various cardioplegic solutions, the dosing strategies, and regimens. MATERIAL AND METHODS The PubMed database was searched using the terms cardioplegia, I-R, and pediatric population, and studies that investigated the influence of cardioplegic strategies on markers of cardiac muscle damage were further analyzed in this review. CONCLUSIONS A large body of evidence suggested more prominent benefits achieved with blood compared to those with crystalloid cardioplegia in pediatric myocardium preservation. However, standardized and uniform protocols have not been established so far, and an experienced surgeon chooses the type of cardioplegia solution based on the individual needs of patients, while the severity of myocardial damage strongly depends on the type and duration of the surgical procedure, overall patient condition, and presence of comorbidities, etc.
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Tan J, Bi S, Li J, Gu J, Wang Y, Xiong J, Yu X, Du L. Comparative effects of different types of cardioplegia in cardiac surgery: A network meta-analysis. Front Cardiovasc Med 2022; 9:996744. [PMID: 36176979 PMCID: PMC9513158 DOI: 10.3389/fcvm.2022.996744] [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: 07/18/2022] [Accepted: 08/25/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectiveTo compare the outcomes of four types of cardioplegia during cardiac surgery: del Nido (DN), blood cardioplegia (BC), histidine-tryptophan-ketoglutarate (HTK) and St. Thomas.MethodsRandomized controlled trials (RCTs) and observational cohort studies from 2005 to 2021 were identified in PubMed, Embase, and Cochrane databases. Data were extracted for the primary endpoint of perioperative mortality as well as the following secondary endpoints: atrial fibrillation, renal failure, stroke, use of an intra-aortic balloon pump, re-exploration, intensive care unit stay and hospital stay. A network meta-analysis comparing all four types of cardioplegia was performed, as well as direct meta-analysis comparing pairs of cardioplegia types.ResultsData were extracted from 18 RCTs and 49 observational cohort studies involving 18,191 adult patients (55 studies) and 1,634 children (12 studies). Among adult patients, risk of mortality was significantly higher for HTK (1.89, 95% CI 1.10, 3.52) and BC (RR 1.73, 95% CI 1.22, 2.79) than for DN. Risk of atrial fibrillation was significantly higher for BC (RR 1.41, 95% CI 1.09, 1.86) and DN (RR 1.51, 95% CI 1.15, 2.03) than for HTK. Among pediatric patients, no significant differences in endpoints were observed among the four types of cardioplegia.ConclusionsThis network meta-analysis suggests that among adult patients undergoing cardiac surgery, DN may be associated with lower perioperative mortality than HTK or BC, while risk of atrial fibrillation may be lower with HTK than with BC or DN.
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Affiliation(s)
- Jia Tan
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
| | - Siwei Bi
- Department of Burn and Plastic Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Jingyi Li
- West China School of Medicine, Sichuan University, Chengdu, China
| | - Jun Gu
- Department of Cardiovascular Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Yishun Wang
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
| | - Jiyue Xiong
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
| | - Xiang Yu
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
| | - Lei Du
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
- *Correspondence: Lei Du
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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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Lewis MJ, Khaliulin I, Hall K, Suleiman MS. Cardioprotection of Immature Heart by Simultaneous Activation of PKA and Epac: A Role for the Mitochondrial Permeability Transition Pore. Int J Mol Sci 2022; 23:ijms23031720. [PMID: 35163640 PMCID: PMC8836102 DOI: 10.3390/ijms23031720] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Revised: 01/25/2022] [Accepted: 01/30/2022] [Indexed: 02/04/2023] Open
Abstract
Metabolic and ionic changes during ischaemia predispose the heart to the damaging effects of reperfusion. Such changes and the resulting injury differ between immature and adult hearts. Therefore, cardioprotective strategies for adults must be tested in immature hearts. We have recently shown that the simultaneous activation of protein kinase A (PKA) and exchange protein activated by cAMP (Epac) confers marked cardioprotection in adult hearts. The aim of this study is to investigate the efficacy of this intervention in immature hearts and determine whether the mitochondrial permeability transition pore (MPTP) is involved. Isolated perfused Langendorff hearts from both adult and immature rats were exposed to global ischaemia and reperfusion injury (I/R) following control perfusion or perfusion after an equilibration period with activators of PKA and/or Epac. Functional outcome and reperfusion injury were measured and in parallel, mitochondria were isolated following 5 min of reperfusion to determine whether cardioprotective interventions involved changes in MPTP opening behaviour. Perfusion for 5 min preceding ischaemia of injury-matched adult and immature hearts with 5 µM 8-Br (8-Br-cAMP-AM), an activator of both PKA and Epac, led to significant reduction in post-reperfusion CK release and infarct size. Perfusion with this agent also led to a reduction in MPTP opening propensity in both adult and immature hearts. These data show that immature hearts are innately more resistant to I/R injury than adults, and that this is due to a reduced tendency of MPTP opening following reperfusion. Furthermore, simultaneous stimulation of PKA and Epac causes cardioprotection, which is additive to the innate resistance.
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Affiliation(s)
- Martin John Lewis
- School of Physiology, Pharmacology & Neuroscience, University of Bristol, Bristol BS8 1TD, UK
- Correspondence:
| | - Igor Khaliulin
- School of Pharmacy, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 91120, Israel;
| | - Katie Hall
- Bristol Medical School, University of Bristol, Bristol BS8 1TH, UK; (K.H.); (M.S.S.)
| | - M. Saadeh Suleiman
- Bristol Medical School, University of Bristol, Bristol BS8 1TH, UK; (K.H.); (M.S.S.)
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Caputo M, Scott LJ, Deave T, Dabner L, Parry A, Angelini GD, Sheehan K, Stoica S, Ellis L, Harris R, Rogers CA. A randomized controlled trial comparing controlled reoxygenation and standard cardiopulmonary bypass in paediatric cardiac surgery. Eur J Cardiothorac Surg 2021; 59:349-358. [PMID: 33123718 PMCID: PMC7850030 DOI: 10.1093/ejcts/ezaa318] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Revised: 06/22/2020] [Accepted: 07/28/2020] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVES Controlled reoxygenation on starting cardiopulmonary bypass (CPB) rather than hyperoxic CPB may confer clinical advantages during surgery for congenital cyanotic heart disease. METHODS A single-centre, randomized controlled trial was carried out to compare the effectiveness of controlled reoxygenation (normoxia) versus hyperoxic CPB in children with congenital cyanotic heart disease undergoing open-heart surgery (Oxic-2). The co-primary clinical outcomes were duration of inotropic support, intubation time and postoperative intensive care unit (ICU) and hospital stay. Analysis of the primary outcomes included data from a previous trial (Oxic-1) conducted to the same protocol. RESULTS Ninety participants were recruited to Oxic-2 and 79 were recruited to the previous Oxic-1 trial. There were no significant differences between the groups for any of the co-primary outcomes: inotrope duration geometric mean ratio (normoxia/hyperoxic) 0.97, 95% confidence interval (CI) (0.69-1.37), P-value = 0.87; intubation time hazard ratio (HR) 1.03, 95% CI (0.74-1.42), P-value = 0.87; postoperative ICU stay HR 1.14 95% CI (0.77-1.67), P-value = 0.52, hospital stay HR 0.90, 95% CI (0.65-1.25), P-value = 0.53. Lower oxygen levels were successfully achieved during the operative period in the normoxic group. Serum creatinine levels were lower in the normoxic group at day 2, but not on days 1, 3-5. Childhood developmental outcomes were similar. In the year following surgery, 85 serious adverse events were reported (51 normoxic group and 34 hyperoxic group). CONCLUSIONS Controlled reoxygenation (normoxic) CPB is safe but with no evidence of a clinical advantage over hyperoxic CPB. CLINICAL TRIAL REGISTRATION NUMBER Current Controlled Trials-ISRCTN81773762.
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Affiliation(s)
- Massimo Caputo
- Department of Cardiac Surgery, Bristol Royal Hospital for Children, University Hospitals Bristol NHS Foundation Trust, Bristol, UK.,Department of Cardiac Surgery, Bristol Heart Institute, University of Bristol, Bristol, UK
| | - Lauren J Scott
- Department of Cardiac Surgery, Clinical Trials and Evaluation Unit, Bristol Trials Centre, University of Bristol, Bristol, UK
| | - Toity Deave
- Department of Cardiac Surgery, Centre for Health and Clinical Research, University of the West of England, Bristol, UK
| | - Lucy Dabner
- Department of Cardiac Surgery, Clinical Trials and Evaluation Unit, Bristol Trials Centre, University of Bristol, Bristol, UK
| | - Andrew Parry
- Department of Cardiac Surgery, Bristol Royal Hospital for Children, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Gianni D Angelini
- Department of Cardiac Surgery, Bristol Heart Institute, University of Bristol, Bristol, UK
| | - Karen Sheehan
- Department of Cardiac Surgery, Bristol Royal Hospital for Children, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Serban Stoica
- Department of Cardiac Surgery, Bristol Royal Hospital for Children, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Lucy Ellis
- Department of Cardiac Surgery, Clinical Trials and Evaluation Unit, Bristol Trials Centre, University of Bristol, Bristol, UK
| | - Rosie Harris
- Department of Cardiac Surgery, Clinical Trials and Evaluation Unit, Bristol Trials Centre, University of Bristol, Bristol, UK
| | - Chris A Rogers
- Department of Cardiac Surgery, Clinical Trials and Evaluation Unit, Bristol Trials Centre, University of Bristol, Bristol, UK
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12
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Romanowicz J, Guerrelli D, Dhari Z, Mulvany C, Reilly M, Swift L, Vasandani N, Ramadan M, Leatherbury L, Ishibashi N, Posnack NG. Chronic perinatal hypoxia delays cardiac maturation in a mouse model for cyanotic congenital heart disease. Am J Physiol Heart Circ Physiol 2021; 320:H1873-H1886. [PMID: 33739154 DOI: 10.1152/ajpheart.00870.2020] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Compared with acyanotic congenital heart disease (CHD), cyanotic CHD has an increased risk of lifelong mortality and morbidity. These adverse outcomes may be attributed to delayed cardiomyocyte maturation, since the transition from a hypoxic fetal milieu to oxygen-rich postnatal environment is disrupted. We established a rodent model to replicate hypoxic myocardial conditions spanning perinatal development, and tested the hypothesis that chronic hypoxia impairs cardiac development. Pregnant mice were housed in hypoxia beginning at embryonic day 16. Pups stayed in hypoxia until postnatal day (P)8 when cardiac development is nearly complete. Global gene expression was quantified at P8 and at P30, after recovering in normoxia. Phenotypic testing included electrocardiogram, echocardiogram, and ex vivo electrophysiology study. Hypoxic P8 animals were 47% smaller than controls with preserved heart size. Gene expression was grossly altered by hypoxia at P8 (1,427 genes affected), but normalized after recovery (P30). Electrocardiograms revealed bradycardia and slowed conduction velocity in hypoxic animals at P8, with noticeable resolution after recovery (P30). Notable differences that persisted after recovery (P30) included a 65% prolongation in ventricular effective refractory period, sinus node dysfunction, 23% reduction in ejection fraction, and 16% reduction in fractional shortening in animals exposed to hypoxia. We investigated the impact of chronic hypoxia on the developing heart. Perinatal hypoxia was associated with changes in gene expression and cardiac function. Persistent changes to the electrophysiological substrate and contractile function warrant further investigation and may contribute to adverse outcomes observed in the cyanotic CHD population.NEW & NOTEWORTHY We utilized a new mouse model of chronic perinatal hypoxia to simulate the hypoxic myocardial conditions present in cyanotic congenital heart disease. Hypoxia caused numerous abnormalities in cardiomyocyte gene expression, the electrophysiologic substrate of the heart, and contractile function. Taken together, alterations observed in the neonatal period suggest delayed cardiac development immediately following hypoxia.
