1
|
Yang X, Zhu L, Pan H, Yang Y. Cardiopulmonary bypass associated acute kidney injury: better understanding and better prevention. Ren Fail 2024; 46:2331062. [PMID: 38515271 PMCID: PMC10962309 DOI: 10.1080/0886022x.2024.2331062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 03/11/2024] [Indexed: 03/23/2024] Open
Abstract
Cardiopulmonary bypass (CPB) is a common technique in cardiac surgery but is associated with acute kidney injury (AKI), which carries considerable morbidity and mortality. In this review, we explore the range and definition of CPB-associated AKI and discuss the possible impact of different disease recognition methods on research outcomes. Furthermore, we introduce the specialized equipment and procedural intricacies associated with CPB surgeries. Based on recent research, we discuss the potential pathogenesis of AKI that may result from CPB, including compromised perfusion and oxygenation, inflammatory activation, oxidative stress, coagulopathy, hemolysis, and endothelial damage. Finally, we explore current interventions aimed at preventing and attenuating renal impairment related to CPB, and presenting these measures from three perspectives: (1) avoiding CPB to eliminate the fundamental impact on renal function; (2) optimizing CPB by adjusting equipment parameters, optimizing surgical procedures, or using improved materials to mitigate kidney damage; (3) employing pharmacological or interventional measures targeting pathogenic factors.
Collapse
Affiliation(s)
- Xutao Yang
- The Fourth Affiliated Hospital of School of Medicine, and International School of Medicine, International Institutes of Medicine, Zhejiang University, Yiwu, China
| | - Li Zhu
- The Fourth Affiliated Hospital of School of Medicine, and International School of Medicine, International Institutes of Medicine, Zhejiang University, Yiwu, China
- The Jinhua Affiliated Hospital of Zhejiang University School of Medicine, Yiwu, China
| | - Hong Pan
- The Fourth Affiliated Hospital of School of Medicine, and International School of Medicine, International Institutes of Medicine, Zhejiang University, Yiwu, China
| | - Yi Yang
- The Fourth Affiliated Hospital of School of Medicine, and International School of Medicine, International Institutes of Medicine, Zhejiang University, Yiwu, China
| |
Collapse
|
2
|
Jones IA, LoBasso MA, Wier J, Gettleman BS, Richardson MK, Ratto CE, Lieberman JR, Heckmann ND. Perioperative Dexamethasone in Diabetic Patients: A Systematic Review and Meta-Analysis of Randomized, Placebo-Controlled Trials. Anesth Analg 2024; 139:479-489. [PMID: 39151134 DOI: 10.1213/ane.0000000000007007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/18/2024]
Abstract
BACKGROUND The perioperative use of dexamethasone in diabetic patients remains controversial due to concerns related to infection and adverse events. This study aimed to determine whether clinical evidence supports withholding dexamethasone in diabetic patients due to concern for infection risk. We hypothesized that there is no difference in infectious outcomes between dexamethasone-treated patients and controls. METHODS A literature search was performed on November 22, 2022 to identify randomized, placebo-controlled trials investigating short-course (<72 hours), perioperative dexamethasone that explicitly included diabetic patients and measured at least 1 clinical outcome. Pertinent studies were independently searched in PubMed, Embase, and Cochrane. Authors for all identified studies were contacted with the aim of performing quantitative subgroup analyses of diabetic patients. The primary end point was surgical site infection and the secondary end point was a composite of adverse events. Qualitative remarks were reported based on the total available data and a quality assessment tool. Meta-analyses were performed using inverse variance with random effects. Heterogeneity was assessed via standard χ2 and I2 tests. RESULTS Sixteen unique studies were included, 5 of which were analyzed quantitatively. Of the 2592 diabetic patients, 2344 (1184 randomized to dexamethasone and 1160 to placebo) were analyzed in at least 1 quantitative outcome. Quantitative analysis showed that the use of perioperative dexamethasone had no effect on the risk of surgical site infections (log odds ratio [LOR], -0.10, 95%; 95% confidence interval [CI], -0.64 to 0.44) while significantly reducing the risk of composite adverse events (LOR, -0.33; 95% CI, -0.62 to -0.05). Qualitative analysis reinforced these findings, demonstrating noninferior to superior results across all clinical outcomes. There was high heterogeneity between the included studies. CONCLUSIONS Current evidence suggests perioperative dexamethasone may be given to diabetic patients without increasing the risk of infectious complications. Prospective investigations aimed at optimizing dose, frequency, and timing are needed, as well as studies aimed explicitly at exploring the use of dexamethasone in patients with poorly controlled diabetes.
Collapse
Affiliation(s)
- Ian A Jones
- From the Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington
| | - Michael A LoBasso
- Department of Anesthesiology and Perioperative Medicine, University of California, Los Angeles, Los Angeles, California
| | - Julian Wier
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Brandon S Gettleman
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Mary K Richardson
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Christina E Ratto
- Department of Anesthesiology, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Jay R Lieberman
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Nathanael D Heckmann
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| |
Collapse
|
3
|
Banerjee D, Feng J, Sellke FW. Strategies to attenuate maladaptive inflammatory response associated with cardiopulmonary bypass. Front Surg 2024; 11:1224068. [PMID: 39022594 PMCID: PMC11251955 DOI: 10.3389/fsurg.2024.1224068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 06/07/2024] [Indexed: 07/20/2024] Open
Abstract
Cardiopulmonary bypass (CPB) initiates an intense inflammatory response due to various factors: conversion from pulsatile to laminar flow, cold cardioplegia, surgical trauma, endotoxemia, ischemia-reperfusion injury, oxidative stress, hypothermia, and contact activation of cells by the extracorporeal circuit. Redundant and overlapping inflammatory cascades amplify the initial response to produce a systemic inflammatory response, heightened by coincident activation of coagulation and fibrinolytic pathways. When unchecked, this inflammatory response can become maladaptive and lead to serious postoperative complications. Concerted research efforts have been made to identify technical refinements and pharmacologic interventions that appropriately attenuate the inflammatory response and ultimately translate to improved clinical outcomes. Surface modification of the extracorporeal circuit to increase biocompatibility, miniaturized circuits with sheer resistance, filtration techniques, and minimally invasive approaches have improved clinical outcomes in specific populations. Pharmacologic adjuncts, including aprotinin, steroids, monoclonal antibodies, and free radical scavengers, show real promise. A multimodal approach incorporating technical, circuit-specific, and pharmacologic strategies will likely yield maximal clinical benefit.
Collapse
Affiliation(s)
| | | | - Frank W. Sellke
- Division of Cardiothoracic Surgery, Department of Surgery, Brown University/Rhode Island Hospital, Providence, RI, United States
| |
Collapse
|
4
|
Milne B, Gilbey T, De Somer F, Kunst G. Adverse renal effects associated with cardiopulmonary bypass. Perfusion 2024; 39:452-468. [PMID: 36794518 PMCID: PMC10943608 DOI: 10.1177/02676591231157055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
Cardiac surgery on cardiopulmonary bypass (CPB) is associated with postoperative renal dysfunction, one of the most common complications of this surgical cohort. Acute kidney injury (AKI) is associated with increased short-term morbidity and mortality and has been the focus of much research. There is increasing recognition of the role of AKI as the key pathophysiological state leading to the disease entities acute and chronic kidney disease (AKD and CKD). In this narrative review, we will consider the epidemiology of renal dysfunction after cardiac surgery on CPB and the clinical manifestations across the spectrum of disease. We will discuss the transition between different states of injury and dysfunction, and, importantly, the relevance to clinicians. The specific facets of kidney injury on extracorporeal circulation will be described and the current evidence evaluated for the use of perfusion-based techniques to reduce the incidence and mitigate the complications of renal dysfunction after cardiac surgery.
Collapse
Affiliation(s)
- Benjamin Milne
- Department of Anaesthesia & Pain Medicine, King’s College Hospital NHS Foundation Trust, London, UK
| | - Tom Gilbey
- Department of Anaesthesia & Pain Medicine, King’s College Hospital NHS Foundation Trust, London, UK
- Nuffield Department of Anaesthesia, John Radcliffe Hospital, Oxford, UK
| | - Filip De Somer
- Department of Human Structure and Repair, Faculty of Medicine and Health Sciences, Ghent University Hospital, Ghent, Belgium
| | - Gudrun Kunst
- Department of Anaesthesia & Pain Medicine, King’s College Hospital NHS Foundation Trust, London, UK
- School of Cardiovascular and Metabolic Medicine and Sciences, King’s College London British Heart Foundation Centre of Excellence, London, UK
| |
Collapse
|
5
|
Chen YC, Liu CC, Hsu HC, Hung KC, Chang YJ, Ho CN, Hsing CH, Yiu CY. Systemic immune-inflammation index for predicting postoperative atrial fibrillation following cardiac surgery: a meta-analysis. Front Cardiovasc Med 2024; 11:1290610. [PMID: 38374999 PMCID: PMC10875005 DOI: 10.3389/fcvm.2024.1290610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 01/24/2024] [Indexed: 02/21/2024] Open
Abstract
Background Postoperative atrial fibrillation (POAF) is a frequent complication that may increase morbidity and mortality risk following cardiac surgery. The systemic immune-inflammation index (SII) is an emerging biomarker that provides an integrated measure of inflammation by incorporating neutrophil, lymphocyte, and platelet counts. Recent studies have reported associations between elevated SII and increased POAF risk; however, significant heterogeneity exists regarding its predictive efficacy. This meta-analysis aimed to assess SII's diagnostic efficacy for predicting POAF risk. Methods To synthesize existing evidence on the ability of perioperative SII for predicting POAF in patients undergoing cardiac surgery, a systematic review and meta-analysis was conducted. In August 2023, a comprehensive literature search was performed to identify relevant studies reporting SII cutoff values with corresponding sensitivity and specificity. The primary aim was to evaluate SII's diagnostic utility for predicting POAF, whereas secondary outcomes included the pooled incidence of POAF and the relationship between the SII and POAF. Results Eight studies published between 2021 and 2023 with 3,245 patients were included. Six studies involved coronary artery bypass grafting (CABG) surgery; one encompassed various cardiac procedures, and another focused solely on mitral valve surgery. The pooled incidence of POAF was 23.6% [95% confidence interval (CI), 18.7%-29.2%]. Elevated SII significantly increased the odds of POAF by 3.24-fold (odds ratio, 3.24; 95% CI, 1.6-6.55; p = 0.001). SII's pooled sensitivity and specificity for predicting POAF were 0.80 (95% CI, 0.68-0.89) and 0.53 (95% CI, 0.23-0.8), respectively. The SII had moderate predictive accuracy based on a hierarchical summary receiver operating characteristic (HSROC) area under the curve of 0.78 (95% CI, 0.74-0.81). Subgroup analyses, whether focusing on CABG alone or CABG with cardiopulmonary bypass (CPB), both indicated an area under the HSROC curve of 0.78 (95% CI, 0.74-0.81). Conclusion Elevated SII is significantly correlated with an increased POAF risk following cardiac surgery, highlighting its utility as a predictive biomarker. Considering its moderate diagnostic accuracy, further research is essential for clarifying SII's clinical effectiveness, either as an independent predictor or combined with other risk factors, for stratifying patients at high POAF risk. Systematic Review Registration https://www.crd.york.ac.uk/prospero/, identifier [CRD42023456128].
