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Liu CH, Huang ZH, Huang SC, Jou TS. Endocytosis of peroxiredoxin 1 links sterile inflammation to immunoparalysis in pediatric patients following cardiopulmonary bypass. Redox Biol 2021; 46:102086. [PMID: 34332210 PMCID: PMC8339339 DOI: 10.1016/j.redox.2021.102086] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 07/19/2021] [Accepted: 07/27/2021] [Indexed: 11/17/2022] Open
Abstract
After cardiopulmonary bypass (CPB), the occurrence of systemic inflammatory response is often accompanied by a persistent compensatory anti-inflammatory response syndrome that can lead to a compromised immune competence termed immunoparalysis, rendering the patients susceptible to infections which is a leading complication following cardiac surgery. However, the underlying mechanisms of CPB-elicited immunoparalysis remain obscure. In this study we showed that peroxiredoxin 1 (Prdx1), a putative cytosolic antioxidant, was released immediately after CPB in a cohort of pediatric patients receiving congenital cardiac surgery. This increased Prdx1 was correlated to a reduced human leukocyte antigen-DR expression and an elevated interleukin-10 (IL-10) production, as well as a hypo-responsiveness of macrophages to endotoxin and a higher incidence of nosocomial infection. We demonstrated that substitution of Ser83 for Cys83 prevented Prdx1 from oligomerization and subsequent binding and internalization to macrophages. These effects mitigated Prdx1-induced IL-10 induction and endotoxin tolerance. Furthermore, after engagement with toll-like receptor (TLR) 4, clathrin-dependent endocytosis is crucial for Prdx1 to elicit IL-10 production in phagocytes. Congruently, inhibition of Prdx1/TLR4 endocytosis in phagocytes reversed the Prdx1/IL-10-mediated hypo-responsiveness to endotoxin. Our findings unveiled the possible mechanisms by which Prdx1 undertakes to cause immunoparalysis, and targeting endocytosis of Prdx1 could be a novel therapeutic approach for postoperative infections associated with CPB. Cardiopulmonary bypass-elicited ischemia/reperfusion injury causes release of Prdx1. High molecular weight forms of Prdx1 interact with TLR4 to initiate sterile inflammation. Endocytosis of Prdx1/TLR4 induces IL-10 production that leads to immunoparalysis and subsequent septic inflammation. Inhibition of Prdx1/TLR4 endocytosis reverses Prdx1/IL-10-mediated hypo-responsiveness to endotoxin in phagocytes.
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Affiliation(s)
- Chia-Hsiung Liu
- Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan; Department of Surgery, College of Medicine, National Taiwan University, Taipei, Taiwan.
| | - Zheng-Hua Huang
- Department of Surgery, College of Medicine, National Taiwan University, Taipei, Taiwan.
| | - Shu-Chien Huang
- Department of Surgery, College of Medicine, National Taiwan University, Taipei, Taiwan.
| | - Tzuu-Shuh Jou
- Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan; Department of Internal Medicine, National Taiwan University Hospital, Taiwan; Center of Precision Medicine, College of Medicine, National Taiwan University, Taiwan.
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Faerber JA, Huang J, Zhang X, Song L, DeCost G, Mascio CE, Ravishankar C, O'Byrne ML, Naim MY, Kawut SM, Goldmuntz E, Mercer-Rosa L. Identifying Risk Factors for Complicated Post-operative Course in Tetralogy of Fallot Using a Machine Learning Approach. Front Cardiovasc Med 2021; 8:685855. [PMID: 34368247 PMCID: PMC8339319 DOI: 10.3389/fcvm.2021.685855] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 06/21/2021] [Indexed: 11/15/2022] Open
Abstract
Introduction: Tetralogy of Fallot (TOF) repair is associated with excellent operative survival. However, a subset of patients experiences post-operative complications, which can significantly alter the early and late post-operative course. We utilized a machine learning approach to identify risk factors for post-operative complications after TOF repair. Methods: We conducted a single-center prospective cohort study of children <2 years of age with TOF undergoing surgical repair. The outcome was occurrence of post-operative cardiac complications, measured between TOF repair and hospital discharge or death. Predictors included patient, operative, and echocardiographic variables, including pre-operative right ventricular strain and fractional area change as measures of right ventricular function. Gradient-boosted quantile regression models (GBM) determined predictors of post-operative complications. Cross-validated GBMs were implemented with and without a filtering stage non-parametric regression model to select a subset of clinically meaningful predictors. Sensitivity analysis with gradient-boosted Poisson regression models was used to examine if the same predictors were identified in the subset of patients with at least one complication. Results: Of the 162 subjects enrolled between March 2012 and May 2018, 43 (26.5%) had at least one post-operative cardiac complication. The most frequent complications were arrhythmia requiring treatment (N = 22, 13.6%), cardiac catheterization (N = 17, 10.5%), and extracorporeal membrane oxygenation (ECMO) (N = 11, 6.8%). Fifty-six variables were used in the machine learning analysis, of which there were 21 predictors that were already identified from the first-stage regression. Duration of cardiopulmonary bypass (CPB) was the highest ranked predictor in all models. Other predictors included gestational age, pre-operative right ventricular (RV) global longitudinal strain, pulmonary valve Z-score, and immediate post-operative arterial oxygen level. Sensitivity analysis identified similar predictors, confirming the robustness of these findings across models. Conclusions: Cardiac complications after TOF repair are prevalent in a quarter of patients. A prolonged surgery remains an important predictor of post-operative complications; however, other perioperative factors are likewise important, including pre-operative right ventricular remodeling. This study identifies potential opportunities to optimize the surgical repair for TOF to diminish post-operative complications and secure improved clinical outcomes. Efforts toward optimizing pre-operative ventricular remodeling might mitigate post-operative complications and help reduce future morbidity.
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Affiliation(s)
- Jennifer A Faerber
- Data Science and Biostatistics Unit, Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Jing Huang
- Department of Biostatistics, Epidemiology & Informatics, University of Pennsylvania, Philadelphia, PA, United States.,Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Xuemei Zhang
- Data Science and Biostatistics Unit, Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Lihai Song
- Data Science and Biostatistics Unit, Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Grace DeCost
- School of Public Health, Brown University, Providence, RI, United States
| | - Christopher E Mascio
- Division of Cardiothoracic Surgery, Department of Surgery, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
| | - Chitra Ravishankar
- Division of Cardiology, Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
| | - Michael L O'Byrne
- Data Science and Biostatistics Unit, Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, PA, United States.,Division of Cardiology, Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States.,Leonard Davis Institute and Center for Cardiovascular Outcomes, Quality, and Evaluative Research, University of Pennsylvania, Philadelphia, PA, United States
| | - Maryam Y Naim
- Departments of Anesthesiology, Critical Care Medicine and Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
| | - Steven M Kawut
- Departments of Medicine and Epidemiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
| | - Elizabeth Goldmuntz
- Division of Cardiology, Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
| | - Laura Mercer-Rosa
- Division of Cardiology, Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
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Swinkels BM, Ten Berg JM, Kelder JC, Vermeulen FE, Van Boven WJ, de Mol BA. Effect of aortic cross-clamp time on late survival after isolated aortic valve replacement. Interact Cardiovasc Thorac Surg 2021; 32:222-228. [PMID: 33491739 DOI: 10.1093/icvts/ivaa244] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 09/15/2020] [Accepted: 09/27/2020] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Longer aortic cross-clamp (ACC) time is associated with decreased early survival after cardiac surgery. Because maximum follow-up in previous studies on this subject is confined to 28 months, it is unknown whether this adverse effect is sustained far beyond this term. We aimed to determine whether longer ACC time was independently associated with decreased late survival after isolated aortic valve replacement in patients with severe aortic stenosis during 25 years of follow-up. METHODS In this retrospective cohort study, multivariable analysis was performed to identify possible independent predictors of decreased late survival, including ACC and cardiopulmonary bypass (CPB) time, in a cohort of 456 consecutive patients with severe aortic stenosis, who had undergone isolated aortic valve replacement between 1990 and 1993. RESULTS Mean follow-up was 25.3 ± 2.7 years. Median (interquartile range) and mean ACC times were normal: 63.0 (20.0) and 64.2 ± 16.1 min, respectively. Age, operative risk scores and New York Heart Association class were similar in patients with ACC time above, versus those with ACC time below the median. Longer ACC time was independently associated with decreased late survival: hazards ratio (HR) 1.01 per minute increase of ACC time (95% confidence interval [CI] 1.00-1.02; P = 0.012). Longer CPB time was not associated with decreased late survival (HR 1.00 per minute increase of CPB time [95% CI 1.00-1.00; P = 0.30]). CONCLUSIONS Longer ACC time, although still within normal limits, was independently associated with decreased late survival after isolated aortic valve replacement in patients with severe aortic stenosis.
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Affiliation(s)
- Ben M Swinkels
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, Netherlands
| | - Jurriën M Ten Berg
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, Netherlands
| | - Johannes C Kelder
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, Netherlands
| | - Freddy E Vermeulen
- Department of Cardiothoracic Surgery, St. Antonius Hospital, Nieuwegein, Netherlands
| | - Wim Jan Van Boven
- Department of Cardiothoracic Surgery, Amsterdam University Medical Center, Location Academic Medical Center, Amsterdam, Netherlands
| | - Bas A de Mol
- Department of Cardiothoracic Surgery, Amsterdam University Medical Center, Location Academic Medical Center, Amsterdam, Netherlands
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Loughlin JM, Browne L, Hinchion J. The impact of exogenous nitric oxide during cardiopulmonary bypass for cardiac surgery. Perfusion 2021; 37:656-667. [PMID: 33983090 DOI: 10.1177/02676591211014821] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Cardiac surgery using cardiopulmonary bypass frequently provokes a systemic inflammatory response syndrome. This can lead to the development of low cardiac output syndrome (LCOS). Both of these can affect morbidity and mortality. This study is a systematic review of the impact of gaseous nitric oxide (gNO), delivered via the cardiopulmonary bypass (CPB) circuit during cardiac surgery, on post-operative outcomes. It aims to summarise the evidence available, to assess the effectiveness of gNO via the CPB circuit on outcomes, and highlight areas of further research needed to develop this hypothesis. METHODS A comprehensive search of Pubmed, Embase, Web of Science and the Cochrane Library was performed in May 2020. Only randomised control trials (RCTs) were considered. RESULTS Three studies were identified with a total of 274 patients. There was variation in the outcomes measures used across the studies. These studies demonstrate there is evidence that this intervention may contribute towards cardioprotection. Significant reductions in cardiac troponin I (cTnI) levels and lower vasoactive inotrope scores were seen in intervention groups. A high degree of heterogeneity between the studies exists. Meta-analysis of the duration of mechanical ventilation, length of ICU stay and length of hospital stay showed no significant differences. CONCLUSION This systematic review explored the findings of three pilot RCTs. Overall the hypothesis that NO delivered via the CPB circuit can provide cardioprotection has been supported by this study. There remains a significant gap in the evidence, further high-quality research is required in both the adult and paediatric populations.
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Affiliation(s)
- Joseph Mc Loughlin
- Department of Cardiothoracic Surgery, Cork University Hospital, Cork, Ireland
| | - Lorraine Browne
- Department of Clinical Perfusion, Cork University Hospital, Cork, Ireland
| | - John Hinchion
- Department of Cardiothoracic Surgery, Cork University Hospital, Cork, Ireland
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Ayıkgöz Y, Salih Aydın M, Kankılıç N, Temiz E. Nuclear factor erythroid 2-related factor 2 (Nrf2), tumor necrosis factor alpha protein (TNF-α), heme oxygenase-1 (HO-1) gene expressions during cardiopulmonary bypass. Gene 2021; 790:145690. [PMID: 33961973 DOI: 10.1016/j.gene.2021.145690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 04/14/2021] [Accepted: 04/30/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE During extracorporeal circulation, blood is in contact with nonendothelial surfaces. The increase in the amount of blood touching the non-endothelial surface increases the damage to the blood elements. This initiates and increases oxidative stress. Increased oxidative stress leads to the activation of antioxidant systems. These two systems work gradually in the process of Cardiopulmonary Bypass. This study aims to investigate the changes of TNF-α, Nrf2 and HO-1 gene expression in extracorporeal circulation. MATERIALS AND METHODS Fifteen patients who underwent open heart surgery were included in the study. Blood samples were taken preoperatively, during cardiopulmonary bypass (CPB) and 24 hours postoperatively. TNF-α, Nrf2 and HO-1 gene expressions in plasma samples were studied by using appropriate kits. Changes in gene expressions were compared. RESULTS TNF-α gene expression increased during CPB compared to preoperative levels (p <0.05). Similarly, Nrf-2 gene expression increased significantly during CPB (p <0.001) and decreased postoperatively (p <0.001). There was a significant increase in HO-1 gene expression during CPB (p <0.01). Postoperatively, this increase was found to decrease similar to Nrf2 (p <0.05). CONCLUSIONS According to the results, TNF-α, Nrf2, HO-1 gene expressions increase during CPB and these values decrease after the operation. This shows that oxidative stress and inflammatory processes start with CPB and antioxidant processes start similarly. With the termination of CPB, both processes are terminated. This has been demonstrated by gene expressions. Future studies will make it easier to understand these processes.