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Affiliation(s)
- Jennifer Romanowicz
- Children's National Heart Institute, Children's National Hospital, Washington, District of Columbia
| | - Devon Guerrelli
- Children's National Heart Institute, Children's National Hospital, Washington, District of Columbia.,Sheikh Zayed Institute for Pediatric Surgical Innovation, Children's National Research Institute, Washington, District of Columbia.,Department of Biomedical Engineering, George Washington University, Washington, District of Columbia
| | - Zaenab Dhari
- Center for Neuroscience Research, Children's National Research Institute, Washington, District of Columbia
| | - Colm Mulvany
- Sheikh Zayed Institute for Pediatric Surgical Innovation, Children's National Research Institute, Washington, District of Columbia
| | - Marissa Reilly
- Sheikh Zayed Institute for Pediatric Surgical Innovation, Children's National Research Institute, Washington, District of Columbia
| | - Luther Swift
- Children's National Heart Institute, Children's National Hospital, Washington, District of Columbia.,Sheikh Zayed Institute for Pediatric Surgical Innovation, Children's National Research Institute, Washington, District of Columbia
| | - Nimisha Vasandani
- Center for Neuroscience Research, Children's National Research Institute, Washington, District of Columbia
| | - Manelle Ramadan
- Children's National Heart Institute, Children's National Hospital, Washington, District of Columbia.,Sheikh Zayed Institute for Pediatric Surgical Innovation, Children's National Research Institute, Washington, District of Columbia
| | - Linda Leatherbury
- Children's National Heart Institute, Children's National Hospital, Washington, District of Columbia
| | - Nobuyuki Ishibashi
- Children's National Heart Institute, Children's National Hospital, Washington, District of Columbia.,Sheikh Zayed Institute for Pediatric Surgical Innovation, Children's National Research Institute, Washington, District of Columbia.,Center for Neuroscience Research, Children's National Research Institute, Washington, District of Columbia.,Department of Pediatrics, George Washington University, Washington, District of Columbia.,Department of Pharmacology & Physiology, George Washington University, Washington, District of Columbia
| | - Nikki Gillum Posnack
- Children's National Heart Institute, Children's National Hospital, Washington, District of Columbia.,Sheikh Zayed Institute for Pediatric Surgical Innovation, Children's National Research Institute, Washington, District of Columbia.,Department of Pediatrics, George Washington University, Washington, District of Columbia.,Department of Pharmacology & Physiology, George Washington University, Washington, District of Columbia
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13
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Heys R, Stoica S, Angelini G, Beringer R, Evans R, Ghorbel M, Lansdowne W, Parry A, Pieles G, Reeves B, Rogers C, Saxena R, Sheehan K, Smith S, Walker-Smith T, Tulloh RM, Caputo M. Intermittent antegrade warm-blood versus cold-blood cardioplegia in children undergoing open heart surgery: a protocol for a randomised controlled study (Thermic-3). BMJ Open 2020; 10:e036974. [PMID: 33055113 PMCID: PMC7559029 DOI: 10.1136/bmjopen-2020-036974] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
INTRODUCTION Surgical repair of congenital heart defects often requires the use of cardiopulmonary bypass (CPB) and cardioplegic arrest. Cardioplegia is used during cardiac surgery requiring CPB to keep the heart still and to reduce myocardial damage as a result of ischaemia-reperfusion injury. Cold cardioplegia is the prevalent method of myocardial protection in paediatric patients; however, warm cardioplegia is used as part of usual care throughout the UK in adults. We aim to provide evidence to support the use of warm versus cold blood cardioplegia on clinical and biochemical outcomes during and after paediatric congenital heart surgery. METHODS AND ANALYSIS We are conducting a single-centre randomised controlled trial in paediatric patients undergoing operations requiring CPB and cardioplegic arrest at the Bristol Royal Hospital for Children. We will randomise participants in a 1:1 ratio to receive either 'cold-blood cardioplegia' or 'warm-blood cardioplegia'. The primary outcome will be the difference between groups with respect to Troponin T levels over the first 48 postoperative hours. Secondary outcomes will include measures of cardiac function; renal function; cerebral function; arrythmias during and postoperative hours; postoperative blood loss in the first 12 hours; vasoactive-inotrope score in the first 48 hours; intubation time; chest and wound infections; time from return from theatre until fit for discharge; length of postoperative hospital stay; all-cause mortality to 3 months postoperative; myocardial injury at the molecular and cellular level. ETHICS AND DISSEMINATION This trial has been approved by the London - Central Research Ethics Committee. Findings will be disseminated to the academic community through peer-reviewed publications and presentation at national and international meetings. Patients will be informed of the results through patient organisations and newsletters to participants. TRIAL REGISTRATION NUMBER ISRCTN13467772; Pre-results.
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Affiliation(s)
- Rachael Heys
- Bristol Trials Centre, Clincal Trials and Evaulation Unit, Bristol Medical School, University of Bristol, Bristol, UK
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, UK
| | - Serban Stoica
- Bristol Royal Hospital for Children, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Gianni Angelini
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, UK
- Bristol Heart Institue, University of Bristol, Bristol, UK
| | - Richard Beringer
- Bristol Royal Hospital for Children, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Rebecca Evans
- Bristol Trials Centre, Clincal Trials and Evaulation Unit, Bristol Medical School, University of Bristol, Bristol, UK
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, UK
| | | | - William Lansdowne
- Bristol Royal Hospital for Children, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Andrew Parry
- Bristol Royal Hospital for Children, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Guido Pieles
- Bristol Royal Hospital for Children, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Barnaby Reeves
- Bristol Trials Centre, Clincal Trials and Evaulation Unit, Bristol Medical School, University of Bristol, Bristol, UK
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, UK
| | - Chris Rogers
- Bristol Trials Centre, Clincal Trials and Evaulation Unit, Bristol Medical School, University of Bristol, Bristol, UK
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, UK
| | - Rohit Saxena
- Cardiac Intensive Care, Great Ormond Street Hospital For Children NHS Foundation Trust, London, UK
| | - Karen Sheehan
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, UK
- Bristol Royal Hospital for Children, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Stella Smith
- Bristol Royal Hospital for Children, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Terrie Walker-Smith
- Bristol Trials Centre, Clincal Trials and Evaulation Unit, Bristol Medical School, University of Bristol, Bristol, UK
| | - Robert Mr Tulloh
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, UK
- Bristol Royal Hospital for Children, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
- Bristol Heart Institue, University of Bristol, Bristol, UK
| | - Massimo Caputo
- Bristol Royal Hospital for Children, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
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14
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Drury NE, Bi R, Woolley RL, Stickley J, Morris KP, Montgomerie J, van Doorn C, Dunn WB, Madhani M, Ives NJ, Kirchhof P, Jones TJ. Bilateral Remote Ischaemic Conditioning in Children (BRICC) trial: protocol for a two-centre, double-blind, randomised controlled trial in young children undergoing cardiac surgery. BMJ Open 2020; 10:e042176. [PMID: 33033035 PMCID: PMC7542918 DOI: 10.1136/bmjopen-2020-042176] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
INTRODUCTION Myocardial protection against ischaemic-reperfusion injury is a key determinant of heart function and outcome following cardiac surgery in children. However, with current strategies, myocardial injury occurs routinely following aortic cross-clamping, as demonstrated by the ubiquitous rise in circulating troponin. Remote ischaemic preconditioning, the application of brief, non-lethal cycles of ischaemia and reperfusion to a distant organ or tissue, is a simple, low-risk and readily available technique which may improve myocardial protection. The Bilateral Remote Ischaemic Conditioning in Children (BRICC) trial will assess whether remote ischaemic preconditioning, applied to both lower limbs immediately prior to surgery, reduces myocardial injury in cyanotic and acyanotic young children. METHODS AND ANALYSIS The BRICC trial is a two-centre, double-blind, randomised controlled trial recruiting up to 120 young children (age 3 months to 3 years) undergoing primary repair of tetralogy of Fallot or surgical closure of an isolated ventricular septal defect. Participants will be randomised in a 1:1 ratio to either bilateral remote ischaemic preconditioning (3×5 min cycles) or sham immediately prior to surgery, with follow-up until discharge from hospital or 30 days, whichever is sooner. The primary outcome is reduction in area under the time-concentration curve for high-sensitivity (hs) troponin-T release in the first 24 hours after aortic cross-clamp release. Secondary outcome measures include peak hs-troponin-T, vasoactive inotrope score, arterial lactate and central venous oxygen saturations in the first 12 hours, and lengths of stay in the paediatric intensive care unit and the hospital. ETHICS AND DISSEMINATION The trial was approved by the West Midlands-Solihull National Health Service Research Ethics Committee (16/WM/0309) on 5 August 2016. Findings will be disseminated to the academic community through peer-reviewed publications and presentation at national and international meetings. Parents will be informed of the results through a newsletter in conjunction with a local charity. TRIAL REGISTRATION NUMBER ISRCTN12923441.
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Affiliation(s)
- Nigel E Drury
- Paediatric Cardiac Surgery, Birmingham Children's Hospital, Birmingham, West Midlands, UK
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, West Midlands, UK
| | - Rehana Bi
- Paediatric Cardiac Surgery, Birmingham Children's Hospital, Birmingham, West Midlands, UK
- Paediatric Intensive Care, Birmingham Children's Hospital, Birmingham, West Midlands, UK
| | - Rebecca L Woolley
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, West Midlands, UK
- Institute of Applied Health Research, University of Birmingham, Birmingham, West Midlands, UK
| | - John Stickley
- Paediatric Cardiac Surgery, Birmingham Children's Hospital, Birmingham, West Midlands, UK
| | - Kevin P Morris
- Paediatric Intensive Care, Birmingham Children's Hospital, Birmingham, West Midlands, UK
- Institute of Applied Health Research, University of Birmingham, Birmingham, West Midlands, UK
| | - James Montgomerie
- Paediatric Cardiac Anaesthesia, Birmingham Children's Hospital, Birmingham, West Midlands, UK
| | - Carin van Doorn
- Congenital Cardiac Surgery, Leeds Teaching Hospitals NHS Trust, Leeds, West Yorkshire, UK
| | - Warwick B Dunn
- School of Biosciences, University of Birmingham, Birmingham, West Midlands, UK
- Phenome Centre Birmingham, University of Birmingham, Birmingham, West Midlands, UK
| | - Melanie Madhani
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, West Midlands, UK
| | - Natalie J Ives
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, West Midlands, UK
- Institute of Applied Health Research, University of Birmingham, Birmingham, West Midlands, UK
| | - Paulus Kirchhof
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, West Midlands, UK
- Cardiology, University Heart and Vascular Center, UKE, Hamburg, Germany
| | - Timothy J Jones
- Paediatric Cardiac Surgery, Birmingham Children's Hospital, Birmingham, West Midlands, UK
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, West Midlands, UK
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15
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Commentary: Two birds with one stone. J Thorac Cardiovasc Surg 2020; 162:238-239. [PMID: 32977960 DOI: 10.1016/j.jtcvs.2020.08.075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2020] [Revised: 08/22/2020] [Accepted: 08/24/2020] [Indexed: 11/21/2022]
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16
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Topcu AC, Bolukcu A, Ozeren K, Kavasoglu T, Kayacioglu I. Normoxic management of cardiopulmonary bypass reduces myocardial oxidative stress in adult patients undergoing coronary artery bypass graft surgery. Perfusion 2020; 36:261-268. [PMID: 32755372 DOI: 10.1177/0267659120946733] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
INTRODUCTION We aimed to investigate whether normoxic cardiopulmonary bypass would limit myocardial oxidative stress in adults undergoing coronary artery bypass grafting. METHODS Patients scheduled to undergo elective isolated on-pump coronary artery bypass grafting were randomized to normoxia and hyperoxia groups. The normoxia group received 35% oxygen during anesthetic induction, 35% during hypothermic bypass, and 45% during rewarming. The hyperoxia group received 70%, 50%, and 70% oxygen, respectively. Coronary sinus blood samples were taken prior to initiation of cardiopulmonary bypass and after reperfusion for myocardial total oxidant and antioxidant status measurements. The primary endpoint was myocardial total oxidant status. Secondary endpoints were myocardial total antioxidant status and length of intensive care unit and hospital stay. RESULTS Forty-eight patients were included. Twenty-two received normoxic management. Mean ± standard deviation of age was 58 ± 9.07 years. Groups were balanced in terms of demographics, risk factors, and operative data. Myocardial total oxidant status was significantly lower in the normoxia group following reperfusion (p = 0.03). There was no statistically significant difference regarding myocardial total antioxidant status and length of intensive care unit and hospital stay (p = 0.08, p = 0.82, and p = 0.54, respectively). CONCLUSIONS Normoxic cardiopulmonary bypass is associated with reduced myocardial oxidative stress compared to hyperoxic cardiopulmonary bypass in adult coronary artery bypass patients.
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Affiliation(s)
- Ahmet Can Topcu
- Department of Cardiovascular Surgery, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Ahmet Bolukcu
- Department of Cardiovascular Surgery, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Kamile Ozeren
- Department of Cardiovascular Surgery, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Tugba Kavasoglu
- Department of Anesthesiology and Reanimation, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Ilyas Kayacioglu
- Department of Cardiovascular Surgery, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
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17
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Stoica SC, Dorobantu DM, Vardeu A, Biglino G, Ford KL, Bruno DV, Zakkar M, Mumford A, Angelini GD, Caputo M, Emanueli C. MicroRNAs as potential biomarkers in congenital heart surgery. J Thorac Cardiovasc Surg 2020; 159:1532-1540.e7. [PMID: 31043318 DOI: 10.1016/j.jtcvs.2019.03.062] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2018] [Revised: 03/10/2019] [Accepted: 03/26/2019] [Indexed: 12/22/2022]
Abstract
OBJECTIVE Pediatric congenital heart surgery (CHS) involves intracardiac, valvular, and vascular repairs. Accurate tools to aid short-term outcome prediction in pediatric CHS are lacking. Clinical scores, such as the vasoactive-inotrope score and ventilation index, are used to define outcome in clinical studies. MicroRNA-1-3p (miR-1) is expressed by both cardiomyocytes and vascular cells and is regulated by hypoxia. In adult patients, miR-1 increases in the circulation after open-heart cardiac surgery, suggesting its potential as a clinical biomarker. Thus, we investigated whether perioperative circulating miR-1 measurements can help predict post-CHS short-term outcomes in pediatric patients. METHODS Plasma miR-1 was retrospectively measured in a cohort of 199 consecutive pediatric CHS patients (median age 1.2 years). Samples were taken before surgery and at the end of the operation. Plasma miR-1 concentration was measured by reverse transcription-quantitative polymerase chain reaction and expressed as miR-1 copies/μL and as relative expression to spiked-in exogenous cel-miR-39. RESULTS Baseline plasma miR-1 did not vary across different diagnoses, increased during surgery (204-fold median relative increase, P < .001), and was associated with aortic crossclamp duration postoperatively (P < .001). Importantly, miR-1 levels at the end of the operation positively correlated with intensive care stay (P < .001), early severe cardiovascular events (P = .01), and with high vasoactive-inotrope score (P = .001) and ventilation index (P < .001), suggesting that miR-1 could accelerate the identification of patients with cardiopulmonary bypass-related ischemic complications, requiring more intensive support. CONCLUSIONS Our study suggests miR-1 as a novel potential circulating biomarker to predict early postoperative outcome and inform clinical management in pediatric heart surgery.