Collapse
Affiliation(s)
- Yu-Chou Chen
- Department of Anesthesiology, Chi Mei Medical Center, Tainan, Taiwan
| | - Chien-Cheng Liu
- Department of Anesthesiology, E-Da Hospital, I-Shou University, Kaohsiung, Taiwan
- Department of Nursing, College of Medicine, I-Shou University, Kaohsiung, Taiwan
- School of Medicine, I-Shou University, Kaohsiung, Taiwan
| | - Hui-Chen Hsu
- Department of Otolaryngology, Kuang Tien General Hospital, Taichung, Taiwan
| | - Kuo-Chuan Hung
- Department of Anesthesiology, Chi Mei Medical Center, Tainan, Taiwan
| | - Ying-Jen Chang
- Department of Anesthesiology, Chi Mei Medical Center, Tainan, Taiwan
- Department of Recreation and Health-Care Management, College of Recreation and Health Management, Chia Nan University of Pharmacy and Science, Tainan, Taiwan
| | - Chun-Ning Ho
- Department of Anesthesiology, Chi Mei Medical Center, Tainan, Taiwan
| | - Chung-Hsi Hsing
- Department of Anesthesiology, Chi Mei Medical Center, Tainan, Taiwan
- Department of Medical Research, Chi-Mei Medical Center, Tainan, Taiwan
| | - Ching-Yi Yiu
- Department of Otolaryngology, Chi Mei Medical Center, Liouying, Tainan, Taiwan
- Department of Dental Laboratory Technology, Min-Hwei Junior College of Health Care Management, Liouying, Tainan, Taiwan
| |
Collapse
|
6
|
Laudanski K, Liu D, Karnatovskaia L, Devang S, Mathew A, Szeto WY. Whole Blood Reactivity to Viral and Bacterial Pathogens after Non-Emergent Cardiac Surgery during the Acute and Convalescence Periods Demonstrates a Distinctive Profile of Cytokines Production Compared to the Preoperative Baseline in Cohort of 108 Patients, Suggesting Immunological Reprogramming during the 28 Days Traditionally Recognized as the Post-Surgical Recovery Period. Biomedicines 2023; 12:28. [PMID: 38275389 PMCID: PMC10812925 DOI: 10.3390/biomedicines12010028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 11/19/2023] [Accepted: 12/06/2023] [Indexed: 01/27/2024] Open
Abstract
The release of danger signals from tissues in response to trauma during cardiac surgery creates conditions to reprogram the immune system to subsequent challenges posed by pathogens in the postoperative period. To demonstrate this, we tested immunoreactivity before surgery as the baseline (tbaseline), followed by subsequent challenges during the acute phase (t24h), convalescence (t7d), and long-term recovery (t3m). For 108 patients undergoing elective heart surgery, whole blood was stimulated with lipopolysaccharide (LPS), Influenza A virus subtype N2 (H3N2), or the Flublok™ vaccine to represent common pathogenic challenges. Leukocytosis, platelet count, and serum C-reactive protein (CRP) were used to measure non-specific inflammation. Cytokines were measured after 18 h of stimulation to reflect activation of the various cell types (activated neutrophils-IL-8; activated T cells-IL-2, IFNγ, activated monocyte (MO)-TNFα, IL-6, and deactivated or atypically activated MO and/or T cells-M-CSF, IL-10). IL-2 and IL-10 were increased at t7d, while TNFα was suppressed at t24h when LPS was utilized. Interestingly, M-CSF and IL-6 production was elevated at seven days in response to all stimuli compared to baseline. While some non-specific markers of inflammation (white cell count, IL-6, and IL-8) returned to presurgical levels at t3m, CRP and platelet counts remained elevated. We showed that surgical stimulus reprograms leukocyte response to LPS with only partial restoration of non-specific markers of inflammation.
Collapse
Affiliation(s)
- Krzysztof Laudanski
- Department of Anesthesiology and Perioperative Care, Mayo Clinic, Rochester, MN 55905, USA
| | - Da Liu
- Department of Obstetrics and Gynecology, Shengjing Hospital of China Medical University, Shenyang 110055, China;
| | - Lioudmila Karnatovskaia
- Division of Pulmonary and Critical Care, Department of Internal Medicine, Mayo Clinic, Rochester, MN 55905, USA;
| | - Sanghavi Devang
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL 32224, USA;
| | - Amal Mathew
- School of Biomedical Engineering, Science and Health Systems, Drexel University, Philadelphia, PA 19104, USA;
| | - Wilson Y. Szeto
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA 19104, USA;
| |
Collapse
|
7
|
Mc Loughlin J, Hinchion J. The gut microbiome and cardiac surgery an unusual symphony. Perfusion 2023; 38:1330-1339. [PMID: 35466814 DOI: 10.1177/02676591221097219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
The relationship between the gut microbiome and various organ systems has gained interest throughout the scientific community in recent times. The understanding of these complex relationships has greatly improved with clinical benefits now being seen. Cardiopulmonary bypass (CPB) is a form of extracorporeal circulation that provides circulatory and respiratory support during cardiac surgery. This physiological support facilitates a still and bloodless field facilitating operations on the heart to be performed. Through various mechanisms CPB results in a systemic inflammatory response syndrome (SIRS). This response can vary from mild hypotension to multiple organ failure. It remains difficult to predict the degree to which a patient will experience SIRS post-operatively. The relationship between the composition of the gut microbiome and inflammatory processes associated with disease has been seen across several fields including gastroenterology, neurology, psychiatry and cardiology. To date, minimal research has been undertaken to examine the impact the gut microbiome has on outcomes following cardiac surgery. This review paper explores the pathophysiology behind the SIRS response associated with CPB for cardiac surgery and the hypothesis that a correlation exists between a patients gut microbiome composition and the degree of inflammatory response experienced following cardiac surgery.
Collapse
Affiliation(s)
- Joseph Mc Loughlin
- Department of Cardiothoracic Surgery, Cork University Hospital, Cork, Ireland
| | - J Hinchion
- Department of Cardiothoracic Surgery, Cork University Hospital, Cork, Ireland
| |
Collapse
|
8
|
Coronary artery bypass grafting after iatrogenic coronary artery dissection: A single center eight years' experience. COR ET VASA 2023. [DOI: 10.33678/cor.2022.093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
|
9
|
Effect of Dexmedetomidine on Cardiac Surgery Patients. J Cardiovasc Pharmacol 2023; 81:104-113. [PMID: 36607614 DOI: 10.1097/fjc.0000000000001384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Accepted: 10/10/2022] [Indexed: 01/07/2023]
Abstract
ABSTRACT Dexmedetomidine, an alpha-2 adrenoreceptor agonist that is widely used as a sedative medication, is becoming more and more attractive in clinical application on cardiac surgery patients. In this review, we aim to summarize and discuss both retrospective studies and clinical trials regarding the effect of dexmedetomidine on patients who underwent cardiac surgery (including coronary artery bypass grafting, valve surgery, aortic surgery, percutaneous coronary intervention, and so on), which illustrates that the clinical effects of dexmedetomidine could effectively reduce mortality, major complications, and the intensive care unit and hospital length of stay without comprising safety. In addition, inconsistent results from both retrospective studies and clinical trials have also been demonstrated. Although the effectiveness and safety of dexmedetomidine on cardiac surgery patients is suggested, high-quality clinical trials are needed for further verification.
Collapse
|
10
|
Kim HH, Yoo KJ, Youn YN. A Randomized Trial of Clopidogrel vs Ticagrelor After Off-Pump Coronary Bypass. Ann Thorac Surg 2022; 115:1127-1134. [PMID: 36395875 DOI: 10.1016/j.athoracsur.2022.10.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 10/11/2022] [Accepted: 10/15/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND This study aimed to compare the outcomes of aspirin in combination with either ticagrelor or clopidogrel after off-pump coronary artery bypass (OPCAB) in patients with clopidogrel resistance. METHODS Between November 2014 and November 2020, 1739 patients underwent OPCAB. Aspirin and clopidogrel treatment was initiated the day after surgery. On postoperative days 7 to 9, clopidogrel resistance was evaluated using a point-of-care assay. A total of 278 (18.9%) patients had clopidogrel resistance ( platelet reaction unit >208) and were enrolled in the study. The study investigators excluded patients with coresistance to aspirin (n = 74) and divided the remaining patients (mean age, 67.4 ± 8.5 years) into 2 groups (an aspirin and ticagrelor group [AT group; n = 102] and an aspirin and clopidogrel group [AC group; n = 102]), randomly assigned using a 1:1 ratio block table. The primary end point was graft patency and major adverse cardiovascular events (MACEs; defined as the composite of cardiovascular mortality, myocardial infarction, and repeat revascularization at 1 year after OPCAB), and the coprimary end point was the graft patency rate. The data were analyzed using the intent-to-treat method. RESULTS The graft occlusion rates in the AT and AC groups were 3.9% and 5.9%, respectively (P = .52). Neither death from cardiovascular causes (1.0% vs 2.9%; P = .32) nor myocardial infarction showed significant differences (1.0% vs 3.9%; P = .18). No significant difference in the rates of major bleeding were found between the 2 groups (P = .75). However, the AT group was associated with a lower rate of MACEs after OPCAB (hazard ratio, 0.77; 95% CI, 0.684-0.891; P = .01). CONCLUSIONS These results suggest that ticagrelor may be associated with reducing MACEs in patients with clopidogrel resistance after OPCAB.
Collapse
Affiliation(s)
- Hyo-Hyun Kim
- Division of Cardiovascular Surgery, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Yonsei University Health System, Seoul, Republic of Korea
| | - Kyung-Jong Yoo
- Division of Cardiovascular Surgery, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Yonsei University Health System, Seoul, Republic of Korea
| | - Young-Nam Youn
- Division of Cardiovascular Surgery, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Yonsei University Health System, Seoul, Republic of Korea.
| |
Collapse
|
11
|
Gao S, Ma G, Zhou L, Guan S, Zhang J. Effects of Dexmedetomidine Pretreatment, Posttreatment, and Whole-Course Pumping on Myocardial Damage during Cardiac Valve Replacement. Int Heart J 2022; 63:837-842. [DOI: 10.1536/ihj.22-008] [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: 11/18/2022]
Affiliation(s)
- Shenqiang Gao
- Department of Anesthesia, Tai'an City Central Hospital
| | - Guifen Ma
- Department of Anesthesia, Tai'an City Central Hospital
| | - Lina Zhou
- Department of Anesthesia, Tai'an City Central Hospital
| | - Shanhui Guan
- Department of Anesthesia, Tai'an City Central Hospital
| | - Jinjun Zhang
- Taishan Sanatorium and Hospital of Shandong Province
| |
Collapse
|
12
|
Application of Adsorptive Blood Purification Techniques during Cardiopulmonary Bypass in Cardiac Surgery. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2022; 2022:6584631. [PMID: 35663201 PMCID: PMC9159835 DOI: 10.1155/2022/6584631] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Revised: 05/13/2022] [Accepted: 05/16/2022] [Indexed: 02/05/2023]
Abstract
By reason of surgical demand, the majority of cardiovascular procedures still depend on the use of cardiopulmonary bypass (CPB). Due to the nonphysiological state of CPB, it can cause complex and unpredictable inflammatory response, which may lead to significant morbidity and mortality. Unfortunately, the pharmacological and mechanical strategies that currently exist do not offer significant advantages in controlling inflammatory response and improving patient outcomes. The best strategy to reduce inflammation in CPB is still uncertain. In recent years, adsorptive blood purification techniques (BPTs) have emerged, among which CytoSorb is the latest representative device. Currently, the primary application area of adsorptive BPTs is in the control and treatment of systemic hyperinflammatory states, such as refractory septic shock patients. However, the evidences on efficacy and safety of adsorptive BPTs application during CPB surgery are still inconclusive, so we summarize the relevant evidences here and suggest future potential research areas.
Collapse
|
13
|
Hasselbach L, Weidner J, Elsässer A, Theilmeier G. Heart Failure Relapses in Response to Acute Stresses - Role of Immunological and Inflammatory Pathways. Front Cardiovasc Med 2022; 9:809935. [PMID: 35548445 PMCID: PMC9081344 DOI: 10.3389/fcvm.2022.809935] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Accepted: 03/23/2022] [Indexed: 12/15/2022] Open
Abstract
Cardiovascular diseases continue to be the most imminent health care problems in the western world, accounting for numerous deaths per year. Heart failure (HF), namely the reduction of left ventricular function, is one of the major cardiovascular disease entities. It is chronically progressing with relapsing acute decompensations and an overall grave prognosis that is little different if not worse than most malignant diseases. Interestingly acute metabolically and/or immunologically challenging events like infections or major surgical procedures will cause relapses in the course of preexisting chronic heart failure, decrease the patients wellbeing and worsen myocardial function. HF itself and or its progression has been demonstrated to be driven at least in part by inflammatory pathways that are similarly turned on by infectious or non-infectious stress responses. These thus add to HF progression or relapse. TNF-α plasma levels are associated with disease severity and progression in HF. In addition, several cytokines (e.g., IL-1β, IL-6) are involved in deteriorating left ventricular function. Those observations are based on clinical studies using inhibitors of cytokines or their receptors or they stem from animal studies examining the effect of cytokine mediated inflammation on myocardial remodeling in models of heart failure. This short review summarizes the known underlying immunological processes that are shared by and drive all: chronic heart failure, select infectious diseases, and inflammatory stress responses. In conclusion the text provides a brief summary of the current development in immunomodulatory therapies for HF and their overlap with treatments of other disease entities.
