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Arnold M, Do P, Davidson SM, Large SR, Helmer A, Beer G, Siepe M, Longnus SL. Metabolic Considerations in Direct Procurement and Perfusion Protocols with DCD Heart Transplantation. Int J Mol Sci 2024; 25:4153. [PMID: 38673737 PMCID: PMC11050041 DOI: 10.3390/ijms25084153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Revised: 04/04/2024] [Accepted: 04/05/2024] [Indexed: 04/28/2024] Open
Abstract
Heart transplantation with donation after circulatory death (DCD) provides excellent patient outcomes and increases donor heart availability. However, unlike conventional grafts obtained through donation after brain death, DCD cardiac grafts are not only exposed to warm, unprotected ischemia, but also to a potentially damaging pre-ischemic phase after withdrawal of life-sustaining therapy (WLST). In this review, we aim to bring together knowledge about changes in cardiac energy metabolism and its regulation that occur in DCD donors during WLST, circulatory arrest, and following the onset of warm ischemia. Acute metabolic, hemodynamic, and biochemical changes in the DCD donor expose hearts to high circulating catecholamines, hypoxia, and warm ischemia, all of which can negatively impact the heart. Further metabolic changes and cellular damage occur with reperfusion. The altered energy substrate availability prior to organ procurement likely plays an important role in graft quality and post-ischemic cardiac recovery. These aspects should, therefore, be considered in clinical protocols, as well as in pre-clinical DCD models. Notably, interventions prior to graft procurement are limited for ethical reasons in DCD donors; thus, it is important to understand these mechanisms to optimize conditions during initial reperfusion in concert with graft evaluation and re-evaluation for the purpose of tailoring and adjusting therapies and ensuring optimal graft quality for transplantation.
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Affiliation(s)
- Maria Arnold
- Department of Cardiac Surgery, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
- Department for BioMedical Research, University of Bern, 3008 Bern, Switzerland
| | - Peter Do
- Department of Cardiac Surgery, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
| | - Sean M. Davidson
- The Hatter Cardiovascular Institute, University College London, London WC1E 6HX, UK
| | - Stephen R. Large
- Royal Papworth Hospital, Biomedical Campus, Cambridge CB2 0AY, UK
| | - Anja Helmer
- Department of Cardiac Surgery, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
- Department for BioMedical Research, University of Bern, 3008 Bern, Switzerland
- Graduate School for Cellular and Biomedical Sciences, University of Bern, 3012 Bern, Switzerland
| | - Georgia Beer
- Department of Cardiac Surgery, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
- Department for BioMedical Research, University of Bern, 3008 Bern, Switzerland
- Graduate School for Cellular and Biomedical Sciences, University of Bern, 3012 Bern, Switzerland
| | - Matthias Siepe
- Department of Cardiac Surgery, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
| | - Sarah L. Longnus
- Department of Cardiac Surgery, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
- Department for BioMedical Research, University of Bern, 3008 Bern, Switzerland
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Ahmed A, Ahmed S, Arvidsson M, Bouzina H, Lundgren J, Rådegran G. Elevated plasma sRAGE and IGFBP7 in heart failure decrease after heart transplantation in association with haemodynamics. ESC Heart Fail 2020; 7:2340-2353. [PMID: 32548968 PMCID: PMC7524060 DOI: 10.1002/ehf2.12772] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2020] [Revised: 04/25/2020] [Accepted: 04/28/2020] [Indexed: 12/26/2022] Open
Abstract
Aims Metabolic derangement is implicated in the pathophysiology of heart failure (HF) and pulmonary hypertension (PH). We aimed to identify the dynamics of metabolic plasma proteins linked to end‐stage HF and associated PH in relation to haemodynamics, before and after heart transplantation (HT). Methods and results Twenty‐one metabolic plasma proteins were analysed with proximity extension assay in 20 controls and 26 patients before and 1 year after HT. Right heart catheterizations were performed in the HF patients pre‐operatively and 1 year after HT. Plasma levels of soluble receptor for advanced glycation end products (sRAGE) and insulin‐like growth factor‐binding protein 7 (IGFBP7) were higher in HF patients compared with controls (P < 0.0001) and decreased after HT (P < 0.0001), matching controls' levels. The decrease in sRAGE after HT correlated with improved mean pulmonary arterial pressure (rs = 0.7; P < 0.0001), pulmonary arterial wedge pressure (rs = 0.73; P < 0.0001), pulmonary vascular resistance (rs = 0.65; P = 0.00062), and pulmonary arterial compliance (rs = −0.52; P = 0.0074). The change in plasma IGFBP7 after HT correlated with improved mean right atrial pressure (rs = 0.71; P = 0.00011) and N‐terminal pro‐brain natriuretic peptide (rs = 0.71; P < 0.0001). Conclusions Our results indicate that plasma sRAGE may reflect passive pulmonary vascular congestion and the ‘mechanical’ state of the pulmonary vasculature in HF patients with or without related PH. Furthermore, sRAGE and IGFBP7 may provide additional insight into the pathophysiological mechanisms in HF and associated PH. Their potential clinical and therapeutic relevance in HF and associated PH need further investigation.