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Affiliation(s)
- Serban C Stoica
- Bristol Heart Institute, University of Bristol, Bristol, United Kingdom; Royal Hospital for Children, University Hospitals Bristol National Health System Trust, Department of Cardiac Surgery and Cardiology, Bristol, United Kingdom
| | - Dan M Dorobantu
- Royal Hospital for Children, University Hospitals Bristol National Health System Trust, Department of Cardiac Surgery and Cardiology, Bristol, United Kingdom; "Professor C.C. Iliescu" Emergency Institute for Cardiovascular Diseases, Cardiology Department, Bucharest, Romania
| | - Antonella Vardeu
- Bristol Heart Institute, University of Bristol, Bristol, United Kingdom
| | - Giovanni Biglino
- Bristol Heart Institute, University of Bristol, Bristol, United Kingdom
| | - Kerrie L Ford
- Bristol Heart Institute, University of Bristol, Bristol, United Kingdom
| | - Domenico V Bruno
- Bristol Heart Institute, University of Bristol, Bristol, United Kingdom; Royal Hospital for Children, University Hospitals Bristol National Health System Trust, Department of Cardiac Surgery and Cardiology, Bristol, United Kingdom
| | - Mustafa Zakkar
- Royal Hospital for Children, University Hospitals Bristol National Health System Trust, Department of Cardiac Surgery and Cardiology, Bristol, United Kingdom
| | - Andrew Mumford
- Bristol Heart Institute, University of Bristol, Bristol, United Kingdom
| | - Gianni D Angelini
- Bristol Heart Institute, University of Bristol, Bristol, United Kingdom; Royal Hospital for Children, University Hospitals Bristol National Health System Trust, Department of Cardiac Surgery and Cardiology, Bristol, United Kingdom
| | - Massimo Caputo
- Bristol Heart Institute, University of Bristol, Bristol, United Kingdom; Royal Hospital for Children, University Hospitals Bristol National Health System Trust, Department of Cardiac Surgery and Cardiology, Bristol, United Kingdom; Rush Medical Center, Chicago, Ill
| | - Costanza Emanueli
- Bristol Heart Institute, University of Bristol, Bristol, United Kingdom; National Heart and Lung Institute, Imperial College London, London, United Kingdom.
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18
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Pérez-Andreu J, Fernández-Doblas J, Sao Avilés A, de la Torre García T, Roses Noguer F, Abella RF. Myocardial protection in the arterial switch operation: Custodiol versus cold blood cardioplegia. Interact Cardiovasc Thorac Surg 2020; 30:136-143. [PMID: 31873745 DOI: 10.1093/icvts/ivz216] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 08/09/2019] [Accepted: 08/11/2019] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES The optimal myocardial protective solution in the neonatal arterial switch operation remains controversial. The aim of this study was to demonstrate that Bretschneider's histidine-tryptophan-ketoglutarate crystalloid solution (Custodiol) offers protection at least similar to that of cold blood cardioplegia. METHODS Patients who underwent the neonatal arterial switch operation with Custodiol between January 2016 and December 2018 (n = 23) were compared with an historical cohort from August 2010 to December 2015 in which cold blood cardioplegia was used (n = 41). A linear mixed-effect model for repeated measures was performed to test the recovery of myocardial function based on inotropic and vasoactive inotropic scores, cardiac enzyme release and left ventricular ejection fraction. RESULTS Patients in the cold blood cardioplegia group had higher inotropic scores in the first 24 h (0 h, P = 0.001 and 24 h, P = 0.006) and higher vasoactive inotropic scores in the first 72 h (0 h, 24 h and 48 h, P < 0.001; 72 h, P = 0.012). Cardiac troponin-I concentrations were higher in the cold blood cardioplegia group at postoperative hours 1-72 (1 h, 6 h, 12 h and 24 h, P < 0.001; 48 h, P = 0.001 and 72 h, P = 0.003). Creatinine-kinase-MB concentrations were higher in the cold blood cardioplegia group at postoperative hours 1-24 (1 h, 6 h and 12 h, P < 0.001; 24 h, P = 0.042). The left ventricular ejection fraction was higher in the Custodiol group just after the operation (P = 0.005), at 24 h (P = 0.001) and on the first day without inotropic support (P = 0.011). CONCLUSIONS Neonatal myocardium protected with Custodiol during the arterial switch operation presented optimal ventricular function recovery with less inotropic support and less myocardial damage compared with cold blood cardioplegia.
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Affiliation(s)
- Joaquín Pérez-Andreu
- Paediatric Cardiac Surgery Department, Vall d´Hebron University Hospital, Barcelona, Spain
| | | | - Augusto Sao Avilés
- Biostatistics, Cardiology Department, Vall d´Hebron University Hospital, Barcelona, Spain
| | | | - Ferrán Roses Noguer
- Paediatric Cardiology Department, Vall d´Hebron University Hospital, Barcelona, Spain
| | - Raúl F Abella
- Paediatric Cardiac Surgery Department, Vall d´Hebron University Hospital, Barcelona, Spain
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19
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Dolcino A, Gaudin R, Pontailler M, Raisky O, Vouhé P, Bojan M. Single-Shot Cold Histidine-Tryptophan-Ketoglutarate Cardioplegia for Long Aortic Cross-Clamping Durations in Neonates. J Cardiothorac Vasc Anesth 2019; 34:959-965. [PMID: 31543295 DOI: 10.1053/j.jvca.2019.08.039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Revised: 08/19/2019] [Accepted: 08/22/2019] [Indexed: 11/11/2022]
Abstract
OBJECTIVE More than 30% of European pediatric cardiac surgery centers use single-dose cold histidine-tryptophan-ketoglutarate cardioplegia (Custodiol; Dr Franz Köhler Chemie GmbH, Bensheim, Germany). In neonates with transposition of the great arteries, arterial switch surgery (ASO) implies aortic division, and it is unknown whether repeated ostial cannulation causes intimal insult and affects long-term results, and therefore, single-dose Custodiol is appealing. The present study investigated the association among myocardial no-flow duration, postoperative troponins, and postoperative outcomes in neonates undergoing ASO with Custodiol cardioplegia. DESIGN Retrospective analysis of the association among myocardial no-flow duration, postoperative troponin release (concentration magnitude × measurement duration within 48 h), and outcomes using stratification according to coronary anatomy and attending surgeon. SETTING Single-institutional, tertiary pediatric cardiac surgery unit of a university hospital. PARTICIPANTS The study comprised 101 neonates undergoing ASO. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The mean age of patients was 6.1 ± 5.4 days, the cardiopulmonary bypass duration was 108.7 ± 54.1 minutes, the temperature during cross-clamping was 31.1°C ± 1.7°C, the duration of mechanical ventilation was 4 (3-6) days, the length of intensive care unit stay was 7 (5-8) days, delayed sternal closure occurred in 32 (31.7%) patients, and no patients died. The myocardial no-flow duration averaged 62.3 ± 14.6 minutes and was linked with both troponin release (p = 0.04) and low cardiac output syndrome, as assessed by the requirement for delayed sternal closure (p = 0.03), regardless of cardiopulmonary bypass duration and temperature. Eighty-two percent of the patients with myocardial no-flow duration >74 minutes necessitated delayed sternal closure. CONCLUSIONS Single-dose Custodiol may be inadequate for prolonged cross-clamping durations without myocardial perfusion in neonates.
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Affiliation(s)
- Andrea Dolcino
- Department of Anesthesiology and Critical Care, Necker-Enfants Malades University Hospital, Paris, France
| | - Regis Gaudin
- Department of Pediatric Cardiac Surgery, Necker-Enfants Malades University Hospital, Paris, France
| | - Margaux Pontailler
- Department of Pediatric Cardiac Surgery, Necker-Enfants Malades University Hospital, Paris, France; Paris Descartes University, Paris, France
| | - Olivier Raisky
- Department of Pediatric Cardiac Surgery, Necker-Enfants Malades University Hospital, Paris, France; Paris Descartes University, Paris, France
| | - Pascal Vouhé
- Department of Pediatric Cardiac Surgery, Necker-Enfants Malades University Hospital, Paris, France; Paris Descartes University, Paris, France
| | - Mirela Bojan
- Department of Anesthesiology, Congenital Cardiac Unit, Marie Lannelongue Hospital, Le Plessis Robinson, France.
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Drury NE, Yim I, Patel AJ, Oswald NK, Chong CR, Stickley J, Jones TJ. Cardioplegia in paediatric cardiac surgery: a systematic review of randomized controlled trials. Interact Cardiovasc Thorac Surg 2019; 28:144-150. [PMID: 29947787 DOI: 10.1093/icvts/ivy199] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2018] [Accepted: 05/24/2018] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Cardioplegia is the primary method for myocardial protection during cardiac surgery. We conducted a systematic review of randomized controlled trials of cardioplegia in children to evaluate the current evidence base. METHODS We searched MEDLINE, CENTRAL and LILACS and manually screened retrieved references and systematic reviews to identify all randomized controlled trials comparing cardioplegia solutions or additives in children undergoing cardiac surgery published in any language; secondary publications and those reporting inseparable adult data were excluded. Two or more reviewers independently screened studies for eligibility and extracted data; the Cochrane Risk of Bias tool was used to assess for potential biases. RESULTS We identified 26 trials randomizing 1596 children undergoing surgery; all were single-centre, Phase II trials, recruiting few patients (median 48, interquartile range 30-99). The most frequent comparison was blood versus crystalloid in 10 (38.5%) trials, and the most common end points were biomarkers of myocardial injury (17, 65.4%), inotrope requirements (15, 57.7%) and length of stay in the intensive care unit (11, 42.3%). However, the heterogeneity of patients, interventions and reported outcome measures prohibited meta-analysis. Overall risk of bias was high in 3 (11.5%) trials, unclear in 23 (88.5%) and low in none. CONCLUSIONS The current literature on cardioplegia in children contains no late phase trials. The small size, inconsistent use of end points and low quality of reported trials provide a limited evidence base to inform practice. A core outcome set of clinically important, standardized, validated end points for assessing myocardial protection in children should be developed to facilitate the conduct of high-quality, multicentre trials. PROSPERO registration CRD42017080205.
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Affiliation(s)
- Nigel E Drury
- Department of Paediatric Cardiac Surgery, Birmingham Children's Hospital, Birmingham, UK.,Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| | - Ivan Yim
- Department of Paediatric Cardiac Surgery, Birmingham Children's Hospital, Birmingham, UK
| | - Akshay J Patel
- Department of Paediatric Cardiac Surgery, Birmingham Children's Hospital, Birmingham, UK
| | - Nicola K Oswald
- Department of Paediatric Cardiac Surgery, Birmingham Children's Hospital, Birmingham, UK
| | - Cher-Rin Chong
- Department of Physiology, Anatomy and Genetics, University of Oxford, Oxford, UK
| | - John Stickley
- Department of Paediatric Cardiac Surgery, Birmingham Children's Hospital, Birmingham, UK
| | - Timothy J Jones
- Department of Paediatric Cardiac Surgery, Birmingham Children's Hospital, Birmingham, UK
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Valente AS, Lustosa GP, Mota LAM, Lima A, Mesquita FAD, Gondim A, Rodrigues FA, Pompeu RG, Branco KC. Comparative Analysis of Myocardial Protection with HTK Solution and Hypothermic Hyperkalemic Blood Solution in the Correction of Acyanogenic Congenital Cardiopathies - A Randomized Study. Braz J Cardiovasc Surg 2019; 34:271-278. [PMID: 31310464 PMCID: PMC6629237 DOI: 10.21470/1678-9741-2018-0243] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE The goal of the present study was to compare the myocardial protection obtained with histidine-tryptophan-ketoglutarate (HTK) cardioplegic solution (Custodiol®) and with intermittent hypothermic blood solution. METHODS Two homogenous groups of 25 children with acyanotic congenital heart disease who underwent total correction with mean aortic clamping time of 60 minutes were evaluated in this randomized study. Troponin and creatine kinase-MB curves, vasoactive-inotropic score, and left ventricular function were obtained by echocardiogram in each group. The values were correlated and presented through graphs and tables after adequate statistical treatment. RESULTS It was observed that values of all the studied variables varied over time, but there was no difference between the groups. CONCLUSION We conclude that in patients with acyanotic congenital cardiopathies submitted to total surgical correction, mean aortic clamping time around one hour, and cardiopulmonary bypass with moderate hypothermia, the HTK crystalloid cardioplegic solution offers the same myocardial protection as the cold-blood hyperkalemic cardioplegic solution analyzed, according to the variables considered in our study model.
