Serum vitamin D status following pediatric cardiac surgery and association with clinical outcome

Effect of Vitamin D Supplementation on Postoperative Outcomes in Cardiac Surgery Patients: A Systematic Review

Background Vitamin D deficiency is a very common occurrence in cardiac patients. It has been proved that cardiac surgery and cardiopulmonary bypass accelerate the deficiency further. The postoperative outcomes of patients deteriorate in the presence of vitamin D deficiency. Perioperative supplementation of vitamin D is the only solution to the problem. Hence, the present systematic review was conducted to derive the efficacy and safety of vitamin D supplementation on postoperative outcomes in cardiac surgery patients.

Method Publications over duration of last 10 years was searched from different database and web sites. The data from full-text research articles were analyzed for the effect on different postoperative outcomes and side effects.

Result Eight randomized control trials were retrieved on the effect of perioperative vitamin D supplementation in cardiac surgery patients and their postoperative outcomes. Six articles (75%) were found to be in favor of improvement in postoperative outcome. Two articles (25%) did not find any difference of outcome between the control and treatment group. All the studies observed the restoration of vitamin D to normal and no adverse effects from supplementation.

Conclusion Perioperative vitamin D supplementation improves the postoperative outcomes after cardiac surgery. It is effective and safe to supplement vitamin D in cardiac surgery patients.

Accelerated Cardiac Aging in Patients With Congenital Heart Disease

An increasing number of patients with congenital heart disease (CHD) survive into adulthood but develop long-term complications including heart failure (HF). Cellular senescence, classically defined as stable cell cycle arrest, is implicated in biological processes such as embryogenesis, wound healing, and aging. Senescent cells have a complex senescence-associated secretory phenotype (SASP), involving a range of pro-inflammatory factors with important paracrine and autocrine effects on cell and tissue biology. While senescence has been mainly considered as a cause of diseases in the adulthood, it may be also implicated in some of the poor outcomes seen in patients with complex CHD. We propose that patients with CHD suffer from multiple repeated stress from an early stage of the life, which wear out homeostatic mechanisms and cause premature cardiac aging, with this term referring to the time-related irreversible deterioration of the organ physiological functions and integrity. In this review article, we gathered evidence from the literature indicating that growing up with CHD leads to abnormal inflammatory response, loss of proteostasis, and precocious age in cardiac cells. Novel research on this topic may inspire new therapies preventing HF in adult CHD patients.

Vitamin D and morbidity in children with multisystem inflammatory syndrome related to Covid-19

Background

Multisystem inflammatory syndrome (MIS-C) is a clinical presentation reported in children related to Coronavirus-19 infection who present with a toxic shock like syndrome. Vitamin D deficiency has been postulated to play a role with severity of coronavirus infection in adult patients and other viral respiratory infections.

Objective

This study aims to investigate if severe vitamin D deficiency was associated with increased disease severity and cardiac involvement in MIS-C.

Methods

This is a retrospective and single center study. We included hospitalized patients less than 18 years of age with diagnosis of MIS-C between March and July 2020. Severe vitamin D deficiency was defined as 25-OH vitamin D level < 10 ng/ml within 48 h of admission. The composite outcome severe disease included patients requiring inotropes, mechanical ventilation, and extracorporeal membrane oxygenation.

Results

Of the 31 patients with MIS-C, 45% were male and 58% were African American. The median age was 8 (1–13) years. Ten patients had severe vitamin D deficiency with a mean level of 7.2 ng/ml. Ninety percent of patients with severe vitamin D deficiency had severe disease (P < 0.001). Patients with severe vitamin D deficiency had an increased risk of cardiac involvement (P < 0.001).

Conclusions

We describe a potential association between severe vitamin D deficiency and severe disease in children presenting with MIS-C. Severe vitamin D deficiency predisposes patients for cardiovascular involvement and may play a critical role in the host immune response to COVID-19 infection. Future prospective studies at the basic science and clinical level should be pursued to better delineate this association.

Association Between the Circulating Level of 25-Hydroxyvitamin D and Clinical Results After Cardiac Surgery: A Meta-Analysis and Systematic Review

Background: Vitamin D (VitD) is an important pleiotropic hormone for organ systems. Studies have focused on the level of VitD, especially that of 25-hydroxyvitamin D (25-(OH)-VitD), in patients after cardiac surgery and the relationship between VitD deficiency and adverse outcomes, but the results have been inconsistent. We carried out a meta-analysis to evaluate differences in the 25-(OH)-VitD level before and after cardiac surgery, and evaluated the predictive value of 25-(OH)-VitD level in the clinical outcomes of patients undergoing cardiac surgery.

Methods: Studies related to VitD level and cardiac surgery were searched from PubMed, EMBASE, Web of Science, and Cochrane Central Register of Controlled Trials databases from inception to October 2020. We applied the Newcastle–Ottawa Scale to assess the risk of a bias in individual studies. We examined the heterogeneity and publication bias and performed subgroup analyses and sensitivity analyses.

Results: Fifteen studies were included in our analysis. The 25-(OH)-VitD level was significantly lower immediately after surgery [stand mean difference (SMD), 0.69; 95%CI (0.1, 1.28), P = 0.023] and 24-h after surgery [0.84; (0.47, 1.21), 0.000] compared with that before surgery. A higher prevalence of 25-(OH)-VitD deficiency was recorded 24 h after surgery [RR, 0.59; 95%CI (0.47, 0.73), P = 0.00]. Pooled results demonstrated a significant relationship between the preoperative 25-(OH)-VitD level and vasoactive-inotropic score (VIS) [SMD, −3.71; 95%CI (−6.32, −1.10); P = 0.005], and patients with 25-(OH)-VitD deficiency revealed a comparatively poor prognosis and severe condition after cardiac surgery [−0.80; (−1.41, −0.19), 0.01]. However, 25-(OH)-VitD deficiency was not associated with the duration of stay in the intensive care unit.