Collapse
Affiliation(s)
- Lisa Hasselbach
- Division of Cardiology and Division of Perioperative Inflammation and Infection, Department Human Medicine, University of Oldenburg, Oldenburg, Germany
| | - Johannes Weidner
- Division of Perioperative Inflammation and Infection, Department Human Medicine, University of Oldenburg, Oldenburg, Germany
| | - Albrecht Elsässer
- Division of Cardiology, Department Human Medicine, University of Oldenburg, Oldenburg, Germany
| | - Gregor Theilmeier
- Division of Perioperative Inflammation and Infection, Department Human Medicine, University of Oldenburg, Oldenburg, Germany
| |
Collapse
|
14
|
Abbasciano RG, Koulouroudias M, Chad T, Mohamed W, Leeman I, Pellowe C, Kunst G, Klein A, Murphy GJ. Role of hypothermia in adult cardiac surgery patients: a systematic review and meta-analysis. J Cardiothorac Vasc Anesth 2022; 36:1883-1890. [DOI: 10.1053/j.jvca.2022.01.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Revised: 01/07/2022] [Accepted: 01/17/2022] [Indexed: 11/11/2022]
|
15
|
Hori K, Usuba K, Sakuyama A, Adachi Y, Hirakawa K, Nakayama A, Nagayama M, Shimokawa T, Takanashi S, Isobe M. Hospitalization-Associated Disability After Cardiac Surgery in Elderly Patients - Exploring the Risk Factors Using Machine Learning Algorithms. Circ Rep 2021; 3:423-430. [PMID: 34414331 PMCID: PMC8338437 DOI: 10.1253/circrep.cr-21-0057] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 06/17/2021] [Accepted: 06/22/2021] [Indexed: 01/06/2023] Open
Abstract
Background:
Hospitalization-associated disability (HAD) is associated with prolonged functional decline and increased mortality after discharge. Therefore, we examined the incidence and risk factors associated with HAD in elderly patients undergoing cardiac surgery in Japan. Methods and Results:
We retrospectively examined 2,262 elderly patients who underwent elective cardiac surgery at Sakakibara Heart Institute. HAD was defined as a functional decline between time of admission and discharge measured by the Barthel Index. We analyzed clinical characteristics using machine learning algorithms to identify the risk factors associated with HAD. After excluding 203 patients, 2,059 patients remained, of whom 108 (5.2%) developed HAD after cardiac surgery. The risk factors identified were age, serum albumin concentration, estimated glomerular filtration rate, Revised Hasegawa’s Dementia Scale, N-terminal pro B-type natriuretic peptide, vital capacity, preoperative Short Physical Performance Battery (SPPB) score, operation times, cardiopulmonary bypass times, ventilator times, length of postoperative intensive care unit stay, and postoperative ambulation start day. The highest incidence of HAD was found in patients with an SPPB score ≤9 and in those who started ambulation >6 days after surgery (76.9%). Conclusions:
Several risk factors for HAD are components of frailty, suggesting that preoperative rehabilitation to reduce the risk of HAD is feasible. Furthermore, the association between HAD and a delayed start of ambulation reaffirms the importance of early mobilization and rehabilitation.
Collapse
Affiliation(s)
- Kentaro Hori
- Department of Rehabilitation, Sakakibara Heart Institute Tokyo Japan
| | - Koyo Usuba
- Research Centre for Evaluating Children's Health Outcomes (ECHO), Laurentian University Sudbury, ON Canada.,Child Health Evaluative Sciences Program, Research Institute, The Hospital for Sick Children (SickKids) Toronto, ON Canada
| | - Akihiro Sakuyama
- Department of Physical Therapy, Faculty of Health Science, Juntendo University Tokyo Japan
| | - Yuichi Adachi
- Department of Rehabilitation, Sakakibara Heart Institute Tokyo Japan
| | - Kotaro Hirakawa
- Department of Rehabilitation, Sakakibara Heart Institute Tokyo Japan
| | - Atsuko Nakayama
- Department of Cardiology, Sakakibara Heart Institute Tokyo Japan
| | | | - Tomoki Shimokawa
- Department of Cardiovascular Surgery, Sakakibara Heart Institute Tokyo Japan.,Department of Cardiovascular Surgery, Teikyo University Hospital Tokyo Japan
| | - Shuichiro Takanashi
- Department of Cardiovascular Surgery, Sakakibara Heart Institute Tokyo Japan.,Department of Cardiovascular Surgery, Kawasaki Saiwai Hospital Kanagawa Japan
| | | |
Collapse
|
16
|
Immunohistochemistry in the Postmortem Diagnosis of Sepsis: A Systematic Review. Appl Immunohistochem Mol Morphol 2021; 28:571-578. [PMID: 31290786 DOI: 10.1097/pai.0000000000000790] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
It is not uncommon for the forensic pathologist to question whether a deceased person had experienced sepsis that could have either been the cause of or contributed to the person's death. Often, the missing typical pathologic factors or lack of clinical and circumstantial information on the death render the autopsy of a sepsis-related death a difficult task for the forensic pathologist. Several authors emphasize on how an immunohistochemical analysis could help in diagnosing death related to sepsis. The research we carried out analyzes the main scientific studies in the literature, primarily the tracing of 21 immunohistochemical antigens evaluated to help diagnose death related to sepsis. The purpose of this review was to analyze and summarize the markers studied until now and to consider the limitations of immunohistochemistry that currently exist with regard to this particular field of forensic pathology. Immunohistochemistry provided interesting and promising results, but further studies are needed in order for them to be confirmed, so that they may be applied in standard forensic practice.
Collapse
|
17
|
Dynamic changes in insulin requirements with post-operative time using bedside artificial pancreas to maintain normoglycemia without hypoglycemia after cardiac surgery. J Artif Organs 2021; 25:72-81. [PMID: 34191199 DOI: 10.1007/s10047-021-01286-0] [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: 05/03/2021] [Accepted: 06/24/2021] [Indexed: 10/21/2022]
Abstract
It is difficult to manage postoperative blood glucose levels without hyperglycemia and hypoglycemia in cardiac surgery patients even if continuous intravenous insulin infusion is used. Therefore, the insulin requirements for maintaining normoglycemia may be difficult to evaluate and need to be elucidated. In this single-center retrospective study, 30 adult patients (age 71.5 ± 9.0 years old, men 67%, BMI 22.0 ± 3.1 kg/m2, diabetes 33%) who underwent cardiac surgery and used bedside artificial pancreas (STG-55) as a perioperative glycemic control were included. We investigated the insulin and glucose requirements to maintain normoglycemia until the day after surgery. The bedside artificial pancreas achieved intensive glycemic control without hypoglycemia under fasting conditions for 15 h after surgery (mean blood glucose level was 103.3 ± 3.1 mg/dL and percentage of time in range (70-140 mg/dL) was 99.4 ± 2.0%). The total insulin requirement for maintaining normoglycemia differed among surgical procedures, including the use of cardiopulmonary bypass during surgery, while it was not affected by age, body mass index, or the capacity of insulin secretion. Moreover, the mean insulin requirement and the standard deviation of the insulin requirements were variable and high, especially during the first several hours after surgery. Treatment using the bedside artificial pancreas enabled intensive postoperative glycemic control without hypoglycemia. Furthermore, the insulin requirements for maintaining normoglycemia after cardiac surgery vary based on surgical strategies and change dynamically with postoperative time, even in the short term.
Collapse
|
18
|
Bastopcu M, Sargın M, Kuplay H, Erdoğan SB, Yapıcı N, Aka SA. Risk factors for vasoplegia after coronary artery bypass and valve surgery. J Card Surg 2021; 36:2729-2734. [PMID: 34018257 DOI: 10.1111/jocs.15663] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 03/26/2021] [Accepted: 04/13/2021] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Vasoplegia denotes a state of low tissue perfusion characterized by hypotension, tachycardia, and low systemic vascular resistance. This state results in increased mortality and morbidity following cardiac surgery. A better understanding of the associated risk factors will guide the surgical team in patient management. The aim of this study is to determine which risk factors are involved in its emergence. METHODS This prospective observational study included adult cardiac surgery patients between February - September 2018 at a single cardiothoracic surgery center. Patients were evaluated for cardiac contractility, surgical drainage, inotrope, and vasopressor requirement perioperatively. The groups were compared for demographic, echocardiographic, and operative variables. Variables significant in univariate analysis were carried on to binary logistic regression for risk factor analysis. RESULTS A total of 31 patients were vasoplegic among a total of 487 included patients, resulting in a 6.37% incidence. In the vasoplegia group, chronic kidney failure, use of angiotensin-converting enzyme (ACE) inhibitors, use of angiotensin receptor blockers, and use of diuretics were more frequent, cardiopulmonary bypass (CPB) and aortic cross-clamp durations were longer, and mean Euroscore II was higher. Vasoplegia was more frequent in valve surgery and resternotomy patients. CPB duration, use of ACE inhibitors, use of angiotensin receptor blockers, and chronic renal failure were independent risk factors. CONCLUSION Patients with long CPB duration, preoperative use of ACE inhibitors or Angiotensin receptor blockers, and a history of renal failure requiring dialysis are under increased risk of vasoplegia. Vasoplegia necessitates large-scale studies for a better understanding of its risk factors.
Collapse
Affiliation(s)
- Murat Bastopcu
- Department of Cardiovascular Surgery, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Murat Sargın
- Department of Cardiovascular Surgery, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Hüseyin Kuplay
- Department of Cardiovascular Surgery, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Sevinç Bayer Erdoğan
- Department of Cardiovascular Surgery, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Nihan Yapıcı
- Department of Anesthesiology, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Serap Aykut Aka
- Department of Cardiovascular Surgery, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| |
Collapse
|
19
|
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
|
20
|
Bostan C, Kaya A, Yiğit Z. Changes in pentraxin 3 and oxidative parameters during coronary bypass grafting and factors affecting postoperative atrial fibrillation. J Int Med Res 2020; 48:300060520967561. [PMID: 33147418 PMCID: PMC7780577 DOI: 10.1177/0300060520967561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objective The performance of coronary bypass grafting (CBG) induces a type of subclinical systemic inflammatory response syndrome. The present study was performed to examine the changes in pentraxin 3 (PTX3) and oxidative parameters during cross-clamping in patients undergoing CBG. We also examined factors affecting the development of postoperative atrial fibrillation (POAF). Method This study involved 40 patients who underwent elective on-pump CBG (33 men, 7 women; mean age, 60.8 ± 8.0 years). Blood specimens were drawn before anaesthesia and after aortic cross-clamping. POAF was detected by analysing the rhythm records of telemetry units for 96 hours postoperatively. Results The mean PTX3 concentration prior to surgery was 176.3 ± 148.4 pg/mL. After cross-clamping, it increased to 947.7 ± 377.2 pg/mL. The increase was statistically significant. Twelve patients had POAF. The leucocyte count and change in the oxidative stress index were significantly higher in patients without than with POAF. Although the increase in PTX3 was higher in patients without POAF, the difference was not statistically significant. Conclusion The PTX3 concentration significantly increases during CBG. A significant change in the oxidative stress index and a more intense increase in the PTX3 concentration were seen in patients without POAF.
Collapse
Affiliation(s)
- Cem Bostan
- Department of Cardiology, Istanbul University-Cerrahpasa Institute of Cardiology, Istanbul, Turkey
| | - Ayşem Kaya
- Department of Cardiology, Biochemistry Laboratory, Istanbul University-Cerrahpasa Institute of Cardiology, Istanbul, Turkey
| | - Zerrin Yiğit
- Department of Cardiology, Istanbul University-Cerrahpasa Institute of Cardiology, Istanbul, Turkey
| |
Collapse
|
21
|
Jiang Q, Wang Z, Guo J, Yu T, Zhang X, Hu S. Retrospective Comparison of Endoscopic Versus Open Procedure for Mitral Valve Disease. J INVEST SURG 2020; 34:1000-1006. [PMID: 32064986 DOI: 10.1080/08941939.2020.1726531] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVES We investigated whether the totally video-assisted thoracoscopic mitral valve surgery provides superior clinical outcomes and less inflammatory injury reaction compared with conventional sternotomy. METHODS A total of 504 consecutive patients admitted for mitral valve surgery from May 2014 through May 2019 in a single center were retrospectively analyzed according to two distinct procedure approach: the totally video-assisted thoracoscopic approach (group A, n = 127) and standard median sternotomy (group B, n = 377). The primary end point was the durations of cardiopulmonary bypass, aortic cross-clamping, the ventilation time and intensive care unit of stay; the secondary endpoints included inflammation indexes like high sensitivity C-reactive protein, neutrophil-lymphocyte ratio and metabolic injury parameters cardiac Troponin and lactate. RESULTS There was only one in-hospital death due to diffuse intravascular coagulation in group A, but similar complications such as repair failure, re-thoracotomy and stroke in both groups. The durations of cardiopulmonary bypass and aortic cross-clamping were significantly longer in group A. In contrast, ventilation time and intensive care unit of stay were shortened compared with these in group B. In addition, postoperative equivalent lactate clearance but lower high sensitivity C-reactive protein, neutrophil-lymphocyte ratio and cardiac Troponin level was in group A than those in group B within postoperative 24 hours(P < 0.05). CONCLUSIONS The analysis of present study indicated despite relatively longer cardiopulmonary bypass time, the totally thoracoscopic mitral valve procedure seemed to be favorable with regard to the extent of inflammatory reaction, cardiac injury and postoperative recovery compared with conventional median sternotomy.