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Affiliation(s)
- Acrisio Sales Valente
- Hospital de Messejana Dr. Carlos Alberto Studart Gomes Department of Surgery Fortaleza Ceará Brazil Department of Surgery, Hospital de Messejana Dr. Carlos Alberto Studart Gomes, Fortaleza, Ceará, Brazil.,Centro Universitário Unichristus Fortaleza Ceará Brazil Centro Universitário Unichristus, Fortaleza, Ceará, Brazil
| | - Gustavo Porto Lustosa
- Centro Universitário Unichristus Fortaleza Ceará Brazil Centro Universitário Unichristus, Fortaleza, Ceará, Brazil
| | - Lia Alves Martins Mota
- Centro Universitário Unichristus Fortaleza Ceará Brazil Centro Universitário Unichristus, Fortaleza, Ceará, Brazil
| | - Adriano Lima
- Hospital de Messejana Dr. Carlos Alberto Studart Gomes Department of Surgery Fortaleza Ceará Brazil Department of Surgery, Hospital de Messejana Dr. Carlos Alberto Studart Gomes, Fortaleza, Ceará, Brazil
| | - Fernando Antônio de Mesquita
- Hospital de Messejana Dr. Carlos Alberto Studart Gomes Department of Surgery Fortaleza Ceará Brazil Department of Surgery, Hospital de Messejana Dr. Carlos Alberto Studart Gomes, Fortaleza, Ceará, Brazil
| | - Aloísio Gondim
- Hospital de Messejana Dr. Carlos Alberto Studart Gomes Department of Surgery Fortaleza Ceará Brazil Department of Surgery, Hospital de Messejana Dr. Carlos Alberto Studart Gomes, Fortaleza, Ceará, Brazil
| | - Fábio Alércio Rodrigues
- Hospital de Messejana Dr. Carlos Alberto Studart Gomes Department of Surgery Fortaleza Ceará Brazil Department of Surgery, Hospital de Messejana Dr. Carlos Alberto Studart Gomes, Fortaleza, Ceará, Brazil
| | - Ronald Guedes Pompeu
- Hospital de Messejana Dr. Carlos Alberto Studart Gomes Department of Congenital Heart Disease Fortaleza Ceará Brazil Department of Congenital Heart Disease, Hospital de Messejana Dr. Carlos Alberto Studart Gomes, Fortaleza, Ceará, Brazil
| | - Klébia Castelo Branco
- Hospital de Messejana Dr. Carlos Alberto Studart Gomes Department of Congenital Heart Disease Fortaleza Ceará Brazil Department of Congenital Heart Disease, Hospital de Messejana Dr. Carlos Alberto Studart Gomes, Fortaleza, Ceará, Brazil
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Effects of phentolamine infusion during normoxic cardiopulmonary bypass on the outcome of cardiac surgery in children with cyanotic heart disease. EGYPTIAN JOURNAL OF ANAESTHESIA 2019. [DOI: 10.1016/j.egja.2017.05.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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23
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Taylor DM, Aronow BJ, Tan K, Bernt K, Salomonis N, Greene CS, Frolova A, Henrickson SE, Wells A, Pei L, Jaiswal JK, Whitsett J, Hamilton KE, MacParland SA, Kelsen J, Heuckeroth RO, Potter SS, Vella LA, Terry NA, Ghanem LR, Kennedy BC, Helbig I, Sullivan KE, Castelo-Soccio L, Kreigstein A, Herse F, Nawijn MC, Koppelman GH, Haendel M, Harris NL, Rokita JL, Zhang Y, Regev A, Rozenblatt-Rosen O, Rood JE, Tickle TL, Vento-Tormo R, Alimohamed S, Lek M, Mar JC, Loomes KM, Barrett DM, Uapinyoying P, Beggs AH, Agrawal PB, Chen YW, Muir AB, Garmire LX, Snapper SB, Nazarian J, Seeholzer SH, Fazelinia H, Singh LN, Faryabi RB, Raman P, Dawany N, Xie HM, Devkota B, Diskin SJ, Anderson SA, Rappaport EF, Peranteau W, Wikenheiser-Brokamp KA, Teichmann S, Wallace D, Peng T, Ding YY, Kim MS, Xing Y, Kong SW, Bönnemann CG, Mandl KD, White PS. The Pediatric Cell Atlas: Defining the Growth Phase of Human Development at Single-Cell Resolution. Dev Cell 2019; 49:10-29. [PMID: 30930166 PMCID: PMC6616346 DOI: 10.1016/j.devcel.2019.03.001] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2018] [Revised: 02/11/2019] [Accepted: 03/01/2019] [Indexed: 12/15/2022]
Abstract
Single-cell gene expression analyses of mammalian tissues have uncovered profound stage-specific molecular regulatory phenomena that have changed the understanding of unique cell types and signaling pathways critical for lineage determination, morphogenesis, and growth. We discuss here the case for a Pediatric Cell Atlas as part of the Human Cell Atlas consortium to provide single-cell profiles and spatial characterization of gene expression across human tissues and organs. Such data will complement adult and developmentally focused HCA projects to provide a rich cytogenomic framework for understanding not only pediatric health and disease but also environmental and genetic impacts across the human lifespan.
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Affiliation(s)
- Deanne M Taylor
- Department of Biomedical and Health Informatics, The Children's Hospital of Philadelphia, and the Department of Pediatrics, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, USA.
| | - Bruce J Aronow
- Department of Biomedical Informatics, University of Cincinnati College of Medicine, and Cincinnati Children's Hospital Medical Center, Division of Biomedical Informatics, Cincinnati, OH 45229, USA.
| | - Kai Tan
- Department of Biomedical and Health Informatics, The Children's Hospital of Philadelphia, and the Department of Pediatrics, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, USA.
| | - Kathrin Bernt
- Division of Oncology, Department of Pediatrics, The Children's Hospital of Philadelphia and The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, USA; Center for Childhood Cancer Research, The Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Nathan Salomonis
- Department of Biomedical Informatics, University of Cincinnati College of Medicine, and Cincinnati Children's Hospital Medical Center, Division of Biomedical Informatics, Cincinnati, OH 45229, USA
| | - Casey S Greene
- Childhood Cancer Data Lab, Alex's Lemonade Stand Foundation, Philadelphia, PA 19102, USA; Department of Systems Pharmacology and Translational Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Alina Frolova
- Institute of Molecular Biology and Genetics, National Academy of Science of Ukraine, Kyiv 03143, Ukraine
| | - Sarah E Henrickson
- Division of Allergy Immunology, Department of Pediatrics, The Children's Hospital of Philadelphia and the Institute for Immunology, the University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, USA
| | - Andrew Wells
- Department of Pathology and Laboratory Medicine, The Children's Hospital of Philadelphia and The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, USA
| | - Liming Pei
- Department of Pathology and Laboratory Medicine, The Children's Hospital of Philadelphia and The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, USA; Center for Mitochondrial and Epigenomic Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Jyoti K Jaiswal
- Department of Genomics and Precision Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC, USA; Center for Genetic Medicine Research, Children's National Medical Center, NW, Washington, DC, 20010-2970, USA
| | - Jeffrey Whitsett
- Cincinnati Children's Hospital Medical Center, Section of Neonatology, Perinatal and Pulmonary Biology, Perinatal Institute, Cincinnati, OH 45229, USA
| | - Kathryn E Hamilton
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, The Children's Hospital of Philadelphia and The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, USA
| | - Sonya A MacParland
- Multi-Organ Transplant Program, Toronto General Hospital Research Institute, Departments of Laboratory Medicine and Pathobiology and Immunology, University of Toronto, Toronto, ON, Canada
| | - Judith Kelsen
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, The Children's Hospital of Philadelphia and The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, USA
| | - Robert O Heuckeroth
- Department of Systems Pharmacology and Translational Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - S Steven Potter
- Division of Developmental Biology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA
| | - Laura A Vella
- Division of Infectious Diseases, Department of Pediatrics, The Children's Hospital of Philadelphia and The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, USA
| | - Natalie A Terry
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, The Children's Hospital of Philadelphia and The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, USA
| | - Louis R Ghanem
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, The Children's Hospital of Philadelphia and The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, USA
| | - Benjamin C Kennedy
- Division of Neurosurgery, Department of Surgery, The Children's Hospital of Philadelphia and The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, USA
| | - Ingo Helbig
- Division of Neurology, Department of Pediatrics, The Children's Hospital of Philadelphia and The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, USA; Department of Biomedical and Health Informatics, The Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Kathleen E Sullivan
- Division of Allergy Immunology, Department of Pediatrics, The Children's Hospital of Philadelphia and the Institute for Immunology, the University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, USA
| | - Leslie Castelo-Soccio
- Department of Pediatrics, Section of Dermatology, The Children's Hospital of Philadelphia and University of Pennsylvania Perleman School of Medicine, Philadelphia, PA 19104, USA
| | - Arnold Kreigstein
- Eli and Edythe Broad Center of Regenerative Medicine and Stem Cell Research, University of California, San Francisco, San Francisco, CA, USA; Department of Neurology, University of California, San Francisco, San Francisco, CA, USA
| | - Florian Herse
- Experimental and Clinical Research Center, A Joint Cooperation Between the Charité Medical Faculty and the Max-Delbrueck Center for Molecular Medicine, Berlin, Germany
| | - Martijn C Nawijn
- Department of Pathology and Medical Biology, University of Groningen, University Medical Center Groningen, and Groningen Research Institute for Asthma and COPD (GRIAC), Groningen, the Netherlands
| | - Gerard H Koppelman
- University of Groningen, University Medical Center Groningen, Beatrix Children's Hospital, Department of Pediatric Pulmonology and Pediatric Allergology, and Groningen Research Institute for Asthma and COPD (GRIAC), Groningen, the Netherlands
| | - Melissa Haendel
- Oregon Clinical & Translational Research Institute, Oregon Health & Science University, Portland, OR, USA; Linus Pauling Institute, Oregon State University, Corvallis, OR, USA
| | - Nomi L Harris
- Environmental Genomics and Systems Biology Division, E. O. Lawrence Berkeley National Laboratory, Berkeley, CA, USA
| | - Jo Lynne Rokita
- Department of Biomedical and Health Informatics, The Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Yuanchao Zhang
- Department of Biomedical and Health Informatics, The Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA; Department of Genetics, Rutgers University, Piscataway, NJ 08854, USA
| | - Aviv Regev
- Klarman Cell Observatory, Broad Institute of MIT and Harvard, Cambridge, MA 02142, USA; Howard Hughes Medical Institute, Koch Institure of Integrative Cancer Research, Department of Biology, Massachusetts Institute of Technology, Cambridge, MA 02140, USA
| | - Orit Rozenblatt-Rosen
- Klarman Cell Observatory, Broad Institute of MIT and Harvard, Cambridge, MA 02142, USA
| | - Jennifer E Rood
- Klarman Cell Observatory, Broad Institute of MIT and Harvard, Cambridge, MA 02142, USA
| | - Timothy L Tickle
- Data Sciences Platform, Broad Institute of MIT and Harvard, Cambridge, MA 02142, USA; Klarman Cell Observatory, Broad Institute of MIT and Harvard, Cambridge, MA 02142, USA
| | - Roser Vento-Tormo
- Wellcome Sanger Institute, Wellcome Trust Genome Campus, Hinxton, South Cambridgeshire CB10 1SA, UK
| | - Saif Alimohamed
- Department of Biomedical Informatics, University of Cincinnati College of Medicine, and Cincinnati Children's Hospital Medical Center, Division of Biomedical Informatics, Cincinnati, OH 45229, USA
| | - Monkol Lek
- Department of Genetics, Yale University School of Medicine, New Haven, CT 06520-8005, USA
| | - Jessica C Mar
- Australian Institute for Bioengineering and Nanotechnology, the University of Queensland, Brisbane, QLD 4072, Australia
| | - Kathleen M Loomes
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, The Children's Hospital of Philadelphia and The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, USA
| | - David M Barrett
- Division of Oncology, Department of Pediatrics, The Children's Hospital of Philadelphia and The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, USA; Center for Childhood Cancer Research, The Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Prech Uapinyoying
- National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD 20892, USA; Center for Genetic Medicine Research, Children's National Medical Center, NW, Washington, DC, 20010-2970, USA
| | - Alan H Beggs
- Division of Genetics and Genomics, The Manton Center for Orphan Disease Research, Boston Children's Hospital and Harvard Medical School, Boston, MA 02115, USA
| | - Pankaj B Agrawal
- The Manton Center for Orphan Disease Research, Divisions of Newborn Medicine and of Genetics and Genomics, Boston Children's Hospital and Harvard Medical School, Boston, MA 02115, USA
| | - Yi-Wen Chen
- Department of Genomics and Precision Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC, USA; Center for Genetic Medicine Research, Children's National Medical Center, NW, Washington, DC, 20010-2970, USA
| | - Amanda B Muir
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, The Children's Hospital of Philadelphia and The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, USA
| | - Lana X Garmire
- Department of Computational Medicine & Bioinformatics, The University of Michigan Medical School, University of Michigan, Ann Arbor, MI, USA
| | - Scott B Snapper
- Division of Gastroenterology, Hepatology, and Nutrition, Boston Children's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Javad Nazarian
- Department of Genomics and Precision Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC, USA; Center for Genetic Medicine Research, Children's National Medical Center, NW, Washington, DC, 20010-2970, USA
| | - Steven H Seeholzer
- Protein and Proteomics Core Facility, The Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Hossein Fazelinia
- Protein and Proteomics Core Facility, The Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA; Department of Biomedical and Health Informatics, The Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Larry N Singh
- Center for Mitochondrial and Epigenomic Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Robert B Faryabi
- Department of Pathology and Laboratory Medicine, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, USA
| | - Pichai Raman
- Department of Biomedical and Health Informatics, The Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Noor Dawany
- Department of Biomedical and Health Informatics, The Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Hongbo Michael Xie
- Department of Biomedical and Health Informatics, The Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Batsal Devkota
- Department of Biomedical and Health Informatics, The Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Sharon J Diskin
- Division of Oncology, Department of Pediatrics, The Children's Hospital of Philadelphia and The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, USA; Center for Childhood Cancer Research, The Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Stewart A Anderson
- Department of Psychiatry, The Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Eric F Rappaport
- Nucleic Acid PCR Core Facility, The Children's Hospital of Philadelphia Research Institute, Philadelphia, PA 19104, USA
| | - William Peranteau
- Department of Surgery, Division of General, Thoracic, and Fetal Surgery, The Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Kathryn A Wikenheiser-Brokamp
- Department of Pathology & Laboratory Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA; Divisions of Pathology & Laboratory Medicine and Pulmonary Biology in the Perinatal Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA
| | - Sarah Teichmann
- Wellcome Sanger Institute, Wellcome Trust Genome Campus, Hinxton, South Cambridgeshire CB10 1SA, UK; European Molecular Biology Laboratory - European Bioinformatics Institute, Wellcome Trust Genome Campus, Hinxton, South Cambridgeshire CB10 1SA, UK; Cavendish Laboratory, Theory of Condensed Matter, 19 JJ Thomson Ave, Cambridge CB3 1SA, UK
| | - Douglas Wallace
- Center for Mitochondrial and Epigenomic Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA; Department of Genetics, The Children's Hospital of Philadelphia and The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, USA
| | - Tao Peng
- Department of Biomedical and Health Informatics, The Children's Hospital of Philadelphia, and the Department of Pediatrics, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, USA
| | - Yang-Yang Ding
- Division of Oncology, Department of Pediatrics, The Children's Hospital of Philadelphia and The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, USA; Center for Childhood Cancer Research, The Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Man S Kim
- Department of Biomedical and Health Informatics, The Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Yi Xing
- Department of Pathology and Laboratory Medicine, The Children's Hospital of Philadelphia and The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, USA; Center for Computational and Genomic Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Sek Won Kong
- Computational Health Informatics Program, Boston Children's Hospital, Departments of Biomedical Informatics and Pediatrics, Harvard Medical School, Boston, MA 02115, USA
| | - Carsten G Bönnemann
- National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD 20892, USA; Department of Genomics and Precision Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Kenneth D Mandl
- Computational Health Informatics Program, Boston Children's Hospital, Departments of Biomedical Informatics and Pediatrics, Harvard Medical School, Boston, MA 02115, USA
| | - Peter S White
- Department of Biomedical Informatics, University of Cincinnati College of Medicine, and Cincinnati Children's Hospital Medical Center, Division of Biomedical Informatics, Cincinnati, OH 45229, USA
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24
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Negi SL, Mandal B, Singh RS, Puri GD. Myocardial protection and clinical outcomes in Tetralogy of Fallot patients undergoing intracardiac repair: a randomized study of two cardioplegic techniques. Perfusion 2019; 34:495-502. [DOI: 10.1177/0267659119828890] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Background:Myocardial protection in Tetralogy of Fallot patients undergoing intracardiac repair is suboptimal due to hypertrophied right ventricle. Hypertrophied myocardium is more susceptible to poor myocardial preservation because of inadequate capillary density as compared to the myocytes. There is a capillary to myocyte ratio mismatch. But del Nido Cardioplegia owing to its less viscosity is able to get more evenly distributed under hypothermic cardiopulmonary bypass as opposed to blood Cardioplegia. We hypothesized that the del Nido Cardioplegia technique, would be beneficial in myocardial protection because of its composition and method of delivery, leading into better early and late clinical outcomes in patients undergoing Tetralogy of Fallot repair as compared to blood cardioplegia reconstituted using St Thomas Cardioplegia solution. The objective of the study was to identify a better technique of myocardial preservation in Tetralogy of Fallot patient.Methods:In total, 56 Tetralogy of Fallot patients undergoing intracardiac repair under mild hypothermic cardiopulmonary bypass were randomly allocated to receive antegrade Cardioplegia with either standard blood Cardioplegia (Group I) or del Nido Cardioplegia (Group II). Preoperative as well as postoperative data including echocardiographic parameters for right ventricle functions, creatine kinase MB level, inotropic requirement, mechanical ventilation duration, intensive care unit stay and hospital mortality were evaluated.Results:Inotropic score in the first 24 hours postoperatively was significantly lower in Group II compared to Group I (13.4 ± 7.2 vs. 21.2 ± 9.6, p = 0.003). Creatine kinase MB level (ng/mL) was comparable between the groups. Echocardiographic parameters for right ventricle functions were also comparable between the groups during early as well as after 3 to 6 months postoperatively.Conclusion:Del Nido Cardioplegia is equally efficacious in providing myocardial protection during intracardiac repair under mild hypothermic cardiopulmonary bypass in Tetralogy of Fallot patients as compared to blood Cardioplegia solution with the added benefit of reducing inotropic requirement in first 24 hours postoperative period.