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Affiliation(s)
- Yusuf Ayıkgöz
- Department of Cardiovascular Surgery, Medical Faculty, Harran University, Şanlıurfa, Turkey
| | - Mehmet Salih Aydın
- Department of Cardiovascular Surgery, Medical Faculty, Harran University, Şanlıurfa, Turkey
| | - Nazım Kankılıç
- Department of Cardiovascular Surgery, Medical Faculty, Harran University, Şanlıurfa, Turkey.
| | - Ebru Temiz
- Medical Promotion and Marketing Program, Health Services Vocational School, Harran University, Department of Biochemistry, Medical Faculty, Harran University, Şanlıurfa, Turkey
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van Groenendael R, Beunders R, Hemelaar P, Hofland J, Morshuis WJ, van der Hoeven JG, Gerretsen J, Wensvoort G, Kooistra EJ, Claassen WJ, Waanders D, Lamberts MGA, Buijsse LSE, Kox M, van Eijk LT, Pickkers P. Safety and Efficacy of Human Chorionic Gonadotropin Hormone-Derivative EA-230 in Cardiac Surgery Patients: A Randomized Double-Blind Placebo-Controlled Study. Crit Care Med 2021; 49:790-803. [PMID: 33591006 PMCID: PMC8043513 DOI: 10.1097/ccm.0000000000004847] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVES To determine the safety and efficacy of human chorionic gonadotropin hormone-derivative EA-230 in cardiac surgery patients. Cardiac surgery induces systemic inflammation and may impair renal function, affecting patient outcome. EA-230 exerted immunomodulatory and renoprotective effects in preclinical models and was safe and showed efficacy in phase I and II human studies. DESIGN Double-blinded, placebo-controlled, randomized study. SETTING Collaboration of the Cardiothoracic Surgery, Anesthesiology, and the Intensive Care departments of a tertiary hospital in the Netherlands. PATIENTS One hundred eighty patients undergoing an on-pump coronary artery bypass procedure with or without concomitant valve surgery. INTERVENTIONS Ninety mg/kg/hr EA-230 or placebo administered during surgery. MEASUREMENTS AND MAIN RESULTS During the study, no safety concerns emerged. EA-230 did not modulate interleukin-6 plasma concentrations (area under the curve 2,730 pg/mL × hr [1,968-3,760] vs 2,680 pg/mL × hr [2,090-3,570] for EA-230 and placebo group, respectively; p = 0.80). Glomerular filtration rate increased following surgery (mean ± sem increase in the EA-230 vs placebo groups: glomerular filtration rateiohexol measured using iohexol plasma clearance: 19 ± 2 vs 16 ± 2 mL/min/1.73 m2; p = 0.13 and estimated glomerular filtration rate with the Modification of Diet in Renal Disease equation using creatinine: 6 ± 1 vs 2 ± 1 mL/min/1.73 m2; p = 0.01). The "injury" stage of the Risk, Injury, Failure, Loss of kidney function, and End-stage kidney disease criteria for acute kidney injury was 7% in the EA-230 group versus 18% in the placebo group (p = 0.07). In addition, EA-230-treated patients had a less positive fluid balance compared with placebo-treated patients (217 ± 108 vs 605 ± 103 mL; p = 0.01), while the use of vasoactive agents was similar in both groups (p = 0.39). Finally, hospital length of stay was shorter in EA-230 treated patients (8 d [7-11] vs 10 d [8-12]; p = 0.001). Efficacy results were more pronounced in patients that had longer duration of surgery and thus longer duration of study drug infusion. CONCLUSIONS EA-230 was safe in patients undergoing on-pump cardiac surgery. It did not modulate interleukin-6 plasma concentrations but appeared to exert beneficial renal and cardiovascular effects and shortened in-hospital length of stay.
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Affiliation(s)
- Roger van Groenendael
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
- Radboud Center for Infectious Diseases (RCI), Radboud University Medical Center, Nijmegen, The Netherlands
- Radboud Institute for Molecular Life Sciences (RIMLS), Radboud University Medical Center, Nijmegen, The Netherlands
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Remi Beunders
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
- Radboud Institute for Molecular Life Sciences (RIMLS), Radboud University Medical Center, Nijmegen, The Netherlands
| | - Pleun Hemelaar
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
- Radboud Center for Infectious Diseases (RCI), Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jan Hofland
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Wim J. Morshuis
- Department of Cardiothoracic Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Johannes G. van der Hoeven
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
- Radboud Center for Infectious Diseases (RCI), Radboud University Medical Center, Nijmegen, The Netherlands
- Radboud Institute for Molecular Life Sciences (RIMLS), Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jelle Gerretsen
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
- Radboud Center for Infectious Diseases (RCI), Radboud University Medical Center, Nijmegen, The Netherlands
| | - Gert Wensvoort
- Exponential Biotherapies, Inc. (EBI), The Hague, The Netherlands
| | - Emma J. Kooistra
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
- Radboud Center for Infectious Diseases (RCI), Radboud University Medical Center, Nijmegen, The Netherlands
- Radboud Institute for Molecular Life Sciences (RIMLS), Radboud University Medical Center, Nijmegen, The Netherlands
| | - Wout J. Claassen
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Denise Waanders
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Maud G. A. Lamberts
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Leonie S. E. Buijsse
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Matthijs Kox
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
- Radboud Center for Infectious Diseases (RCI), Radboud University Medical Center, Nijmegen, The Netherlands
- Radboud Institute for Molecular Life Sciences (RIMLS), Radboud University Medical Center, Nijmegen, The Netherlands
| | - Lucas T. van Eijk
- Radboud Center for Infectious Diseases (RCI), Radboud University Medical Center, Nijmegen, The Netherlands
- Radboud Institute for Molecular Life Sciences (RIMLS), Radboud University Medical Center, Nijmegen, The Netherlands
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Peter Pickkers
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
- Radboud Center for Infectious Diseases (RCI), Radboud University Medical Center, Nijmegen, The Netherlands
- Radboud Institute for Molecular Life Sciences (RIMLS), Radboud University Medical Center, Nijmegen, The Netherlands
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Laudisio A, Nenna A, Musarò M, Angeletti S, Nappi F, Lusini M, Chello M, Incalzi RA. Perioperative management after elective cardiac surgery: the predictive value of procalcitonin for infective and noninfective complications. Future Cardiol 2021; 17:1349-1358. [PMID: 33876946 DOI: 10.2217/fca-2020-0245] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Objective: Procalcitonin (PCT) has been associated with adverse outcomes after cardiac surgery. Nevertheless, there is no consensus on thresholds and timing of PCT measurement to predict adverse outcomes. Materials & methods: A total of 960 patients undergoing elective cardiac surgery were retrospectively evaluated. PCT levels were measured from the first to the seventh postoperative day (POD). The onset of complications was recorded. Results: Complications occurred in 421 (44%) patients. PCT on the third POD was associated with the occurrence of any kind of complications (odds ratio: 1.06; p: 0.037), and noninfectious complications (odds ratio: 1.05; p: 0.035), after adjusting. PCT above the median value at the third POD (>0.33 μg/l) predicted postoperative complications (incidence rate ratio: 1.13; p = 0.035). Conclusion: PCT seems to predict postoperative complications in cardiac surgery. The determination at the third POD yields the greatest sensitivity and specificity.
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Affiliation(s)
- Alice Laudisio
- Geriatrics, Università Campus Bio-Medico di Roma, Rome 00128, Italy
| | - Antonio Nenna
- Cardiovascular Surgery, Università Campus Bio-Medico di Roma, Rome 00128, Italy
| | - Marta Musarò
- Geriatrics, Università Campus Bio-Medico di Roma, Rome 00128, Italy
| | - Silvia Angeletti
- Clinical Laboratory Science, Università Campus Bio-Medico di Roma, Rome 00128, Italy
| | - Francesco Nappi
- Cardiac Surgery, Centre Cardiologique du Nord de Saint-Denis, Paris 93200, France
| | - Mario Lusini
- Cardiovascular Surgery, Università Campus Bio-Medico di Roma, Rome 00128, Italy
| | - Massimo Chello
- Cardiovascular Surgery, Università Campus Bio-Medico di Roma, Rome 00128, Italy
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Kaźmierski J, Miler P, Pawlak A, Jerczyńska H, Woźniak J, Frankowska E, Brzezińska A, Woźniak K, Krejca M, Wilczyński M. Elevated Monocyte Chemoattractant Protein-1 as the Independent Risk Factor of Delirium after Cardiac Surgery. A Prospective Cohort Study. J Clin Med 2021; 10:jcm10081587. [PMID: 33918634 PMCID: PMC8070441 DOI: 10.3390/jcm10081587] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 04/02/2021] [Accepted: 04/06/2021] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND The pathogenesis of postoperative delirium is largely unknown. The primary objective of this study is to assess whether increased levels of monocyte chemoattractant protein-1 (MCP-1) and high-sensitivity C-reactive protein (hsCRP) are associated with postoperative delirium in patients who have undergone cardiac surgery. The secondary objective is to investigate whether any association between raised inflammatory biomarkers levels and delirium is related to surgical and anesthetic procedures or mediated by pre-existing psychiatric conditions associated with raised pro-inflammatory markers levels. METHODS The patients were screened for cognitive impairment one day preoperatively with the use of the Mini-Mental State Examination Test and the Clock Drawing Test. A diagnosis of major depressive disorder (MDD) and anxiety disorders was established on the basis of Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria. Blood samples were collected pre- and postoperatively for hsCRP and chemokine levels. RESULTS Postoperative delirium developed in 34% (61 of 177) of patients. Both pre- and postoperative hsCRP, and preoperative MCP-1 levels were associated with postoperative delirium in univariate comparisons; p = 0.001; p < 0.001; p < 0.001, respectively. However, according to a multivariable logistic regression analysis, only a raised MCP-1 concentration before surgery was independently associated with postoperative delirium, and related to advancing age, preoperative anxiety disorders and prolonged intubation. CONCLUSIONS The present study suggests that an elevated preoperative MCP-1 concentration is associated with delirium after cardiac surgery. Monitoring of this inflammatory marker may reveal the cardiovascular disease (CVD) patients who are at risk of neuropsychiatric syndromes development.
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Affiliation(s)
- Jakub Kaźmierski
- Department of Old Age Psychiatry and Psychotic Disorders, Medical University of Lodz, 92-216 Lodz, Poland; (J.W.); (E.F.)
- Correspondence: ; Tel.: +48-42-675-7372
| | - Piotr Miler
- Central Clinical Hospital of Medical University of Lodz, 92-216 Lodz, Poland; (P.M.); (A.P.); (A.B.)
| | - Agnieszka Pawlak
- Central Clinical Hospital of Medical University of Lodz, 92-216 Lodz, Poland; (P.M.); (A.P.); (A.B.)
| | - Hanna Jerczyńska
- CoreLab Central Scientific Laboratory of Medical University of Lodz, Medical University of Lodz, 92-215 Lodz, Poland;
| | - Joanna Woźniak
- Department of Old Age Psychiatry and Psychotic Disorders, Medical University of Lodz, 92-216 Lodz, Poland; (J.W.); (E.F.)
| | - Emilia Frankowska
- Department of Old Age Psychiatry and Psychotic Disorders, Medical University of Lodz, 92-216 Lodz, Poland; (J.W.); (E.F.)
| | - Agnieszka Brzezińska
- Central Clinical Hospital of Medical University of Lodz, 92-216 Lodz, Poland; (P.M.); (A.P.); (A.B.)
| | - Katarzyna Woźniak
- Department of Cardiac Surgery, Medical University of Lodz, 92-213 Lodz, Poland; (K.W.); (M.K.); (M.W.)
| | - Michał Krejca
- Department of Cardiac Surgery, Medical University of Lodz, 92-213 Lodz, Poland; (K.W.); (M.K.); (M.W.)
| | - Mirosław Wilczyński
- Department of Cardiac Surgery, Medical University of Lodz, 92-213 Lodz, Poland; (K.W.); (M.K.); (M.W.)
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BOLAT A, SURER S, GÜLBAHAR Ö, BOLAT E, GÜLTEKİN Y, KUTSAL A. The effect of phosphorolcoline-coated cardiopulmonary by-pass circuits on morbidity and mortality in patients with congenital open cardiac surgery. JOURNAL OF HEALTH SCIENCES AND MEDICINE 2021. [DOI: 10.32322/jhsm.854196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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60
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Parikh AN, Merritt TC, Carvajal HG, Shepard MS, Canter MW, Abarbanell AM, Eghtesady P, Nath DS. A comparison of cardiopulmonary bypass versus extracorporeal membrane oxygenation: Does intraoperative circulatory support strategy affect outcomes in pediatric lung transplantation? Clin Transplant 2021; 35:e14289. [PMID: 33714228 DOI: 10.1111/ctr.14289] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 03/05/2021] [Accepted: 03/09/2021] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Data on adult lung transplantation suggest perioperative benefits of intraoperative extracorporeal membrane oxygenation (ECMO) compared to cardiopulmonary bypass (CPB). Information regarding their pediatric counterparts, however, is limited. This study compares outcomes of intraoperative ECMO versus CPB in pediatric lung transplantation. METHODS We reviewed all pediatric lung transplants at our institution from 2014 to 2019 and compared those supported intraoperatively on ECMO (n = 13) versus CPB (n = 22), plus a conditional analysis excluding re-transplantations (ECMO [n = 13] versus CPB [n = 20]). We evaluated survival, surgical times, intraoperative transfusions, postoperative support, complications, and duration of hospitalization. RESULTS Total time on ECMO support was significantly less than that of CPB support (P = .018). Intraoperatively, the ECMO group required fewer transfusions of fresh-frozen plasma (8.9 [5.8-22.3] vs 16.6 [11.4-39.0] mL/kg, P = .049) and platelets (4.2 [0.0-6.7] vs 8.0 [3.5-14.0] mL/kg, P = .049). When excluding re-transplantations, patients on ECMO required fewer packed red blood cells intraoperatively (12.6 [2.1-30.7] vs 28.2 [14.0-54.0] mL/kg, P = .048). There were no differences in postoperative support requirements, complications, or mortality at one, six, and twelve months. CONCLUSIONS Intraoperative ECMO support during pediatric lung transplantation appears to decrease intraoperative transfusion requirements when compared to CPB. Data from additional institutions may strengthen these observations.