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Affiliation(s)
- Abdulla Ahmed
- Department of Clinical Sciences, Lund, The Section for Cardiology, Lund University, Lund, Sweden.,The Haemodynamic Lab, The Section for Heart Failure and Valvular Disease, VO Heart and Lung Medicine, Skåne University Hospital, Lund, Sweden
| | - Salaheldin Ahmed
- Department of Clinical Sciences, Lund, The Section for Cardiology, Lund University, Lund, Sweden.,The Haemodynamic Lab, The Section for Heart Failure and Valvular Disease, VO Heart and Lung Medicine, Skåne University Hospital, Lund, Sweden
| | - Mattias Arvidsson
- Department of Clinical Sciences, Lund, The Section for Cardiology, Lund University, Lund, Sweden.,The Haemodynamic Lab, The Section for Heart Failure and Valvular Disease, VO Heart and Lung Medicine, Skåne University Hospital, Lund, Sweden
| | - Habib Bouzina
- Department of Clinical Sciences, Lund, The Section for Cardiology, Lund University, Lund, Sweden.,The Haemodynamic Lab, The Section for Heart Failure and Valvular Disease, VO Heart and Lung Medicine, Skåne University Hospital, Lund, Sweden
| | - Jakob Lundgren
- Department of Clinical Sciences, Lund, The Section for Cardiology, Lund University, Lund, Sweden.,The Haemodynamic Lab, The Section for Heart Failure and Valvular Disease, VO Heart and Lung Medicine, Skåne University Hospital, Lund, Sweden
| | - Göran Rådegran
- Department of Clinical Sciences, Lund, The Section for Cardiology, Lund University, Lund, Sweden.,The Haemodynamic Lab, The Section for Heart Failure and Valvular Disease, VO Heart and Lung Medicine, Skåne University Hospital, Lund, Sweden
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3
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Deussen A. Klinische Relevanz des Energiestoffwechsels im Herzen. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2017. [DOI: 10.1007/s00398-017-0178-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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4
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Teh ES, Zal F, Polard V, Menasché P, Chambers DJ. HEMO2life as a protective additive to Celsior solution for static storage of donor hearts prior to transplantation. ARTIFICIAL CELLS NANOMEDICINE AND BIOTECHNOLOGY 2017; 45:717-722. [DOI: 10.1080/21691401.2016.1265974] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Elaine S. Teh
- Cardiac Surgical Research/Cardiothoracic Surgery, the Rayne Institute (King’s College London), Guy’s and St Thomas’ NHS Foundation Trust, St Thomas’ Hospital, London, UK
| | - Franck Zal
- Biotechnopôle, Hemarina SA, Aéropôle Centre, Morlaix, France
| | - Valérie Polard
- Biotechnopôle, Hemarina SA, Aéropôle Centre, Morlaix, France
| | - Philippe Menasché
- Assistance Publique-Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Department of Cardiovascular Surgery, Université Paris Descartes, Sorbonne Paris Cité; INSERM U 970, Paris, France
| | - David J. Chambers
- Cardiac Surgical Research/Cardiothoracic Surgery, the Rayne Institute (King’s College London), Guy’s and St Thomas’ NHS Foundation Trust, St Thomas’ Hospital, London, UK
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5
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Rutaecarpine and evodiamine selected as β1-AR inhibitor candidates using β1-AR/CMC-offline-UPLC/MS prevent cardiac ischemia–reperfusion injury via energy modulation. J Pharm Biomed Anal 2015; 115:307-14. [DOI: 10.1016/j.jpba.2015.07.022] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Revised: 07/14/2015] [Accepted: 07/21/2015] [Indexed: 11/20/2022]
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6