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Affiliation(s)
- Sunder Lal Negi
- Department of Anaesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Banashree Mandal
- Department of Anaesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Rana Sandeep Singh
- Department of Cardiothoracic and Vascular Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Goverdhan Dutt Puri
- Department of Anaesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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25
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Drury NE, Horsburgh A, Bi R, Willetts RG, Jones TJ. Cardioplegia practice in paediatric cardiac surgery: a UK & Ireland survey. Perfusion 2018; 34:125-129. [PMID: 30095360 PMCID: PMC6378396 DOI: 10.1177/0267659118794343] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Introduction: Many techniques are available for cardioplegic arrest in children, but there is a lack of late phase clinical trials to guide practice. We surveyed paediatric cardiac surgeons and perfusionists to establish current practice and willingness to change within a clinical trial. Methods: An online survey was sent to all consultant paediatric cardiac surgeons and chief perfusionists in paediatric centres in the UK and Ireland. Information was sought on cardioplegia type, composition, temperature, topical cooling, dosing for induction and maintenance, interval between doses, whether practice changed with patient age or complexity and whether respondents would be willing and able to use different cardioplegia solutions within a randomised trial. Results: Responses were obtained from 32 (78.0%) surgeons and 12 (100%) perfusionists. Twenty-seven (84.4%) surgeons use blood cardioplegia in infants, with St. Thomas’ Harefield preparation the most popular (19, 59.4%), used routinely in eight (66.7%) centres. Twenty-two (68.8%) administer at 4-6°C, 18 (56.3%) use topical cooling, 18 (56.3%) give 30 ml/kg induction and 15 ml/kg maintenance, with 23 (71.9%) re-dosing every 20-25 minutes. Thirty (93.8%) surgeons were open to randomising patients in a trial, with del Nido (29, 90.6%) the most popular. Conclusions: This survey demonstrates heterogeneity in cardioplegia practice. Whilst most surgeons use blood cardioplegia, there is variation in type, temperature, topical cooling, dosing and intervals. Combined with a lack of evidence from late phase trials, our findings support the presence of clinical equipoise. Surgeons are willing to change practice, suggesting that a pragmatic, multi-centre, randomised, controlled trial of cardioplegia in children is feasible.
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Affiliation(s)
- Nigel E Drury
- 1 Department of Paediatric Cardiac Surgery, Birmingham Children's Hospital, Birmingham, UK.,2 Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| | - Angela Horsburgh
- 1 Department of Paediatric Cardiac Surgery, Birmingham Children's Hospital, Birmingham, UK
| | - Rehana Bi
- 1 Department of Paediatric Cardiac Surgery, Birmingham Children's Hospital, Birmingham, UK
| | - Robert G Willetts
- 1 Department of Paediatric Cardiac Surgery, Birmingham Children's Hospital, Birmingham, UK
| | - Timothy J Jones
- 1 Department of Paediatric Cardiac Surgery, Birmingham Children's Hospital, Birmingham, UK
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Abdul-Ghani S, Fleishman AN, Khaliulin I, Meloni M, Angelini GD, Suleiman MS. Remote ischemic preconditioning triggers changes in autonomic nervous system activity: implications for cardioprotection. Physiol Rep 2018; 5:5/3/e13085. [PMID: 28193783 PMCID: PMC5309573 DOI: 10.14814/phy2.13085] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2016] [Revised: 11/21/2016] [Accepted: 11/22/2016] [Indexed: 01/30/2023] Open
Abstract
Cardioprotective efficacy of remote ischemic preconditioning (RIPC) remains controversial. Experimental studies investigating RIPC have largely monitored cardiovascular changes during index ischemia and reperfusion with little work investigating changes during RIPC application. This work aims to identify cardiovascular changes associated with autonomic nervous system (ANS) activity during RIPC and prior to index ischemia. RIPC was induced in anesthetized male C57/Bl6 mice by four cycles of 5 min of hindlimb ischemia using inflated cuff (200 mmHg) followed by 5 min reperfusion. Electrocardiography (ECG) and microcirculatory blood flow in both hindlimbs were recorded throughout RIPC protocol. Heart rate variability (HRV) analysis was performed using ECG data. Hearts extracted at the end of RIPC protocol were used either for measurement of myocardial metabolites using high‐performance liquid chromatography or for Langendorff perfusion to monitor function and injury during 30 min index ischemia and 2 h reperfusion. Isolated‐perfused hearts from RIPC animals had significantly less infarct size after index ischemia and reperfusion (34 ± 5% vs. 59 ± 7%; mean ± SE P < 0.05). RIPC protocol was associated with increased heart rate measured both in ex vivo and in vivo. Frequency ratio of HRV spectra was altered in RIPC compared to control. RIPC was associated with a standard hyperemic response in the cuffed‐limb but there was a sustained reduction in blood flow in the uncuffed contralateral limb. RIPC hearts (prior to index ischemia) had significantly lower phosphorylation potential and energy charge compared to the control group. In conclusion, RIPC is associated with changes in ANS activity (heart rate, blood flow, HRV) and mild myocardial ischemic stress that would contribute to cardioprotection.
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Affiliation(s)
- Safa Abdul-Ghani
- Bristol Heart Institute, School of Clinical Sciences, Faculty of Medicine & Dentistry, University of Bristol, Bristol, United Kingdom
| | - Arnold N Fleishman
- Research Institute for Complex Problems of Hygiene and Occupational Diseases, Novokuznetsk Kemerovo Oblast, Russia
| | - Igor Khaliulin
- Bristol Heart Institute, School of Clinical Sciences, Faculty of Medicine & Dentistry, University of Bristol, Bristol, United Kingdom
| | - Marco Meloni
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Gianni D Angelini
- Bristol Heart Institute, School of Clinical Sciences, Faculty of Medicine & Dentistry, University of Bristol, Bristol, United Kingdom
| | - M-Saadeh Suleiman
- Bristol Heart Institute, School of Clinical Sciences, Faculty of Medicine & Dentistry, University of Bristol, Bristol, United Kingdom
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27
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Lewis M, Szobi A, Balaska D, Khaliulin I, Adameova A, Griffiths E, Orchard CH, Suleiman MS. Consecutive Isoproterenol and Adenosine Treatment Confers Marked Protection against Reperfusion Injury in Adult but Not in Immature Heart: A Role for Glycogen. Int J Mol Sci 2018; 19:E494. [PMID: 29414860 PMCID: PMC5855716 DOI: 10.3390/ijms19020494] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Revised: 02/02/2018] [Accepted: 02/02/2018] [Indexed: 01/16/2023] Open
Abstract
Consecutive treatment of adult rat heart with isoproterenol and adenosine (Iso/Aden), known to consecutively activate PKA/PKC signaling, is cardioprotective against ischemia and reperfusion (I/R). Whether this is cardioprotective in an immature heart is unknown. Langendorff-perfused hearts from adult and immature (60 and 14 days old) male Wistar rats were exposed to 30 min ischemia and 120 min reperfusion, with or without prior perfusion with 5 nM Iso for 3 min followed by 30 μM Aden for 5 min. Changes in hemodynamics (developed pressure and coronary flow) and cardiac injury (Lactate Dehydrogenase (LDH) release and infarct size) were measured. Additional hearts were used to measure glycogen content. Iso induced a similar inotropic response in both age groups. Treatment with Iso/Aden resulted in a significant reduction in time to the onset of ischemic contracture in both age groups whilst time to peak contracture was significantly shorter only in immature hearts. Upon reperfusion, the intervention reduced cardiac injury and functional impairment in adults with no protection of immature heart. Immature hearts have significantly less glycogen content compared to adult. This work shows that Iso/Aden perfusion confers protection in an adult heart but not in an immature heart. It is likely that metabolic differences including glycogen content contribute to this difference.
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Affiliation(s)
- Martin Lewis
- Bristol Medical School, University of Bristol, Bristol BS8 1TH, UK.
| | - Adrian Szobi
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Comenius University in Bratislava, 814 99 Bratislava, Slovakia.
| | - Dirki Balaska
- School of Biochemistry, University of Bristol, Bristol BS8 1TH, UK.
| | - Igor Khaliulin
- Bristol Medical School, University of Bristol, Bristol BS8 1TH, UK.
| | - Adriana Adameova
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Comenius University in Bratislava, 814 99 Bratislava, Slovakia.
| | - Elinor Griffiths
- School of Biochemistry, University of Bristol, Bristol BS8 1TH, UK.
| | - Clive H Orchard
- School of Physiology, Pharmacology & Neuroscience, University of Bristol, Bristol BS8 1TH, UK.
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28
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Bond AR, Iacobazzi D, Abdul-Ghani S, Ghorbel M, Heesom K, Wilson M, Gillett C, George SJ, Caputo M, Suleiman S, Tulloh RMR. Changes in contractile protein expression are linked to ventricular stiffness in infants with pulmonary hypertension or right ventricular hypertrophy due to congenital heart disease. Open Heart 2018; 5:e000716. [PMID: 29344379 PMCID: PMC5761287 DOI: 10.1136/openhrt-2017-000716] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2017] [Revised: 11/15/2017] [Accepted: 11/18/2017] [Indexed: 12/12/2022] Open
Abstract
Background The right ventricle (RV) is not designed to sustain high pressure leading to failure. There are no current medications to help RV contraction, so further information is required on adaption of the RV to such hypertension. Methods The Right Ventricle in Children (RVENCH) study assessed infants with congenital heart disease undergoing cardiac surgery with hypertensive RV. Clinical and echocardiographic data were recorded, and samples of RV were taken from matched infants, analysed for proteomics and compared between pathologies and with clinical and echocardiographic outcome data. Results Those with tetralogy of Fallot (TOF) were significantly more cyanosed than those with ventricular septal defect (median oxygen saturation 83% vs 98%, P=0.0038), had significantly stiffer RV (tricuspid E wave/A wave ratio 1.95 vs 0.84, P=0.009) and had most had restrictive physiology. Gene ontology in TOF, with enrichment analysis, demonstrated significant increase in proteins of contractile mechanisms and those of calmodulin, actin binding and others associated with contractility than inventricular septal defect. Structural proteins were also found to be higher in association with sarcomeric function: Z-disc, M-Band and thin-filament proteins. Remaining proteins associated with actin binding, calcium signalling and myocyte cytoskeletal development. Phosphopeptide enrichment led to higher levels of calcium signalling proteins in TOF. Conclusion This is the first demonstration that those with an RV, which is stiff and hypertensive in TOF, have a range of altered proteins, often in calcium signalling pathways. Information about these alterations might guide treatment options both in terms of individualised therapy or inotropic support for the Right ventricle when hypertensive due to pulmoanry hypertension or congenital heart disease.
