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Méndez-Carmona N, Wyss RK, Arnold M, Segiser A, Kalbermatter N, Joachimbauer A, Carrel TP, Longnus SL. Effects of graft preservation conditions on coronary endothelium and cardiac functional recovery in a rat model of donation after circulatory death. J Heart Lung Transplant 2021; 40:1396-1407. [PMID: 34509349 DOI: 10.1016/j.healun.2021.07.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 07/15/2021] [Accepted: 07/26/2021] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Use of cardiac grafts obtained with donation after circulatory death (DCD) could significantly improve donor heart availability. As DCD hearts undergo potentially deleterious warm ischemia and reperfusion, clinical protocols require optimization to ensure graft quality. Thus, we investigated effects of alternative preservation conditions on endothelial and/or vascular and contractile function in comparison with the current clinical standard. METHODS Using a rat DCD model, we compared currently used graft preservation conditions, St. Thomas n°2 (St. T) at 4°C, with potentially more suitable conditions for DCD hearts, adenosine-lidocaine preservation solution (A-L) at 4°C or 22°C. Following general anesthesia and diaphragm transection, hearts underwent either 0 or 18 min of in-situ warm ischemia, were explanted, flushed and stored for 15 min with either St. T at 4°C or A-L at 4°C or 22°C, and then reperfused under normothermic, aerobic conditions. Endothelial integrity and contractile function were determined. RESULTS Compared to 4°C preservation, 22°C A-L significantly increased endothelial nitric oxide synthase (eNOS) dimerization and reduced oxidative tissue damage (p < 0.05 for all). Furthermore, A-L at 22°C better preserved the endothelial glycocalyx and coronary flow compared with St. T, tended to reduce tissue calcium overload, and stimulated pro-survival signaling. No significant differences were observed in cardiac function among ischemic groups. CONCLUSIONS Twenty-two-degree Celsius A-L solution better preserves the coronary endothelium compared to 4°C St. T, which likely results from greater eNOS dimerization, reduced oxidative stress, and activation of the reperfusion injury salvage kinase (RISK) pathway. Improving heart preservation conditions immediately following warm ischemia constitutes a promising approach for the optimization of clinical protocols in DCD heart transplantation.
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Affiliation(s)
- Natalia Méndez-Carmona
- Department of Cardiovascular Surgery, Inselspital, Bern University Hospital and Department for BioMedical Research (DBMR), University of Bern, Bern, Switzerland
| | - Rahel K Wyss
- Department of Cardiovascular Surgery, Inselspital, Bern University Hospital and Department for BioMedical Research (DBMR), University of Bern, Bern, Switzerland
| | - Maria Arnold
- Department of Cardiovascular Surgery, Inselspital, Bern University Hospital and Department for BioMedical Research (DBMR), University of Bern, Bern, Switzerland
| | - Adrian Segiser
- Department of Cardiovascular Surgery, Inselspital, Bern University Hospital and Department for BioMedical Research (DBMR), University of Bern, Bern, Switzerland
| | - Nina Kalbermatter
- Department of Cardiovascular Surgery, Inselspital, Bern University Hospital and Department for BioMedical Research (DBMR), University of Bern, Bern, Switzerland
| | - Anna Joachimbauer
- Department of Cardiovascular Surgery, Inselspital, Bern University Hospital and Department for BioMedical Research (DBMR), University of Bern, Bern, Switzerland
| | - Thierry P Carrel
- Department of Cardiovascular Surgery, Inselspital, Bern University Hospital and Department for BioMedical Research (DBMR), University of Bern, Bern, Switzerland
| | - Sarah L Longnus
- Department of Cardiovascular Surgery, Inselspital, Bern University Hospital and Department for BioMedical Research (DBMR), University of Bern, Bern, Switzerland.
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Longchamp A, Harputlugil E, Corpataux JM, Ozaki CK, Mitchell JR. Is Overnight Fasting before Surgery Too Much or Not Enough? How Basic Aging Research Can Guide Preoperative Nutritional Recommendations to Improve Surgical Outcomes: A Mini-Review. Gerontology 2017; 63:228-237. [PMID: 28052287 DOI: 10.1159/000453109] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2016] [Accepted: 11/07/2016] [Indexed: 12/15/2022] Open
Abstract
Dietary restriction (DR) is best known for extending lifespan in experimental model organisms, but also increases resistance to a variety of clinically relevant stressors, including those associated with surgery. Extended periods of DR, lasting months to years, are required for optimal longevity benefits in rodents, but short-term dietary preconditioning (less than 1 week) remarkably protects from acute injury. Here, we discuss recent advances in our understanding of the mechanistic basis of short-term DR and fasting in the context of surgical stress resistance, including upstream amino acid sensing by the GCN2 and mTORC1 pathways, and downstream effector mechanisms including increased insulin-dependent prosurvival signaling and elevated endogenous hydrogen sulfide production. We also review the current trend in preoperative nutrition away from preoperative fasting and towards carbohydrate loading. Finally, we discuss the rationale for the nonmutually exclusive use of brief DR or pharmacological DR mimetics to precondition against the stress and potential complications of surgery.