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Affiliation(s)
- Amisha N Parikh
- Washington University in St. Louis School of Medicine, St. Louis, MO, USA
| | - Taylor C Merritt
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University in St. Louis School of Medicine/St. Louis Children's Hospital, St. Louis, MO, USA
| | - Horacio G Carvajal
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University in St. Louis School of Medicine/St. Louis Children's Hospital, St. Louis, MO, USA
| | - Mark S Shepard
- The Heart Center, St. Louis Children's Hospital, St. Louis, MO, USA
| | - Matthew W Canter
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University in St. Louis School of Medicine/St. Louis Children's Hospital, St. Louis, MO, USA
| | - Aaron M Abarbanell
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University in St. Louis School of Medicine/St. Louis Children's Hospital, St. Louis, MO, USA
| | - Pirooz Eghtesady
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University in St. Louis School of Medicine/St. Louis Children's Hospital, St. Louis, MO, USA
| | - Dilip S Nath
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University in St. Louis School of Medicine/St. Louis Children's Hospital, St. Louis, MO, USA
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61
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Bag-1L Protects against Cell Apoptosis in an In Vitro Model of Lung Ischemia-Reperfusion Injury through the C-Terminal "Bag" Domain. BIOMED RESEARCH INTERNATIONAL 2021; 2021:8822807. [PMID: 34056003 PMCID: PMC8123090 DOI: 10.1155/2021/8822807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 01/13/2021] [Accepted: 02/08/2021] [Indexed: 11/17/2022]
Abstract
Bcl-2-associated athanogene 1 (Bag-1) is a multifunctional and antiapoptotic protein that binds to the antiapoptosis regulator Bcl-2 and promotes cell survival. To investigate the protective function of Bag-1, we examined the effects of Bag-1L, one isoform of Bag-1, in an in vitro cell culture model of lung ischemia-reperfusion injury (LIRI) generated by treatment of A549 cells with hypoxia/reoxygenation. Overexpression of full-length Bag-1L increased the viability of A549 cells and reduced cell apoptosis in response to 6 h of hypoxia/reoxygenation treatment. Furthermore, Bag-1L overexpression enhanced the heat shock protein 70 (HSP70) and Bcl-2 protein levels, increased the phosphorylation of AKT, decreased Bax and cleaved caspase-3 levels, and was able to overcome cell cycle arrest. These effects were not observed in A549 cells overexpressing a truncated form of Bag-1L lacking the "Bag domain," denoted Bag-1L△C. The "Bag domain" is the C-terminal 47 amino acids. Taken together, the results of this study suggest that Bag-1L overexpression can protect against oxidative stress and apoptosis in an in vitro LIRI model, with a dependence on the Bag domain.
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62
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Zhou Z, Liang M, Wu H, Huang S, Weng R, Hou J, Wu Z. Preoperative Lymphocyte-to-Monocyte Ratio as a Prognostic Predictor of Long-Term Mortality in Cardiac Surgery Patients: A Propensity Score Matching Analysis. Front Cardiovasc Med 2021; 8:639890. [PMID: 33693038 PMCID: PMC7937643 DOI: 10.3389/fcvm.2021.639890] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Accepted: 02/01/2021] [Indexed: 12/20/2022] Open
Abstract
Aims: To evaluate the prognostic value of the preoperative lymphocyte-to-monocyte ratio (LMR) in patients who underwent cardiac surgery. Methods: Clinical data were extracted from the Medical Information Mart for Intensive Care III (MIMIC-III) database. The optimal cutoff value of LMR was determined by X-tile software. The Cox proportional hazard model was applied for the identification of independent prognostic factors of 4-year mortality and survival curves were estimated using the Kaplan-Meier method. In order to balance the influence of potential confounding factors, a 1:1 propensity score matching (PSM) method was performed. Results: A total of 1,701 patients were included. The X-tile software indicated that the optimal cutoff value of the LMR for 4-year mortality was 3.58. After PSM, 489 pairs of score-matched patients were generated. The Cox proportional hazard model showed that patients with an LMR < 3.58 had a significantly higher 4-year mortality than patients with an LMR ≥ 3.58 in the entire cohort (HR = 1.925, 95%CI: 1.509-2.456, p < 0.001) and the PSM subset (HR = 1.568, 95%CI: 1.2-2.05, p = 0.001). The survival curves showed that patients with an LMR < 3.58 had a significant lower 4-year survival rate in the entire cohort (71.7 vs. 88.5%, p < 0.001) and the PSM subset (73.2 vs. 81.4%, p = 0.002). Conclusions: A lower LMR (<3.58) was associated with a higher risk of 4-year mortality and can serve as a prognostic predictor of the long-term mortality in cardiac surgery patients.
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Affiliation(s)
- Zhuoming Zhou
- Department of Cardiac Surgery, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,NHC Key Laboratory of Assisted Circulation, Sun Yat-sen University, Guangzhou, China
| | - Mengya Liang
- Department of Cardiac Surgery, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,NHC Key Laboratory of Assisted Circulation, Sun Yat-sen University, Guangzhou, China
| | - Huawei Wu
- Department of Neurobiology, Physiology and Behavior, College of Biological Sciences, University of California, Davis, Davis, CA, United States
| | - Suiqing Huang
- Department of Cardiac Surgery, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,NHC Key Laboratory of Assisted Circulation, Sun Yat-sen University, Guangzhou, China
| | - Rennan Weng
- Department of Cardiac Surgery, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,NHC Key Laboratory of Assisted Circulation, Sun Yat-sen University, Guangzhou, China
| | - Jian Hou
- Department of Cardiac Surgery, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,NHC Key Laboratory of Assisted Circulation, Sun Yat-sen University, Guangzhou, China
| | - Zhongkai Wu
- Department of Cardiac Surgery, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,NHC Key Laboratory of Assisted Circulation, Sun Yat-sen University, Guangzhou, China
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63
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Retrospective evaluation of ultrafiltration during cardiac surgery with cardiopulmonary bypass in adult patients with increased neutrophil to lymphocyte ratio. JOURNAL OF SURGERY AND MEDICINE 2020. [DOI: 10.28982/josam.814941] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
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64
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Abstract
This article provides an overview of knowledge gaps that need to be addressed in cardiac anesthesia, including mitigating the inflammatory effects of cardiopulmonary bypass, defining myocardial infarction after cardiac surgery, improving perioperative neurologic outcomes, and the optimal management of patients undergoing valve replacement. In addition, emerging approaches to research conduct are discussed, including the use of new analytical techniques like machine learning, pragmatic trials, and adaptive designs.
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Affiliation(s)
- Jessica Spence
- Departments of Anesthesia and Critical Care and Health Research Methods, Evaluation, and Impact, McMaster University, HSC 2V9 - 1280 Main Street West, Hamilton, ON L8S 4K1, Canada; Population Health Research Institute (PHRI), C3-7B David Braley Cardiac, Vascular and Stroke Research Institute (DBCVSRI), 237 Barton Street East, Hamilton, ON L8L 2X2, Canada
| | - C David Mazer
- Department of Anesthesia, Li Ka Shing Knowledge Institute of St. Michael's Hospital, 30 Bond Street, Toronto, ON M5B 1W8, Canada; Departments of Anesthesia and Physiology, University of Toronto, Toronto, ON, Canada.
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65
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Abdelrahman KA, Hassan SA, Mohammed AA, Abdelhakeem EE, Abd-Elshafy SK, Salama RH, Abdalla EM. The effect of dexmedetomidine on the inflammatory response in children undergoing repair of congenital heart disease: a randomized controlled clinical trial. EGYPTIAN JOURNAL OF ANAESTHESIA 2020. [DOI: 10.1080/11101849.2020.1849957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Affiliation(s)
- Khaled A Abdelrahman
- Department of Anesthesia and Intensive Care, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Shimaa A Hassan
- Department of Anesthesia and Intensive Care, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Ahmed A Mohammed
- Department of Anesthesia and Intensive Care, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Essam E Abdelhakeem
- Department of Anesthesia and Intensive Care, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Sayed K. Abd-Elshafy
- Department of Anesthesia and Intensive Care, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Ragaa H Salama
- Department of Biochemistry, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Esam M Abdalla
- Department of Anesthesia and Intensive Care, Faculty of Medicine, Assiut University, Assiut, Egypt
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66
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Suzuki H, Oshima N, Watari T. Effect of modified ultrafiltration on cytokines and hemoconcentration in dogs undergoing cardiopulmonary bypass. J Vet Med Sci 2020; 82:1589-1593. [PMID: 33012753 PMCID: PMC7719890 DOI: 10.1292/jvms.20-0143] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Cardiac surgery using cardiopulmonary bypass (CPB) generates severe inflammatory reactions secondary to hemodilution and surgical stress. This study was
conducted to evaluate whether modified ultrafiltration (MUF) could be performed safely and to clarify its effects during mitral valve repair in dogs in terms of
hemodilution and the status of inflammatory cytokines. We retrospectively studied 38 dogs with mitral valve disease who underwent MUF immediately after mitral
valve repair under CPB. To determine the effect of MUF, we measured the pre- and post-MUF blood dilution and blood cytokine levels. The levels of red blood
cells, hematocrit (HCT), and albumin were significantly increased after MUF, whereas interleukin (IL)-6 levels were significantly increased from 24.3 (range
9.6–54.6) to 32.3 (15.9–65.1) pg/ml. The levels of IL-8 and IL-10 declined significantly after MUF, from 368.2 (246.1–669.4)
and 45.4 (28.6–76.1) to 272.2 (174.1–414.4) and 28.8 (18.8–44.5) pg/ml, respectively. Our results demonstrated that MUF can be
applied in dogs undergoing CPB and is effective in achieving hemoconcentration. Moreover, MUF may be useful for the removal of cytokines. Further studies are
needed to validate these findings and clarify the effects of inflammatory cytokines after CPB.
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Affiliation(s)
- Haruhiko Suzuki
- Laboratory of Veterinary Internal Medicine, College of Bioresource Sciences, Nihon University, 1866 Kameino, Fujisawa, Kanagawa 252-0880, Japan
| | - Naoko Oshima
- Laboratory of Veterinary Internal Medicine, College of Bioresource Sciences, Nihon University, 1866 Kameino, Fujisawa, Kanagawa 252-0880, Japan
| | - Toshihiro Watari
- Laboratory of Veterinary Internal Medicine, College of Bioresource Sciences, Nihon University, 1866 Kameino, Fujisawa, Kanagawa 252-0880, Japan
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67
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Cardiopulmonary Bypass Induces Acute Lung Injury via the High-Mobility Group Box 1/Toll-Like Receptor 4 Pathway. DISEASE MARKERS 2020; 2020:8854700. [PMID: 33062073 PMCID: PMC7532999 DOI: 10.1155/2020/8854700] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 08/23/2020] [Accepted: 08/31/2020] [Indexed: 11/25/2022]
Abstract
During cardiopulmonary bypass (CPB), pulmonary ischemia/reperfusion (I/R) injury can cause acute lung injury (ALI). Our previous research confirmed that abnormal high-mobility group box 1 (HMGB1) release after CPB was closely related to ALI. However, the mechanism underlying the HMGB1-mediated induction of ALI after CPB is unclear. Our previous study found that HMGB1 binds Toll-like receptor 4 (TLR4), leading to lung injury, but direct evidence of a role for these proteins in the mechanism of CPB-induced lung injury has not been shown. We examined the effects of inhibiting HMGB1 or reducing TLR4 expression on CPB-induced lung injury in rats administered anti-HMBG1 antibody or TLR4 short-hairpin RNA (shTLR4), respectively. In these rat lungs, we studied the histologic changes and levels of interleukin- (IL-) 1β, tumour necrosis factor- (TNF-) α, HMGB1, and TLR4 after CPB. After CPB, the lung tissues from untreated rats showed histologic features of injury and significantly elevated levels of IL-1β, TNF-α, HMGB1, and TLR4. Treatment with anti-HMGB1 attenuated the CPB-induced morphological inflammatory response and protein levels of IL-1β, TNF-α, HMGB1, and TLR4 in the lung tissues and eventually alleviated the ALI after CPB. Treatment with shTLR4 attenuated the CPB-induced morphological inflammatory response and protein levels of IL-1β, TNF-α, and TLR4 in the lung tissues and eventually alleviated the ALI after CPB, but could not alleviate the HMGB1 protein levels induced by CPB. In summary, the present study demonstrated that the HMGB1/TLR4 pathway mediated the development of ALI induced by CPB.
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68
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Tremblay JA, Laramée P, Lamarche Y, Denault A, Beaubien-Souligny W, Frenette AJ, Kontar L, Serri K, Charbonney E. Potential risks in using midodrine for persistent hypotension after cardiac surgery: a comparative cohort study. Ann Intensive Care 2020; 10:121. [PMID: 32926256 PMCID: PMC7490305 DOI: 10.1186/s13613-020-00737-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Accepted: 09/06/2020] [Indexed: 12/16/2022] Open
Abstract
Background Persistent hypotension is a frequent complication after cardiac surgery with cardiopulmonary bypass (CPB). Midodrine, an orally administered alpha agonist, could potentially reduce intravenous vasopressor use and accelerate ICU discharge of otherwise stable patients. The main objective of this study was to explore the clinical impacts of administering midodrine in patients with persistent hypotension after CPB. Our hypothesis was that midodrine would safely accelerate ICU discharge and be associated with more days free from ICU at 30 days. Results We performed a retrospective cohort study that included all consecutive patients having received midodrine while being on vasopressor support in the ICU within the first week after cardiac surgery with CPB, between January 2014 and January 2018 at the Montreal Heart Institute. A contemporary propensity score matched control group that included patients who presented similarly prolonged hypotension after cardiac surgery was formed. After matching, 74 pairs of patients (1:1) fulfilled inclusion criteria for the study and control groups. Midodrine use was associated with fewer days free from ICU (25.8 [23.7–27.1] vs 27.2 [25.9–28] days, p = 0.002), higher mortality (10 (13.5%) vs 1 (1.4%), p = 0.036) and longer ICU length of stay (99 [68–146] vs 68 [48–99] hours, p = 0.001). There was no difference in length of intravenous vasopressors (63 [40–87] vs 44 [26–66] hours, p = 0.052), rate of ICU readmission (6 (8.1%) vs 2 (2.7%), p = 0.092) and occurrence of severe kidney injury (11 (14.9%) vs 10 (13.5%) patients, p = 0.462) between groups. Conclusion The administration of midodrine for sustained hypotension after cardiac surgery with CPB was associated with fewer days free from ICU and higher mortality. Routine prescription of midodrine to hasten ICU discharge after cardiac surgery should be used with caution until further prospective studies are conducted.