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Affiliation(s)
- Andrew R Bond
- Clinical Sciences, Bristol Heart Institute, Bristol Royal Infirmary, Bristol, UK
| | - Dominga Iacobazzi
- Clinical Sciences, Bristol Heart Institute, Bristol Royal Infirmary, Bristol, UK
| | - Safa Abdul-Ghani
- Clinical Sciences, Bristol Heart Institute, Bristol Royal Infirmary, Bristol, UK
| | - Mohammed Ghorbel
- Clinical Sciences, Bristol Heart Institute, Bristol Royal Infirmary, Bristol, UK
| | - Kate Heesom
- Proteomics Facility, University of Bristol, Bristol, UK
| | | | | | - Sarah J George
- Clinical Sciences, Bristol Heart Institute, Bristol Royal Infirmary, Bristol, UK
| | - Massimo Caputo
- Clinical Sciences, Bristol Heart Institute, Bristol Royal Infirmary, Bristol, UK.,Department of Congenital Heart Disease, King David Building, Bristol, UK
| | - Saadeh Suleiman
- Clinical Sciences, Bristol Heart Institute, Bristol Royal Infirmary, Bristol, UK
| | - Robert M R Tulloh
- Clinical Sciences, Bristol Heart Institute, Bristol Royal Infirmary, Bristol, UK.,Department of Congenital Heart Disease, King David Building, Bristol, UK
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29
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Frogoudaki AA. Pathophysiology and Causes of Heart Failure in Adult Congenital Heart Disease. HEART FAILURE IN ADULT CONGENITAL HEART DISEASE 2018. [DOI: 10.1007/978-3-319-77803-7_2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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30
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Talwar S, Selvam MS, Makhija N, Lakshmy R, Choudhary SK, Sreenivas V, Airan B. Effect of administration of allopurinol on postoperative outcomes in patients undergoing intracardiac repair of tetralogy of Fallot. J Thorac Cardiovasc Surg 2018; 155:335-343. [DOI: 10.1016/j.jtcvs.2017.08.115] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Revised: 07/15/2017] [Accepted: 08/07/2017] [Indexed: 11/26/2022]
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31
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Kharabish A, Meierhofer C, Hadamitzky M, Nadjiri J, Martinoff S, Ewert P, Stern H. Long-Standing Cyanosis in Congenital Heart Disease Does not Cause Diffuse Myocardial Fibrosis. Pediatr Cardiol 2018; 39:105-110. [PMID: 28948316 DOI: 10.1007/s00246-017-1734-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Accepted: 09/13/2017] [Indexed: 11/29/2022]
Abstract
The assumption of the presence of diffuse myocardial fibrosis in long-standing cyanotic congenital heart disease (CHD) inspired us to noninvasively determine the myocardial extracellular volume (ECV) using contrast CMR. T1 maps were measured pre and 10 min after the injection of 0.15 mmol/kg of gadolinium in 25 subjects. Seven patients with long-standing cyanotic CHD and no previous cardiac surgery (aged 16-53 years and oxygen saturations of 69-90%), nine normal subjects (aged 14-49 years), and nine patients with previously cyanotic CHD, who had been corrected by open heart surgery (aged 2 months-58 years, mean 9 years). Late gadolinium enhancement was performed to exclude scar areas. The T1 values were measured in the interventricular septum and in the left lateral or inferior ventricular wall, such that same areas were assessed in every patient in the pre- and post-contrast T1 scan. ECV was calculated according to ΔR1myocardium/ΔR1blood * (1 - hematocrit). Cyanotic patients had significantly lower ECV percentage than the previous cyanotic patients (septum: 22 ± 2.7% vs 35 ± 4.6%, p = 0.002; LV wall: 22 ± 2.2% vs 30 ± 3.7%, p = 0.01, respectively). No significant differences were found between cyanotic patients and normal controls (septum: 22 ± 2.7% vs 24 ± 1.4%, p = 0.44; LV wall: 22 ± 2.2% vs 24 ± 2%, p = 0.57, respectively). Long-standing cyanosis in CHD without cardiac surgery does not cause diffuse myocardial fibrosis or expansion of the myocardial ECV.
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Affiliation(s)
- Ahmed Kharabish
- Department of Radiology, Cairo University Hospitals, Cairo, Egypt.
| | - Christian Meierhofer
- Department of Congenital Heart Disease and Pediatric Cardiology, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Martin Hadamitzky
- Department of Radiology, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Jonathan Nadjiri
- Department of Diagnostic and Interventional Radiology, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Stefan Martinoff
- Department of Radiology, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Peter Ewert
- Department of Congenital Heart Disease and Pediatric Cardiology, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Heiko Stern
- Department of Congenital Heart Disease and Pediatric Cardiology, Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
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32
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Mylonas KS, Tzani A, Metaxas P, Schizas D, Boikou V, Economopoulos KP. Blood Versus Crystalloid Cardioplegia in Pediatric Cardiac Surgery: A Systematic Review and Meta-analysis. Pediatr Cardiol 2017; 38:1527-1539. [PMID: 28948337 DOI: 10.1007/s00246-017-1732-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Accepted: 09/13/2017] [Indexed: 01/01/2023]
Abstract
The benefit of blood cardioplegia (BCP) compared to crystalloid cardioplegia (CCP) is still debatable. Our aim was to systematically review and synthesize all available evidence on the use of BCP and CCP to assess if any modality provides superior outcomes in pediatric cardiac surgery. A systematic literature search of the PubMed and Cochrane databases was performed with respect to the PRISMA statement (end-of-search date: January 30th, 2017). We extracted data on study design, demographics, cardioplegia regimens, and perioperative outcomes as well as relevant biochemical markers, namely cardiac troponin I (cTnI), lactate, and ATP levels at baseline, after reperfusion and postoperatively at 1, 4, 12, and 24 h as applicable. Data were appropriately pooled using random and mixed effects models. Our systematic review includes 56 studies reporting on a total of 7711 pediatric patients. A meta-analysis of the 10 eligible studies directly comparing BCP (n = 416) to CCP (n = 281) was also performed. There was no significant difference between the two groups with regard to cTnI and Lac at any measured time point, ATP levels after reperfusion, length of intensive care unit stay (WMD: -0.08, 95% CI -1.52 to 1.36), length of hospital stay (WMD: 0.13, 95% CI -0.85 to 1.12), and 30-day mortality (OR 1.11, 95% CI 0.43-2.88). Only cTnI levels at 4 h postoperatively were significantly lower with BCP (WMD: -1.62, 95% CI -2.07 to -1.18). Based on the available data, neither cardioplegia modality seems to be superior in terms of clinical outcomes, ischemia severity, and overall functional recovery.
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Affiliation(s)
- Konstantinos S Mylonas
- Division of Pediatric Surgery, Massachusetts General Hospital, Harvard Medical School, Warren 11, 55 Fruit Street, Boston, MA, 02114, USA. .,Surgery Working Group, Society of Junior Doctors, Athens, Greece.
| | - Aspasia Tzani
- Surgery Working Group, Society of Junior Doctors, Athens, Greece
| | | | - Dimitrios Schizas
- Surgery Working Group, Society of Junior Doctors, Athens, Greece.,First Department of Surgery, Laiko General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Konstantinos P Economopoulos
- Surgery Working Group, Society of Junior Doctors, Athens, Greece.,Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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33
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Chen H, Liu S, Liu X, Yang J, Wang F, Cong X, Chen X. Lysophosphatidic Acid Pretreatment Attenuates Myocardial Ischemia/Reperfusion Injury in the Immature Hearts of Rats. Front Physiol 2017; 8:153. [PMID: 28377726 PMCID: PMC5359218 DOI: 10.3389/fphys.2017.00153] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Accepted: 02/27/2017] [Indexed: 02/01/2023] Open
Abstract
The cardioprotection of the immature heart during cardiac surgery remains controversial due to the differences between the adult heart and the newborn heart. Lysophosphatidic acid (LPA) is a small bioactive molecule with diverse functions including cell proliferation and survival via its receptor: LPA1–LPA6. We previously reported that the expressions of LPA1 and LPA3 in rat hearts were much higher in immature hearts and then declined rapidly with age. In this study, we aimed to investigate whether LPA signaling plays a potential protective role in immature hearts which had experienced ischemia/reperfusion (I/R) injury. The results showed that in Langendorff-perfused immature rat hearts (2 weeks), compared to I/R group, LPA pretreatment significantly enhanced the cardiac function, attenuated myocardial infarct size and CK-MB release, decreased myocardial apoptosis and increased the expression of pro-survival signaling molecules. All these effects could be abolished by Ki16425, an antagonist to LPA1 and LPA3. Similarly, LPA pretreatment protected H9C2 from hypoxia-reoxygenation (H/R) induced apoptosis and necrosis in vitro. The mechanisms underlying the anti-apoptosis effects were related to activation of the phosphatidylinositol 3-kinase (PI3K)/protein kinas B (AKT) signaling pathways as well as phosphorylation of the downstream effector of AKT, glycogen synthase kinase 3 beta (GSK3β), through LPA1 and/or LPA3. What's more, we found that LPA preconditioning increased glucose uptake of H9C2 subjected to H/R by the activation of AMP-Activated Protein Kinase (AMPK) but not the translocation of GLUT4. In conclusion, our study indicates that LPA is a potent survival factor for immature hearts against I/R injuries and has the potential therapeutic function as a cardioplegia additive for infantile cardiac surgery.
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Affiliation(s)
- Haibo Chen
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences - Peking Union Medical College Beijing, China
| | - Si Liu
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences - Peking Union Medical College Beijing, China
| | - Xuewen Liu
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences - Peking Union Medical College Beijing, China
| | - Jinjing Yang
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences - Peking Union Medical College Beijing, China
| | - Fang Wang
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences - Peking Union Medical College Beijing, China
| | - Xiangfeng Cong
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences - Peking Union Medical College Beijing, China
| | - Xi Chen
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences - Peking Union Medical College Beijing, China
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34
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Talwar S, Bhoje A, Sreenivas V, Makhija N, Aarav S, Choudhary SK, Airan B. Comparison of del Nido and St Thomas Cardioplegia Solutions in Pediatric Patients: A Prospective Randomized Clinical Trial. Semin Thorac Cardiovasc Surg 2017; 29:366-374. [DOI: 10.1053/j.semtcvs.2017.08.017] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/22/2017] [Indexed: 11/11/2022]
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Lim KHH, Halestrap AP, Angelini GD, Suleiman MS. Propofol Is Cardioprotective in a Clinically Relevant Model of Normothermic Blood Cardioplegic Arrest and Cardiopulmonary Bypass. Exp Biol Med (Maywood) 2016; 230:413-20. [PMID: 15956771 DOI: 10.1177/15353702-0323006-09] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The general anesthetic propofol has been shown to be cardioprotective. However, its benefits when used in cardioplegia during cardiac surgery have not been demonstrated. In this study, we investigated the effects of propofol on metabolic stress, cardiac function, and injury in a clinically relevant model of normothermic cardioplegic arrest and cardiopulmonary bypass. Twenty anesthetized pigs, randomized to propofol treatment ( n = 8) and control ( n =12) groups, were surgically prepared for cardiopulmonary bypass (CPB) and cardioplegic arrest. Doses of warm blood cardioplegia were delivered at 15-min intervals during a 60-min aortic cross-clamped period. Propofol was continuously infused for the duration of CPB and was therefore present in blood cardioplegia. Myocardial biopsies were collected before, at the end of cardioplegic arrest, and 20 mins after the release of the aortic cross-clamp. Hemodynamic parameters were monitored and blood samples collected for cardiac troponin I measurements. Propofol infusion during CPB and before ischemia did not alter cardiac function or myocardial metabolism. Propofol treatment attenuated the changes in myocardial tissue levels of adenine nucleotides, lactate, and amino acids during ischemia and reduced cardiac troponin I release on reperfusion. Propofol treatment reduced measurable hemodynamic dysfunction after cardioplegic arrest when compared to untreated controls. In conclusion, propofol protects the heart from ischemia-reperfusion injury in a clinically relevant experimental model. Propofol may therefore be a useful adjunct to cardioplegic solutions as well as being an appropriate anesthetic for cardiac surgery.