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Pischke SE, Hyler S, Tronstad C, Bergsland J, Fosse E, Halvorsen PS, Skulstad H, Tønnessen TI. Myocardial tissue CO2 tension detects coronary blood flow reduction after coronary artery bypass in real-time†. Br J Anaesth 2014; 114:414-22. [PMID: 25392231 DOI: 10.1093/bja/aeu381] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Coronary stenosis after coronary artery bypass grafting (CABG) may lead to myocardial ischaemia and is clinically difficult to diagnose. In a CABG model, we aimed at defining variables that detect hypoperfusion in real-time and correlate with impaired regional ventricular function by monitoring myocardial tissue metabolism. METHODS Off-pump CABG was performed in 10 pigs. Graft blood flow was reduced in 18 min intervals to 75, 50, and 25% of baseline flow with reperfusion between each flow reduction. Myocardial tissue Pco2 (Pt(CO2)), Po2, pH, glucose, lactate, and glycerol from the graft supplied region and a control region were obtained. Regional cardiac function was assessed as radial strain. RESULTS In comparison with baseline, myocardial pH decreased during 75, 50, and 25% flow reduction (-0.15; -0.22; -0.37, respectively, all P<0.05) whereas Pt(CO2) increased (+4.6 kPa; +7.8 kPa; +12.9 kPa, respectively, all P<0.05). pH and Pt(CO2) returned to baseline upon reperfusion. Lactate and glycerol increased flow-dependently, while glucose decreased. Regional ventricular contractile function declined significantly. All measured variables remained normal in the control region. Pt(CO2) correlated strongly with tissue lactate, pH, and contractile function (R=0.86, R=-0.91, R=-0.70, respectively, all P<0.001). New conductometric Pt(CO2) sensors were in agreement with established fibre-optic probes. Cardiac output was not altered. CONCLUSIONS Myocardial pH and Pt(CO2) monitoring can quantify the degree of regional tissue hypoperfusion in real-time and correlated well with cellular metabolism and contractile function, whereas cardiac output did not. New robust conductometric Pt(CO2) sensors have the potential to serve as a clinical cardiac monitoring tool during surgery and postoperatively.
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Affiliation(s)
- S E Pischke
- The Intervention Centre, Division for Emergencies and Critical Care Medicine
| | | | - C Tronstad
- Department of Clinical and Biomedical Engineering
| | | | - E Fosse
- The Intervention Centre, Institute for Clinical Medicine, University of Oslo, Oslo, Norway
| | | | - H Skulstad
- Clinic of Cardiology, Oslo University Hospital and
| | - T I Tønnessen
- Division for Emergencies and Critical Care Medicine, Institute for Clinical Medicine, University of Oslo, Oslo, Norway
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7
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Wu R, Chang HC, Khechaduri A, Chawla K, Tran M, Chai X, Wagg C, Ghanefar M, Jiang X, Bayeva M, Gonzalez F, Lopaschuk G, Ardehali H. Cardiac-specific ablation of ARNT leads to lipotoxicity and cardiomyopathy. J Clin Invest 2014; 124:4795-806. [PMID: 25329697 DOI: 10.1172/jci76737] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2014] [Accepted: 09/08/2014] [Indexed: 12/20/2022] Open
Abstract
Patients with type 2 diabetes often present with cardiovascular complications; however, it is not clear how diabetes promotes cardiac dysfunction. In murine models, deletion of the gene encoding aryl hydrocarbon nuclear translocator (ARNT, also known as HIF1β) in the liver or pancreas leads to a diabetic phenotype; however, the role of ARNT in cardiac metabolism is unknown. Here, we determined that cardiac-specific deletion of Arnt in adult mice results in rapid development of cardiomyopathy (CM) that is characterized by accumulation of lipid droplets. Compared with hearts from ARNT-expressing mice, ex vivo analysis of ARNT-deficient hearts revealed a 2-fold increase in fatty acid (FA) oxidation as well as a substantial increase in the expression of PPARα and its target genes. Furthermore, deletion of both Arnt and Ppara preserved cardiac function, improved survival, and completely reversed the FA accumulation phenotype, indicating that PPARα mediates the detrimental effects of Arnt deletion in the heart. Finally, we determined that ARNT directly regulates Ppara expression by binding to its promoter and forming a complex with HIF2α. Together, these findings suggest that ARNT is a critical regulator of myocardial FA metabolism and that its deletion leads to CM and an increase in triglyceride accumulation through PPARα.