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Affiliation(s)
- Jan-Alexis Tremblay
- Critical Care, Université de Montréal, 2900 Boulevard Edouard-Montpetit, Montréal, QC, H3T 1J4, Canada.
| | - Philippe Laramée
- Emergency Medicine, Université de Montréal, 2900 Boulevard Edouard-Montpetit, Montréal, QC, H3T 1J4, Canada
| | - Yoan Lamarche
- Critical Care, Institut de Cardiologie de Montréal, 5000 Rue Bélanger, Montréal, QC, H3T 1J4, Canada.,Cardiac Surgery, Institut de Cardiologie de Montréal, 5000 Rue Bélanger, Montréal, QC, H3T 1J4, Canada
| | - André Denault
- Critical Care, Institut de Cardiologie de Montréal, 5000 Rue Bélanger, Montréal, QC, H3T 1J4, Canada
| | | | - Anne-Julie Frenette
- Critical Care, Hôpital du Sacré-Cœur de Montréal, 5400 Boul Gouin O, Montréal, QC, H3T 1J4, Canada
| | - Loay Kontar
- Critical Care, Institut de Cardiologie de Montréal, 5000 Rue Bélanger, Montréal, QC, H3T 1J4, Canada
| | - Karim Serri
- Critical Care, Hôpital du Sacré-Cœur de Montréal, 5400 Boul Gouin O, Montréal, QC, H3T 1J4, Canada
| | - Emmanuel Charbonney
- Critical Care, Hôpital du Sacré-Cœur de Montréal, 5400 Boul Gouin O, Montréal, QC, H3T 1J4, Canada
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69
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Lanier OL, Velez C, Arnold DP, Dobson J. Model of Magnetic Particle Capture Under Physiological Flow Rates for Cytokine Removal During Cardiopulmonary Bypass. IEEE Trans Biomed Eng 2020; 68:1198-1207. [PMID: 32915721 DOI: 10.1109/tbme.2020.3023392] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
OBJECTIVE The objective of this study is to design a physical model of a magnetic filtration system which can separate magnetic nanoparticle (MNP)-tagged cytokines from fluid at physiologically relevant flow rates employed during cardiopulmonary bypass (CPB) procedures. METHODS The Navier-Stokes equations for the pressure driven flow in the chamber and the quasistatic stray magnetic field produced by an array of permanent magnets were solved using finite element analysis in COMSOL Multiphysics for 2D and 3D representations of the flow chamber. Parameters affecting the drag and magnetic forces including flow chamber dimensions, high gradient magnet array configurations, and particle properties, were changed and evaluated for their effect on MNP capture. RESULTS Flow chamber dimensions which achieve appropriate flow conditions for CPB were identified, and magnetic force within the chamber decreased with increased chamber height. A magnetic "block" array produced the highest magnetic force within the chamber. Polymeric microparticles loaded with MNPs were shown to have increased particle capture with increased hydrodynamic diameter. CONCLUSION The model achieved a predicted efficiency up to 100% capture in a single-pass of fluid flowing at 1.75 L/min. SIGNIFICANCE This work is an important step in designing a magnetic flow chamber that can remove the magnetically tagged cytokines under high flow employed during CPB. Cytokines have been shown to stimulate the systemic inflammatory response (SIR) associated with CPB and are an established therapeutic target to mitigate the SIR. In the long term, this work aims to guide researchers in the more accurate design of magnetic separation systems.
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70
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Niebler RA, Chiang-Ching H, Daley K, Janecke R, Jobe SM, Mitchell ME, Varner C, Woods K, Scott JP. Nitric oxide added to the sweep gas of the oxygenator during cardiopulmonary bypass in infants: A pilot randomized controlled trial. Artif Organs 2020; 45:22-28. [PMID: 32737900 DOI: 10.1111/aor.13788] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 07/16/2020] [Accepted: 07/21/2020] [Indexed: 01/08/2023]
Abstract
Our objective was to assess the effect of nitric oxide added to the sweep gas of the oxygenator during cardiopulmonary bypass (CPB) in infants on platelet count, platelet function, clinical outcomes, and safety. A randomized, double-blinded, placebo-controlled clinical trial in infants less than a year of age undergoing cardiac surgery requiring CPB was undertaken. Nitric oxide at a dose of 20 ppm was added to the sweep gas in the treatment group. Blood was collected at baseline and prior to separation from CPB to measure platelet count and function as determined by responsiveness to specific agonists. Clinical outcomes were observed through hospital discharge. Methemoglobin levels were measured preoperatively, at the conclusion of CPB, and upon admission to the ICU. Forty patients consented and were randomized in the trial. Eighteen patients were randomized to the treatment group and 22 were included in the placebo group. The groups were similar in terms of age, weight, gender, and surgical complexity. No significant differences were found in measures of platelet count, platelet response to agonist, or clinical outcomes. Patients in the treatment group had higher methemoglobin levels after receiving nitric oxide, but no levels approached toxicity (maximum 2.4%). Nitric oxide added to the sweep gas of the oxygenator during CPB in infants did not have an appreciable effect on the preservation of platelet count, platelet responsiveness to agonist, or clinical outcomes. Methemoglobin levels were increased after receiving nitric oxide but were far below a toxic level of 15%.
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Affiliation(s)
- Robert A Niebler
- Departments of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA.,Herma Heart Institute, Children's Wisconsin, Milwaukee, WI, USA
| | | | - Kevin Daley
- Herma Heart Institute, Children's Wisconsin, Milwaukee, WI, USA
| | - Rae Janecke
- Versiti Blood Research Institute, Milwaukee, WI, USA
| | - Shawn M Jobe
- Departments of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA.,Versiti Blood Research Institute, Milwaukee, WI, USA
| | - Michael E Mitchell
- Herma Heart Institute, Children's Wisconsin, Milwaukee, WI, USA.,Departments of Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Caleb Varner
- Herma Heart Institute, Children's Wisconsin, Milwaukee, WI, USA
| | - Katherine Woods
- Departments of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA
| | - John P Scott
- Herma Heart Institute, Children's Wisconsin, Milwaukee, WI, USA.,Departments of Anesthesia, Medical College of Wisconsin, Milwaukee, WI, USA
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71
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Hamiko M, Charitos EI, Velten M, Hilbert T, Putensen C, Treede H, Duerr GD. Mannitol Is Associated with Less Postoperative Delirium after Aortic Valve Surgery in Patients Treated with Bretschneider Cardioplegia. Thorac Cardiovasc Surg 2020; 70:549-557. [PMID: 32886926 PMCID: PMC9556161 DOI: 10.1055/s-0040-1715891] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Background
Heart surgery with extracorporeal circulation (ECC) often leads to postoperative delirium (POD). This is associated with increased morbidity resulting in longer hospital stay and associated costs. The purpose of our study was to analyze the effect of intraoperative mannitol application on POD in patients undergoing elective aortic valve replacement (AVR).
Materials and Method
s In our retrospective single-center study, 259 patients underwent elective AVR, using Bretschneider cardioplegic solution for cardiac arrest, between 2014 and 2017. Patients were divided in mannitol (
n
= 188) and nonmannitol (
n
= 71) groups. POD was assessed using the confusion assessment method for the intensive care unit (ICU). Statistical significance was assumed at
p
< 0.05.
Results
Baseline patient characteristics did not differ between the groups. Incidence of POD was significantly higher in the nonmannitol group (33.8 vs. 13.8%;
p
= 0.001). These patients required longer ventilation time (24.1 vs. 17.1 hours;
p
= 0.021), higher reintubation rate (11.3 vs. 2.7%;
p
= 0.009), ICU readmission (12.7 vs. 4.8%;
p
= 0.026), prolonged ICU (112 vs. 70 hours;
p
= 0.040), and hospital stay (17.8 vs. 12.6 days;
p
< 0.001), leading to higher expenses (19,349 € vs. 16,606 €,
p
< 0.001). A 30-day mortality was not affected, but nonmannitol group showed higher Simplified Acute Physiology Score II score (32.2 vs. 28.7;
p
< 0.001). Mannitol substitution was independently associated with lower incidence of POD (odds ratio: 0.40; 95% confidence interval: 0.18–0.89;
p
= 0.02).
Conclusion
Treatment with mannitol during ECC was associated with decreased incidence of POD. This was accompanied by shorter ventilation time, ICU and hospital stay, and lower treatment expenses.
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Affiliation(s)
- Marwan Hamiko
- Department of Cardiac Surgery, University Clinical Center Bonn, Bonn, North Rhine-Westphalia, Germany
| | - Efstratios I Charitos
- Department of Cardiac Surgery, University Clinical Center Bonn, Bonn, North Rhine-Westphalia, Germany
| | - Markus Velten
- Department of Anaesthesiology and Intensive Care Medicine, University Clinical Center Bonn, Bonn, North Rhine-Westphalia, Germany
| | - Tobias Hilbert
- Department of Anaesthesiology and Intensive Care Medicine, University Clinical Center Bonn, Bonn, North Rhine-Westphalia, Germany
| | - Christian Putensen
- Department of Anaesthesiology and Intensive Care Medicine, University Clinical Center Bonn, Bonn, North Rhine-Westphalia, Germany
| | - Hendrik Treede
- Department of Cardiac Surgery, University Clinical Center Bonn, Bonn, North Rhine-Westphalia, Germany
| | - Georg Daniel Duerr
- Department of Cardiac Surgery, University Clinical Center Bonn, Bonn, North Rhine-Westphalia, Germany
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72
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Postbypass Immunoparalysis in Children: Observable, but Actionable? Ann Thorac Surg 2020; 111:1642. [PMID: 32698020 DOI: 10.1016/j.athoracsur.2020.05.119] [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: 05/29/2020] [Accepted: 05/29/2020] [Indexed: 11/22/2022]
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73
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Ellam S, Hartikainen J, Korvenoja P, Pitkänen O, Tyrväinen E, Valtola A, Halonen J. Impact of minimal invasive extracorporeal circulation on atrial fibrillation after coronary artery bypass surgery. Artif Organs 2020; 44:1176-1183. [PMID: 32557731 DOI: 10.1111/aor.13756] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 06/02/2020] [Accepted: 06/05/2020] [Indexed: 01/04/2023]
Abstract
Postoperative atrial fibrillation (POAF) is the most common arrhythmia after cardiac surgery with an incidence between 15% and 50% and pathophysiology not fully known. By choosing the method of extracorporeal circulation with focus on the reduction of systemic inflammatory response, one can potentially decrease the risk of POAF. In this prospective, randomized trial, we compared minimal invasive extracorporeal circulation (MiECC) with conventional extracorporeal circulation (CECC) in the prevention of POAF after coronary artery bypass surgery (CABG). A total of 240 patients who were scheduled for their first on-pump CABG, were randomized to MiECC or CECC. The primary outcome measure was the incidence of first POAF during the first 84 hours after surgery. POAF occurred in 42/120 (35.0%) MiECC patients and 43/120 (35.8%) CECC patients with nonsignificant difference between the groups (OR 1.043, 95% CI 0.591-1.843, P = .884). The first postoperative creatine kinase-MB mass (CK-MBm) value was lower in the MiECC group, 13.95 [10.5-16.7] (median [IQR]) than in the CECC group, 15.30 [11.4-18.9] (P = .036), whereas the use of perioperative dobutamine was higher in the MiECC group, 18/120 (15.0%), than in the CECC group 8/120 (6.7%) (P = .038). The incidence of a stroke, perioperative myocardial infarction, and resternotomy caused by bleeding did not differ in the MiECC and CECC groups. Age (OR 1.08, 95% CI 1.04-1.13, P = .000) and peak postoperative CK-MBm (OR 1.57, 95% CI 1.06-2.37, P = .026) were independent predictors of POAF. MiECC compared to CECC was not effective in reducing the incidence of POAF in patients undergoing CABG.
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Affiliation(s)
- Sten Ellam
- Department of Anesthesiology and Operative Services, Kuopio University Hospital, Kuopio, Finland
| | - Juha Hartikainen
- Heart Center, Kuopio University Hospital, and School of Medicine, University of Eastern Finland, Kuopio, Finland
| | - Pekka Korvenoja
- Acute Care, South Karelia Central Hospital, Lappeenranta, Finland
| | - Otto Pitkänen
- Department of Anesthesiology and Operative Services, Kuopio University Hospital, Kuopio, Finland
| | - Esko Tyrväinen
- Department of Anesthesiology and Operative Services, Kuopio University Hospital, Kuopio, Finland
| | - Antti Valtola
- Heart Center, Kuopio University Hospital, and School of Medicine, University of Eastern Finland, Kuopio, Finland
| | - Jari Halonen
- Heart Center, Kuopio University Hospital, and School of Medicine, University of Eastern Finland, Kuopio, Finland
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Myocardial Fluid Balance and Pathophysiology of Myocardial Edema in Coronary Artery Bypass Grafting. Cardiol Res Pract 2020; 2020:3979630. [PMID: 32550020 PMCID: PMC7256715 DOI: 10.1155/2020/3979630] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Accepted: 05/05/2020] [Indexed: 12/11/2022] Open
Abstract
Myocardial edema is one of the most common complications of coronary artery bypass grafting (CABG) that is linearly related to many coronary artery diseases. Myocardial edema can cause several consequences including systolic dysfunction, diastolic dysfunction, arrhythmia, and cardiac tissue fibrosis that can increase mortality in CABG. Understanding myocardial fluid balance and tissue and systemic fluid regulation is crucial in order to ultimately link how coronary artery bypass grafting can cause myocardial edema in such a setting. The identification of susceptible patients by using imaging modalities is still challenging. Future studies about the technique of imaging modalities, examination protocols, prevention, and treatment of myocardial edema should be carried out, in order to limit myocardial edema occurrence and prevent complications.