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Affiliation(s)
- Alban Longchamp
- Department of Genetics and Complex Diseases, Harvard T.H. Chan School of Public Health, Boston, MA, USA
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3
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Sanfilippo F, Chiarenza F, Cassisi C, Santonocito C, Tsoutsouras T, Trivella M, Gerry S, Astuto M, George S, Taggart DP. The Effects of On-Pump and Off-Pump Coronary Artery Bypass Surgery on Metabolic Profiles in the Early Postoperative Period. J Cardiothorac Vasc Anesth 2016; 30:909-16. [PMID: 27241767 DOI: 10.1053/j.jvca.2016.02.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2015] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Hyperlactatemia and base deficit (BD) are markers of adverse outcome after cardiac surgery, and their derangement can be influenced by the use of extracorporeal circulation. The authors hypothesized a better postoperative metabolic profile in off-pump coronary artery bypass grafting (OPCABG) compared with "on-pump" coronary artery bypass grafting (ONCABG). DESIGN This was a retrospective study, with consecutive data collected for 1 year from electronic medical records. SETTING Cardiothoracic intensive care unit at a tertiary university hospital. PARTICIPANTS The study comprised 339 patients who underwent elective coronary artery bypass grafting (ONCABG [n = 215], OPCABG [n = 124]). INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The metabolic (arterial lactatemia, pH, and BD) and hemodynamic (inotropic/vasopressor support) parameters of OPCABG and ONCABG patients were compared at 7 predefined time points (intensive care admission and the 1st, 3rd, 6th, 12th, 18th, and 24th postoperative hours). For each output of interest, mixed-effects linear regression models were used (with time as random-effect to allow for clustering of repeated measures) and adjusted for a predetermined set of covariates. Arterial lactatemia and pH were comparable at all time points; BD was worse in the ONCABG group overall (p = 0.01) and at most time points (except at the 1st and 24th postoperative hours). For the whole period, inotropic support was more common in ONCABG patients (p<0.05), whereas vasopressor use was more frequent in the OPCABG group (p< 0.05). CONCLUSIONS Improved postoperative BD values were demonstrated in the OPCABG group, although pH and lactatemia were similar between groups. Inotropic support was less common in the OPCABG group at the expense of more frequent vasopressor support.
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Affiliation(s)
- Filippo Sanfilippo
- Cardiothoracic Intensive Care Unit, Oxford Heart Centre, John Radcliffe Hospital-Oxford University Hospitals, Oxford, United Kingdom; School of Anaesthesia and Intensive Care, University of Catania, Catania, Italy.
| | - Federica Chiarenza
- Cardiothoracic Intensive Care Unit, Oxford Heart Centre, John Radcliffe Hospital-Oxford University Hospitals, Oxford, United Kingdom; School of Anaesthesia and Intensive Care, University of Catania, Catania, Italy
| | - Cesare Cassisi
- Cardiothoracic Intensive Care Unit, Oxford Heart Centre, John Radcliffe Hospital-Oxford University Hospitals, Oxford, United Kingdom; School of Anaesthesia and Intensive Care, University of Catania, Catania, Italy
| | - Cristina Santonocito
- Cardiothoracic Intensive Care Unit, Oxford Heart Centre, John Radcliffe Hospital-Oxford University Hospitals, Oxford, United Kingdom; School of Anaesthesia and Intensive Care, University of Catania, Catania, Italy
| | - Theodoros Tsoutsouras
- Cardiothoracic Intensive Care Unit, Oxford Heart Centre, John Radcliffe Hospital-Oxford University Hospitals, Oxford, United Kingdom
| | - Marialena Trivella
- Centre for Statistics in Medicine, University of Oxford, Oxford, United Kingdom
| | - Stephen Gerry
- Centre for Statistics in Medicine, University of Oxford, Oxford, United Kingdom
| | - Marinella Astuto
- School of Anaesthesia and Intensive Care, University of Catania, Catania, Italy
| | - Shane George
- Cardiothoracic Intensive Care Unit, Oxford Heart Centre, John Radcliffe Hospital-Oxford University Hospitals, Oxford, United Kingdom
| | - David P Taggart
- Cardiothoracic Intensive Care Unit, Oxford Heart Centre, John Radcliffe Hospital-Oxford University Hospitals, Oxford, United Kingdom; Nuffield Department of Surgery, John Radcliffe Hospital-University of Oxford,Oxford, United Kingdom
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Dobson GP, Faggian G, Onorati F, Vinten-Johansen J. Hyperkalemic cardioplegia for adult and pediatric surgery: end of an era? Front Physiol 2013; 4:228. [PMID: 24009586 PMCID: PMC3755226 DOI: 10.3389/fphys.2013.00228] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2013] [Accepted: 08/05/2013] [Indexed: 12/16/2022] Open
Abstract