Collapse
Affiliation(s)
- Qin Jiang
- Department of Cardiac Surgery, Sichuan Provincial People's Hospital, Affiliated Hospital of University of Electronic Science and Technology, Chengdu, China
| | - Zhilan Wang
- Department of Gastroenterology, Sichuan Provincial People's Hospital, Affiliated Hospital of University of Electronic Science and Technology, Chengdu, China
| | - Jing Guo
- Department of Cardiac Surgery, Sichuan Provincial People's Hospital, Affiliated Hospital of University of Electronic Science and Technology, Chengdu, China
| | - Tao Yu
- Department of Cardiac Surgery, Sichuan Provincial People's Hospital, Affiliated Hospital of University of Electronic Science and Technology, Chengdu, China
| | - Xiaoshen Zhang
- Department of Cardiac Surgery, Affiliated Hospital of University of Jinan, Guangzhou, China
| | - Shengshou Hu
- Department of Cardiac Surgery, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| |
Collapse
|
22
|
Ankylosing Spondyloarthritis Resulting Severe Aortic Insufficiency and Aortitis: Exacerbation of Ankylosing Spondyloarthritis and Stenosis of the Main Left Coronary Artery after Mechanical Aortic Valve Implantation with Cardiopulmonary Bypass. Case Rep Rheumatol 2020; 2020:9538527. [PMID: 31984147 PMCID: PMC6964718 DOI: 10.1155/2020/9538527] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Accepted: 12/17/2019] [Indexed: 12/03/2022] Open
Abstract
Ankylosing spondyloarthritis (AS) is a chronic inflammatory rheumatic disease, strongly related to human leukocyte antigen (HLA)-B27. Cardiac involvement in AS manifests in 2 to 10% of patients as aortic insufficiency, aortitis, mitral valve fibrosis, or disturbance in the conduction of the heart. In this article, we present a case of a 49-year-old male patient with AS, who was referred to our medical institution for elective aortic valve surgery because of severe aortic regurgitation. The histological findings revealed fibrosing endocarditis of aortic valve and nonspecific aortitis of aortic root. Late postoperatively, we observed exacerbation of AS and narrowing of the main left coronary artery (LAD). Our case highlights the importance of proper treatment of AS before and after cardiac surgery. Furthermore, in this case, we suspect association between cardiopulmonary bypass, activity of AS, and coronary artery disease.
Collapse
|
23
|
Everett AD, Alam SS, Owens SL, Parker DM, Goodrich C, Likosky DS, Thiessen-Philbrook H, Wyler von Ballmoos M, Lobdell K, MacKenzie TA, Jacobs J, Parikh CR, DiScipio AW, Malenka DJ, Brown JR. The Association between Cytokines and 365-Day Readmission or Mortality in Adult Cardiac Surgery. THE JOURNAL OF EXTRA-CORPOREAL TECHNOLOGY 2019; 51:201-209. [PMID: 31915403 PMCID: PMC6936301 DOI: 10.1182/ject-1900014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Accepted: 08/26/2019] [Indexed: 11/20/2022]
Abstract
Cardiac surgery results in a multifactorial systemic inflammatory response with inflammatory cytokines, such as interleukin-10 and 6 (IL-10 and IL-6), shown to have potential in the prediction of adverse outcomes including readmission or mortality. This study sought to measure the association between IL-6 and IL-10 levels and 1-year hospital readmission or mortality following cardiac surgery. Plasma biomarkers IL-6 and IL-10 were measured in 1,047 patients discharged alive after isolated coronary artery bypass graft surgery from eight medical centers participating in the Northern New England Cardiovascular Disease Study Group between 2004 and 2007. Readmission status and mortality were ascertained using Medicare, state all-payer claims, and the National Death Index. We evaluated the association between preoperative and postoperative cytokines and 1-year readmission or mortality using Kaplan-Meier estimates and Cox's proportional hazards modeling, adjusting for covariates used in the Society of Thoracic Surgeons 30-day readmission model. The median follow-up time was 1 year. After adjustment, patients in the highest tertile of postoperative IL-6 values had a significantly increased risk of readmission or death within 1 year (HR: 1.38; 95% CI: 1.03-1.85), and an increased risk of death within 1 year of discharge (HR: 4.88; 95% CI: 1.26-18.85) compared with patients in the lowest tertile. However, postoperative IL-10 levels, although increasing through tertiles, were not found to be significantly associated independently with 1-year readmission or mortality (HR: 1.25; 95% CI: .93-1.69). Pro-inflammatory cytokine IL-6 and anti-inflammatory cytokine IL-10 may be postoperative markers of cardiac injury, and IL-6, specifically, shows promise in predicting readmission and mortality following cardiac surgery.
Collapse
Affiliation(s)
- Allen D. Everett
- Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Shama S. Alam
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine, Lebanon, New Hampshire
| | - Sherry L. Owens
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine, Lebanon, New Hampshire
| | - Devin M. Parker
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine, Lebanon, New Hampshire
| | - Christine Goodrich
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine, Lebanon, New Hampshire
| | - Donald S. Likosky
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan
| | - Heather Thiessen-Philbrook
- Department of Internal Medicine and Program of Applied Translational Research Yale University School of Medicine, New Haven, Connecticut
| | - Moritz Wyler von Ballmoos
- Department of Thoracic and Cardiovascular Surgery, Duke University School of Medicine, Durham, North Carolina
| | - Kevin Lobdell
- Carolinas Healthcare System, Charlotte, North Carolina
| | - Todd A. MacKenzie
- Department of Biomedical Data Science, Geisel School of Medicine, Lebanon, New Hampshire
| | - Jeffrey Jacobs
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Division of Cardiovascular Surgery, Department of Surgery, Johns Hopkins All Children’s Hospital, Saint Petersburg, Florida
| | - Chirag R. Parikh
- Department of Internal Medicine and Program of Applied Translational Research Yale University School of Medicine, New Haven, Connecticut
| | - Anthony W. DiScipio
- Department of Surgery and Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - David J. Malenka
- Section of Cardiac Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire; and
| | - Jeremiah R. Brown
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine, Lebanon, New Hampshire
- Department of Biomedical Data Science, Geisel School of Medicine, Lebanon, New Hampshire
- Department of Epidemiology, Geisel School of Medicine, Lebanon, New Hampshire
| |
Collapse
|
24
|
Abqari S, Kappanayil M, Sudhakar A, Balachandran R, Nair SG, Kumar RK. Common inflammatory markers after cardiac surgery in infants and their relation to blood stream sepsis. Heliyon 2019; 5:e02841. [PMID: 31768439 PMCID: PMC6872838 DOI: 10.1016/j.heliyon.2019.e02841] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2018] [Revised: 09/15/2019] [Accepted: 11/11/2019] [Indexed: 01/06/2023] Open
Abstract
Background Limited information exists on trends of common inflammatory markers after infant heart surgery and their role in identifying post-operative sepsis. Methods 275 consecutive infants undergoing cardiac surgery (231 with and 44 without Cardiopulmonary Bypass) were studied prospectively. Daily trends (0-4 day post-operative) of leucocyte counts, platelet counts and C-reactive protein were recorded. Association of these trends with early post-operative bloodstream sepsis, Cardiopulmonary Bypass and surgical outcomes were studied. Observations Trends of these inflammatory markers were noted. While off-Cardiopulmonary Bypass Surgery, and sepsis were associated with a statisticaly insignificant rise in total leucocyte count peaking on first post-operative day, Cardiopulmonary Bypass exposure was associated with significant decline (p = 0.002), more pronounced with Cardiopulmonary Bypass-exposure exceeding 150 min. Percentage of neutrophils showed a rise (maximum on first post-operative day) but no significant association with sepsis or Cardiopulmonary Bypass.Platelet counts significantly declined after surgery, with nadir on 2nd POD (p < 0.001), the drop being more marked in patients operated on Cardiopulmonary Bypass (p < 0.005). Counts were significantly lower in patients exposed to >150 min Cardiopulmonary Bypass compared to those with shorter Cardiopulmonary Bypass. Septic patients had significantly lower platelet counts than uninfected patients, decline >2 SD from mean pre-operative level strongly associated with sepsis (p < 0.001).C-Reactive Protein levels rose markedly after surgery, peaking on 2nd POD; levels were significantly higher if operated on Cardiopulmonary Bypass. Cardiopulmonary Bypass >150 min was associated with lower mean C-Reactive Protein on first post-operative day, but significantly higher values on third and fourth post-operative days, as compared to Cardiopulmonary Bypass <150 min. Comparison of infected versus non-infected patients showed significantly higher mean C-Reactive Protein in the former group. Conclusion While leucocyte count, platelet count and C-Reactive Protein emerged as useful markers of post-operative inflammatory response and reaction to Cardiopulmonary Bypass, they proved unsatisfactory predictors of early post-operative sepsis.
Collapse
Affiliation(s)
- Shaad Abqari
- Department of Pediatric Cardiology, Amrita Institute of Medical Sciences and Research Center, Cochin, Kerala, India
| | - Mahesh Kappanayil
- Department of Pediatric Cardiology, Amrita Institute of Medical Sciences and Research Center, Cochin, Kerala, India
| | - Abish Sudhakar
- Department of Pediatric Cardiology, Amrita Institute of Medical Sciences and Research Center, Cochin, Kerala, India
| | - Rakhi Balachandran
- Department of Cardiac Anesthesiology, Amrita Institute of Medical Sciences and Research Center, Cochin, Kerala, India
| | - Suresh G Nair
- Department of Cardiac Anesthesiology, Amrita Institute of Medical Sciences and Research Center, Cochin, Kerala, India
| | - R Krishna Kumar
- Department of Pediatric Cardiology, Amrita Institute of Medical Sciences and Research Center, Cochin, Kerala, India
| |
Collapse
|
25
|
Scholz AS, Handke J, Gillmann HJ, Zhang Q, Dehne S, Janssen H, Arens C, Espeter F, Sander A, Giannitsis E, Uhle F, Weigand MA, Motsch J, Larmann J. Frontline Science: Low regulatory T cells predict perioperative major adverse cardiovascular and cerebrovascular events after noncardiac surgery. J Leukoc Biol 2019; 107:717-730. [PMID: 31523852 DOI: 10.1002/jlb.5hi1018-392rr] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Revised: 08/04/2019] [Accepted: 08/28/2019] [Indexed: 12/29/2022] Open
Abstract
Immune cells drive atherosclerotic lesion progression and plaque destabilization. Coronary heart disease patients undergoing noncardiac surgery are at risk for perioperative major adverse cardiac and cerebrovascular events (MACCE). It is unclear whether differential leukocyte subpopulations contribute to perioperative MACCE and thereby could aid identification of patients prone to perioperative cardiovascular events. First, we performed a hypothesis-generating post hoc analysis of the LeukoCAPE-1 study (n = 38). We analyzed preoperative counts of 6 leukocyte subpopulations in coronary heart disease patients for association with MACCE (composite of cardiac death, myocardial infarction, myocardial ischemia, myocardial injury after noncardiac surgery, thromboembolic stroke) within 30 d after surgery. Regulatory T cells (Tregs) were the only leukocyte subgroup associated with MACCE. We found reduced Tregs in patients experiencing MACCE versus no-MACCE (0.02 [0.01; 0.03] vs. 0.04 [0.03; 0.05] Tregs nl-1 , P = 0.002). Using Youden index, we derived the optimal threshold value for association with MACCE to be 0.027 Tregs nl-1 . Subsequently, we recruited 233 coronary heart disease patients for the prospective, observational LeukoCAPE-2 study and independently validated this Treg cutoff for prediction of MACCE within 30 d after noncardiac surgery. After multivariate logistic regression, Tregs < 0.027 cells nl-1 remained an independent predictor for MACCE (OR = 2.54 [1.22; 5.23], P = 0.012). Tregs improved risk discrimination of the revised cardiac risk index based on ΔAUC (area under the curve; ΔAUC = 0.09, P = 0.02), NRI (0.26), and IDI (0.06). Preoperative Treg levels below 0.027 cells nl-1 predicted perioperative MACCE and can be measured to increase accuracy of established preoperative cardiac risk stratification in coronary heart disease patients undergoing noncardiac surgery.