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Drury NE, Howell NJ, Calvert MJ, Weber RJM, Senanayake EL, Lewis ME, Hyde JAJ, Green DH, Mascaro JG, Wilson IC, Graham TR, Rooney SJ, Viant MR, Freemantle N, Frenneaux MP, Pagano D. The effect of perhexiline on myocardial protection during coronary artery surgery: a two-centre, randomized, double-blind, placebo-controlled trial. Eur J Cardiothorac Surg 2014; 47:464-72. [PMID: 24948413 PMCID: PMC4324609 DOI: 10.1093/ejcts/ezu238] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
OBJECTIVES Perhexiline is thought to modulate metabolism by inhibiting mitochondrial carnitine palmitoyltransferase-1, reducing fatty acid uptake and increasing carbohydrate utilization. This study assessed whether preoperative perhexiline improves markers of myocardial protection in patients undergoing coronary artery bypass graft surgery and analysed its effect on the myocardial metabolome. METHODS In a prospective, randomized, double-blind, placebo-controlled trial, patients at two centres were randomized to receive either oral perhexiline or placebo for at least 5 days prior to surgery. The primary outcome was a low cardiac output episode in the first 6 h. All pre-specified analyses were conducted according to the intention-to-treat principle with a statistical power of 90% to detect a relative risk of 0.5 and a conventional one-sided α-value of 0.025. A subset of pre-ischaemic left ventricular biopsies was analysed using mass spectrometry-based metabolomics. RESULTS Over a 3-year period, 286 patients were randomized, received the intervention and were included in the analysis. The incidence rate of a low cardiac output episode in the perhexiline arm was 36.7% (51/139) vs 34.7% (51/147) in the control arm [odds ratio (OR) 0.92, 95% confidence interval (CI) 0.56–1.50, P = 0.74]. Perhexiline was associated with a reduction in the cardiac index at 6 h [difference in means 0.19, 95% CI 0.07–0.31, P = 0.001] and an increase in inotropic support in the first 12 h (OR 0.55, 95% CI 0.34–0.89, P = 0.015). There were no significant differences in myocardial injury with troponin-T or electrocardiogram, reoperation, renal dysfunction or length of stay. No difference in the preischaemic left ventricular metabolism was identified between groups on metabolomics analysis. CONCLUSIONS Preoperative perhexiline does not improve myocardial protection in patients undergoing coronary surgery and in fact reduced perioperative cardiac output, increasing the need for inotropic support. Perhexiline has no significant effect on the mass spectrometry-visible polar myocardial metabolome in vivo in humans, supporting the suggestion that it acts via a pathway that is independent of myocardial carnitine palmitoyltransferase inhibition and may explain the lack of clinical benefit observed following surgery. ClinicalTrials.Gov ID NCT00845364.
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Affiliation(s)
- Nigel E Drury
- Department of Cardiothoracic Surgery, Queen Elizabeth Hospital Birmingham, Birmingham, UK School of Clinical and Experimental Medicine, University of Birmingham, Birmingham, UK
| | - Neil J Howell
- Department of Cardiothoracic Surgery, Queen Elizabeth Hospital Birmingham, Birmingham, UK School of Clinical and Experimental Medicine, University of Birmingham, Birmingham, UK
| | - Melanie J Calvert
- School of Health and Population Sciences, University of Birmingham, Birmingham, UK
| | - Ralf J M Weber
- Centre for Systems Biology, School of Biosciences, University of Birmingham, Birmingham, UK
| | - Eshan L Senanayake
- Department of Cardiothoracic Surgery, Queen Elizabeth Hospital Birmingham, Birmingham, UK School of Clinical and Experimental Medicine, University of Birmingham, Birmingham, UK
| | - Michael E Lewis
- Department of Cardiothoracic Surgery, Royal Sussex County Hospital, Brighton
| | - Jonathan A J Hyde
- Department of Cardiothoracic Surgery, Royal Sussex County Hospital, Brighton
| | - David H Green
- Department of Cardiac Anesthesia, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Jorge G Mascaro
- Department of Cardiothoracic Surgery, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Ian C Wilson
- Department of Cardiothoracic Surgery, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Timothy R Graham
- Department of Cardiothoracic Surgery, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Stephen J Rooney
- Department of Cardiothoracic Surgery, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Mark R Viant
- Centre for Systems Biology, School of Biosciences, University of Birmingham, Birmingham, UK
| | - Nick Freemantle
- Department of Primary Care and Population Health, University College London, London, UK
| | | | - Domenico Pagano
- Department of Cardiothoracic Surgery, Queen Elizabeth Hospital Birmingham, Birmingham, UK School of Clinical and Experimental Medicine, University of Birmingham, Birmingham, UK
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Longnus SL, Mathys V, Dornbierer M, Dick F, Carrel TP, Tevaearai HT. Heart transplantation with donation after circulatory determination of death. Nat Rev Cardiol 2014; 11:354-63. [DOI: 10.1038/nrcardio.2014.45] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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10