Despite surgical proficiency and innovation driving low mortality rates in cardiac surgery, the disease severity, comorbidity rate, and operative procedural difficulty have increased. Today's cardiac surgery patient is older, has a "sicker" heart and often presents with multiple comorbidities; a scenario that was relatively rare 20 years ago. The global challenge has been to find new ways to make surgery safer for the patient and more predictable for the surgeon. A confounding factor that may influence clinical outcome is high K(+) cardioplegia. For over 40 years, potassium depolarization has been linked to transmembrane ionic imbalances, arrhythmias and conduction disturbances, vasoconstriction, coronary spasm, contractile stunning, and low output syndrome. Other than inducing rapid electrochemical arrest, high K(+) cardioplegia offers little or no inherent protection to adult or pediatric patients. This review provides a brief history of high K(+) cardioplegia, five areas of increasing concern with prolonged membrane K(+) depolarization, and the basic science and clinical data underpinning a new normokalemic, "polarizing" cardioplegia comprising adenosine and lidocaine (AL) with magnesium (Mg(2+)) (ALM™). We argue that improved cardioprotection, better outcomes, faster recoveries and lower healthcare costs are achievable and, despite the early predictions from the stent industry and cardiology, the "cath lab" may not be the place where the new wave of high-risk morbid patients are best served.
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Affiliation(s)
- Geoffrey P. Dobson
- Department of Physiology and Pharmacology, Heart and Trauma Research Laboratory, James Cook UniversityTownsville, QLD, Australia
| | - Giuseppe Faggian
- Division of Cardiac Surgery, University of Verona Medical SchoolVerona, Italy
| | - Francesco Onorati
- Division of Cardiac Surgery, University of Verona Medical SchoolVerona, Italy
| | - Jakob Vinten-Johansen
- Cardiothoracic Research Laboratory of Emory University Hospital Midtown, Carlyle Fraser Heart CenterAtlanta, GA, USA
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Rudd DM, Dobson GP. Early reperfusion with warm, polarizing adenosine–lidocaine cardioplegia improves functional recovery after 6 hours of cold static storage. J Thorac Cardiovasc Surg 2011; 141:1044-55. [DOI: 10.1016/j.jtcvs.2010.04.040] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2010] [Revised: 03/16/2010] [Accepted: 04/04/2010] [Indexed: 11/16/2022]
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Prophylactic amiodarone versus lidocaine for prevention of reperfusion ventricular fibrillation after release of aortic cross-clamp. Eur J Anaesthesiol 2009; 26:1056-60. [DOI: 10.1097/eja.0b013e32832f0dfb] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Wijeysundera DN, Bender JS, Beattie WS. Alpha-2 adrenergic agonists for the prevention of cardiac complications among patients undergoing surgery. Cochrane Database Syst Rev 2009:CD004126. [PMID: 19821319 DOI: 10.1002/14651858.cd004126.pub2] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND The surgical stress response plays an important role on the pathogenesis of perioperative cardiac complications. Alpha-2 adrenergic agonists attenuate this response and may thereby prevent cardiac complications. OBJECTIVES This review assessed the efficacy and safety of preoperative (within 24 hours), intraoperative, and postoperative (first 48 hours) alpha-2 adrenergic agonists for preventing mortality and cardiac complications after surgery performed under either general or neuraxial anaesthesia, or both. SEARCH STRATEGY We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2008, Issue 3), MEDLINE (1950 to August week 4 2008), EMBASE (1980 to week 36 2008), the Science Citation Index, and reference lists of articles. SELECTION CRITERIA We included randomized controlled trials that compared alpha-2 adrenergic agonists (clonidine, dexmedetomidine, or mivazerol) against placebo or non-alpha-2 adrenergic agonists. Included studies had to report on mortality, myocardial infarction, myocardial ischaemia, or supraventricular tachyarrhythmia. DATA COLLECTION AND ANALYSIS Three authors independently assessed trial quality and extracted data. Two authors independently performed computer entry of abstracted data. We contacted study authors for additional information. Adverse event data were gathered from the trials. MAIN RESULTS We included 31 studies (4578 participants). Study quality was generally inadequate, with only six studies clearly reporting methods for blinding and allocation concealment. Overall, alpha-2 adrenergic agonists reduced mortality (relative risk (RR) 0.66; 95% CI 0.44 to 0.98; P = 0.04) and myocardial ischaemia (RR 0.68; 95% CI 0.57 to 0.81; P < 0.0001). However, their effects appeared to vary with the surgical procedure. The most encouraging data pertained to vascular surgery, where they reduced mortality (RR 0.47; 95% CI 0.25 to 0.90; P = 0.02), cardiac mortality (RR 0.36; 95% CI 0.16 to 0.79; P = 0.01), and myocardial infarction (RR 0.66; 95% CI 0.46 to 0.94; P = 0.02). With regard to adverse effects, alpha-2 adrenergic agonists significantly increased perioperative hypotension (RR 1.32; 95% CI 1.07 to 1.62; P = 0.009) and bradycardia (RR 1.66; 95% CI 1.14 to 2.41; P = 0.008). AUTHORS' CONCLUSIONS Our study provides encouraging evidence that alpha-2 adrenergic agonists may reduce cardiac risk, especially during vascular surgery. Nonetheless, these data remain insufficient to make firm conclusions about their efficacy and safety. A large randomized trial of alpha-2 adrenergic agonists is therefore warranted. Additionally, future research must determine which specific alpha-2 adrenergic agonist should be used, and whether it is safe to combine them with other perioperative interventions (for example beta-adrenergic blockade).