Collapse
Affiliation(s)
- Anna S Scholz
- Department of Anesthesiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Jessica Handke
- Department of Anesthesiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Hans-Jörg Gillmann
- Department of Anesthesiology and Intensive Care Medicine, Hannover Medical School, Hannover, Germany
| | - Qinya Zhang
- Department of Anesthesiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Sarah Dehne
- Department of Anesthesiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Henrike Janssen
- Department of Anesthesiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Christoph Arens
- Department of Anesthesiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Florian Espeter
- Department of Anesthesiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Anja Sander
- Institute of Medical Biometry and Informatics, University of Heidelberg, Heidelberg, Germany
| | - Evangelos Giannitsis
- Department of Internal Medicine III, Heidelberg University Hospital, Heidelberg, Germany
| | - Florian Uhle
- Department of Anesthesiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Markus A Weigand
- Department of Anesthesiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Johann Motsch
- Department of Anesthesiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Jan Larmann
- Department of Anesthesiology, University Hospital Heidelberg, Heidelberg, Germany
| |
Collapse
|
26
|
Effect of sevoflurane-based or propofol-based anaesthesia on the incidence of postoperative acute kidney injury. Eur J Anaesthesiol 2019; 36:649-655. [DOI: 10.1097/eja.0000000000001020] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
|
27
|
Rodrigues C, Siciliano RF, Filho HC, Charbel CE, de Carvalho Sarahyba da Silva L, Baiardo Redaelli M, de Paula Rosa Passetti AP, Franco MRG, Rossi F, Zeigler R, De Backer D, Franco RA, de Almeida JP, Rizk SI, Fukushima JT, Landoni G, Uip DE, Hajjar LA, Strabelli TMV. The effect of a rapid molecular blood test on the use of antibiotics for nosocomial sepsis: a randomized clinical trial. J Intensive Care 2019; 7:37. [PMID: 31367384 PMCID: PMC6647273 DOI: 10.1186/s40560-019-0391-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Accepted: 07/08/2019] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Appropriate use of antimicrobials is essential to improve outcomes in sepsis. The aim of this study was to determine whether the use of a rapid molecular blood test-SeptiFast (SF) reduces the antibiotic consumption through early de-escalation in patients with nosocomial sepsis compared with conventional blood cultures (BCs). METHODS This was a prospective, randomized, superiority, controlled trial conducted at Sao Paulo Heart Institute in the period October 2012-May 2016. Adult patients admitted to the hospital for at least 48 h with a diagnosis of nosocomial sepsis underwent microorganism identification by both SF test and BCs. Patients randomized into the intervention group received antibiotic therapy adjustment according to the results of SF. Patients randomized into the control group received standard antibiotic adjustment according to the results of BCs. The primary endpoint was antimicrobial consumption during the first 14 days after randomization. RESULTS A total of 200 patients were included (100 in each group). The intention to treat analysis found no significant differences in median antibiotic consumption. In the subgroup of patients with positive SF and blood cultures (19 and 25 respectively), we found a statistically significant reduction in the median antimicrobial consumption which was 1429 (1071-2000) days of therapy (DOT)/1000 patients-day in the intervention group and 1889 (1357-2563) DOT/1000 patients-day in the control group (p = 0.017), in the median time of antimicrobial de-escalation (8 versus 54 h-p < 0.001), in the duration of antimicrobial therapy (p = 0.039) and in anti-gram-positive antimicrobial costs (p = 0.002). Microorganism identification was possible in 24.5% of patients (45/184) by SF and 21.2% (39/184) by BC (p = 0.45). CONCLUSION This randomized clinical trial showed that the use of a rapid molecular-based pathogen identification test does not reduce the median antibiotic consumption in nosocomial sepsis. However, in patients with positive microbiological tests, the use of SeptiFast reduced antimicrobial consumption through early de-escalation compared to conventional blood cultures. These results were driven by a reduction in the consumption of antimicrobials used for Gram-positive bacteria. TRIAL REGISTRATION The trial was registered at ClinicalTrials.gov (NCT01450358) on 12th October 2011.
Collapse
Affiliation(s)
- Cristhieni Rodrigues
- Infectious Diseases Control, Heart Institute, University of Sao Paulo, São Paulo, Brazil
| | | | | | | | | | - Martina Baiardo Redaelli
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Vita-Salute San Raffaele University of Milan, Milan, Italy
| | | | | | - Flávia Rossi
- Microbiology Division, University of Sao Paulo, São Paulo, Brazil
| | - Rogerio Zeigler
- Infectious Diseases Control, Heart Institute, University of Sao Paulo, São Paulo, Brazil
| | - Daniel De Backer
- Department of Intensive Care at the Erasme University, Universite Libre de Bruxelles, Bruxelles, Belgium
| | - Rafael Alves Franco
- Intensive Care Unit, Instituto do Cancer, University of Sao Paulo, São Paulo, Brazil
| | | | - Stéphanie Itala Rizk
- Intensive Care Unit, Instituto do Cancer, University of Sao Paulo, São Paulo, Brazil
| | - Julia Tizue Fukushima
- Intensive Care Unit, Instituto do Cancer, University of Sao Paulo, São Paulo, Brazil
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Vita-Salute San Raffaele University of Milan, Milan, Italy
| | - David Everson Uip
- Infectious Diseases Control, Heart Institute, University of Sao Paulo, São Paulo, Brazil
| | | | | |
Collapse
|
28
|
Chew STH, Hwang NC. Acute Kidney Injury After Cardiac Surgery: A Narrative Review of the Literature. J Cardiothorac Vasc Anesth 2019; 33:1122-1138. [DOI: 10.1053/j.jvca.2018.08.003] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2018] [Indexed: 02/07/2023]
|
29
|
Brettner F, Chappell D, Nebelsiek T, Hauer D, Schelling G, Becker BF, Rehm M, Weis F. Preinterventional hydrocortisone sustains the endothelial glycocalyx in cardiac surgery. Clin Hemorheol Microcirc 2019; 71:59-70. [DOI: 10.3233/ch-180384] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- Florian Brettner
- Department of Anaesthesiology, University Hospital of Munich, LMU Munich, Munich, Germany
- Walter-Brendel Centre of Experimental Medicine, Ludwig-Maximilians-University Munich, Martinsried, Germany
| | - Daniel Chappell
- Department of Anaesthesiology, University Hospital of Munich, LMU Munich, Munich, Germany
| | - Tim Nebelsiek
- Department of Anaesthesiology, University Hospital of Munich, LMU Munich, Munich, Germany
| | - Daniela Hauer
- Department of Anaesthesiology, University Hospital of Munich, LMU Munich, Munich, Germany
| | - Gustav Schelling
- Department of Anaesthesiology, University Hospital of Munich, LMU Munich, Munich, Germany
| | - Bernhard F. Becker
- Walter-Brendel Centre of Experimental Medicine, Ludwig-Maximilians-University Munich, Martinsried, Germany
| | - Markus Rehm
- Department of Anaesthesiology, University Hospital of Munich, LMU Munich, Munich, Germany
| | - Florian Weis
- Department of Anaesthesiology and Intensive Care Medicine, Klinikum Fürstenfeldbruck, Fürstenfeldbruck, Germany
| |
Collapse
|
30
|
Affiliation(s)
- Junichi Sugita
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo
| | - Katsuhito Fujiu
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo.,Department of Advanced Cardiology, Graduate School of Medicine, The University of Tokyo
| |
Collapse
|
31
|
Schmidt AK, Assmann A, Lichtenberg A, Boeken U. Systemische Inflammation und Herzchirurgie. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2018. [DOI: 10.1007/s00398-017-0173-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
|
32
|
Brettner F, Chappell D, Schwartz L, Lukasz A, Kümpers P, Becker BF, Reichart B, Rehm M, Bruegger D. Vascular Endothelial Dysfunction during Cardiac Surgery: On-Pump versus Off-Pump Coronary Surgery. Eur Surg Res 2017; 58:354-368. [PMID: 29073603 DOI: 10.1159/000480431] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Accepted: 08/16/2017] [Indexed: 01/05/2023]
Abstract
BACKGROUND Cardiac surgery often causes ischemia and development of a systemic inflammatory response syndrome, which impairs vascular barrier function, normally maintained by the endothelial cell line and the endothelial glycocalyx (EG). The EG normally covers and protects healthy endothelial cells throughout the vasculature. The aim of the present study was to assess the disruption of the cellular part of the microvascular barrier by determining parameters of endothelial cell activation known to influence and reflect cell-cell junctional integrity. Particular attention was placed on angiopoietins and their important effects on endothelial gap junctions. Furthermore, comparative measurements were undertaken in patients undergoing on- and off-pump cardiac surgery, the latter group presumably experiencing less ischemic stress. METHODS 30 patients undergoing elective coronary artery bypass surgery were assigned to the conventional coronary artery bypass (CCAB) group (n = 15) or the off-pump coronary artery bypass grafting (OPCAB) group (n = 15). Blood samples were obtained for measuring angiopoietin-1 (Ang-1), angiopoietin-2 (Ang-2), vascular endothelial (VE)-cadherin, and endocan at various time points. RESULTS There were significant increases in all measured parameters in both study groups versus the respective basal values. Maximal increases were as follows: Ang-1: CCAB +220%, OPCAB +166%, p < 0.05 each; Ang-2: CCAB +150%, OPCAB +20%, p < 0.05 each; VE-cadherin: CCAB +87%, OPCAB +66%, p < 0.05 each; endocan: CCAB +323%, OPCAB +72%, p < 0.05 each. CONCLUSION The present study demonstrates the activation of endothelial cells, shedding of cell-cell contacts and a potential intrinsic counterregulation by Ang-1 and endocan in patients undergoing major cardiac surgery. Quantitatively greater deviations of parameters in the CCAB than in the OPCAB group suggest a relation between the occurrence of ischemia/reperfusion and the extent of endothelial activation.
Collapse
Affiliation(s)
- Florian Brettner
- Department of Anaesthesiology, University Hospital of Munich (LMU), Munich, Germany.,Walter-Brendel-Centre of Experimental Medicine, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Daniel Chappell
- Department of Anaesthesiology, University Hospital of Munich (LMU), Munich, Germany
| | - Lisa Schwartz
- Department of Anaesthesiology, University Hospital of Munich (LMU), Munich, Germany
| | - Alexander Lukasz
- Department of Medicine, Division of General Internal Medicine, Nephrology, and Rheumatology, University Hospital Münster, Münster, Germany
| | - Philipp Kümpers
- Department of Medicine, Division of General Internal Medicine, Nephrology, and Rheumatology, University Hospital Münster, Münster, Germany
| | - Bernhard F Becker
- Walter-Brendel-Centre of Experimental Medicine, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Bruno Reichart
- Department of Cardiac Surgery, University Hospital of Munich (LMU), Munich, Germany
| | - Markus Rehm
- Department of Anaesthesiology, University Hospital of Munich (LMU), Munich, Germany
| | - Dirk Bruegger
- Department of Anaesthesiology, University Hospital of Munich (LMU), Munich, Germany
| |
Collapse
|
33
|
Poon KS, Palanisamy K, Chang SS, Sun KT, Chen KB, Li PC, Lin TC, Li CY. Plasma exosomal miR-223 expression regulates inflammatory responses during cardiac surgery with cardiopulmonary bypass. Sci Rep 2017; 7:10807. [PMID: 28883474 PMCID: PMC5589826 DOI: 10.1038/s41598-017-09709-w] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Accepted: 07/28/2017] [Indexed: 01/24/2023] Open
Abstract
Cardiopulmonary bypass (CPB) induces inflammatory responses, and effective endogenous homeostasis is important for preventing systemic inflammation. We assessed whether plasma exosomal microRNAs in patients undergoing cardiac surgery with CPB are involved in the regulation of inflammatory responses. Plasma samples were isolated from CPB patients (n = 21) at 5 specified time points: pre-surgery, pre-CPB and 2 hours (h), 4 h and 24 h after CPB began. Plasma TNF-α expression was increased after CPB began compared to that in the pre-surgery samples. Plasma IL-8 and IL-6 expression peaked at 4 h after CPB began but was downregulated at 24 h. The number of plasma exosomes collected at 2 h (55.1 ± 8.3%), 4 h (63.8 ± 10.1%) and 24 h (83.5 ± 3.72%) after CPB began was significantly increased compared to that in the pre-CPB samples (42.8 ± 0.11%). These exosomes had a predominantly parental cellular origin from RBCs and platelets. Additionally, the plasma exosomal miR-223 levels were significantly increased after CPB began compared to those in the pre-CPB samples. Further, exosomal miR-223 from plasma collected after CPB began downregulated IL-6 and NLRP3 expression in the monocytes. Here, we present the novel findings that increased plasma exosomal miR-223 expression during cardiac surgery with CPB might play homeostatic roles in downregulating inflammatory responses through intercellular communication.