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"Polarizing" microplegia improves cardiac cycle efficiency after CABG for unstable angina. Int J Cardiol 2012; 167:2739-46. [PMID: 22795715 DOI: 10.1016/j.ijcard.2012.06.099] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2012] [Revised: 05/15/2012] [Accepted: 06/24/2012] [Indexed: 11/21/2022]
Abstract
BACKGROUND Myocardial protection during coronary artery bypass grafting (CABG) for unstable angina (UA) still represents a major challenge, ought to the risk for further ischemia/reperfusion injury. Few studies investigate the biochemical, hemodynamic and echocardiographic results of microplegia (Mic) in UA. METHODS Eighty UA-patients undergoing CABG were randomized to Mic (Mic-Group) or standard 4:1 blood Buckberg-cardioplegia (Buck-Group). Troponin-I and lactate were sampled from coronary sinus at reperfusion (T1), and from peripheral blood preoperatively (T0), at 6 (T2), 12 (T3) and 48 (T4) hours. Cardiac index (CI), indexed systemic vascular resistances (ISVR), Δp/Δt, cardiac cycle efficiency (CCE), and central venous pressure (CVP) were collected preoperatively (T0), and since Intensive Care Unit (ICU)-arrival (T1) to 24h (T5). Echocardiographic E-wave (E), A-wave (A), E/A, peak early-diastolic TDI-mitral annular-velocity (Ea), and E/Ea investigated the diastolic function and Wall Motion Score Index (WMSI) the systolic function, preoperatively (T0) and at 96h (T1). RESULTS Mic-Group showed lower troponin-I and lactate from coronary sinus (p=.0001 for both) and during the postoperative course (between-groups p=.001 and .0001, respectively). WMSI improved only after Mic (time-p=.001). Higher CI Δp/Δt and CCE (between-groups p=.0001), with comparable CVP and ISVR (p=N.S.) were detected after Mic. Diastolic function improved in both groups, but better after Mic (between-groups p=.003, .001, and .013 for E, E/A, and Ea, respectively). Mic resulted in lower transfusions (p=.006) and hospitalization (p=.002), and a trend towards lower need/duration of inotropes (p=.04 and p=.041, respectively), and ICU-stay (p=.015). CONCLUSION Microplegia attenuates myocardial damage in UA, reduces transfusions, improves postoperative systo-diastolic function, and shortens hospitalization.
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Pischke SE, Tronstad C, Holhjem L, Halvorsen PS, Tønnessen TI. Perioperative detection of myocardial ischaemia/reperfusion with a novel tissue CO2 monitoring technology†. Eur J Cardiothorac Surg 2012; 42:157-63. [DOI: 10.1093/ejcts/ezr278] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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12
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Ahlsson A, Sobrosa C, Kaijser L, Jansson E, Bomfim V. Adenosine in cold blood cardioplegia--a placebo-controlled study. Interact Cardiovasc Thorac Surg 2011; 14:48-55. [PMID: 22108937 DOI: 10.1093/icvts/ivr027] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE Adenosine as an additive in blood cardioplegia is cardioprotective in animal studies, but its clinical role in myocardial protection remains controversial. The aim of this study was to investigate whether the addition of adenosine in continuous cold blood cardioplegia would enhance myocardial protection. METHODS In a prospective double-blind study comparing adenosine 400 μmol l(-1) to placebo in continuous cold blood cardioplegia, 80 patients undergoing isolated aortic valve replacement were randomized into four groups: antegrade cardioplegia with adenosine (n = 19), antegrade cardioplegia with placebo (n = 21), retrograde cardioplegia with adenosine (n = 21) and retrograde cardioplegia with placebo (n = 19). Myocardial arteriovenous differences in oxygen and lactate were measured before, during and after aortic occlusion. Myocardial concentrations of adenine nucleotides and lactate were determined from left ventricular biopsies obtained before aortic occlusion, after bolus cardioplegia, at 60 min of aortic occlusion and at 20 min after aortic occlusion. Plasma creatine kinase (CK-MB) and troponin T were measured at 1, 3, 6, 9, 12 and 24 h after aortic occlusion. Haemodynamic profiles were obtained before surgery and 1, 8 and 24 h after cardiopulmonary bypass. Repeated-measures analysis of variance was used for significance testing. RESULTS Adenosine had no effects on myocardial metabolism of oxygen, lactate and adenine nucleotides, postoperative enzyme release or haemodynamic performance. When compared with the antegrade groups, the retrograde groups showed higher myocardial oxygen uptake (17.3 ± 11.4 versus 2.5 ± 3.6 ml l(-1) at 60 min of aortic occlusion, P < 0.001) and lactate accumulation (43.1 ± 20.7 versus 36.3 ± 23.0 µmol g(-1) at 60 min of aortic occlusion, P = 0.052) in the myocardium during aortic occlusion, and lower postoperative left ventricular stroke work index (27.2 ± 8.4 versus 30.1 ± 7.9 g m m(-2), P = 0.034). CONCLUSIONS Adenosine 400 μmol l(-1) in cold blood cardioplegia showed no cardioprotective effects on the parameters studied. Myocardial ischaemia was more pronounced in patients receiving retrograde cardioplegia.