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Affiliation(s)
- Duminda N Wijeysundera
- Department of Anesthesia, Toronto General Hospital and University of Toronto, EN 3-450, Toronto General Hospital,, 200 Elizabeth Street, Toronto, Ontario, Canada, M5G 2C4
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After Four Hours of Cold Ischemia and Cardioplegic Protocol, the Heart Can Still Be Rescued With Postconditioning. Transplantation 2007; 84:1474-82. [DOI: 10.1097/01.tp.0000288637.18796.0e] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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9
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Günzinger R, Wildhirt SM, Schad H, Heimisch W, Gurdan M, Mendler N, Grammer J, Lange R, Bauernschmitt R. A rat model of cardiopulmonary bypass with cardioplegic arrest and hemodynamic assessment by conductance catheter technique. Basic Res Cardiol 2007; 102:508-17. [PMID: 17668258 DOI: 10.1007/s00395-007-0668-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2007] [Revised: 06/13/2007] [Accepted: 06/26/2007] [Indexed: 11/26/2022]
Abstract
BACKGROUND Cardiopulmonary bypass (CPB) is known to induce systemic inflammation and cardiac dysfunction associated with a significant morbidity. Aim of the study was to develop an in vivo model of rat CPB with hypothermic cardiac arrest and the use of cardioplegia. MATERIAL AND METHODS The CPB circuit consisted of a venous reservoir, membrane oxygenator, heat exchanger, and roller pump. CPB was instituted in adult male Wistar rats (400-500 g) for 60 min at a flow rate of 120 ml x kg(-1) x min(-1), including 15 min cooling to 32 degrees C, 30 min cardiac arrest with the use of cold crystalloid cardioplegia after aortic cross clamping, and 15 min of reperfusion and rewarming to 37 degrees C. Arterial blood pressure (MAP) and heart rate (HR) were monitored, arterial blood samples were analyzed. Left ventricular (LV) function parameters were assessed by intraventricular conductance catheter. Important technical aspects are: ventilation is required during partial bypass; anticoagulation should be performed immediately prior to CPB to reduce blood loss; active suction on venous drainage allows higher pump flows; and the small priming volume of the extracorporeal circuit (8 ml) avoids the need for donor blood. RESULTS MAP remained stable prior to and during CPB.MAP and HR were significantly decreased 60 min after weaning from bypass. Hct was significantly lowered after hemodilution, but remained stable during CPB and 60 min after weaning from bypass. BE and pH remained stable throughout the experiment.Without inotropic support diastolic and systolic LV function parameters were impaired after 30 min of cardioplegic arrest followed by 15 min of reperfusion. Myocardial TNF-alpha mRNA levels were slightly increased (1.28-fold, p = 0.71), and IL-6 mRNA was significantly increased in the cardioplegia group (90.3-fold, p = 0.001). Both IL-6 and TNF-alpha plasma levels were significantly elevated in the cardioplegia group (TNF-alpha: 4.6-fold increase,p < 0.05; IL-6: 426.8-fold increase, p < 0.001). CONCLUSIONS We have developed a rat CPB with mild hypothermic cardioplegic arrest. This rodent model is suitable to study clinically relevant problems related to CPB,myocardial protection and systemic inflammation.