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Rodríguez RX, Villarroel LA, Meza RA, Peña JI, Musalem C, Kattan J, Urzúa S. Infection profile in neonatal patients during extracorporeal membrane oxygenation. Int J Artif Organs 2020; 43:391398820911379. [PMID: 32195608 DOI: 10.1177/0391398820911379] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVES To describe risk factors for acquired infection during neonatal extracorporeal membrane oxygenation and to examine the predictive value of inflammatory markers in the diagnosis of infection. METHODS A retrospective study was conducted with data for patients under 30 days supported with extracorporeal membrane oxygenation from 2003 to April 2016, in a neonatal intensive care unit. RESULTS Our study included 160 neonatal patients, the average age of connection was 8.5 days and the duration of extracorporeal membrane oxygenation support was 9.7 days. The incidence of confirmed infection was 23%. Patients with confirmed infection present more frequently: vaginal delivery, lower birth weight, female sex, diagnosis of congenital diaphragmatic hernia, and longer duration of extracorporeal membrane oxygenation. When comparing the group of patients with confirmed infection and suspicion of infection, there were no significant differences in the inflammatory markers. When calculating the slope for each one, the difference in white blood cell count slope 72 h before the infection is significant; in patients with confirmed infection, the count of white blood cell increases (slope: 0.25), versus the group of patients with suspected infection in whom the count decreases (slope: -0.39). No differences were found in other variables. CONCLUSION Our study describes that the factors that increase the risk of infection are lower birth weight, vaginal birth, duration of extracorporeal membrane oxygenation, and a positive trend of white blood cell 72 h prior to infection/suspicion. Further studies are necessary to include or definitively rule out the use of these factors and the biomarkers as predictors of infection in neonatal patients supported with extracorporeal membrane oxygenation.
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Affiliation(s)
| | - Luis A Villarroel
- Department of Public Health, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Rodrigo A Meza
- Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Javier I Peña
- Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Claudia Musalem
- Department of Statistics, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Javier Kattan
- Department of Neonatology, Division of Pediatrics, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Soledad Urzúa
- Department of Neonatology, Division of Pediatrics, Pontificia Universidad Católica de Chile, Santiago, Chile
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Rahimzadeh M, Montazerghaem H, Chegeni SA, Naderi N. Interleukin -17 Serum Levels and Polymorphisms in Acute Kidney Injury Patients. Endocr Metab Immune Disord Drug Targets 2020; 20:400-408. [PMID: 32138639 DOI: 10.2174/1871530319666191009152048] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2019] [Revised: 08/20/2019] [Accepted: 08/21/2019] [Indexed: 11/22/2022]
Abstract
BACKGROUND Cardiopulmonary bypass (CPB) has been demonstrated to provoke a systemic inflammatory response believed to be responsible for some of the serious postoperative complications such as renal dysfunction. Therefore, we tested the hypothesis suggesting that the serum levels of IL- 17A (IL-17), as an inflammatory cytokine, and its gene variants are associated with acute kidney injury after CPB (AKI-CPB). METHODS A total of 135 Iranian patients undergoing cardiopulmonary bypass were included in this study, of whom 65 (48.1%) developed AKI. Blood specimens were collected preoperatively and at 12 hours postoperatively. The IL-17 gene polymorphisms (rs2275913 and rs3819024) were determined using sequence-specific primers (PCR-SSP) technique.Pre- and postoperative IL-17 levels were measured and analyzed in relation to polymorphisms. RESULTS IL-17 concentrations in CBP subjects, were increased after cardiopulmonary bypass (P<0.00001)but there were no statistically significant differences in IL-17 serum level between AKI and non-AKI groups. Different genotypes of IL-17 rs2275913 SNP (G→A) were associated with different circulating IL-17 levels before bypass and also after AKI development. There were no associations between gene polymorphisms (rs2275913and rs3819024) and incidence of AKI- CPB. There was an association between thers2275913 SNP and the severity of AKI. CONCLUSION This study clarified that the rs2275913 SNP to some extent determines plasma IL-17 concentrations in CPB patients. No significant association was found between IL-17 levels or gene polymorphisms (rs2275913and rs3819024) and incidence of AKI-CPB. Our results suggest that there is an association between rs2275913 and the severity of AKI- CPB.
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Affiliation(s)
- Mahsa Rahimzadeh
- Department of Biochemistry, Faculty of Medicine, Hormozgan University of Medical Sciences, Bandar Abbas, Iran
| | - Hossein Montazerghaem
- Cardiovascular Research Center, Hormozgan University of Medical Sciences, Bandar Abbas, Iran
| | - Sara A Chegeni
- Department of Biochemistry, Faculty of Medicine, Hormozgan University of Medical Sciences, Bandar Abbas, Iran
| | - Nadereh Naderi
- Department of Immunology, Faculty of Medicine, Hormozgan University of Medical Sciences, Bandar Abbas, Iran
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77
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Platelet dysfunction during pediatric cardiac ECMO. PROGRESS IN PEDIATRIC CARDIOLOGY 2020. [DOI: 10.1016/j.ppedcard.2019.101187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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78
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Ji Q, Qi XM, Shen JQ, Wang YL, Yang Y, Ding WJ, Xia LM, Wang CS. Patients over 70 years of age with moderate ischemic mitral regurgitation undergoing surgical revascularization plus mitral valve repair: insights from a single-center study of propensity-matched data. Cardiovasc Diagn Ther 2020; 9:568-577. [PMID: 32038946 DOI: 10.21037/cdt.2019.10.06] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Background Elderly patients, compared with the young, have a higher burden of surgical risk factors with reduced functional capacity and increased comorbidities conditions, and may have worse clinical outcomes. So far, few reports have focused on clinical outcomes of patients over 70 years of age with moderate chronic ischemic mitral regurgitation (IMR) undergoing mitral valve repair at the time of coronary artery bypass grafting (CABG). This single-center study of propensity-matched data attempts to answer a question: compared with patients with age of 70 or less, whether patients over 70 years of age with moderate IMR undergoing CABG plus mitral valve repair receive poor outcomes. Methods All eligible patients were included in this study and were entered into either an elderly group (n=142) or a control group (n=182) according to patients' age. In-hospital outcomes (consisting of surgical mortality and major postoperative morbidity) and midterm clinical outcomes (including all-cause mortality and recurrent mitral regurgitation) were compared after propensity score matching (1:1). Results Using propensity-score matching, 103 pairs of patients were successfully established in a 1:1 ratio. No significant differences between the two matched groups were found with regard to surgical mortality (5.8% vs. 3.9%, P=0.754) and major postoperative morbidity. A total of 184 patients (91 in the elderly group and 93 in the control group) received regular follow-up visit with the median duration of 38 months [interquartile range (IQR), 27-56 months]. There were not any significant differences between the two matched groups regarding overall survival and recurrent IMR-free survival (stratified log-rank P=0.185 and stratified log-rank P=0.453, respectively). The elderly group as compared to the control group did not affect midterm mortality via cox proportional hazard regression (propensity score adjusted hazard ratio, 1.143; 95% confidence interval, 0.761-1.943; P=0.285). Conclusions Patients over 70 years of age with moderate chronic IMR undergoing combined CABG and mitral valve repair may receive favorable in-hospital and midterm clinical outcomes.
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Affiliation(s)
- Qiang Ji
- Department of Cardiovascular Surgery of Zhongshan Hospital Fudan University, Shanghai 200032, China
| | - Xiao-Min Qi
- Shanghai Municipal Institute of Cardiovascular Diseases, Shanghai 200032, China
| | - Jin-Qiang Shen
- Department of Cardiovascular Surgery of Zhongshan Hospital Fudan University, Shanghai 200032, China
| | - Yu-Lin Wang
- Department of Cardiovascular Surgery of Zhongshan Hospital Fudan University, Shanghai 200032, China
| | - Ye Yang
- Department of Cardiovascular Surgery of Zhongshan Hospital Fudan University, Shanghai 200032, China
| | - Wen-Jun Ding
- Department of Cardiovascular Surgery of Zhongshan Hospital Fudan University, Shanghai 200032, China
| | - Li-Min Xia
- Department of Cardiovascular Surgery of Zhongshan Hospital Fudan University, Shanghai 200032, China.,Department of Cardiovascular Surgery of Xiamen Branch of Zhongshan Hospital Fudan University, Xiamen 510530, China
| | - Chun-Sheng Wang
- Shanghai Municipal Institute of Cardiovascular Diseases, Shanghai 200032, China
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79
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Xie Z, Li Z, Shao Y, Liao C. Discovery and development of plasma kallikrein inhibitors for multiple diseases. Eur J Med Chem 2020; 190:112137. [PMID: 32066009 DOI: 10.1016/j.ejmech.2020.112137] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2019] [Revised: 02/08/2020] [Accepted: 02/08/2020] [Indexed: 01/06/2023]
Abstract
Plasma kallikrein (PKal) belongs to the family of trypsin-like serine proteases. The expression of PKal is associated with multiple physiological systems or pathways such as coagulation pathway, platelet aggregation process, kallikrein-kinin system, renin-angiotensin system and complement pathway. On the basis of PKal's multiple physiological functions, it has been considered as a potential target for several diseases including hereditary angioedema, microvascular complications of diabetes mellitus and cerebrovascular disease. Up to now, many PKal inhibitors have been identified and a few of them have reached clinical trials or market. This review summarizes the development of small molecule and peptide PKal inhibitors having different scaffolds and discusses their structure-activity relationship and selectivity. We hope this review facilitates a comprehensive understanding of the types of PKal inhibitors developed to tackle different manifestations of PKal-associated diseases.
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Affiliation(s)
- Zhouling Xie
- Key Laboratory of Metabolism and Regulation for Major Diseases of Anhui Higher Education Institutes, Hefei University of Technology, Hefei, Anhui, 230009, PR China; School of Food and Biological Engineering, Hefei University of Technology, Hefei, Anhui, 230009, PR China.
| | - Zhen Li
- School of Food and Biological Engineering, Hefei University of Technology, Hefei, Anhui, 230009, PR China
| | - Yanruisheng Shao
- School of Food and Biological Engineering, Hefei University of Technology, Hefei, Anhui, 230009, PR China
| | - Chenzhong Liao
- Key Laboratory of Metabolism and Regulation for Major Diseases of Anhui Higher Education Institutes, Hefei University of Technology, Hefei, Anhui, 230009, PR China; School of Food and Biological Engineering, Hefei University of Technology, Hefei, Anhui, 230009, PR China.
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80
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Abstract
Extracorporeal life support (ECLS) is a widely used lifesaving technology. Whether ECLS results in immune dysregulation is unclear. This study's aim was to examine whether ECLS affected innate immune response. All patients placed on ECLS were eligible. Blood was obtained before, during, and after ECLS. Function of the innate immune system was measured by ex vivo lipopolysaccharide (LPS)-induced tumor necrosis factor-α (TNF-α) and plasma cytokine levels (interleukin [IL]-6, IL-8, IL-10, and TNF-α). Immunoparalysis was defined as ex vivo TNF-α levels less than 200 pg/ml. Nineteen patients were enrolled with twelve <18 years old. Median ECLS duration was 10 days (range: 3-108); nine patients died. After stratifying the cohort by the presence of immunoparalysis before ECLS, those immunoparalyzed showed increased response to LPS on days 1 and 3 (p = 0.016). Those without pre-ECLS immunoparalysis showed a transient decrease in response on day 3 (p = 0.008). Plasma IL-10 levels were elevated in those with pre-ECLS immunoparalysis and dropped significantly by day 1 (p = 0.031). The number treated with steroids was similar in the two groups. In conclusion, patients with immunoparalysis before ECLS showed a gradual increase in immune function during ECLS, whereas those without immunoparalysis had a transient decrease in responsiveness on day 3.
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81
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Dell'Amore A, Campisi A, Congiu S, Mazzarra S, Pastore S, Dolci G, Baiocchi M, Frascaroli G. Extracorporeal life support during and after bilateral sequential lung transplantation in patients with pulmonary artery hypertension. Artif Organs 2020; 44:628-637. [PMID: 31885090 DOI: 10.1111/aor.13628] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Revised: 11/12/2019] [Accepted: 12/27/2019] [Indexed: 12/12/2022]
Abstract
The use of extracorporeal membrane oxygenator instead of standard cardiopulmonary bypass during lung transplantation is debatable. Moreover, recently, the concept of prolonged postoperative extracorporeal membrane oxygenator (ECMO) support has been introduced in many transplant centers to prevent primary graft dysfunction (PGD) and improve early and long-term results. The objective of this study was to review the results of our extracorporeal life support strategy during and after bilateral sequential lung transplantation (BSLT) for pulmonary artery hypertension. We review retrospectively our experience in BSLT for pulmonary artery hypertension between January 2010 and August 2018. A total of 38 patients were identified. Nine patients were transplanted using cardiopulmonary bypass (CPB), in eight cases CPB was followed by a prolonged ECMO (pECMO) support, 14 patients were transplanted on central ECMO support, and seven patients were transplanted with central ECMO support followed by a pECMO assistance. The effects of different support strategies were evaluated, in particular in-hospital morbidity, mortality, incidence of PGD, and long-term follow-up. The use of CPB was associated with poor postoperative results and worse long-term survival compared with ECMO-supported patients. Predictive preoperative factors for the need of intraoperative CPB instead of ECMO were identified. The pECMO strategy had a favorable effect to mitigate postoperative morbidity and mortality, not only in intraoperative ECMO-supported patients, but even in CPB-supported cases. In our experience, ECMO may be considered as the first choice circulatory support for lung transplantation. Sometimes, in very complex cases, CBP is still necessary. The pECMO strategy is very effective to reduce incidence of PGD even in CPB-supported patients.