Conclusions: Cardiac surgery would leads to deficiency of 25-(OH)-VitD. And the preoperative and postoperative levels of 25-(OH)-VitD are associated with adverse events, which is eligible to work as an indicator to demonstrate clinical outcomes.

The Relationship Between Vitamin D Status and Cardiovascular Diseases

With cardiovascular conditions being a leading cause of mortality and morbidity globally, several studies have identified that there is an important correlation between the level of Vitamin D and cardiovascular diseases, including an increased risk of hypertension, heart failure, and coronary artery diseases. Current published studies are in the form of both in vivo and in vitro studies and they primarily showed the evidence of how Vitamin D can downregulate Renin-Angiotensin-Aldosterone system activity and therefore providing a cardioprotective role. Nevertheless, most of these studies are observational, and there yet to be large-scale randomized controlled trials which would increase the evidence of the findings.This review aims to capture the current evidence of Vitamin D as a metabolite which is critical in reducing cardiovascular conditions and the possible physiological pathways that it works via.

Preoperative Vitamin D Deficiency Is Associated With Higher Vasoactive-Inotropic Scores Following Pediatric Cardiac Surgery in Chinese Children

The relationship between vitamin D and cardiovascular health in children remains unclear. Vitamin D deficiency (VDD) is supposed to be a potential risk factor associated with poorer outcomes after congenital heart disease (CHD) surgery. The maximum vasoactive-inotropic use after cardiac surgery is considered to be a good predictor of adverse outcomes. We aimed to assess the correlation between preoperative VDD and the maximum vasoactive-inotropic score (VIS_max) at 24 h postoperatively. Nine hundred children with CHD were enrolled in this study, and preoperative total serum 25-hydroxyvitamin D [25(OH)D] concentrations were measured by liquid chromatography-tandem mass spectrometry. Related demographic and clinical characteristics were collected. A total of 490 boys (54.4%) and 410 girls (45.6%) with a mean age of 1 year (range: 6 months-3 years) were enrolled. The median 25(OH)D level was 24.0 ng/mL, with 32.6% of patients having VDD [25(OH)D < 20 ng/mL]. The univariate analysis indicated that VDD [odds ratio (OR): 2.27; 95% confidence interval (CI): 1.48-3.50] is associated with a risk of increased VISmax at 24 h postoperation. Multivariate analysis revealed that VDD (OR: 1.85; 95% CI: 1.09-3.02), a Risk-adjusted Congenital Heart Surgery score of at least three points (OR: 1.55; 95% CI: 1.09-2.19), and cardiopulmonary bypass time (OR: 1.02; 95% CI: 1.01-1.02) were independently associated with an increased VISmax within 24 h after cardiac surgery. VDD in pediatric patients before cardiac surgery is associated with the need for increased postoperative inotropic support at 24 h postoperation.

Prevention of post-cardiac surgery vitamin D deficiency in children with congenital heart disease: a pilot feasibility dose evaluation randomized controlled trial

Background

The vast majority of children undergoing cardiac surgery have low vitamin D levels post-operative, which may contribute to greater illness severity and worse clinical outcomes. Prior to the initiation of a large phase III clinical trial focused on clinical outcomes, studies are required to evaluate the feasibility of the study protocol, including whether the proposed dosing regimen can safely prevent post-operative vitamin D deficiency in this high-risk population.

Methods

We conducted a two-arm, double-blind dose evaluation randomized controlled trial in children requiring cardiopulmonary bypass for congenital heart disease. Pre-operatively, participants were randomized to receive cholecalciferol representing usual care (< 1 year = 400 IU/day, > 1 year = 600 IU/day) or a higher dose approximating the Institute of Medicine tolerable upper intake level (< 1 year = 1600 IU/day, > 1 year = 2400 IU/day). The feasibility outcomes were post-operative vitamin D status (primary), vitamin D-related adverse events, accrual rate, study withdrawal rate, blinding, and protocol non-adherence.

Results

Forty-six children were randomized, and five withdrew prior to surgery, leaving 41 children (21 high dose, 20 usual care) in the final analysis. The high dose group had higher 25-hydroxyvitamin D concentrations both intraoperatively (mean difference + 25.9 nmol/L; 95% CI 8.3–43.5) and post-operatively (mean difference + 17.2 nmol/L; 95% CI 5.5–29.0). Fewer participants receiving high-dose supplementation had post-operative serum 25-hydroxyvitamin D concentrations under 50 nmol/L, compared with usual care (RR 0.31, 95% CI 0.11–0.87). Post-operative vitamin D status was associated with the treatment arm and the number of doses received. There were no cases of hypercalcemia, and no significant adverse events related to vitamin D. While only 75% of the target sample size was recruited (limited funding), the consent rate (83%), accrual rate (1.5 per site month), number of withdrawals (11%), and ability to maintain blinding support feasibility of a larger trial.

Conclusions

Pre-operative daily high-dose supplementation improved vitamin D status pre-operatively and at time of pediatric ICU admission. The protocol for a more definitive trial should limit enrollment of children with at least 30 days between randomization and surgery to allow adequate duration of supplementation or consider a loading dose.

Trial registration

ClinicalTrials.gov, NCT01838447. Registered on April 24, 2013