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Affiliation(s)
- Ralf Günzinger
- Dept of Cardiovascular Surgery, German Heart Center Munich, Technical University of Munich, Munich, Germany
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10
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Günzinger* R, Wildhirt* SM, Schad H, Heimisch W, Mendler N, Grammer J, Lange R, Bauernschmitt R. A rat model of cardiopulmonary bypass with cardioplegic arrest and hemodynamic assessment by conductance catheter technique. Basic Res Cardiol 2007. [DOI: 10.1007/s00395-007-0677-9] [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: 11/29/2022]
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11
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Shi Y, Denault AY, Couture P, Butnaru A, Carrier M, Tardif JC. Biventricular diastolic filling patterns after coronary artery bypass graft surgery. J Thorac Cardiovasc Surg 2006; 131:1080-6. [PMID: 16678593 DOI: 10.1016/j.jtcvs.2006.01.015] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2005] [Revised: 01/10/2006] [Accepted: 01/13/2006] [Indexed: 10/24/2022]
Abstract
OBJECTIVE We sought to study the evolution of biventricular filling properties after coronary artery bypass grafting. BACKGROUND The evolution of diastolic function as defined with newer echocardiographic modalities after coronary artery bypass grafting surgery is unknown in patients with preoperative left ventricular diastolic dysfunction. METHODS Transthoracic echocardiography was performed preoperatively and 48 hours and 6 months after coronary artery bypass grafting in 49 patients (randomized to milrinone [n = 25]) or placebo [n = 24]) with preoperative left ventricular diastolic dysfunction classified according to published criteria. Mild right ventricular diastolic dysfunction was defined as the ratio of early to atrial filling velocity of less than 1 in transtricuspid flow or the velocity of reversed atrial flow of greater than 50% of that of systolic flow in hepatic venous flow or the ratio of tricuspid annulus velocity during early and atrial filling of less than 1 if both the ratio of early to atrial filling velocity and the ratio of systolic to diastolic velocity was greater than 1 in hepatic venous flow. Moderate right ventricular diastolic dysfunction was diagnosed when there was a ratio of early to atrial filling velocity of greater than 1 with a ratio of systolic to diastolic velocity of less than 1. Severe right ventricular diastolic dysfunction was defined as a ratio of early to atrial filling velocity of greater than 1 associated with reversed systolic wave in hepatic venous flow. RESULTS Moderate and severe left ventricular diastolic dysfunction increased from preoperatively to 48 hours after coronary artery bypass grafting from 8.2% to 53.7% and from 2.0% to 9.7%, respectively (P < .0001, 48 hours vs preoperatively for both), and the patterns at 6 months were similar to those observed preoperatively. Similar evolution over time was found for right ventricular diastolic dysfunction. CONCLUSIONS In patients with preoperative left ventricular diastolic dysfunction, biventricular filling patterns are impaired initially but return to preoperative status 6 months after coronary artery bypass grafting.
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Affiliation(s)
- Yanfen Shi
- Department of Medicine, Montreal Heart Institute, and University of Montreal, Montreal, Quebec, Canada
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Kazanskaya GM, Volkov AM, Nepomnyashchikh LM, Malinovskaya YV, Chernyavskii AM, Gorbatykh YN, D'yakonitsa TM. Ultrastructural Analysis of Secretory Granules of Myocardial Capillary Endothelium in Cardiosurgical Stress. Bull Exp Biol Med 2005; 140:257-61. [PMID: 16283016 DOI: 10.1007/s10517-005-0460-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
In patients with chronic myocardial tissue hypoxia irrespective of the disease (Fallot's tetralogy, coronary disease) factors of cardiosurgical stress initiate a drop of secretory production in coronary capillary endothelium and obstruction of the intravascular space by blood cells. In children the peak of exocytosis of secretory granules coincides with the period of aortic occlusion, while in adults it is attained at the stage of reperfusion.
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Affiliation(s)
- G M Kazanskaya
- E. N. Meshalkin Novosibirsk Institute of Circulatory Diseases, Ministry of Health of Siberian Region of Russian Federation, Novosibirsk
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Mukherjee R, Yarbrough WM, Reese ES, Leiser JS, Sample JA, Mingoia JT, Hardin AE, Stroud RE, McLean JE, Hendrick JW, Spinale FG. Myocyte contractility with caspase inhibition and simulated hyperkalemic cardioplegic arrest. Ann Thorac Surg 2004; 77:1684-9; discussion 1689-90. [PMID: 15111166 DOI: 10.1016/j.athoracsur.2003.10.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/08/2003] [Indexed: 10/26/2022]
Abstract
BACKGROUND Exposure of left ventricular (LV) myocytes to simulated hyperkalemic cardioplegic arrest (HCA) has been demonstrated to perturb ionic homeostasis and adversely affect myocyte contractility on rewarming. Altered ionic homeostasis can cause cytosolic activation of the caspases. While caspases participate in apoptosis, these proteases can degrade myocyte contractile proteins, and thereby alter myocyte contractility. Accordingly, this study tested the hypothesis that caspase inhibition during HCA would attenuate the degree of myocyte contractile dysfunction upon rewarming, independent of a loss in myocyte viability. METHODS Porcine (n = 8) LV myocytes were isolated and assigned to the following treatment groups: normothermic control: incubation in cell culture media for 2 hours at 37 degrees C; HCA only: incubation for 2 hours in hypothermic HCA solution (4 degrees C, 24 mEq K(+)); or incubation in hypothermic HCA solution supplemented with 10 microM of the caspase inhibitor, z-VAD (z-Val-Ala-Asp-fluoromethyl-ketone, HCA+zVAD). Myocyte viability, assayed as a function of mitochondrial function, was determined to be similar in the normothermic and both HCA groups. RESULTS The HCA caused a significant reduction in myocyte shortening velocity compared with normothermic control values (41 +/- 6 versus 86 +/- 8 microm/s, p < 0.05). The HCA+zVAD group had significantly improved myocyte shortening velocity compared with the HCA only group (63 +/- 7 microm/s, p < 0.05). CONCLUSIONS Independent of changes in viability, caspase inhibition attenuated myocyte contractile dysfunction after HCA and rewarming. Thus, caspase activation during HCA contributes, at least in part, to impaired myocyte contractility with rewarming. Supplementation of HCA with caspase inhibitors may provide a means to preserve myocyte contractile function after cardioplegic arrest.