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Affiliation(s)
- Anders Ahlsson
- Department of Thoracic and Cardiovascular Surgery, Örebro University Hospital, Örebro, Sweden.
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Hatzakorzian R, Carvalho G, Bui H, Sato T, Wykes L, Shum-Tim D, Schricker T. High-dose insulin administration is associated with hypoaminoacidemia during cardiac surgery. Metabolism 2011; 60:1392-7. [PMID: 21616512 DOI: 10.1016/j.metabol.2011.03.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2011] [Revised: 03/07/2011] [Accepted: 03/13/2011] [Indexed: 10/18/2022]
Abstract
Although the effects of insulin on glucose homeostasis are well recognized in surgical patients, its effect on perioperative protein metabolism has received little attention. The purpose of this study was to examine the effect of high-dose insulin therapy on the plasma concentrations of amino acids (AAs) in patients undergoing coronary artery bypass grafting surgery. We studied 20 nondiabetic patients scheduled for elective coronary artery bypass grafting surgery. Patients were randomly allocated to receive either standard metabolic care (target glycemia 6.0-10.0 mmol/L, control group, n = 10) or high-dose insulin therapy (insulin group, n = 10). Insulin was administered at 5 mU·kg(-1)·min(-1) beginning at skin incision. Simultaneously, 20% dextrose was infused at a variable rate adjusted to maintain glycemia between 4.0 and 6.0 mmol/L. Plasma AAs, glucose, cortisol, and insulin were measured immediately before surgery and at sternal closure. Differences in mean values were assessed by Student t test. Plasma concentrations of all AAs decreased in the insulin group, with 15 of 22 AAs, including all branched-chain AAs, being significantly lower at sternal closure when compared with the control group. At the end of surgery, plasma glucose concentration was significantly lower in the insulin group (4.2 ± 0.6 vs 7.3 ± 1.0 mmol/L, P = .0001), whereas plasma cortisol levels did not show any difference between groups. High-dose insulin therapy resulted in a significant reduction in plasma AAs, particularly branched-chain AAs, during cardiac surgery.
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Affiliation(s)
- Roupen Hatzakorzian
- Department of Anaesthesia, McGill University Health Center, Royal Victoria Hospital, Montreal, Quebec, Canada H3A 1A1.
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Abstract
The main role of insulin in the heart under physiological conditions is obviously the regulation of substrate utilization. Indeed, insulin promotes glucose uptake and its utilization via glycolysis. Insulin, promoting glucose as the main cardiac energy substrate, reduces myocardial O(2) consumption and increases cardiac efficiency. Moreover, insulin seems to augment cardiomyocyte contraction, while it affects favorably myocardial relaxation, increases ribosomal biogenesis and protein synthesis, stimulates vascular endothelial growth factor (VEGF) and thereby angiogenesis, suppresses apoptosis, promotes cell survival and finally ameliorates both myocardial microcirculation and coronary artery resistance, leading to increased blood perfusion of myocardium. Thus, insulin acts directly on heart muscle, and this action is mediated principally through PKB/Akt signal pathway. Under pathological conditions, such as type 2 diabetes, myocardial ischaemia, and cardiac hypertrophy, insulin signal transduction pathways and action are clearly modified. In this review we summarize the evidence that the heart is an important target of insulin action and that elimination of these actions is important in disease states.
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Affiliation(s)
- Fotios Iliadis
- Diabetes Division, 1st Propedeutic Department of Internal Medicine, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece.