Collapse
Affiliation(s)
- Kin-Shing Poon
- Department of Anesthesiology, China Medical University and Hospital, Taichung, Taiwan
| | - Kalaiselvi Palanisamy
- Graduate Institute of Clinical Medical Science, China Medical University, Taichung, Taiwan
| | - Shih-Sheng Chang
- Graduate Institute of Clinical Medical Science, China Medical University, Taichung, Taiwan.,Division of Cardiology, Department of Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Kuo-Ting Sun
- Department of Pediatric Dentistry, China Medical University Hospital, Taichung, Taiwan.,School of Dentistry, China Medical University, Taichung, Taiwan
| | - Kuen-Bao Chen
- Department of Anesthesiology, China Medical University and Hospital, Taichung, Taiwan
| | - Ping-Chun Li
- Department of Surgery, China Medical University Hospital, Taichung, Taiwan
| | - Tso-Chou Lin
- Department of Anesthesiology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Chi-Yuan Li
- Department of Anesthesiology, China Medical University and Hospital, Taichung, Taiwan. .,Graduate Institute of Clinical Medical Science, China Medical University, Taichung, Taiwan.
| |
Collapse
|
34
|
Andersen LW. Lactate Elevation During and After Major Cardiac Surgery in Adults: A Review of Etiology, Prognostic Value, and Management. Anesth Analg 2017; 125:743-752. [PMID: 28277327 DOI: 10.1213/ane.0000000000001928] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Elevated lactate is a common occurrence after cardiac surgery. This review summarizes the literature on the complex etiology of lactate elevation during and after cardiac surgery, including considerations of oxygen delivery, oxygen utilization, increased metabolism, lactate clearance, medications and fluids, and postoperative complications. Second, the association between lactate and a variety of outcomes are described, and the prognostic role of lactate is critically assessed. Despite the fact that elevated lactate is strongly associated with many important outcomes, including postoperative complications, length of stay, and mortality, little is known about the optimal management of postoperative patients with lactate elevations. This review ends with an assessment of the limited literature on this subject.
Collapse
Affiliation(s)
- Lars W Andersen
- From the *Research Center for Emergency Medicine, Aarhus University Hospital, Aarhus, Denmark; †Center for Resuscitation Science, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts; ‡Department of Anesthesiology, Aarhus University Hospital, Aarhus, Denmark; and §Department of Medicine, Regional Hospital Holstebro, Aarhus University, Holstebro, Denmark
| |
Collapse
|
35
|
Kudlová M, Koláčková M, Kuneš P, Lonský V, Manďák J, Andrýs C, Krejsek J. Expression of an Activated Form of Integrin β2 Chain CD18 in Cardiac Surgical Operations. ACTA MEDICA (HRADEC KRÁLOVÉ) 2017; 50:187-193. [DOI: 10.14712/18059694.2017.81] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Background: Myeloid cells are extensively activated in patients undergoing cardiosurgical operations. It is supposed that this activation is more profound in patients operated with cardiopulmonary bypass (CPB) („on-pump“) in comparison with patients operated without CPB („off-pump“). Aims: To evaluate changes in the expression of a novel activation marker expressed on myeloid cells recognized by MEM-148 antibody. Patients and Methods: The expression of MEM-148 positive myeloid cells was evaluated by flow cytometry in 40 patients who underwent coronary artery bypass surgery (CABG) randomly assigned to „on-pump“ or „off-pump“ technique. Results: The relative and absolute number of MEM-148 positive myeloid cells is significantly diminished during „on-pump“ surgery. A significant increase in their number in postoperative period in both „on-pump“ and „off-pump“ patients was found. There were no significant differencies between „on-pump“ and „off-pump“ patients. Conclusions: The very trauma of surgery seems to be more relevant in starting on activation of myeloid cells them CPB itself.
Collapse
|
36
|
Zawadka M, Wahome J, Oszkiel H, Szeto WY, Cobb B, Laudanski K. Long-term alterations in monocyte function after elective cardiac surgery. Anaesthesia 2017; 72:879-888. [PMID: 28407211 DOI: 10.1111/anae.13868] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/10/2017] [Indexed: 12/26/2022]
Abstract
Optimal immunological homoeostasis determines the long-term recovery of patients in the postoperative period. The functional adaptability of monocytes plays a pivotal role in adjusting the host's response to an insult, immunostasis and long-term health, and may help to determine successful recovery. We undertook a longitudinal analysis of the functional adaptability of monocytes in 20 patients undergoing heart surgery with cardiopulmonary bypass, as a model of severe stress. Using each patient's pre-cardiopulmonary bypass data as a baseline, we investigated the characteristics of peripheral blood monocytes' functional plasticity in-vitro before elective bypass, and three months afterwards. Approximately 30% of subjects showed diminished monocyte plasticity, as demonstrated by decreased monocyte differentiation into dendritic cells three months after bypass. Diminished monocyte functional plasticity was related to over-production of macrophage colony-stimulating factor. Adding a neutralising antibody to macrophage colony-stimulating factor corrected the monocytes' differentiation defect. Finally, patients with reduced monocyte plasticity had significantly elevated serum C-reactive protein, with a concomitant increase in cytomegalovirus IgG antibody titres, suggestive of the acquisition of immuno-suppressive traits. Our study shows that severe surgical stress resulted in a lasting immunological defect in individuals who had seemingly recovered.
Collapse
Affiliation(s)
- M Zawadka
- 2nd Department of Anaesthesiology and Intensive Care, Medical University of Warsaw, Warsaw, Poland
| | - J Wahome
- Undergraduate Student Department, Lincoln University, Lincoln, Pennsylvania, USA
| | - H Oszkiel
- Department of Epigenetics, Mossakowski Medical Research Centre, PAS., Warsaw, Poland
| | - W Y Szeto
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - B Cobb
- Department of Anaesthesiology and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - K Laudanski
- Department of Anaesthesiology and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| |
Collapse
|
37
|
Karakisi SO, Kunt AG, Bozok Ş, Çankaya İ, Kocakulak M, Muşabak U, Sargon MF, Ergene Ş, İlhan G, Karamustafa H, Tufekci N, Şener E. Humoral immune response and coated or uncoated oxygenators during cardiopulmonary bypass surgery. Cardiovasc J Afr 2016; 27:242-245. [PMID: 27841912 PMCID: PMC5340897 DOI: 10.5830/cvja-2016-003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Accepted: 01/08/2016] [Indexed: 12/02/2022] Open
Abstract
Aim: To investigate and compare uncoated and phosphorylcholine-coated oxygenators in terms of induction of humoral immune response during coronary artery bypass surgery. Methods: A total of 20 consecutive patients who underwent coronary artery bypass surgery were randomly distributed into two groups according to the type of oxygenator used during surgery. Group 1 consisted of 10 patients who were operated on using phosphorylcholine-coated oxygenators. Group 2 contained 10 patients who underwent surgery using uncoated oxygenators. Blood and oxygenator fibre samples were obtained and compared in terms of immunoglobulins (IgG, IgM), complements (C3c, C4), serum total protein and albumin levels using electron microscopy and flow cytometry. Results: In group 1, levels of IgM, IgG, total protein and serum albumin were significantly increased at the end of cardiopulmonary bypass (CPB) compared to those at the beginning of CPB. In group 2, C3c and C4 levels at the beginning of CPB were found to be significantly higher than at the end. Electron microscopic examination of oxygenator fibres demonstrated that phosphorylcholine-coated fibres were less likely to be adsorbed by serum proteins and complements than the uncoated fibres. Conclusion: Our results indicate that phosphorylcholine-coated oxygenators seemed to induce humoral immune response to a lesser extent than uncoated oxygenators during coronary artery bypass procedures.
Collapse
Affiliation(s)
- Sedat Ozan Karakisi
- Department of Cardiovascular Surgery, Faculty of Medicine, Recep Tayyip Erdogan University, Training and Research Hospital, Rize, Turkey
| | - Ayşe Gül Kunt
- Department of Cardiovascular Surgery, Faculty of Medicine, Yıldırım Beyazıd University, Atatürk Training and Research Hospital, Ankara, Turkey
| | - Şahin Bozok
- Department of Cardiovascular Surgery, Faculty of Medicine, Recep Tayyip Erdogan University, Training and Research Hospital, Rize, Turkey
| | - İdil Çankaya
- Department of Biomedical Engineering, Baskent University, Ankara, Turkey
| | - Mustafa Kocakulak
- Department of Biomedical Engineering, Baskent University, Ankara, Turkey
| | - Uğur Muşabak
- Department of Immunology, Gulhane Military Medical Academy and School of Medicine, Ankara, Turkey
| | - Mustafa Fevzi Sargon
- Department of Anatomy, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Şaban Ergene
- Department of Cardiovascular Surgery, Faculty of Medicine, Recep Tayyip Erdogan University, Training and Research Hospital, Rize, Turkey
| | - Gökhan İlhan
- Department of Cardiovascular Surgery, Faculty of Medicine, Recep Tayyip Erdogan University, Training and Research Hospital, Rize, Turkey
| | - Hakan Karamustafa
- Department of Cardiovascular Surgery, Faculty of Medicine, Recep Tayyip Erdogan University, Training and Research Hospital, Rize, Turkey
| | - Nebiye Tufekci
- Department of Cardiovascular Surgery, Faculty of Medicine, Recep Tayyip Erdogan University, Training and Research Hospital, Rize, Turkey
| | - Erol Şener
- Department of Cardiovascular Surgery, Faculty of Medicine, Yıldırım Beyazıd University, Atatürk Training and Research Hospital, Ankara, Turkey
| |
Collapse
|
38
|
Fakhri D, Busro PW, Rahmat B, Purba S, Mukti AA, Caesario M, Christy K, Santoso A, Djauzi S. Risk factors of sepsis after open congenital cardiac surgery in infants: a pilot study. MEDICAL JOURNAL OF INDONESIA 2016. [DOI: 10.13181/mji.v25i3.1450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
Background: Postsurgical sepsis is one of the main causes of the high mortality and morbidity after open congenital heart surgery in infants. This study aimed to evaluate the role of cardiopulmonary bypass duration, thymectomy, surgical complexity, and nutritional status on postsurgical sepsis after open congenital cardiac surgery in infants.Methods: A total of 40 patients <1 year of age with congenital heart disease, Aristotle Basic Score (ABS) ≥6 were followed for clinical and laboratory data before and after surgery until the occurrence of signs or symptoms of sepsis or until a maximum of 7 days after surgery. Bivariate analyses were performed. Variables with p≤0.200 were then included for logistic regression.Results: Duration of cardiopulmonary bypass ≥90 minutes was associated with 5.538 increased risk of postsurgical sepsis in comparison to those ≤90 minutes (80% vs 25%, RR=5.538, p=0.006). No association was observed between the incidence of postsurgical sepsis with poor nutritional status (86% vs 84%, RR=1.059, p=1.000), thymectomy (and 50% vs 76%, RR=0.481, p=0.157), and Aristotle Basic Score (p=0.870).Conclusion: Cardiopulmonary bypass time influences the incidence of sepsis infants undergoing open congenital cardiac surgery. Further studies are needed to elaborate a number of risk factors associated with the incidence of sepsis in this population.
Collapse
|
39
|
Kanzaki R, Kimura T, Kawamura T, Funaki S, Shintani Y, Minami M, Miyagawa S, Toda K, Sawa Y, Okumura M. Treatment of simultaneously discovered lung cancer and cardiovascular disease: a 20-year single-institution experience. Surg Today 2016; 47:726-732. [PMID: 27688032 DOI: 10.1007/s00595-016-1424-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2016] [Accepted: 09/13/2016] [Indexed: 11/25/2022]
Abstract
PURPOSE To propose a treatment strategy for simultaneously discovered non-small cell lung cancer (NSCLC) and cardiovascular disease (CVD). METHODS Of 1302 patients who underwent surgery for NSCLC, CVD requiring invasive treatment was simultaneously discovered in 33 (3 %). The details of the treatments as well as the short- and long-term outcomes of pulmonary resection were analyzed. RESULTS CVD included coronary artery disease in 20 patients, valvular disease in 6, abdominal aortic aneurysm in 5, and congenital heart disease in 2. Twenty-six patients underwent two-stage treatment, while seven received simultaneous surgery. In 23 patients whose treatment for CVD preceded that for lung cancer, the median interval between those treatments was 78 days (range 18-197 days). Postoperative complications occurred in 8 (31 %) of 26 patients who underwent 2-stage treatment and in 3 (43 %) of 7 who underwent simultaneous surgery. Notably, of 3 patients who underwent lobectomy or bilobectomy, 2 (67 %) experienced respiratory dysfunction that required intubation. The 5-year overall survival rate of all 33 patients was 84.5 %. CONCLUSION The outcomes of two-stage treatment in the present cohort were favorable. Given our experience, simultaneous surgery for lung cancer and CVD should, therefore, be selected only for patients who may benefit from that strategy.