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Affiliation(s)
- Rupak Mukherjee
- Division of Cardiothoracic Surgery Research, Medical University of South Carolina, Charleston, South Carolina 29425, USA.
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Crescenzi G, Scandroglio AM, Pappalardo F, Landoni G, Cedrati V, Bignami E, Aletti G, Zangrillo A. ECG changes after CABG: the role of the surgical technique. J Cardiothorac Vasc Anesth 2004; 18:38-42. [PMID: 14973797 DOI: 10.1053/j.jvca.2003.10.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE The purpose of this study was to determine whether coronary artery bypass grafting (CABG) surgery on the beating heart (BH) is associated with reduction of R-wave potentials on the precordial leads on the surface electrocardiogram (ECG) as previously shown for CABG with cardiopulmonary bypass. METHODS Fifty-four patients undergoing CABG surgery at a single tertiary care university hospital were analyzed. Patients suffering a postoperative cardiac event (myocardial infarction) or nonspecific ECG changes were excluded. ECG results were recorded at arrival in the intensive care unit, after 4 and 18 hours postoperatively; simultaneously, myocardial cell damage biomarkers (CK-MB and cTnI) were assayed. A control group of 31 patients undergoing mitral valve repair was also evaluated. RESULTS Patients operated with the BH (OPCABG) technique did not show any decrease of R-wave amplitude at 0, 4, and 18 hours postoperatively; whereas those operated with CPB, both for coronary artery surgery and for mitral repair, had a similar extent and pattern of R-wave reduction. The release of myocardial necrosis markers was significantly lower in coronary artery patients operated with BH than in those operated with CPB; however, no statistically significant correlation between the ECG changes and release of myocardial cell damage markers was observed in any of the groups. CONCLUSIONS The findings indicate, for the first time, that CABG surgery on the BH is not followed by any reduction of R-wave amplitude on precordial leads and confirms that the BH technique is associated with a lower release of myocardial cell damage markers.
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Affiliation(s)
- Giuseppe Crescenzi
- Department of Cardiovascular Anesthesia, San Raffele Hospital, University of Milan, Milan, Italy.
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Valen G, Owall A, Takeshima S, Goiny M, Ungerstedt U, Vaage J. Metabolic changes induced by ischemia and cardioplegia: a study employing cardiac microdialysis in pigs. Eur J Cardiothorac Surg 2004; 25:69-75. [PMID: 14690735 DOI: 10.1016/s1010-7940(03)00672-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE The present study investigates dynamic changes of myocardial metabolism in response to ischemia, cardioplegia, and extracorporeal circulation (ECC) in order to differentiate between the contributing effects of each of these interventions. Furthermore, warm blood cardioplegia versus empty beating of the heart were compared as methods to resuscitate the ischemic myocardial metabolism. METHODS Swedish Landrace pigs on ECC (ECC) were compared with pigs on ECC with warm ischemic cardiac arrest (ischemia) or on ECC with warm ischemic arrest followed by warm blood cardioplegia (ischemia-cardioplegia), using sham-operated pigs as controls (n=7 in each group). Microdialysis probes were placed on the surface of the left ventricle and in the femoral artery for serial evaluation of metabolites in the intracardiac extracellular fluid and arterial blood. When hearts started in ventricular fibrillation (VF), it was electroconverted after 10 min of normal blood reperfusion. If VF started after 10 min of reperfusion electroconversion was immediately performed. RESULTS There were no differences between groups in arterial contents of serine, citrulline, arginine, inosine, hypoxanthine, guanosine, aspartate, glutamate, pyruvate, or asparagine throughout the observation period. Systemic lactate increased in pigs subjected to ischemia (P<0.001) or ischemia and cardioplegia (P=0.002), highest in the ischemia only group (P=0.002). In left ventricular microdialysates, lactate increased in pigs subjected to ischemia alone (P<0.001 vs. ECC) and ischemia and cardioplegia (P=0.004 vs. ECC). Guanosine increased in ischemia versus ECC (P=0.002), while hypoxanthine was increased in microdialysates of both ischemic (P=0.002) and ischemic-cardioplegic (P=0.001) pig hearts. Inosine was increased in pigs subjected to ischemia and cardioplegia (P<0.001 vs. ECC). All ischemic hearts started with VF, but while in the warm ischemia group VF started within 10 min of reperfusion, the ischemia-cardioplegia group had a longer asystolia with VF starting 11-22 min of blood reperfusion. CONCLUSION The heart should be allowed to start empty beating rather than by the use of warm continuous blood cardioplegia. Microdialysis and sampling of interstitial metabolites may be advantageous when an increased sensitivity is needed or when repeated blood sampling is difficult or contraindicated in monitoring of the myocardium.