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Chilton R, Wyatt J, Nandish S, Oliveros R, Lujan M. Cardiovascular comorbidities of type 2 diabetes mellitus: defining the potential of glucagonlike peptide-1-based therapies. Am J Med 2011; 124:S35-53. [PMID: 21194579 DOI: 10.1016/j.amjmed.2010.11.004] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
The global epidemic of diabetes mellitus (~95% type 2 diabetes) has been fueled by a parallel increase in obesity and overweight. Together, these metabolic disease epidemics have contributed to the increasing incidence and prevalence of cardiovascular disease. The accumulation of metabolic and cardiovascular risk factors in patients with type 2 diabetes--risk factors that may exacerbate one another--complicates treatment. Inadequate treatment, treatment that fails to achieve goals, increases the risk for cardiovascular morbidity and mortality. From a clinical perspective, type 2 diabetes is a cardiovascular disease, an observation that is supported by a range of epidemiologic, postmortem, and cardiovascular imaging studies. Vascular wall dysfunction, and particularly endothelial dysfunction, has been posited as a "common soil" linking dysglycemic and cardiovascular diseases. Vascular wall dysfunction promoted by environmental triggers (e.g., sedentary lifestyle) and metabolic triggers (chronic hyperglycemia, obesity) has been associated with the upregulation of reactive oxygen species and chronic inflammatory and hypercoagulable states, and as such with the pathogenesis of type 2 diabetes, atherosclerosis, and cardiovascular disease. Glucagon-like peptide-1 (GLP)-1, an incretin hormone, and synthetic GLP-1 receptor agonists represent promising new areas of research and therapeutics in the struggle not only against type 2 diabetes but also against the cardiovascular morbidity and mortality associated with type 2 diabetes. In a number of small trials in humans, as well as in preclinical and in vitro studies, both native GLP-1 and GLP-1 receptor agonists have demonstrated positive effects on a range of cardiovascular disease pathologies and clinical targets, including such markers of vascular inflammation as high-sensitivity C-reactive protein, plasminogen activator inhibitor-1, and brain natriuretic peptide. Reductions in markers of dyslipidemia such as elevated levels of triglycerides and free fatty acids have also been observed, as have cardioprotective functions. Larger trials of longer duration will be required to confirm preliminary findings. In large human trials, GLP-1 receptor agonists have been associated with significant reductions in both blood pressure and weight.
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Affiliation(s)
- Robert Chilton
- Catheterization Laboratory, University of Texas Health Science Center at San Antonio, San Antonio, Texas 78229-3900, USA.
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Sato H, Carvalho G, Sato T, Bracco D, Codere-Maruyama T, Lattermann R, Hatzakorzian R, Matsukawa T, Schricker T. Perioperative tight glucose control with hyperinsulinemic-normoglycemic clamp technique in cardiac surgery. Nutrition 2010; 26:1122-9. [DOI: 10.1016/j.nut.2009.10.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2009] [Revised: 10/13/2009] [Accepted: 10/13/2009] [Indexed: 12/15/2022]
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Doenst T, Amorim PA. Metabolic therapy in cardiac surgery--"Optimizing the engine's fuel supply and more...". SCAND CARDIOVASC J 2010; 44:4-8. [PMID: 20141343 DOI: 10.3109/14017430903469928] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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Abstract
The mitochondrion is the most important organelle in determining continued cell survival and cell death. Mitochondrial dysfunction leads to many human maladies, including cardiovascular diseases, neurodegenerative disease, and cancer. These mitochondria-related pathologies range from early infancy to senescence. The central premise of this review is that if mitochondrial abnormalities contribute to the pathological state, alleviating the mitochondrial dysfunction would contribute to attenuating the severity or progression of the disease. Therefore, this review will examine the role of mitochondria in the etiology and progression of several diseases and explore potential therapeutic benefits of targeting mitochondria in mitigating the disease processes. Indeed, recent advances in mitochondrial biology have led to selective targeting of drugs designed to modulate and manipulate mitochondrial function and genomics for therapeutic benefit. These approaches to treat mitochondrial dysfunction rationally could lead to selective protection of cells in different tissues and various disease states. However, most of these approaches are in their infancy.