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Affiliation(s)
- Andrea Dell'Amore
- Department of Cardio-Thoracic Surgery, S.Orsola Malpighi University Hospital, Bologna, Italy
| | - Alessio Campisi
- Department of Cardio-Thoracic Surgery, S.Orsola Malpighi University Hospital, Bologna, Italy
| | - Stefano Congiu
- Department of Cardio-Thoracic Surgery, S.Orsola Malpighi University Hospital, Bologna, Italy
| | - Sara Mazzarra
- Department of Cardio-Thoracic Surgery, S.Orsola Malpighi University Hospital, Bologna, Italy
| | - Saverio Pastore
- Cardio-Thoracic Anesthesiology Unit, S.Orsola Malpighi University Hospital, Bologna, Italy
| | - Giampiero Dolci
- Department of Cardio-Thoracic Surgery, S.Orsola Malpighi University Hospital, Bologna, Italy
| | - Massimo Baiocchi
- Cardio-Thoracic Anesthesiology Unit, S.Orsola Malpighi University Hospital, Bologna, Italy
| | - Guido Frascaroli
- Cardio-Thoracic Anesthesiology Unit, S.Orsola Malpighi University Hospital, Bologna, Italy
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82
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Busse LW, Barker N, Petersen C. Vasoplegic syndrome following cardiothoracic surgery-review of pathophysiology and update of treatment options. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:36. [PMID: 32019600 PMCID: PMC7001322 DOI: 10.1186/s13054-020-2743-8] [Citation(s) in RCA: 85] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 01/16/2020] [Indexed: 12/18/2022]
Abstract
Vasoplegic syndrome is a common occurrence following cardiothoracic surgery and is characterized as a high-output shock state with poor systemic vascular resistance. The pathophysiology is complex and includes dysregulation of vasodilatory and vasoconstrictive properties of smooth vascular muscle cells. Specific bypass machine and patient factors play key roles in occurrence. Research into treatment of this syndrome is limited and extrapolated primarily from that pertaining to septic shock, but is evolving with the expanded use of catecholamine-sparing agents. Recent reports demonstrate potential benefit in novel treatment options, but large clinical trials are needed to confirm.
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Affiliation(s)
- Laurence W Busse
- Department of Medicine, Emory University, Emory Critical Care Center, Atlanta, GA, USA. .,Emory Johns Creek Hospital, 6325 Hospital Parkway, Johns Creek, GA, 30097, USA.
| | - Nicholas Barker
- Department of Pharmacy, Emory St. Joseph's Hospital, Atlanta, GA, USA
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Hill KD, Baldwin HS, Bichel DP, Butts RJ, Chamberlain RC, Ellis AM, Graham EM, Hickerson J, Hornik CP, Jacobs JP, Jacobs ML, Jaquiss RDB, Kannankeril PJ, O'Brien SM, Torok R, Turek JW, Li JS, Van Bergen AH, Wald E, Resheidat A, Vener DF, Jaggers J, Kumar SR, St. Louis J, Hammel J, Overman D, Blasiole B, Scott JP, Benscoter AL, Karamlou T, Ravekes WJ, Ofori-Amanfo G, Buckley JR, Zyblewski SC, McConnell P, Anderson BR, Santana-Acosta D, Eghtesady P, Bleiweis M, Swartz M, Butts RJ, Husain SA, Lambert L, Amula V, Eckhauser R, Griffiths E, Williams R, Witte M, Minich L. Rationale and design of the STeroids to REduce Systemic inflammation after infant heart Surgery (STRESS) trial. Am Heart J 2020; 220:192-202. [PMID: 31855716 PMCID: PMC7008076 DOI: 10.1016/j.ahj.2019.11.016] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2019] [Accepted: 11/27/2019] [Indexed: 11/25/2022]
Abstract
For decades, physicians have administered corticosteroids in the perioperative period to infants undergoing heart surgery with cardiopulmonary bypass (CPB) to reduce the postoperative systemic inflammatory response to CPB. Some question this practice because steroid efficacy has not been conclusively demonstrated and because some studies indicate that steroids could have harmful effects. STRESS is a randomized, placebo-controlled, double-blind, multicenter trial designed to evaluate safety and efficacy of perioperative steroids in infants (age < 1 year) undergoing heart surgery with CPB. Participants (planned enrollment = 1,200) are randomized 1:1 to methylprednisolone (30 mg/kg) administered into the CPB pump prime versus placebo. The trial is nested within the existing infrastructure of the Society of Thoracic Surgeons Congenital Heart Surgery Database. The primary outcome is a global rank score of mortality, major morbidities, and hospital length of stay with components ranked commensurate with their clinical severity. Secondary outcomes include several measures of major postoperative morbidity, postoperative hospital length of stay, and steroid-related safety outcomes including prevalence of hyperglycemia and postoperative infectious complications. STRESS will be one of the largest trials ever conducted in children with heart disease and will answer a decades-old question related to safety and efficacy of perioperative steroids in infants undergoing heart surgery with CPB. The pragmatic "trial within a registry" design may provide a mechanism for conducting low-cost, high-efficiency trials in a heretofore-understudied patient population.
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84
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Ng KT, Van Paassen J, Langan C, Sarode DP, Arbous MS, Alston RP, Dekkers OM. The efficacy and safety of prophylactic corticosteroids for the prevention of adverse outcomes in patients undergoing heart surgery using cardiopulmonary bypass: a systematic review and meta-analysis of randomized controlled trials. Eur J Cardiothorac Surg 2020; 57:620-627. [DOI: 10.1093/ejcts/ezz325] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Revised: 10/12/2019] [Accepted: 11/01/2019] [Indexed: 12/11/2022] Open
Abstract
Abstract
Corticosteroids are often administered prophylactically to attenuate the inflammatory response associated with cardiac surgery using cardiopulmonary bypass (CPB). However, the efficacy and safety profile of corticosteroids remain uncertain. The primary aim of this systematic review and meta-analysis was to investigate the effect of corticosteroids on mortality in adult cardiac surgery using CPB. Secondary aims were to examine the effect of corticosteroids on myocardial adverse events, pulmonary adverse events, atrial fibrillation, surgical site infection, gastrointestinal bleeding and duration of stay in the intensive care unit and hospital. Randomized controlled trials (RCTs) were systematically searched in electronic databases (MEDLINE, EMBASE, CINAHL, CENTRAL and Web of Science) from their inception until March 2019. Observational studies, case reports, case series and literature reviews were excluded. Sixty-two studies (n = 16 457 patients) were included in this meta-analysis. There was no significant difference in mortality between the corticosteroid and placebo groups [odds ratio (OR) 0.96, 95% confidence interval (CI) 0.81–1.14; P = 0.65, participants = 14 693, studies = 24, evidence of certainty: moderate]. Compared to those receiving a placebo, patients who were given corticosteroids had a significantly higher incidence of myocardial adverse events (OR 1.17, 95% CI 1.03–1.33; P = 0.01, participants = 14 512, studies = 23) and a lower incidence of pulmonary adverse events (OR 0.86, 95% CI 0.75–0.98; P = 0.02, participants = 13 426, studies = 17). The incidences of atrial fibrillation (OR 0.87, 95% CI 0.81–0.94; P < 0.001, participants = 14 148, studies = 24) and surgical site infection (OR 0.81, 95% CI 0.73–0.90; P < 0.001, participants = 13 946; studies = 22) were all lower in patients who were given corticosteroids. In the present meta-analysis of 62 RCTs (16 457 patients), including the 2 major RCTs (SIRS and DECS trials: 12 001 patients), we found that prophylactic corticosteroids in cardiac surgery did not reduce mortality. The clinical significance of an increase in myocardial adverse events remains unclear as the definition of a relevant myocardial end point following cardiac surgery varied greatly between RCTs.
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Affiliation(s)
- Ka Ting Ng
- Department of Anaesthesiology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Judith Van Paassen
- Department of Intensive Care, Leiden University Medical Center, Leiden, Netherlands
| | - Clare Langan
- Department of General Surgery, NHS Greater Glasgow & Clyde, Scotland, UK
| | - Deep Pramod Sarode
- Department of General Surgery, NHS Greater Glasgow & Clyde, Scotland, UK
| | - M Sesmu Arbous
- Department of Intensive Care, Leiden University Medical Center, Leiden, Netherlands
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, Netherlands
| | - R Peter Alston
- Department of Anaesthesia, Critical Care and Pain Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Olaf M Dekkers
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, Netherlands
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Liu Q, Välimäki S, Shaukat A, Shen B, Linko V, Kostiainen MA. Serum Albumin-Peptide Conjugates for Simultaneous Heparin Binding and Detection. ACS OMEGA 2019; 4:21891-21899. [PMID: 31891067 PMCID: PMC6933801 DOI: 10.1021/acsomega.9b02883] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Accepted: 11/26/2019] [Indexed: 05/14/2023]
Abstract
Heparin is a polysaccharide-based anticoagulant agent, which is widely used in surgery and blood transfusion. However, overdosage of heparin may cause severe side effects such as bleeding and low blood platelet count. Currently, there is only one clinically licensed antidote for heparin: protamine sulfate, which is known to provoke adverse effects. In this work, we present a stable and biocompatible alternative for protamine sulfate that is based on serum albumin, which is conjugated with a variable number of heparin-binding peptides. The heparin-binding efficiency of the conjugates was evaluated with methylene blue displacement assay, dynamic light scattering, and anti-Xa assay. We found that multivalency of the peptides played a key role in the observed heparin-binding affinity and complex formation. The conjugates had low cytotoxicity and low hemolytic activity, indicating excellent biocompatibility. Furthermore, a sensitive DNA competition assay for heparin detection was developed. The detection limit of heparin was 0.1 IU/mL, which is well below its therapeutic range (0.2-0.4 IU/mL). Such biomolecule-based systems are urgently needed for next-generation biocompatible materials capable of simultaneous heparin binding and sensing.
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Affiliation(s)
- Qing Liu
- Biohybrid
Materials, Department of Bioproducts and Biosystems and HYBER Center of Excellence, Department
of Applied Physics, Aalto University, 00076 Aalto, Finland
| | - Salla Välimäki
- Biohybrid
Materials, Department of Bioproducts and Biosystems and HYBER Center of Excellence, Department
of Applied Physics, Aalto University, 00076 Aalto, Finland
| | - Ahmed Shaukat
- Biohybrid
Materials, Department of Bioproducts and Biosystems and HYBER Center of Excellence, Department
of Applied Physics, Aalto University, 00076 Aalto, Finland
| | - Boxuan Shen
- Biohybrid
Materials, Department of Bioproducts and Biosystems and HYBER Center of Excellence, Department
of Applied Physics, Aalto University, 00076 Aalto, Finland
| | - Veikko Linko
- Biohybrid
Materials, Department of Bioproducts and Biosystems and HYBER Center of Excellence, Department
of Applied Physics, Aalto University, 00076 Aalto, Finland
| | - Mauri A. Kostiainen
- Biohybrid
Materials, Department of Bioproducts and Biosystems and HYBER Center of Excellence, Department
of Applied Physics, Aalto University, 00076 Aalto, Finland
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86
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Li J, Yang L, Wang G, Wang Y, Wang C, Shi S. Severe systemic inflammatory response syndrome in patients following Total aortic arch replacement with deep hypothermic circulatory arrest. J Cardiothorac Surg 2019; 14:217. [PMID: 31842939 PMCID: PMC6916067 DOI: 10.1186/s13019-019-1027-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Accepted: 11/18/2019] [Indexed: 11/25/2022] Open
Abstract
Background This cohort study aims to retrospectively investigate the incidence of severe systemic inflammatory response syndrome (sSIRS) in patients following total aortic arch replacement (TAR) under deep hypothermic circulatory arrest (DHCA) with selective cerebral perfusion and its effect on clinical outcomes. Methods All patients who underwent TAR with DHCA were consecutively enrolled from January 2013 until December 2015 at our institute. sSIRS was diagnosed between 12 and 48 h postoperatively if patients met all four criteria of the SIRS definition. Results Of the 522 patients undergoing TAR with DHCA, 31.4% developed sSIRS. Patients aged under 60 yr were characterized by a higher prevalence of sSIRS (OR = 2.93; 95% CI 2.01–4.28; P <0.001). Higher baseline serum creatinine (OR = 1.61; 95% CI 1.18–2.20; P = 0.003), concomitant coronary disease (OR = 2.00; 95% CI 1.15–3.48; P = 0.015) and extended cardiopulmonary time (OR = 1.63; 95% CI 1.23–2.18; P = 0.001) independently contributed to a greater likelihood of postoperative sSIRS onset, while the preferred administration of ulinastatin (OR = 0.69; 95% CI 0.51–0.93; P = 0.015) and dexmedetomidine (OR = 0.36; 95% CI 0.23–0.56; P < 0.001) attenuated it. Patients with sSIRS had a greater risk of developing postoperative major adverse complications compared with the no sSIRS group [56.7%(93/164) vs 26.8% (96/358), P < 0.001]. sSIRS was found to be a significant risk factor for major adverse complications (OR, 4.52; 95% CI, 3.40–6.01; P < 0.001). A significant difference was revealed in in-hospital death following TAR between the sSIRS group and the no-sSIRS group [4.88% (8/164) vs 1.12% (4/358), P = 0.019]. The Kaplan-Meier curve indicated that the time to discharge from the intensive care unit was significantly prolonged in the sSIRS group compared with patients without it (log-rank p < 0.001). Conclusions sSIRS occurs commonly in patients following TAR with DHCA. There is an inverse association between age and sSIRS onset, whereby age over 60 yr can lower the risk of it. sSIRS development can increase the likelihood of major postoperative major adverse events.