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Affiliation(s)
- Guro Valen
- Crafoord Laboratory of Experimental Surgery, Karolinska Institute, Stockholm, Sweden.
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16
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Schmiedl A, Richter J, Schnabel PA. Different preservation of myocardial capillary endothelial cells and cardiomyocytes during and after cardioplegic ischemia (25 degrees C) of canine hearts. Pathol Res Pract 2002; 198:281-90. [PMID: 12049337 DOI: 10.1078/0344-0338-00255] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Complete resumption of cardiac function after cardioplegic arrest presupposes a well-preserved myocardial ultrastructure during and after ischemia. Therefore, we determined ischemia-induced ultrastructural alterations in the myocardium during and after reversible cardioplegic ischemia using stereological methods. Cardiac arrest was induced with St. Thomas' Hospital- or Custodiol (HTK) solution. Reperfusion with Tyrode's solution followed after reversible cardioplegic ischemia in situ. Samples were taken 1) from beating hearts, 2) from cardioplegically arrested hearts immediately after the end of coronary perfusion, 3) from ischemic hearts incubated in the cardioplegic solution at 25 degrees C, and 4) from reperfused beating hearts after ischemia in situ at 22 degrees C. Cellular swelling was determined as the barrier thickness of capillary endothelium and as the sum of cardiomyocyte volume fractions of free sarcoplasm and mitochondria. In St. Thomas'-arrested hearts, intraischemic volume increase was significantly more pronounced in endothelial cells than in cardiomyocytes. Reperfusion at the intraischemic practical limit of resuscitability (ATP levels of 4 micromol/gww) significantly reduced intraischemic swelling of cardiomyocytes, but not of capillary endothelial cells. Mitochondrial damage was more pronounced in capillary endothelial cells during ischemia and after reperfusion. Thus, after reversible cardioplegic arrest, structural recovery of cardiomyocytes is better than that of capillary endothelial cells. An incomplete structural protection of capillary endothelial cells may predominantly contribute to postischemic dysfunction in the reperfused heart.
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Affiliation(s)
- A Schmiedl
- Department of Anatomy, Division of Electron Microscopy, University of Göttingen, Germany.
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Parolari A, Rubini P, Cannata A, Bonati L, Alamanni F, Tremoli E, Biglioli P. Endothelial damage during myocardial preservation and storage. Ann Thorac Surg 2002; 73:682-90. [PMID: 11845908 DOI: 10.1016/s0003-4975(01)03029-6] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Preservation and storage techniques represent two major issues in routine cardiac surgery and heart transplantation. Historically, these methods were conceived to prevent ischemic injury to myocardium after cardiac arrest during heart operations. Evidence shows that endothelium plays a critical role in the maintenance of normal heart function after cardiac operation, mainly by controlling the coronary circulation. Methods for preservation and storage, developed initially to protect cardiomyocyte function, may be deleterious for vascular endothelium and compromise myocardial protection. In this review article the present knowledge about endothelial injury secondary to preservation and storage techniques is discussed.
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Affiliation(s)
- Alessandro Parolari
- Department of Cardiac Surgery, University of Milan, Centro Cardiologico, Fondazione Monzino IRCCS, Italy.
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18
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Maslow A, Aronson S, Jacobsohn E, Cohn WE, Johnson RG. Case 6--1999. Off-pump coronary artery bypass graft surgery. J Cardiothorac Vasc Anesth 1999; 13:764-81. [PMID: 10622664 DOI: 10.1016/s1053-0770(99)90135-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- A Maslow
- Department of Anesthesia, Rhode Island Hospital, Providence 02903, USA
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19
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Affiliation(s)
- D J Cook
- Department of Anesthesiology, Mayo Clinic, Rochester, Minnesota 55905, USA.