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Affiliation(s)
- Kelvin H H Lim
- Bristol Heart Institute, University of Bristol, Bristol Royal Infirmary, Bristol BS2 8HW, United Kingdom
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36
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Onwugbufor M, Levy RJ, Zurakowski D, Jonas RA, Sinha P. Myocardial cytochrome oxidase activity increases with age and hypoxemia in patients with congenital heart disease. Perfusion 2016; 32:306-312. [PMID: 27913766 DOI: 10.1177/0267659116681435] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Myocardial tolerance to ischemia is influenced by age and preoperative cyanosis through unknown mechanisms and significantly affects postoperative outcomes. Cytochrome c oxidase (CcOx), the terminal enzyme of the mitochondrial electron transport chain, may play a role in the susceptibility to ischemic-reperfusion (IR) injury. Our study aimed at investigating changes in human myocardial CcOx activity based on age and preoperative oxygen saturation to understand its role in transition from neonatal to mature myocardium and hypoxic conditions. METHODS The right atrial appendage from patients undergoing first time surgical repair/palliation of congenital heart defects was analyzed for steady state CcOx activity by oxidation of ferrocytochrome c via spectrophotometry and steady state CcOx subunit I protein content by protein immunoblotting. Student's t-test compared CcOx activity and protein levels between patients with preoperative hypoxia and normoxia. Multiple linear regression analysis was used to assess the effects of age and preoperative arterial oxygen saturations (SaO2) on CcOx protein activity and protein content. RESULTS Thirty-two patients with a median (interquartile range) age of 83 days (8-174) and preoperative oxygen saturation 98% (85-100%) were enrolled. Independent of age, preoperative SaO2 ⩽90% was associated with significantly greater CcOx steady state activity (p=0.004). Additionally, older age itself was associated with increased CcOx steady state activity (p=0.022); the combination of preoperative SaO2 and age account for 33% of the variation in CcOx steady state activity (R2=0.332). There was no increase in the CcOx subunit I protein content with either age or preoperative hypoxia. CONCLUSIONS In patients with congenital heart disease, an increase in CcOx steady state activity is seen with increasing age. Hypoxia leads to upregulation of CcOx steady state activity without an increase in the amount of enzyme protein itself. Higher CcOx activity in older and cyanotic patients may indicate CcOx-dependent reactive oxygen species as the mechanism for IR injury.
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Affiliation(s)
| | - Richard J Levy
- 2 Division of Anesthesiology & Pain Medicine, Children's National Medical Center, Washington, D.C., USA
| | - David Zurakowski
- 3 Departments of Surgery and Anesthesia, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Richard A Jonas
- 4 Department of Cardiovascular Surgery, Children's National Medical Center, Washington, D.C., USA
| | - Pranava Sinha
- 4 Department of Cardiovascular Surgery, Children's National Medical Center, Washington, D.C., USA
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37
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Asada D, Itoi T, Nakamura A, Hamaoka K. Tolerance to ischemia reperfusion injury in a congenital heart disease model. Pediatr Int 2016; 58:1266-1273. [PMID: 27097979 DOI: 10.1111/ped.13022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2016] [Revised: 03/16/2016] [Accepted: 04/12/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND Open heart surgery-associated ischemia/reperfusion (I/R) injury affects postoperative outcome, and a leading cause of this is lipid peroxidation. Congenital heart disease (CHD) patients, however, are less sensitive to I/R injury. Although little is known about the underlying molecular mechanisms, CHD-associated hypoxia alters the polyunsaturated fatty acid (PUFA) composition of membranes, which are the preferential targets for reactive oxygen species (ROS) generated during I/R. Here, using an animal model, we investigated the molecular mechanisms underlying I/R tolerance in CHD. METHODS In order to reproduce I/R injury in vitro, we used a working heart perfusion model, isolated from juvenile control and CHD model rats (CHD rats), and examined the recovery of cardiac function during a period of I/R. PUFA composition of the plasma membrane was determined on gas chromatography/mass spectrometry. Oxidative stress-related cellular responses were investigated on immunoblotting, using antibodies against nuclear factor erythroid 2-related factor (Nrf-2), hemeoxygenase-1 (HO-1), and 4-hydroxy-2-hexanal (4-HHE)-modified protein. RESULTS Ischemia/reperfusion-induced cardiac dysfunction was markedly suppressed in CHD rats, compared with the control rats. n-3/n-6 PUFA ratio was significantly increased in both the pre- and post-I/R phase in CHD rats, but not in the controls. Four-HHE-modified protein, Nrf-2, and HO-1 were significantly increased in CHD rats as well, compared with the controls. CONCLUSIONS Following open heart surgery in CHD patients, the increased n-3/n-6 PUFA ratio may lead to the upregulation of cellular antioxidative system components through the oxidation product, 4-HHE, resulting in an increased tolerance to I/R injury.
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Affiliation(s)
- Dai Asada
- Department of Pediatric Cardiology and Nephrology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Toshiyuki Itoi
- Department of Pediatric Cardiology and Nephrology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Akihiro Nakamura
- Department of Pediatric Cardiology and Nephrology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Kenji Hamaoka
- Department of Pediatric Cardiology and Nephrology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
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Li J, Stokoe J, Konstantinov IE, Kharbanda RK, Redington AN. Evidence for a significant myocardial contribution to total metabolic burden during hypothermic cardiopulmonary bypass: a study of continuously measured oxygen consumption and arterial lactate levels in pigs. Perfusion 2016; 20:277-83. [PMID: 16231624 DOI: 10.1191/0267659105pf823oa] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Objective: We assessed the causes of imbalance of oxygen transport by continuously measuring oxygen consumption (VO2) during hypothermic cardiopulmonary bypass (CPB) in pigs. Methods: Six pigs (17.2±1.6 kg) underwent hypothermic (328C) CPB for 180 min with 120 min of aortic crossclamping (ACC). An AMIS 2000 mass spectrometer was adapted for the on-line measurement of VO2. Arterial lactate was measured at the beginning of CPB, the end of hypothermia, before and 10 min after ACC release, 20 min later, and at the end of CPB. Results: Arterial lactate increased from 1.8±0.7 to 5.1±1.8 mmol/L during CPB. Hypothermia reduced VO2by 0.63±0.29 ml/min/kg per 8C, but lactate increased to 4.2±1.5 mmol/L ( p <0.05). The most rapid rise of VO2and lactate occurred during the first 10 min after ACC removal, accounting for 26% and 68%, respectively, of the total rise during rewarming. Conclusions: Inadequate tissue oxygenation persists throughout hypothermic CPB. The rise in systemic VO2 and lactate immediately after ACC release may reflect inadequate oxygen transport within the myocardium during ischemia and manifest on reperfusion. This simple technique may be used to provide important information regarding the dynamic balance of systemic and myocardial oxygen transport during ischemia - reperfusion.
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Affiliation(s)
- Jia Li
- Division of Cardiology, Hospital for Sick Children, Toronto, Ontario, Canada
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Mimic B, Ilic S, Vulicevic I, Milovanovic V, Tomic D, Mimic A, Stankovic S, Zecevic T, Davies B, Djordjevic M. Comparison of high glucose concentration blood and crystalloid cardioplegia in paediatric cardiac surgery: a randomized clinical trial. Interact Cardiovasc Thorac Surg 2016; 22:553-60. [PMID: 26831677 DOI: 10.1093/icvts/ivv391] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2015] [Accepted: 12/04/2015] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES This study investigates the effects of high glucose content on patients undergoing cold crystalloid versus cold blood cardioplegia in terms of early clinical results, functional myocardial recovery and ischaemia-reperfusion injury in patients undergoing repair of acyanotic cardiac lesions. METHODS Patients were randomly assigned to receive either crystalloid (n = 31) or blood cardioplegia (n = 31). Early clinical results were assessed. Changes in left ventricular fractional shortening, arterial blood lactate levels, central venous saturation, cardiac Troponin I release and blood glucose concentration were measured during the first 24 h after ischaemia. RESULTS There was no significant difference in clinical outcomes and postoperative complication rates between groups. The postoperative changes in left ventricular function, lactate levels, central venous saturation and Troponin I were not significantly different between groups. The use of crystalloid cardioplegia was associated with significant increases in serum glucose compared with blood cardioplegia. CONCLUSIONS A high glucose content blood cardioplegia does not show any advantage compared with crystalloid cardioplegia in terms of clinical outcomes, functional recovery and the degree of ischaemic injury in infants and children undergoing repair of acyanotic heart lesions. High glucose concentration of the cardioplegic solution might potentiate ischaemia-reperfusion injury and diminish the beneficial effects of blood cardioplegia.
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Affiliation(s)
- Branko Mimic
- Department of Cardiac Surgery, University Children's Hospital, Belgrade, Serbia Department of Cardiothoracic Surgery, Great Ormond Street Hospital, London, UK
| | - Slobodan Ilic
- Department of Cardiac Surgery, University Children's Hospital, Belgrade, Serbia School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Irena Vulicevic
- Department of Cardiac Surgery, University Children's Hospital, Belgrade, Serbia
| | | | - Danijela Tomic
- Department of Cardiac Surgery, University Children's Hospital, Belgrade, Serbia
| | - Ana Mimic
- Department of Anaesthesiology, Clinical Centre of Serbia, Belgrade, Serbia
| | - Sanja Stankovic
- Centre for Medical Biochemistry, Clinical Centre of Serbia, Belgrade, Serbia
| | - Tatjana Zecevic
- Department of Cardiac Surgery, University Children's Hospital, Belgrade, Serbia
| | - Ben Davies
- Department of Cardiothoracic Surgery, Great Ormond Street Hospital, London, UK
| | - Miroslav Djordjevic
- School of Medicine, University of Belgrade, Belgrade, Serbia Department of Urology, University Children's Hospital, Belgrade, Serbia
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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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Lee Y, Kubli DA, Hanna RA, Cortez MQ, Lee HY, Miyamoto S, Gustafsson ÅB. Cellular redox status determines sensitivity to BNIP3-mediated cell death in cardiac myocytes. Am J Physiol Cell Physiol 2015; 308:C983-92. [PMID: 25810259 DOI: 10.1152/ajpcell.00273.2014] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2014] [Accepted: 03/13/2015] [Indexed: 11/22/2022]
Abstract
The atypical BH3-only protein Bcl-2/adenovirus E1B 19-kDa interacting protein 3 (BNIP3) is an important regulator of hypoxia-mediated cell death. Interestingly, the susceptibility to BNIP3-mediated cell death differs between cells. In this study we examined whether there are mechanistic differences in BNIP3-mediated cell death between neonatal and adult cardiac myocytes. We discovered that BNIP3 is a potent inducer of cell death in neonatal myocytes, whereas adult myocytes are remarkably resistant to BNIP3. When exploring the potential underlying basis for the resistance, we discovered that adult myocytes express significantly higher levels of the mitochondrial antioxidant manganese superoxide dismutase (MnSOD) than neonatal myocytes. Overexpression of MnSOD confers resistance to BNIP3-mediated cell death in neonatal myocytes. In contrast, the presence of a pharmacological MnSOD inhibitor, 2-methoxyestradiol, results in increased sensitivity to BNIP3-mediated cell death in adult myocytes. Cotreatment with the mitochondria-targeted antioxidant MitoTEMPO or the MnSOD mimetic manganese (III) tetrakis (4-benzoic acid) porphyrin chloride abrogates the increased cell death by 2-methoxyestradiol. Moreover, increased oxidative stress also restores the ability of BNIP3 to induce cell death in adult myocytes. Taken together, these data indicate that redox status determines cell susceptibility to BNIP3-mediated cell death. These findings are clinically relevant, given that pediatric hearts are known to be more vulnerable than the adult heart to ischemic injury. Our studies provide important insight into why pediatric hearts are more sensitive to ischemic injury and may help in the clinical management of childhood heart disease.
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Affiliation(s)
- Youngil Lee
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, San Diego, La Jolla, California; and
| | - Dieter A Kubli
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, San Diego, La Jolla, California; and
| | - Rita A Hanna
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, San Diego, La Jolla, California; and
| | - Melissa Q Cortez
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, San Diego, La Jolla, California; and
| | - Hwa-Youn Lee
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, San Diego, La Jolla, California; and
| | - Shigeki Miyamoto
- Department of Pharmacology, University of California, San Diego, La Jolla, California
| | - Åsa B Gustafsson
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, San Diego, La Jolla, California; and Department of Pharmacology, University of California, San Diego, La Jolla, California
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Shamsuddin AM, Nikman AM, Ali S, Zain MRM, Wong AR, Corno AF. Normothermia for pediatric and congenital heart surgery: an expanded horizon. Front Pediatr 2015; 3:23. [PMID: 25973411 PMCID: PMC4411990 DOI: 10.3389/fped.2015.00023] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2015] [Accepted: 03/14/2015] [Indexed: 12/01/2022] Open
Abstract
Cardiopulmonary bypass (CPB) in pediatric cardiac surgery is generally performed with hypothermia, flow reduction and hemodilution. From October 2013 to December 2014, 55 patients, median age 6 years (range 2 months to 52 years), median weight 18.5 kg (range 3.2-57 kg), underwent surgery with normothermic high flow CPB in a new unit. There were no early or late deaths. Fifty patients (90.9%) were extubated within 3 h, 3 (5.5%) within 24 h, and 2 (3.6%) within 48 h. Twenty-four patients (43.6%) did not require inotropic support, 31 (56.4%) received dopamine or dobutamine: 21 ≤5 mcg/kg/min, 8 5-10 mcg/kg/min, and 2 >10 mcg/kg/min. Two patients (6.5%) required noradrenaline 0.05-0.1 mcg/kg/min. On arrival to ICU and after 3 and 6 h and 8:00 a.m. the next morning, mean lactate levels were 1.9 ± 09, 2.0 ± 1.2, 1.6 ± 0.8, and 1.4 ± 0.7 mmol/L (0.6-5.2 mmol/L), respectively. From arrival to ICU to 8:00 a.m. the next morning mean urine output was 3.8 ± 1.5 mL/kg/h (0.7-7.6 mL/kg/h), and mean chest drainage was 0.6 ± 0.5 mL/kg/h (0.1-2.3 mL/kg/h). Mean ICU and hospital stay were 2.7 ± 1.4 days (2-8 days) and 7.2 ± 2.2 days (4-15 days), respectively. In conclusion, normothermic high flow CPB allows pediatric and congenital heart surgery with favorable outcomes even in a new unit. The immediate post-operative period is characterized by low requirement for inotropic and respiratory support, low lactate production, adequate urine output, minimal drainage from the chest drains, short ICU, and hospital stay.