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Affiliation(s)
- Jun Li
- Department of Anesthesiology, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, National Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Belishi road 167, Xicheng District, Beijing, 100037, China
| | - Lijing Yang
- Department of Anesthesiology, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, National Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Belishi road 167, Xicheng District, Beijing, 100037, China
| | - Guyan Wang
- Department of Anesthesiology, Beijing Tongren Hospital, Capital Medical University, Beijing, 100730, China
| | - Yuefu Wang
- Department of Anesthesiology, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, National Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Belishi road 167, Xicheng District, Beijing, 100037, China.
| | - Chunrong Wang
- Department of Anesthesiology, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, National Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Belishi road 167, Xicheng District, Beijing, 100037, China
| | - Sheng Shi
- Department of Anesthesiology, Fuwai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, National Center for Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Belishi road 167, Xicheng District, Beijing, 100037, China
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87
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Scolletta S, Franchi F, Damiani E, Cennamo A, Domizi R, Meola A, Scorcella C, Vanoli D, Münch C, Adrario E, Marchetti L, Taccone FS, Donati A. Tissue oxygen saturation changes and postoperative complications in cardiac surgery: a prospective observational study. BMC Anesthesiol 2019; 19:229. [PMID: 31842777 PMCID: PMC6916088 DOI: 10.1186/s12871-019-0905-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Accepted: 12/06/2019] [Indexed: 11/27/2022] Open
Abstract
Background Cardiac surgery with extracorporeal circulation (ECC) can induce microvascular dysfunction and tissue hypoperfusion. We hypothesized that the alterations in near-infrared spectroscopy (NIRS)-derived parameters would be associated with post-operative complications in cardiac surgery patients. Methods Prospective observational study performed at two University Hospitals. Ninety patients undergoing cardiac surgery with ECC were enrolled. The NIRS sensor was applied on the thenar eminence. A vascular occlusion test (VOT, 3-min ischemia) was performed at baseline (t0), at Intensive Care Unit (ICU) admission (t1), 3 (t2) and 6 (t3) hours later. Baseline tissue oxygen saturation (StO2), oxygen extraction rate and microvascular reactivity indices were calculated. Results In the first hours after cardiac surgery, StO2 tended to increase (86% [80–89] at T3 versus 82% [79–86] at T0, p = ns), while both tissue oxygen extraction and microvascular reactivity tended to decrease, as indicated by increasing occlusion slope (− 8.1%/min [− 11.2 to − 7] at T3 versus − 11.2%/min [− 13.9 to − 7.9] at T0, p = ns) and decreasing recovery slope (1.9%/sec [1.1–2.9] at T3 versus 3.1%/sec [2.3–3.9] at T0, p = ns). No substantial differences were found in NIRS-derived variables and their changes over time between patients with complications and those without complications. Conclusions Peripheral tissue oxygen extraction and microvascular reactivity were reduced during the first hours after cardiac surgery. NIRS-derived parameters were not able to predict complications in this population of cardiac surgery patients.
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Affiliation(s)
- Sabino Scolletta
- Department of Medicine, Surgery and Neuroscience, Anesthesia and Intensive Care Unit, University of Siena, Via Bracci 1, 53100, Siena, Italy.
| | - Federico Franchi
- Department of Medicine, Surgery and Neuroscience, Anesthesia and Intensive Care Unit, University of Siena, Via Bracci 1, 53100, Siena, Italy
| | - Elisa Damiani
- Department of Biomedical Sciences and Public Health, Clinic of Anesthesiology and Intensive Care, AOU Ospedali Riuniti di Ancona, Università Politecnica delle Marche, via Conca 71, 60126 Torrette di Ancona, Ancona, Italy
| | - Armando Cennamo
- Department of Medicine, Surgery and Neuroscience, Anesthesia and Intensive Care Unit, University of Siena, Via Bracci 1, 53100, Siena, Italy
| | - Roberta Domizi
- Department of Biomedical Sciences and Public Health, Clinic of Anesthesiology and Intensive Care, AOU Ospedali Riuniti di Ancona, Università Politecnica delle Marche, via Conca 71, 60126 Torrette di Ancona, Ancona, Italy
| | - Antonio Meola
- Department of Medicine, Surgery and Neuroscience, Anesthesia and Intensive Care Unit, University of Siena, Via Bracci 1, 53100, Siena, Italy
| | - Claudia Scorcella
- Department of Biomedical Sciences and Public Health, Clinic of Anesthesiology and Intensive Care, AOU Ospedali Riuniti di Ancona, Università Politecnica delle Marche, via Conca 71, 60126 Torrette di Ancona, Ancona, Italy
| | - Davide Vanoli
- Department of Medicine, Surgery and Neuroscience, Anesthesia and Intensive Care Unit, University of Siena, Via Bracci 1, 53100, Siena, Italy
| | - Christopher Münch
- Cardiac Anesthesia and Intensive Care Unit, AOU Ospedali Riuniti di Ancona, via Tronto 10/a, 60126 Torrette di Ancona, Ancona, Italy
| | - Erica Adrario
- Department of Biomedical Sciences and Public Health, Clinic of Anesthesiology and Intensive Care, AOU Ospedali Riuniti di Ancona, Università Politecnica delle Marche, via Conca 71, 60126 Torrette di Ancona, Ancona, Italy
| | - Luca Marchetti
- Department of Medicine, Surgery and Neuroscience, Anesthesia and Intensive Care Unit, University of Siena, Via Bracci 1, 53100, Siena, Italy
| | - Fabio Silvio Taccone
- Department of Intensive Care, Université Libre de Bruxelles, Hospital Erasme, Route de Lennik, 808 -, 1070, Brussels, Belgium
| | - Abele Donati
- Department of Biomedical Sciences and Public Health, Clinic of Anesthesiology and Intensive Care, AOU Ospedali Riuniti di Ancona, Università Politecnica delle Marche, via Conca 71, 60126 Torrette di Ancona, Ancona, Italy.
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88
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Huang D, Chen M, Wang Z, Hou L, Yu W. Electroacupuncture Pretreatment Attenuates Inflammatory Lung Injury After Cardiopulmonary Bypass by Suppressing NLRP3 Inflammasome Activation in Rats. Inflammation 2019; 42:895-903. [PMID: 30680695 DOI: 10.1007/s10753-018-0944-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Cardiopulmonary bypass (CPB) can induce inflammatory lung injury, which is a common complication during cardiac surgery. Nod-like receptor family, pyrin domain-containing 3 (NLRP3) inflammasome-induced inflammation plays a crucial role in lung injury after CPB. Previous studies have shown that electroacupuncture (EA) has potential anti-inflammatory activity. However, the role of EA in CPB is poorly understood. The aim of this study was to determine whether EA was associated with CPB-induced inflammatory lung injury. In the present study, rats were treated with EA for 5 days before CPB. Two hours after CPB, the lung tissue, serum, and bronchoalveolar lavage fluid (BALF) were prepared for assessment. Our results showed that the expression of NLRP3 in the lung tissue increased significantly after CPB. The EA pretreatment suppressed NLRP3 inflammasome activation, reduced lung edema, and inhibited IL-1β release into the serum and BALF after CPB. Our findings suggest that EA pretreatment attenuates inflammatory lung injury after CPB by suppressing NLRP3 inflammasome activation.
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Affiliation(s)
- Dongxiao Huang
- The Third Affiliated Hospital of Soochow University, No.185 Juqian Street, Changzhou, Jiangsu, China.,Department of Anesthesiology, Wuxi People's Hospital, No.299 Qingyang Road, Wuxi, Jiangsu, China
| | - Mo Chen
- The Third Affiliated Hospital of Soochow University, No.185 Juqian Street, Changzhou, Jiangsu, China
| | - Zhankui Wang
- Department of Orthopedics, The First Clinical Medical College, Shaanxi University of Chinese Medicine, Xianyang, Shaanxi, China
| | - Lei Hou
- Department of Anesthesiology, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, No.160 Pudian Road, Shanghai, China
| | - Weifeng Yu
- Department of Anesthesiology, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, No.160 Pudian Road, Shanghai, China. .,Department of Anesthesiology, Shanghai Eastern Hepatobiliary Surgery Hospital, Second Military Medical University, No.225 Changhai Road, Shanghai, 200438, People's Republic of China.
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89
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Nadeem R, Agarwal S, Jawed S, Yasser A, Altahmody K. Impact of Cardiopulmonary Bypass Time on Postoperative Duration of Mechanical Ventilation in Patients Undergoing Cardiovascular Surgeries: A Systemic Review and Regression of Metadata. Cureus 2019; 11:e6088. [PMID: 31857920 PMCID: PMC6897343 DOI: 10.7759/cureus.6088] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
The objective of this study was to detect if cardiopulmonary bypass time duration has any impact on the duration of postoperative mechanical ventilation (MV). The study design was a systematic review and regression analysis of pooled data from previously published studies. All available data are from prospective, retrospective, cross-sectional, and observational studies. Participants included only patient/human studies. There were no interventions. PubMed and Cochrane libraries were searched by utilizing different combinations of keywords: cardiopulmonary bypass and mechanical ventilation. Inclusion criteria were: (1) English articles, (2) studies with an adult population that underwent cardiac surgeries using cardiopulmonary bypass (CPB), (3) studies where the duration of CPB is provided as well as the duration of mechanical ventilation. A regression analysis was performed on the metadata. For the hours of MV, eight studies with 13 data sets (as some studies provide data in subgroups) were included for a total number of 989 subjects. The duration of CPB ranged from 55 to 173.5 minutes for these operations. Postoperative MV hours ranged from nine to 408 hours. Stepwise multiple regression analysis found that cardiopulmonary bypass time (CPBT), age, diabetes, male gender, and ejection fraction correlated with prolonged mechanical ventilation; CPBT was the most strongly correlated variable. Cardiopulmonary bypass time appears to affect clinical outcomes adversely and is associated with prolonged MV. Avoiding CPB or limiting it to a minimum may decrease the days of MV required.
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Affiliation(s)
| | | | - Shafaq Jawed
- Surgery, Jinnah Sindh Medical University, Karachi, PAK
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90
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Maddali MM, Waje ND, Arora NR, Panchatcharam SM. Effect of low-dose dexamethasone on extra vascular lung water in patients following on-pump elective primary coronary artery bypass graft surgery. Ann Card Anaesth 2019; 22:372-378. [PMID: 31621671 PMCID: PMC6813707 DOI: 10.4103/aca.aca_122_18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Background The primary objective was to compare the effect of a low-dose dexamethasone as against a saline placebo on extravascular lung water index (EVLWI) in patients undergoing elective primary coronary artery bypass surgery. The secondary endpoints were to assess the effect of dexamethasone on other volumetric parameters (pulmonary vascular permeability index, global end diastolic volume index, and intrathoracic blood volume index), Vasoactive Inotrope Scores, hemodynamic parameters and serum osmolality in both groups. Settings and Design Prospective observational study performed at a single tertiary cardiac care center. Materials and Methods Twenty patients were randomized to receive either dexamethasone (steroid group, n = 10) or placebo (nonsteroid group, n = 10) twice before the institution of cardiopulmonary bypass (CPB). EVLWI and other volumetric parameters were obtained with the help of VolumeView™ Combo Kit connected to EV 1000 clinical platform at predetermined intervals. Hemodynamic parameters, vasoactive-inotropic Scores, hematocrit values were recorded at the predetermined time intervals. Baseline and 1st postoperative day serum osmolality values were also obtained. Results The two groups were evenly matched in terms of demographic and CPB data. Intra- and inter-group comparison of the baseline EVLWI including other volumetric and hemodynamic parameters with those recorded at subsequent intervals revealed no statistical difference and was similar. Generalized estimating equation model was obtained to compare the changes between the groups over the entire study period which showed that on an average the changes between the steroid and nonsteroid group in terms of all volumetric parameters were not statistically significant. Conclusions There were no beneficial effects of low-dose dexamethasone on EVLWI or other volumetric parameters in patients subjected to on-pump primary coronary bypass surgery. Hemodynamic parameters were also not affected. Probably, the advanced hemodynamic monitoring aided in optimal fluid management in the nonsteroidal group impacting EVLW accumulation.
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Affiliation(s)
- Madan Mohan Maddali
- Department of Cardiac Anesthesia, National Heart Center, Royal Hospital, Muscat, Oman
| | - Niranjan Dilip Waje
- Department of Cardiac Anesthesia, National Heart Center, Royal Hospital, Muscat, Oman
| | - Nishant Ram Arora
- Department of Cardiac Anesthesia, National Heart Center, Royal Hospital, Muscat, Oman
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91
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Abstract
This article provides an overview of knowledge gaps that need to be addressed in cardiac anesthesia, including mitigating the inflammatory effects of cardiopulmonary bypass, defining myocardial infarction after cardiac surgery, improving perioperative neurologic outcomes, and the optimal management of patients undergoing valve replacement. In addition, emerging approaches to research conduct are discussed, including the use of new analytical techniques like machine learning, pragmatic trials, and adaptive designs.