Collapse
Affiliation(s)
- Ryu Kanzaki
- Department of General Thoracic Surgery, Osaka University Graduate School of Medicine, L5-2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan.
| | - Toru Kimura
- Department of General Thoracic Surgery, Osaka University Graduate School of Medicine, L5-2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Tomohiro Kawamura
- Department of General Thoracic Surgery, Osaka University Graduate School of Medicine, L5-2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Soichiro Funaki
- Department of General Thoracic Surgery, Osaka University Graduate School of Medicine, L5-2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Yasushi Shintani
- Department of General Thoracic Surgery, Osaka University Graduate School of Medicine, L5-2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Masato Minami
- Department of General Thoracic Surgery, Osaka University Graduate School of Medicine, L5-2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Shigeru Miyagawa
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Suita, Japan
| | - Koichi Toda
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Suita, Japan
| | - Yoshiki Sawa
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Suita, Japan
| | - Meinoshin Okumura
- Department of General Thoracic Surgery, Osaka University Graduate School of Medicine, L5-2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| |
Collapse
|
40
|
Spoelstra-de Man AME, Smit B, Oudemans-van Straaten HM, Smulders YM. Cardiovascular effects of hyperoxia during and after cardiac surgery. Anaesthesia 2015; 70:1307-19. [PMID: 26348878 DOI: 10.1111/anae.13218] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/20/2015] [Indexed: 12/23/2022]
Abstract
During and after cardiac surgery with cardiopulmonary bypass, high concentrations of oxygen are routinely administered, with the intention of preventing cellular hypoxia. We systematically reviewed the literature addressing the effects of arterial hyperoxia. Extensive evidence from pre-clinical experiments and clinical studies in other patient groups suggests predominant harm, caused by oxidative stress, vasoconstriction, perfusion heterogeneity and myocardial injury. Whether these alterations are temporary and benign, or actually affect clinical outcome, remains to be demonstrated. In nine clinical cardiac surgical studies in low-risk patients, higher oxygen targets tended to compromise cardiovascular function, but did not affect clinical outcome. No data about potential beneficial effects of hyperoxia, such as reduction of gas micro-emboli or post-cardiac surgery infections, were reported. Current evidence is insufficient to specify optimal oxygen targets. Nevertheless, the safety of supraphysiological oxygen suppletion is unproven. Randomised studies with a variety of oxygen targets and inclusion of high-risk patients are needed to identify optimal oxygen targets during and after cardiac surgery.
Collapse
Affiliation(s)
| | - B Smit
- Department of Intensive Care, VU University Medical Centre, Amsterdam, The Netherlands
| | | | - Y M Smulders
- Department of Internal Medicine, VU University Medical Centre, Amsterdam, The Netherlands
| |
Collapse
|
41
|
Janssen H, Wagner CS, Demmer P, Callies S, Sölter G, Loghmani-khouzani H, Hu N, Schuett H, Tietge UJF, Warnecke G, Larmann J, Theilmeier G. Acute perioperative-stress-induced increase of atherosclerotic plaque volume and vulnerability to rupture in apolipoprotein-E-deficient mice is amenable to statin treatment and IL-6 inhibition. Dis Model Mech 2015; 8:1071-80. [PMID: 26092124 PMCID: PMC4582096 DOI: 10.1242/dmm.018713] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2014] [Accepted: 06/09/2015] [Indexed: 01/15/2023] Open
Abstract
Myocardial infarction and stroke are frequent after surgical procedures and consume a considerable amount of benefit of surgical therapy. Perioperative stress, induced by surgery, is composed of hemodynamic and inflammatory reactions. The effects of perioperative stress on atherosclerotic plaques are ill-defined. Murine models to investigate the influence of perioperative stress on plaque stability and rupture are not available. We developed a model to investigate the influence of perioperative stress on plaque growth and stability by exposing apolipoprotein-E-deficient mice, fed a high cholesterol diet for 7 weeks, to a double hit consisting of 30 min of laparotomy combined with a substantial blood loss (approximately 20% of total blood volume; 400 µl). The innominate artery was harvested 72 h after the intervention. Control groups were sham and baseline controls. Interleukin-6 (IL-6) and serum amyloid A (SAA) plasma levels were determined. Plaque load, vascular smooth muscle cell (VSMC) and macrophage content were quantified. Plaque stability was assessed using the Stary score and frequency of signs of plaque rupture were assessed. High-dose atorvastatin (80 mg/kg body weight/day) was administered for 6 days starting 3 days prior to the double hit. A single dose of an IL-6-neutralizing antibody or the fusion protein gp130-Fc selectively targeting IL-6 trans-signaling was subcutaneously injected. IL-6 plasma levels increased, peaking at 6 h after the intervention. SAA levels peaked at 24 h (n=4, P<0.01). Plaque volume increased significantly with the double hit compared to sham (n=8, P<0.01). More plaques were scored as complex or bearing signs of rupture after the double hit compared to sham (n=5-8, P<0.05). Relative VSMC and macrophage content remained unchanged. IL-6-inhibition or atorvastatin, but not blocking of IL-6 trans-signaling, significantly decreased plaque volume and complexity (n=8, P<0.01). Using this model, researchers will be able to further investigate the pathophysiology of perioperative plaque stability, which can result in myocardial infarction, and, additionally, to test potential protective strategies. Summary: We developed a model to study the dynamics of atherosclerotic plaque growth and stability following surgery, and show that IL-6 inhibition and statins beneficially affect plaque volume and complexity.
Collapse
Affiliation(s)
- Henrike Janssen
- Department of Anesthesiology and Intensive Care Medicine, Hannover Medical School, 30625 Hannover, Germany Department of Anesthesiology, University of Heidelberg, 69120 Heidelberg, Germany
| | - Christian S Wagner
- Department of Anesthesiology and Intensive Care Medicine, Hannover Medical School, 30625 Hannover, Germany
| | - Philipp Demmer
- Department of Anesthesiology and Intensive Care Medicine, Hannover Medical School, 30625 Hannover, Germany
| | - Simone Callies
- Department of Anesthesiology and Intensive Care Medicine, Hannover Medical School, 30625 Hannover, Germany
| | - Gesine Sölter
- Department of Anesthesiology and Intensive Care Medicine, Hannover Medical School, 30625 Hannover, Germany
| | - Houra Loghmani-khouzani
- Department of Anesthesiology and Intensive Care Medicine, Hannover Medical School, 30625 Hannover, Germany
| | - Niandan Hu
- Department of Anesthesiology and Intensive Care Medicine, Hannover Medical School, 30625 Hannover, Germany
| | - Harald Schuett
- Department of Cardiology, University Hospital Marburg, 35043 Marburg, Germany
| | - Uwe J F Tietge
- Department of Pediatrics, University of Groningen, UMCG, NL-9700 Groningen, The Netherlands
| | - Gregor Warnecke
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, 30625 Hannover, Germany German Centre for Lung Research (DZL), 30625 Hannover, Germany
| | - Jan Larmann
- Department of Anesthesiology and Intensive Care Medicine, Hannover Medical School, 30625 Hannover, Germany Department of Anesthesiology, University of Heidelberg, 69120 Heidelberg, Germany
| | - Gregor Theilmeier
- Department of Anesthesiology and Intensive Care Medicine, Hannover Medical School, 30625 Hannover, Germany Faculty VI - Medicine and Health Sciences, Dept of Health Services Sciences, University of Oldenburg, 26129 Germany
| |
Collapse
|
42
|
Freundt M, Ried M, Philipp A, Diez C, Kolat P, Hirt SW, Schmid C, Haneya A. Minimized extracorporeal circulation is improving outcome of coronary artery bypass surgery in the elderly. Perfusion 2015; 31:143-8. [PMID: 26034198 DOI: 10.1177/0267659115588634] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Advanced age is a known risk factor for morbidity and mortality after coronary artery bypass grafting (CABG). Minimized extracorporeal circulation (MECC) has been shown to reduce the negative effects associated with conventional extracorporeal circulation (CECC). This trial assesses the impact of MECC on the outcome of elderly patients undergoing CABG. Eight hundred and seventy-five patients (mean age 78.35 years) underwent isolated CABG using CECC (n=345) or MECC (n=530). The MECC group had a significantly shorter extracorporeal circulation time (ECCT), cross-clamp time and reperfusion time and lower transfusion needs. Postoperatively, these patients required significantly less inotropic support, fewer blood transfusions, less postoperative hemodialysis and developed less delirium compared to CECC patients. In the MECC group, intensive care unit (ICU) stay was significantly shorter and 30-day mortality was significantly reduced [2.6% versus 7.8%; p<0.001]. In conclusion, MECC improves outcome in elderly patients undergoing CABG surgery.
Collapse
Affiliation(s)
- Miriam Freundt
- Dept. of Cardiothoracic Surgery, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, D-93053 Regensburg, Germany
| | - Michael Ried
- Dept. of Cardiothoracic Surgery, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, D-93053 Regensburg, Germany
| | - Alois Philipp
- Dept. of Cardiothoracic Surgery, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, D-93053 Regensburg, Germany
| | - Claudius Diez
- Dept. of Cardiothoracic Surgery, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, D-93053 Regensburg, Germany
| | - Philipp Kolat
- Dept. of Cardiothoracic Surgery, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, D-93053 Regensburg, Germany
| | - Stephan W Hirt
- Dept. of Cardiothoracic Surgery, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, D-93053 Regensburg, Germany
| | - Christof Schmid
- Dept. of Cardiothoracic Surgery, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, D-93053 Regensburg, Germany
| | - Assad Haneya
- Dept. of Cardiothoracic Surgery, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, D-93053 Regensburg, Germany
| |
Collapse
|
43
|
A novel minimal invasive mouse model of extracorporeal circulation. Mediators Inflamm 2015; 2015:412319. [PMID: 25705092 PMCID: PMC4325217 DOI: 10.1155/2015/412319] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2014] [Revised: 01/12/2015] [Accepted: 01/12/2015] [Indexed: 02/05/2023] Open
Abstract
Extracorporeal circulation (ECC) is necessary for conventional cardiac surgery and life support, but it often triggers systemic inflammation that can significantly damage tissue. Studies of ECC have been limited to large animals because of the complexity of the surgical procedures involved, which has hampered detailed understanding of ECC-induced injury. Here we describe a minimally invasive mouse model of ECC that may allow more extensive mechanistic studies. The right carotid artery and external jugular vein of anesthetized adult male C57BL/6 mice were cannulated to allow blood flow through a 1/32-inch external tube. All animals (n = 20) survived 30 min ECC and subsequent 60 min observation. Blood analysis after ECC showed significant increases in levels of tumor necrosis factor α, interleukin-6, and neutrophil elastase in plasma, lung, and renal tissues, as well as increases in plasma creatinine and cystatin C and decreases in the oxygenation index. Histopathology showed that ECC induced the expected lung inflammation, which included alveolar congestion, hemorrhage, neutrophil infiltration, and alveolar wall thickening; in renal tissue, ECC induced intracytoplasmic vacuolization, acute tubular necrosis, and epithelial swelling. Our results suggest that this novel, minimally invasive mouse model can recapitulate many of the clinical features of ECC-induced systemic inflammatory response and organ injury.
Collapse
|
44
|
Urhan Küçük M, Sucu N, Şahan Firat S, Aytaçoğlu BN, Vezir Ö, Bozali C, Canacankatan N, Kul S, Tunçtan B. Role of ACE I/D gene polymorphisms on the effect of ramipril in inflammatory response and myocardial injury in patients undergoing coronary artery bypass grafts. Eur J Clin Pharmacol 2014; 70:1443-51. [PMID: 25256070 DOI: 10.1007/s00228-014-1751-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2014] [Accepted: 09/08/2014] [Indexed: 01/13/2023]
Abstract
BACKGROUND Angiotensin-converting enzyme (ACE) inhibitors block angiotensin II formation and release bradykinin, which is effective in the regulation of oxidoinflammatory injury. Some reports denote alterations in the effectiveness of ACE inhibitors in association with ACE insertion/deletion (I/D) gene polymorphisms. This study investigates the effects of ramipril on the oxidoinflammatory cytokines (IL-6, IL-8, TNF-alpha) and TnT (myocardial injury marker) and their alteration in association with ACE I/D gene polymorphisms. METHODS The study group (n = 51) patients received ramipril before coronary artery bypass grafting (CABG), while patients not receiving ramipril (n = 51) constituted the controls. TNFα, IL-6, and IL-8 were evaluated using ELISA and TnT by electrochemiluminescence methods before the induction of anesthesia (t1), at the 20th minute following cross-clamping (t2), at the end of the operation (t3), and at the 24th hour from the commencement of anesthesia (t4). Genotyping was performed by PCR. RESULTS Differences between the groups were significant at t4 for the TNFα and at t3 for IL-6 (p < 0.05). The TnT levels increased from t2 onward in the control group and were highest in t3. Changes in t3 and t4 values in both groups according to their t1 values were significant (p < 0.05). However, differences between the groups were insignificant (p > 0.05). The IL-6, IL-8, TNFα, and TnT serum levels had no correlation with the ACE I/D gene polymorphism. CONCLUSION Low cytokine and TnT levels in the study group, especially after cross-clamping, may indicate the protective effect of ramipril from oxidoinflammatory injury. This effect did not appear to be associated with the ACE I/D gene polymorphism.