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Affiliation(s)
- Ahmad Mahir Shamsuddin
- Pediatric and Congenital Cardiac Surgery Unit, Department of Surgery, School of Medical Sciences, Universiti Sains Malaysia , Kubang Kerian, Kelantan , Malaysia
| | - Ahmad Mohd Nikman
- Department of Anesthesia, School of Medical Sciences, Universiti Sains Malaysia , Kubang Kerian, Kelantan , Malaysia
| | - Saedah Ali
- Department of Anesthesia, School of Medical Sciences, Universiti Sains Malaysia , Kubang Kerian, Kelantan , Malaysia
| | - Mohd Rizal Mohd Zain
- Department of Pediatrics, School of Medical Sciences, Universiti Sains Malaysia , Kubang Kerian, Kelantan , Malaysia
| | - Abdul Rahim Wong
- Pediatric Cardiology, Hospital Raja Perempuan Zainab II , Kota Bharu, Kelantan , Malaysia
| | - Antonio Francesco Corno
- Pediatric and Congenital Cardiac Surgery Unit, Department of Surgery, School of Medical Sciences, Universiti Sains Malaysia , Kubang Kerian, Kelantan , Malaysia ; Department of Pediatrics, School of Medical Sciences, Universiti Sains Malaysia , Kubang Kerian, Kelantan , Malaysia
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Zuo Y, Cheng X, Gu E, Liu X, Zhang L, Cao Y. Effect of aortic root infusion of sufentanil on ischemia-reperfusion injury in patients undergoing mitral valve replacement. J Cardiothorac Vasc Anesth 2014; 28:1474-8. [PMID: 25312265 DOI: 10.1053/j.jvca.2014.04.023] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2014] [Indexed: 11/11/2022]
Abstract
OBJECTIVE This study investigated the effects of aortic root infusion of sufentanil on myocardial ischemia/reperfusion injury in patients undergoing elective mitral valve replacement (MVR) with cardiopulmonary bypass (CPB). DESIGN A prospective, randomized, clinical study. SETTING A university-affiliated teaching hospital. PARTICIPANTS Fifty-three adult patients undergoing elective MVR with CPB. INTERVENTIONS Bolus infusions of sufentanil (0.2 μg/kg, n = 24) or normal saline (n = 29) were administered through the aortic root cardioplegia perfusion catheter 5 minutes before aortic unclamping. MEASUREMENTS AND MAIN RESULTS Plasma concentrations of CK-MB and cTnI and variables including heart rate, mean arterial pressure, central venous pressure, cardiac output, stroke volume, duration of mechanical ventilation, length of ICU stay, length of hospital stay, and 24-hour postoperative inotropic scores were recorded. Plasma concentrations of CK-MB and cTnI were significantly lower 4 and 8 hours after aortic unclamping in the sufentanil postconditioning group compared to control (p<0.05). Inotropic drug use, duration of mechanical ventilation, and length of ICU and hospital stays were reduced significantly in the sufentanil postconditioning group compared to control (p< 0.05). CONCLUSIONS The present study demonstrated that sufentanil can attenuate myocardial ischemia-reperfusion injury in patients undergoing elective MVR with CPB.
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Affiliation(s)
- Youmei Zuo
- Department of Anesthesiology, First Affiliated Hospital of Anhui Medical University, Hefei 230022, China
| | - Xinqi Cheng
- Department of Anesthesiology, First Affiliated Hospital of Anhui Medical University, Hefei 230022, China
| | - Erwei Gu
- Department of Anesthesiology, First Affiliated Hospital of Anhui Medical University, Hefei 230022, China.
| | - Xunqin Liu
- Department of Anesthesiology, First Affiliated Hospital of Anhui Medical University, Hefei 230022, China
| | - Lei Zhang
- Department of Anesthesiology, First Affiliated Hospital of Anhui Medical University, Hefei 230022, China
| | - Yuanyuan Cao
- Department of Anesthesiology, First Affiliated Hospital of Anhui Medical University, Hefei 230022, China
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44
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Normoxic and hyperoxic cardiopulmonary bypass in congenital heart disease. BIOMED RESEARCH INTERNATIONAL 2014; 2014:678268. [PMID: 25328889 PMCID: PMC4189843 DOI: 10.1155/2014/678268] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/30/2014] [Accepted: 08/04/2014] [Indexed: 01/15/2023]
Abstract
Cyanotic congenital heart disease comprises a diverse spectrum of anatomical pathologies. Common to all, however, is chronic hypoxia before these lesions are operated upon when cardiopulmonary bypass is initiated. A range of functional and structural adaptations take place in the chronically hypoxic heart, which, whilst protective in the hypoxic state, are deleterious when the availability of oxygen to the myocardium is suddenly improved. Conventional cardiopulmonary bypass delivers hyperoxic perfusion to the myocardium and is associated with cardiac injury and systemic stress, whilst a normoxic perfusate protects against these insults.
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45
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Caputo M, Mokhtari A, Miceli A, Ghorbel MT, Angelini GD, Parry AJ, Suleiman SM. Controlled reoxygenation during cardiopulmonary bypass decreases markers of organ damage, inflammation, and oxidative stress in single-ventricle patients undergoing pediatric heart surgery. J Thorac Cardiovasc Surg 2014; 148:792-801.e8; discussion 800-1. [DOI: 10.1016/j.jtcvs.2014.06.001] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2014] [Revised: 05/29/2014] [Accepted: 06/02/2014] [Indexed: 11/16/2022]
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Metabolic derangement and cardiac injury early after reperfusion following intermittent cross-clamp fibrillation in patients undergoing coronary artery bypass graft surgery using conventional or miniaturized cardiopulmonary bypass. Mol Cell Biochem 2014; 395:167-75. [PMID: 24934242 DOI: 10.1007/s11010-014-2122-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2014] [Accepted: 06/02/2014] [Indexed: 10/25/2022]
Abstract
Myocardial ischemic stress and early reperfusion injury in patients undergoing coronary artery bypass grafting (CABG) operated on using intermittent cross-clamp fibrillation (ICCF) are not presently known. The role of mini-cardiopulmonary bypass (mCPB) versus conventional CPB (cCPB) during ICCF has not been investigated. These issues have been addressed as secondary objective of randomised controlled trial (ISRCTN30610605) comparing cCPB and mCPB. Twenty-six patients undergoing primary elective CABG using ICCF were randomised to either cCPB or mCPB. Paired left ventricular biopsies collected from 21 patients at the beginning and at the end of CPB were used to measure intracellular substrates (ATP and related compounds). Cardiac troponin T (cTnT) and CK-MB levels were measured in plasma collected from all patients preoperatively and after 1, 30, 60, 120, and 300 min after institution of CPB. ICCF was associated with significant ischemic stress as seen by fall in energy-rich phosphates early after reperfusion. There was also a fall in nicotinamide adenine dinucleotide (NAD(+)) indicating cardiomyocyte death which was confirmed by early release of cTnT and CK-MB during CPB. Ischemic stress and early myocardial injury were similar for cCPB and mCPB. However, the overall cardiac injury was significantly lower in the mCPB group as measured by cTnT (mean ± SEM: 96 ± 14 vs. 59 ± 8 µg/l, p = 0.02), but not with CK-MB. ICCF is associated with significant metabolic derangement and early myocardial injury. This early outcome was not affected by the CPB technique. However, the overall cardiac injury was lower for mCPB only when measured using cTnT.
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47
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Myocardial injury in critically ill children: a case control study. ISRN CARDIOLOGY 2014; 2014:919150. [PMID: 24660069 PMCID: PMC3934765 DOI: 10.1155/2014/919150] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/09/2013] [Accepted: 12/30/2013] [Indexed: 11/18/2022]
Abstract
Objectives. The aim of this study was to investigate the occurrence of myocardial injury in critically ill children through assessment of cardiac troponin T levels and whether levels are associated with disease severity and myocardial dysfunction measured by echocardiography. Methods. Over a 6-month period, this case control study included 50 patients admitted to Pediatric Intensive Care Unit of Zagazig University Children's Hospital. Twenty-five healthy children were included as a control group. Demographic and clinical data including the pediatric index of mortality II score were recorded. Echocardiographic examination was done and level of cardiac troponin T was measured using Elecsys Troponin T STAT Immunoassay. Results. Cardiac troponin T levels were significantly higher in critically ill in comparison to healthy children (median 22 (18–28) pg/mL versus 10 (10-10) pg/mL, P < 0.05). Cardiac troponin T levels correlated positively with duration of ventilation as well as with disease severity and correlated negatively with left ventricular fractional shortening. Moreover, cardiac troponin T levels were significantly higher in nonsurvivors when compared to survivors (median 34.5 (27.5–41.5) pg/mL versus 20 (18–24) pg/mL, P < 0.05). Conclusion. In critically ill children, cardiac troponin T levels were elevated and were associated with duration of ventilation and disease severity.
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48
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Bojan M, Pouard P. Reply: To PMID 23462260. Ann Thorac Surg 2014; 96:2286. [PMID: 24296216 DOI: 10.1016/j.athoracsur.2013.09.053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2013] [Revised: 08/13/2013] [Accepted: 09/19/2013] [Indexed: 10/26/2022]
Affiliation(s)
- Mirela Bojan
- Anesthesia and Critical Care, Necker-Enfants Malades Hospital, Assistance Publique-Hopitaux de Paris, 149, rue de Sèvres, Paris, France 75015.
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Abstract
OBJECTIVE At the present time, there is a trend towards performing open heart surgery at a younger age. Myocardium of infants has been thought to be more vulnerable to cardiopulmonary bypass in comparison with adults. For this study, we evaluated the degree of myocardial injury by measurement of cardiac troponin levels in infants in comparison with older children for similar surgeries. METHODS Serum was collected before bypass, after bypass, and daily after surgery and serum cardiac troponin I level (micrograms per litre). The demographic data, cardiac diagnoses, types of surgery performed, and peri-operative parameters were collected. RESULTS Of the 21 children enrolled consecutively, five were infants. Among the 21 patients, four patients had post-operative peak troponin values greater than 100 (three were infants) and all four patients survived and had normal left ventricular systolic function upon discharge echocardiogram. The five infants had peak troponin levels of 222.3, 202, 129, 26.7, and 82.3. The post-operative peak troponin levels were significantly higher in infants (mean 132.5 with a standard deviation of 81.6) than in the older children (mean 40.3 with a standard deviation of 33.4), although there was no significant difference in bypass time, bypass temperature, cross-clamp time, or the length of stay in the intensive care unit between the two age groups. CONCLUSIONS Higher troponin release is seen in infants in comparison with older children after bypass for similar surgeries. A troponin level greater than 100 after bypass does not necessarily predict death or a severe cardiovascular event in the very young.
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50
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Walker S, Danton M, Peng EWK, Lyall F. Heat shock protein 27 is increased in cyanotic tetralogy of Fallot myocardium and is associated with improved cardiac output and contraction. Cell Stress Chaperones 2013; 18:269-77. [PMID: 23080524 PMCID: PMC3631092 DOI: 10.1007/s12192-012-0379-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2012] [Revised: 10/01/2012] [Accepted: 10/02/2012] [Indexed: 11/26/2022] Open
Abstract
Tetralogy of Fallot (TOF) is a congenital heart condition in which the right ventricle is exposed to cyanosis and pressure overload. Patients have an increased risk of right ventricle dysfunction following corrective surgery. Whether the cyanotic myocardium is less tolerant of injury compared to non-cyanotic is unclear. Heat shock proteins (HSPs) protect against cellular stresses. The aim of this study was to examine HSP 27 expression in the right ventricle resected from TOF patients and determine its relationship with right ventricle function and clinical outcome. Ten cyanotic and ten non-cyanotic patients were studied. Western blotting was used to quantify HSP 27 in resected myocardium at (1) baseline (first 15 min of aortic cross clamp and closest representation of pre-operative status) and (2) after 15 min during ischemia until surgery was complete. The cyanotic group had significantly increased haematocrit, lower O2 saturation, thicker interventricular septal wall thickness and released more troponin-I on post-operative day 1 (p < 0.05). HSP 27 expression was significantly increased in the < 15 min cyanotic compared to the < 15 min non-cyanotic group (p = 0.03). In the cyanotic group, baseline HSP 27 expression also significantly correlated with oxygen extraction ratio (p = 0.028), post-operative basal septal velocity (p = 0.036) and mixed venous oxygen saturation (p = 0.02), markers of improved cardiac output/contraction. Increased HSP 27 expression and associated improved right ventricle function and systemic perfusion supports a cardio-protective effect of HSP 27 in cyanotic TOF.
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Affiliation(s)
- Susan Walker
- />Institute of Medical Genetics, Yorkhill, Glasgow G38SJ UK
| | - Mark Danton
- />Department of Cardiac Surgery, Royal Hospital for Sick Children, Glasgow, G38SJ UK
| | - Edward Weng Koon Peng
- />Department of Cardiac Surgery, Royal Hospital for Sick Children, Glasgow, G38SJ UK
| | - Fiona Lyall
- />Institute of Medical Genetics, Yorkhill, Glasgow G38SJ UK
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