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Sato H, Lattermann R, Carvalho G, Sato T, Metrakos P, Hassanain M, Matsukawa T, Schricker T. Perioperative glucose and insulin administration while maintaining normoglycemia (GIN therapy) in patients undergoing major liver resection. Anesth Analg 2010; 110:1711-8. [PMID: 20375299 DOI: 10.1213/ane.0b013e3181d90087] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Although hyperglycemia is a well-recognized risk factor in the context of cardiac surgery, the relevance of perioperative glycemic control for patients undergoing major noncardiac operations has received little attention. We designed this study to assess the hyperglycemic response to liver resection, and to test the hypothesis that perioperative glucose and insulin administration while maintaining normoglycemia (GIN therapy) provides glycemic control superior to that achieved by the conventional use of insulin. METHODS Patients were randomly assigned to GIN therapy or standard therapy (control group). In the GIN therapy group, insulin was administered at 2 mU . kg(-1) . min(-1) during surgery. At the end of surgery, the insulin infusion was decreased to 1 mU . kg(-1) . min(-1) and continued for 24 hours. Dextrose 20% was infused at a rate adjusted to maintain blood glucose within the target range of 3.5 to 6.1 mmol . L(-1) (63-110 mg . dL(-1)). Patients in the standard therapy group received a conventional insulin sliding scale during and after surgery. The mean and SD of blood glucose as well as the percentage of blood glucose values within the target range were calculated. To evaluate intrasubject variability, the coefficient of variability (CV) of blood glucose was calculated for each patient. Episodes of severe hypoglycemia, i.e., blood glucose <2.2 mmol . L(-1) (40 mg . dL(-1)), were recorded. The primary outcome was the proportion of normoglycemic measurements. RESULTS We studied 52 patients. The mean blood glucose value in patients receiving GIN therapy always remained within the target range. The blood glucose levels were lower in the GIN therapy group than in the standard therapy group (during surgery, P < 0.01; after surgery, P < 0.001). In nondiabetic patients receiving GIN therapy (n = 19), target glycemia was achieved in 90.1% of the blood glucose measurements during surgery and in 77.8% of the measurements after surgery. In diabetic patients receiving GIN therapy (n = 7), target glycemia was achieved in 81.2% of the blood glucose measurements during surgery and in 70.5% of the measurements after surgery. In nondiabetic patients receiving standard therapy (n = 19), target glycemia was achieved in 37.4% of the blood glucose measurements during surgery and in 18.3% of the measurements after surgery. In diabetic patients receiving standard therapy (n = 7), target glycemia was achieved in 4.3% of the blood glucose measurements during surgery and in 2.9% of the measurements after surgery. The SD and CV of blood glucose were smaller in the GIN therapy group than in the standard therapy group, especially in nondiabetic patients after surgery (SD, P < 0.001; CV, P = 0.027). No patients receiving GIN therapy experienced severe hypoglycemia during surgery. One patient receiving GIN therapy experienced hypoglycemia in the intensive care unit after surgery without neurological sequelae. CONCLUSIONS GIN therapy effectively provides normoglycemia in patients undergoing liver resection (clinicaltrials.gov, NCT00774098).
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Affiliation(s)
- Hiroaki Sato
- Department of Anaesthesia, Royal Victoria Hospital, 687 Pine Ave. West, Rm. C5.20, Montreal, QC, Canada H3A 1A1
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Sulistio M, Carothers C, Mangat M, Lujan M, Oliveros R, Chilton R. GLP-1 agonist-based therapies: an emerging new class of antidiabetic drug with potential cardioprotective effects. Curr Atheroscler Rep 2009; 11:93-9. [PMID: 19228481 DOI: 10.1007/s11883-009-0015-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Cardiovascular disease is a leading cause of death in the United States and across the world, and better therapies are constantly being sought to improve patient outcomes. Recent studies have brought our attention to the mechanisms of glucagon-like peptide 1 (GLP-1). Not only does it demonstrate beneficial effects in regard to cardiovascular risk factors (i.e., diabetes, lipid management, and weight control), but it also has been shown in animal studies to have positive cardiac effects irrespective of its effects on glucose control and weight loss. This review discusses the biology of GLP-1 and its effects on cardiovascular risk factors, and it also elaborates on the positive direct cardiovascular outcomes of GLP-1 in animal studies.
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Affiliation(s)
- Melanie Sulistio
- University of Texas Health Science Center, 27971 Smithson Valley, San Antonio, TX 78261, USA
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The metabolic modulators, Etomoxir and NVP-LAB121, fail to reverse pressure overload induced heart failure in vivo. Basic Res Cardiol 2009; 104:547-57. [DOI: 10.1007/s00395-009-0015-5] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2008] [Revised: 02/23/2009] [Accepted: 02/25/2009] [Indexed: 10/21/2022]
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