Collapse
Affiliation(s)
- Meral Urhan Küçük
- Faculty of Medicine, Department of Medical Biology, Mustafa Kemal University, 31024, Antakya, Hatay, Turkey,
| | | | | | | | | | | | | | | | | |
Collapse
|
45
|
Durukan AB, Gurbuz HA, Salman N, Unal EU, Ucar HI, Yorgancioglu CEM. Ventilation during cardiopulmonary bypass did not attenuate inflammatory response or affect postoperative outcomes. Cardiovasc J Afr 2014; 24:224-30. [PMID: 24217262 PMCID: PMC3773583 DOI: 10.5830/cvja-2013-041] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2013] [Accepted: 05/24/2013] [Indexed: 02/05/2023] Open
Abstract
Introduction Cardiopulmonary bypass causes a series of inflammatory events that have adverse effects on the outcome. The release of cytokines, including interleukins, plays a key role in the pathophysiology of the process. Simultaneously, cessation of ventilation and pulmonary blood flow contribute to ischaemia–reperfusion injury in the lungs when reperfusion is maintained. Collapse of the lungs during cardiopulmonary bypass leads to postoperative atelectasis, which correlates with the amount of intrapulmonary shunt. Atelectasis also causes post-perfusion lung injury. In this study, we aimed to document the effects of continued low-frequency ventilation on the inflammatory response following cardiopulmonary bypass and on outcomes, particularly pulmonary function. Methods Fifty-nine patients subjected to elective coronary bypass surgery were prospectively randomised to two groups, continuous ventilation (5 ml/kg tidal volume, 5/min frequency, zero end-expiratory pressure) and no ventilation, during cardiopulmonary bypass. Serum interleukins 6, 8 and 10 (as inflammatory markers), and serum lactate (as a marker for pulmonary injury) levels were studied, and alveolar–arterial oxygen gradient measurements were made after the induction of anaesthesia, and immediately, one and six hours after the discontinuation of cardiopulmonary bypass. Results There were 29 patients in the non-ventilated and 30 in the continuously ventilated groups. The pre-operative demographics and intra-operative characteristics of the patients were comparable. The serum levels of interleukin 6 (IL-6) increased with time, and levels were higher in the non-ventilated group only immediately after discontinuation of cardiopulmonary bypass. IL-8 levels significantly increased only in the non-ventilated group, but the levels did not differ between the groups. Serum levels of IL-10 and lactate also increased with time, and levels of both were higher in the non-ventilated group only immediately after the discontinuation of cardiopulmonary bypass. Alveolar–arterial oxygen gradient measurements were higher in the non-ventilated group, except for six hours after the discontinuation of cardiopulmonary bypass. The intubation time, length of stay in intensive care unit and hospital, postoperative adverse events and mortality rates were not different between the groups. Conclusion Despite higher cytokine and lactate levels and alveolar–arterial oxygen gradients in specific time periods, an attenuation in the inflammatory response following cardiopulmonary bypass due to low-frequency, low-tidal volume ventilation could not be documented. Clinical parameters concerning pulmonary and other major system functions and occurrence of postoperative adverse events were not affected by continuous ventilation.
Collapse
Affiliation(s)
- Ahmet Baris Durukan
- Department of Cardiovascular Surgery, Medicana International Ankara Hospital, Ankara, Turkey
| | | | | | | | | | | |
Collapse
|
46
|
Raja SG, Husain M, Salhiyyah K, Navaratnarajah M, Chudasama D, Walker CP, Amin F, Amrani M. Concomitant off-pump coronary artery bypass grafting results in improved in-hospital outcomes for patients with ischemic mitral regurgitation undergoing surgery. Heart Surg Forum 2013; 16:E15-20. [PMID: 23439351 DOI: 10.1532/hsf98.20121039] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE Surgical management of ischemic mitral regurgitation (IMR) has primarily consisted of revascularization with or without the addition of mitral valve repair or replacement. We hypothesize that performing off-pump coronary artery bypass (OPCAB) grafting before fixing MR improves in-hospital outcomes for patients with IMR undergoing surgery. METHODS From January 2000 through December 2010, a total of 96 consecutive patients with moderate or severe IMR, as determined by preoperative echocardiography, underwent on-pump coronary artery bypass grafting (CABG) (n = 66) or OPCAB (n = 30) revascularization with concomitant mitral valve repair or replacement. A retrospective analysis of a prospectively collected cardiac surgery database (PATS; Dendrite Clinical Systems, Oxford, UK) was performed. In addition, medical notes and charts were reviewed for all study patients. RESULTS The 2 groups had similar preoperative demographic and EuroSCORE risk-stratification characteristics. The operative mortality rate for the entire cohort was 9.4%. Patients who underwent OPCAB grafting had a lower operative mortality than those who underwent CABG (3.3% versus 12.1%; P = .006). The mean ±SD cardiopulmonary bypass time (82.7 ± 34.7 minutes versus 160.7 ± 45.2 minutes; P < .001) and cross-clamp time (49.0 ± 22.4 minutes versus 103.4 ± 39.5 minutes; P < .001) were significantly shorter in the off-pump group than in the on-pump group. The OPCAB group also had significantly less in-hospital morbidity and shorter stays in the intensive care unit and the hospital. CONCLUSION Our analysis shows that OPCAB grafting (compared with conventional CABG) before repairing MR is associated with favorable in-hospital outcomes for patients undergoing surgery for IMR.
Collapse
Affiliation(s)
- Shahzad G Raja
- Department of Cardiac Surgery, Harefield Hospital, London, UK.
| | | | | | | | | | | | | | | |
Collapse
|
47
|
Trop S, Marshall JC, Mazer CD, Gupta M, Dumont DJ, Bourdeau A, Verma S. Perioperative cardiovascular system failure in South Asians undergoing cardiopulmonary bypass is associated with prolonged inflammation and increased Toll-like receptor signaling in inflammatory monocytes. J Surg Res 2013; 187:43-52. [PMID: 24176205 DOI: 10.1016/j.jss.2013.09.035] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2013] [Revised: 09/05/2013] [Accepted: 09/25/2013] [Indexed: 11/28/2022]
Abstract
BACKGROUND South Asian ethnicity is an independent risk factor for mortality after coronary artery bypass. We tested the hypothesis that this risk results from a greater inflammatory response to cardiopulmonary bypass (CPB). METHODS This was a single-site prospective cohort study. We compared the inflammatory response to CPB in 20 Caucasians and 17 South Asians undergoing isolated coronary artery bypass grafting surgery. RESULTS Plasma levels of proinflammatory cytokines (interleukin [IL]-6, IL-8, IL-12, interferon gamma, and tumor necrosis factor) and anti-inflammatory mediators (IL-10 and soluble TNF receptor I) were measured. The Toll-like receptor (TLR) signaling pathway was examined in peripheral blood monocytes by flow cytometry, measuring surface expression of TLR2, TLR4, and coreceptor CD14 and activation of downstream messenger molecules (interleukin-1 receptor-associated kinase 4, nuclear factor kappa from B cells (NF-κB), c-Jun amino-terminal kinase, p38 mitogen-activated protein kinase, and Protein Kinase B). South Asians had persistently higher plasma levels of IL-6 and exhibited increased TLR signaling through the p38 mitogen-activated protein kinase and Protein Kinase B pathways in inflammatory monocytes after CPB. This increased inflammatory response was paralleled clinically by a higher sequential organ failure assessment score (5.1 ± 1.4 versus 1.5 ± 1.6, P = 0.027) and prolonged cardiovascular system failure (23.5% versus 0%) 48 h after CPB. CONCLUSIONS South Asians develop an exacerbated systemic inflammatory response after CPB, which may contribute to the higher morbidity and mortality associated with coronary artery bypass in this population. These patients may benefit from targeted anti-inflammatory therapies designed to mitigate the adverse consequences resulting from this response.
Collapse
Affiliation(s)
- Sébastien Trop
- Clinician Investigator Program, University of Toronto, Toronto, Ontario, Canada; Department of Surgery, Keenan Research Centre in the Li Ka Shing Knowledge Institute at St. Michael's Hospital, Toronto, Ontario, Canada; Platform of Biological Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - John C Marshall
- Department of Surgery, Keenan Research Centre in the Li Ka Shing Knowledge Institute at St. Michael's Hospital, Toronto, Ontario, Canada; Interdivisional Department of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada; Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - C David Mazer
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Department of Anesthesia, Keenan Research Centre in the Li Ka Shing Knowledge Institute at St. Michael's Hospital, Toronto, Ontario, Canada
| | - Milan Gupta
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Canadian Cardiovascular Research Network, Brampton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Daniel J Dumont
- Platform of Biological Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada; Department of Medical Biophysics, University of Toronto, Toronto, Ontario, Canada
| | - Annie Bourdeau
- Platform of Biological Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada; Department of Immunology, University of Toronto, Toronto, Ontario, Canada.
| | - Subodh Verma
- Department of Surgery, Keenan Research Centre in the Li Ka Shing Knowledge Institute at St. Michael's Hospital, Toronto, Ontario, Canada; Department of Surgery, University of Toronto, Toronto, Ontario, Canada.
| |
Collapse
|
48
|
Hall R. Identification of Inflammatory Mediators and Their Modulation by Strategies for the Management of the Systemic Inflammatory Response During Cardiac Surgery. J Cardiothorac Vasc Anesth 2013; 27:983-1033. [DOI: 10.1053/j.jvca.2012.09.013] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2012] [Indexed: 12/21/2022]
|
49
|
Kunes P, Mandak J, Holubcova Z, Kolackova M, Krejsek J. The long pentraxin PTX3: a candidate anti-inflammatory mediator in cardiac surgery. Perfusion 2013; 28:377-89. [DOI: 10.1177/0267659113483799] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Coronary artery bypass grafting (CABG) is performed with the use of cardiopulmonary bypass (CPB) and cardioplegic arrest (CA) of the heart. The advantage of this technique, alternatively referred to as “on-pump” surgery, resides, for the surgeon, in relatively easy access to and manipulation with the non-beating, bloodless heart. However, the advantage that is, thereby, gained by the patient is paid off by an increased susceptibility to postoperative systemic inflammatory response syndrome (SIRS). Under unfavorable conditions, the inflammatory syndrome may develop into life-threatening forms of MODS (multiple organ dysfunction syndrome) or even MOFS (multiple organ failure syndrome). Deliberate avoidance of CPB, also known as “off-pump” surgery, attenuates early postoperative inflammation throughout its trajectory of SIRS→MODS→MOFS, but, in the long run, there appears to be no substantial difference in the overall mortality rates. In the last years, our knowledge of the pathophysiology of surgical inflammation has increased considerably. Recent findings, highlighting the as yet rather obscure role of pentraxin 3 (PTX3) in these processes, are discussed in this review article.
Collapse
Affiliation(s)
- P Kunes
- Deparment of Cardiac Surgery, Charles University in Prague, Medical School and University Hospital in Hradec Kralove, Czech Republic
| | - J Mandak
- Deparment of Cardiac Surgery, Charles University in Prague, Medical School and University Hospital in Hradec Kralove, Czech Republic
| | - Z Holubcova
- Deparment of Cardiac Surgery, Charles University in Prague, Medical School and University Hospital in Hradec Kralove, Czech Republic
| | - M Kolackova
- Department of Clinical Immunology, Charles University in Prague, Medical School and University Hospital in Hradec Kralove, Czech Republic
| | - J Krejsek
- Department of Clinical Immunology, Charles University in Prague, Medical School and University Hospital in Hradec Kralove, Czech Republic
| |
Collapse
|
50
|
Lowry AW. Resuscitation and perioperative management of the high-risk single ventricle patient: first-stage palliation. CONGENIT HEART DIS 2013; 7:466-78. [PMID: 22985457 DOI: 10.1111/j.1747-0803.2012.00710.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Infants born with hypoplastic left heart syndrome or other lesions resulting in a single right ventricle face the highest risk of mortality among all forms of congenital heart disease. Before the modern era of surgical palliation, these conditions were universally lethal; recent refinements in surgical technique and perioperative management have translated into dramatic improvements in survival. Nonetheless, these infants remain at a high risk of morbidity and mortality, and an appreciation of single ventricle physiology is fundamental to the care of these high-risk patients. Herein, resuscitation and perioperative management of infants with hypoplastic left heart syndrome are reviewed. Basic neonatal and pediatric life support recommendations are summarized, and perioperative first-stage clinical management strategies are reviewed.
Collapse
Affiliation(s)
- Adam W Lowry
- Department of Pediatrics, Lillie Frank Abercrombie Section of Pediatric Cardiology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA.
| |
Collapse
|