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20
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21
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22
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Willerson JT. Pharmacologic approaches to reperfusion injury. ADVANCES IN PHARMACOLOGY (SAN DIEGO, CALIF.) 1997; 39:291-312. [PMID: 9160118 DOI: 10.1016/s1054-3589(08)60074-5] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- J T Willerson
- Department of Cardiovascular Research Texas Heart Institute, Houston, USA
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23
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Peterzén B, Lönn U, Babić A, Granfeldt H, Casimir-Ahn H, Rutberg H. Postoperative management of patients with hemopump support after coronary artery bypass grafting. Ann Thorac Surg 1996. [DOI: 10.1016/0003-4975(96)00315-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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24
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Dávila-Román VG, Waggoner AD, Hopkins WE, Barzilai B. Right ventricular dysfunction in low output syndrome after cardiac operations: assessment by transesophageal echocardiography. Ann Thorac Surg 1995; 60:1081-6. [PMID: 7574953 DOI: 10.1016/0003-4975(95)00526-q] [Citation(s) in RCA: 79] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND Low output syndrome after cardiac operations is associated with high morbidity and mortality rates. The contribution of right ventricular dysfunction to this syndrome has not been fully characterized. The purpose of this study was to evaluate the utility of transesophageal echocardiography to identify the frequency and the in-hospital mortality from right ventricular dysfunction in patients with this syndrome. METHODS Seventy-five consecutive patients undergoing transesophageal echocardiography for low output syndrome early after cardiac operations were evaluated. The findings from transesophageal echocardiography were correlated with the type of surgical procedure, cross-clamp time, right heart hemodynamics, and coronary angiography. RESULTS Right ventricular systolic dysfunction occurred in 36 patients (42%); in 17 patients it was isolated and in 19 patients it occurred in combination with left ventricular dysfunction. Postoperative right ventricular dysfunction was not uniformly associated with important right coronary artery disease or with prolonged ischemic time during cardiopulmonary bypass. Hemodynamic data were not useful to distinguish the group with postoperative right ventricular dysfunction. Patients with right ventricular dysfunction had a high (44%) in-hospital mortality rate. CONCLUSIONS Right ventricular dysfunction occurs frequently in patients with low output syndrome after cardiac operations and is associated with a high in-hospital mortality rate. Better understanding of the mechanisms causing postoperative right ventricular dysfunction may provide insight for preventing this complication.
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MESH Headings
- Adult
- Aged
- Aged, 80 and over
- Cardiac Output, Low/complications
- Cardiac Output, Low/physiopathology
- Cardiac Surgical Procedures
- Coronary Angiography
- Echocardiography, Transesophageal
- Female
- Hemodynamics
- Humans
- Male
- Middle Aged
- Postoperative Complications/diagnostic imaging
- Postoperative Complications/physiopathology
- Ventricular Dysfunction, Left/diagnostic imaging
- Ventricular Dysfunction, Left/physiopathology
- Ventricular Dysfunction, Right/diagnostic imaging
- Ventricular Dysfunction, Right/etiology
- Ventricular Dysfunction, Right/mortality
- Ventricular Dysfunction, Right/physiopathology
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Affiliation(s)
- V G Dávila-Román
- Cardiovascular Division, Washington University School of Medicine, St. Louis, Missouri 63110, USA
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Vinten-Johansen J, Sato H, Zhao ZQ. The role of nitric oxide and NO-donor agents in myocardial protection from surgical ischemic-reperfusion injury. Int J Cardiol 1995; 50:273-81. [PMID: 8537152 DOI: 10.1016/0167-5273(95)02388-d] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
The coronary vascular endothelium is injured by ischemia-reperfusion, which may facilitate the pathophysiological role played by neutrophils. Hearts undergoing coronary artery bypass surgery or other surgical procedures requiring cardiopulmonary bypass and elective cardioplegia undergo repetitive episodes of ischemia and reperfusion, which leads to endothelial injury as well as contractile dysfunction and morphological injury, despite the use of cardioprotective cardioplegic solutions and other strategies of myocardial protection. In cardiac surgery, as in coronary occlusion, endothelial injury seems to occur upon reperfusion with unmodified blood. Blood cardioplegia does not prevent this surgical 'reperfusion injury', but does prevent extension of endothelial injury during the period of hypothermic cardioplegic arrest ('protected ischemia'). It is not known whether global cardioplegic ischemia in preoperatively injured hearts impairs the basal release of nitric oxide (NO) and hence obtunds this endogenous protective mechanism. However, enhancement of blood cardioplegia with the NO precursor, L-arginine, reduces postsurgical myocardial injury, suggesting that endogenous or basal release of NO participates in the modulation of ischemic-reperfusion injury. In addition, an NO-donor agent also protects the myocardium from surgical ischemic-reperfusion injury. Both cardioprotective strategies involve inhibition of neutrophil accumulation, consistent with the known inhibitory effects of NO on neutrophil adherence and neutrophil-mediated damage to the coronary endothelium. Therefore, NO-related therapy offers a new strategy to protect the myocardium, including the coronary endothelium, from surgically imposed ischemic-reperfusion injury.
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Affiliation(s)
- J Vinten-Johansen
- Department of Cardiothoracic Surgery, Bowman Gray School of Medicine, Winston-Salem, NC 27157-1096, USA
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