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Affiliation(s)
- Jessica Spence
- Departments of Anesthesia and Critical Care and Health Research Methods, Evaluation, and Impact, McMaster University, HSC 2V9 - 1280 Main Street West, Hamilton, ON L8S 4K1, Canada; Population Health Research Institute (PHRI), C3-7B David Braley Cardiac, Vascular and Stroke Research Institute (DBCVSRI), 237 Barton Street East, Hamilton, ON L8L 2X2, Canada
| | - C David Mazer
- Department of Anesthesia, Li Ka Shing Knowledge Institute of St. Michael's Hospital, 30 Bond Street, Toronto, ON M5B 1W8, Canada; Departments of Anesthesia and Physiology, University of Toronto, Toronto, ON, Canada.
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92
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Jacob KA, Leaf DE. Prevention of Cardiac Surgery-Associated Acute Kidney Injury: A Review of Current Strategies. Anesthesiol Clin 2019; 37:729-749. [PMID: 31677688 PMCID: PMC7644277 DOI: 10.1016/j.anclin.2019.08.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Acute kidney injury is a common and often severe postoperative complication after cardiac surgery, and is associated with poor short-term and long-term outcomes. Numerous randomized controlled trials have been conducted to investigate various strategies for prevention of cardiac surgery-associated acute kidney injury. Unfortunately, most trials that have been conducted to date have been negative. However, encouraging results have been demonstrated with preoperative administration of corticosteroids, leukocyte filtration, and administration of inhaled nitric oxide intraoperatively, and implementation of a Kidney Disease: Improving Global Outcomes bundle of care approach postoperatively. These findings require validation in large, multicenter trials.
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Affiliation(s)
- Kirolos A Jacob
- Department of Cardiothoracic Surgery, University Medical Center Utrecht, Mail Stop E03.511, PO Box 85500, Utrecht 3508 GA, the Netherlands.
| | - David E Leaf
- Division of Renal Medicine, Brigham and Women's Hospital, 75 Francis Street, Medial Research Building Room MR416B, Boston, MA 02115, USA
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93
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Serum Trace Elements in Coronary Artery Bypass Graft Surgery: The Relationship Between Trace Element Supplementation and Period of Mechanical Ventilation in a Randomized Double-Blind Placebo-Controlled Trial. Jundishapur J Nat Pharm Prod 2019. [DOI: 10.5812/jjnpp.68735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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94
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Li PY, Chen Y, Chen CH, Liu Y. Amphiphilic multi-charged cyclodextrins and vitamin K co-assembly as a synergistic coagulant. Chem Commun (Camb) 2019; 55:11790-11793. [PMID: 31524903 DOI: 10.1039/c9cc06545h] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Balancing and neutralizing heparin dosing after surgeries and hemodialysis treatment is of great importance in medical and clinical fields. In this study, a series of new amphiphilic multi-charged cyclodextrins (AMCD)s as anti-heparin coagulants were designed and synthesized. The AMCD assembly was capable of selective heparin binding through multivalent bonding and showed a better neutralizing effect towards both unfractionated heparin and low molecular weight heparin than protamine in plasma. Meanwhile, an AMCD and vitamin K (VK) co-assembly was prepared to realize heparin-responsive VK release and provide a novel VK deficiency treatment for hemodialysis patients. This AMCD-VK co-assembly for heparin neutralization & vitamin K supplementation synergistic coagulation represents a promising candidate as a clinical anti-heparin coagulant.
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Affiliation(s)
- Pei-Yu Li
- College of Chemistry, State Key Laboratory of Elemento-Organic Chemistry, Nankai University, Tianjin 300071, P. R. China.
| | - Yong Chen
- College of Chemistry, State Key Laboratory of Elemento-Organic Chemistry, Nankai University, Tianjin 300071, P. R. China.
| | - Chang-Hui Chen
- College of Chemistry, State Key Laboratory of Elemento-Organic Chemistry, Nankai University, Tianjin 300071, P. R. China.
| | - Yu Liu
- College of Chemistry, State Key Laboratory of Elemento-Organic Chemistry, Nankai University, Tianjin 300071, P. R. China.
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95
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Cashen K, Meert K, Dalton H. Anticoagulation in Neonatal ECMO: An Enigma Despite a Lot of Effort! Front Pediatr 2019; 7:366. [PMID: 31572699 PMCID: PMC6753198 DOI: 10.3389/fped.2019.00366] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2019] [Accepted: 08/21/2019] [Indexed: 12/30/2022] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) is a valuable modality used to support neonates, children, and adults with cardiorespiratory failure refractory to conventional therapy. It requires use of anticoagulation to prevent clotting in the extracorporeal circuit. Balancing bleeding from excessive anticoagulation with thrombotic risk remains a difficult aspect of ECMO care. Despite many advances in ECMO technology, better understanding of the coagulation cascade and new monitoring schemes to adjust anticoagulation, bleeding and thrombosis remain the most frequent complications in ECMO and are associated with morbidity and mortality. In neonates, ECMO is also complicated by the immature hemostatic system, laboratory testing norms which are not specific for neonates, lack of uniformity in management, and paucity of high-quality evidence to determine best practices. Traditional anticoagulation focuses on the use of unfractionated heparin. Direct thrombin inhibitors are also used but have not been well-studied in the neonatal ECMO population. Anticoagulation monitoring is complex and currently available assays do not take into account thrombin generation or platelet contribution to clot formation. Global assays may add valuable information to guide therapy. This review provides an overview of hemostatic alterations, anticoagulation, monitoring and management, novel anticoagulant use, and circuit modifications for neonatal ECMO. Future considerations are also presented.
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Affiliation(s)
- Katherine Cashen
- Division of Critical Care Medicine, Department of Pediatrics, Children's Hospital of Michigan, Wayne State University, Detroit, MI, United States
| | - Kathleen Meert
- Division of Critical Care Medicine, Department of Pediatrics, Children's Hospital of Michigan, Wayne State University, Detroit, MI, United States
| | - Heidi Dalton
- Division of Critical Care Medicine, Department of Pediatrics, INOVA Heart and Vascular Institute, Inova Fairfax Medical Institute, Falls Church, VA, United States
- Department of Surgery, George Washington University, Washington, DC, United States
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96
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Guarnieri M, De Gasperi A, Gianni S, Baciarello M, Bellini V, Bignami E. From the Physiology to the Bedside: Fluid Therapy in Cardiac Surgery and the ICU. CURRENT ANESTHESIOLOGY REPORTS 2019. [DOI: 10.1007/s40140-019-00341-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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97
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Cholette JM, Faraoni D, Goobie SM, Ferraris V, Hassan N. Patient Blood Management in Pediatric Cardiac Surgery: A Review. Anesth Analg 2019; 127:1002-1016. [PMID: 28991109 DOI: 10.1213/ane.0000000000002504] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Efforts to reduce blood product transfusions and adopt blood conservation strategies for infants and children undergoing cardiac surgical procedures are ongoing. Children typically receive red blood cell and coagulant blood products perioperatively for many reasons, including developmental alterations of their hemostatic system, and hemodilution and hypothermia with cardiopulmonary bypass that incites inflammation and coagulopathy and requires systemic anticoagulation. The complexity of their surgical procedures, complex cardiopulmonary interactions, and risk for inadequate oxygen delivery and postoperative bleeding further contribute to blood product utilization in this vulnerable population. Despite these challenges, safe conservative blood management practices spanning the pre-, intra-, and postoperative periods are being developed and are associated with reduced blood product transfusions. This review summarizes the available evidence regarding anemia management and blood transfusion practices in the perioperative care of these critically ill children. The evidence suggests that adoption of a comprehensive blood management approach decreases blood transfusions, but the impact on clinical outcomes is less well studied and represents an area that deserves further investigation.
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Affiliation(s)
- Jill M Cholette
- From the Department of Pediatrics, Golisano Children's Hospital, University of Rochester, Rochester, New York
| | - David Faraoni
- Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Susan M Goobie
- Department of Anesthesiology, Perioperative and Pain Medicine, Boston, Massachusetts.,Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Victor Ferraris
- Department of Surgery, University of Kentucky Chandler Medical Center & Lexington Veterans Affairs Medical Center, Lexington, Kentucky
| | - Nabil Hassan
- Division of Pediatric Critical Care, Children's Hospital of Illinois At OSF St Frances, University of Illinois at Peoria, Peoria, Illinois
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98
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Patel JJ, Venegas-Borsellino C, Willoughby R, Freed JK. High-Dose Vitamin B12 in Vasodilatory Shock: A Narrative Review. Nutr Clin Pract 2019; 34:514-520. [PMID: 31187494 DOI: 10.1002/ncp.10327] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Vasodilatory shock, as observed in postoperative states and sepsis, is hallmarked by low systemic vascular resistance and low blood pressure compensated by increased cardiac output. Gasotransmitters, such as nitric oxide and hydrogen sulfide, are implicated in the development and perpetuation of vasodilatory shock. Established therapies do not target these physiologic drivers of vasodilation. Due to their nontoxic and pleotropic effects, micronutrients are being used as rescue therapy in postoperative vasoplegia and septic shock. Here, we outline the pathophysiology of vasodilatory shock, describe the rationale for vitamin B12 (hydroxocobalamin) in vasodilatory shock, and identify literature evaluating its use in vasoplegic states.
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Affiliation(s)
- Jayshil J Patel
- Division of Pulmonary & Critical Care Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | | | - Rodney Willoughby
- Division of Pediatric Infectious Disease, Children's Hospital of Wisconsin and the Medical College of Wisconsin, Milwaukee, WI, USA
| | - Julie K Freed
- Cardiovascular Center, Medical College of Wisconsin, Milwaukee, WI, USA.,Division of Cardiac Anesthesiology, Medical College of Wisconsin, Milwaukee, WI, USA
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99
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Abstract
In this review the impact of cardiopulmonary bypass (CPB) on the microcirculation is discussed. The impact of conventional non-pulsatile perfusion is contrasted with the microcirculatory impact of pulsatile CPB which is associated with better preservation of microcirculatory function. Evidence that alterations in microcirculatory function that persist following cardiac surgery are associated with adverse clinical outcomes is reviewed. Recent studies using novel techniques employing near infrared reflectance spectroscopy (NIRS) and sublingual microscopy to explore alterations in microcirculatory function during CPB are reviewed and the implications of these observations for studies investigating minimally invasive extracorporeal circulation (MiECC) are discussed.
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Affiliation(s)
- John M Murkin
- Department of Anesthesia & Perioperative Medicine, London Health Sciences Centre, University Hospital, London, ON, Canada
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100
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Chan MXF, Buitinck S, Stooker W, Haak EAF, Wester JPJ, Bosman RJ, van der Voort PHJ. Clinical Effects of Perioperative Selective Decontamination of the Digestive Tract (SDD) in Cardiac Surgery: A Propensity Score Matched Cohort Analysis. J Cardiothorac Vasc Anesth 2019; 33:3001-3009. [PMID: 31101508 DOI: 10.1053/j.jvca.2019.04.013] [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: 02/17/2019] [Revised: 04/14/2019] [Accepted: 04/15/2019] [Indexed: 11/11/2022]
Abstract
OBJECTIVES To determine the clinical effects of perioperative endotoxin reduction in the gut lumen in patients undergoing cardiac surgery with cardiopulmonary bypass. DESIGN Retrospective cohort analysis with propensity score matching according to treatment group. SETTING Tertiary center for cardiopulmonary diseases and intensive care medicine. PARTICIPANTS Included were patients who underwent cardiac surgery with cardiopulmonary bypass between 2008 and 2017. Excluded were readmitted patients. INTERVENTIONS Endotoxin reduction in the gut lumen by ingestion of oral tobramycin 80 mg and polymyxin B 100 mg 4 times daily (TP) as part of selective digestive tract decontamination, which contains amphotericin B 500 mg as well. MEASUREMENTS AND MAIN RESULTS A total of 6,394 patients were included, of whom 2,044 patients were in the intervention group. A total of 835 patients received both pre- and postoperative TP (Pre+/Post+), and 1,165 patients received TP only postoperatively (Pre-/Post+). The control group, not treated with TP at any moment, consisted of 4,350 patients (Pre-/Post-). After matching, 652 Pre+/Post+ patients were compared with an equal number of controls (Pre-/Post-). Pre+/Post+ group did not do better for any clinical outcome. A total of 682 Pre+/Post+ patients matched with an equal number of Pre-/Post+ patients. The latter group had a 0.3 points higher mean Sequential Organ Failure Assessment score and in the regression analysis a significantly higher intensive care unit mortality but not hospital mortality. A significant reduction in length of stay and length of mechanical ventilation for the Pre+/Post+ group was shown compared with Pre-/Post+, but these differences can be explained by unbalanced differences in the severity of illness. CONCLUSION Cardiosurgical patients who receive tobramycin and polymyxin orally preoperatively to reduce the gut endotoxin level do not expose convincing and relevant beneficial effects on clinical outcomes in this retrospective propensity score matching cohort study.
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Affiliation(s)
| | - Sophie Buitinck
- Department of Intensive Care, OLVG, Amsterdam, the Netherlands
| | - Wim Stooker
- Department of Cardio-thoracic Surgery, OLVG, Amsterdam, the Netherlands
| | - Eric A F Haak
- Department of Clinical Pharmacy, OLVG, Amsterdam, the Netherlands
| | - Jos P J Wester
- Department of Intensive Care, OLVG, Amsterdam, the Netherlands
| | - Rob J Bosman
- Department of Intensive Care, OLVG, Amsterdam, the Netherlands
| | - Peter H J van der Voort
- Department of Intensive Care, OLVG, Amsterdam, the Netherlands; TIAS School for Business and Society, Tilburg University, Tilburg, the Netherlands.
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