Natriuretic peptides for perioperative management of cardiac surgery

The Role of the N-Terminal of the Prohormone Brain Natriuretic Peptide in Predicting Postoperative Multiple Organ Dysfunction Syndrome

BACKGROUND

Multiple organ dysfunction syndrome (MODS) is the progressive and potentially reversible dysfunction of at least two organ systems in the course of an acute and life-threatening disorder of systemic homeostasis. MODS is a serious post-cardiac-surgery complication in valvular heart disease that is associated with a high risk of death. This study assessed the predictive ability of selected preoperative and perioperative parameters for the occurrence of MODS in the early postoperative period in a group of patients with severe valvular heart disease.

METHODS

Subsequent patients with significant symptomatic valvular heart disease who underwent cardiac surgery were recruited in the study. The main end-point was postoperative MODS, defined as a dysfunction of at least two organs-perioperative stroke, heart failure requiring mechanical circulatory support, respiratory failure requiring mechanical ventilation, and postoperative acute kidney injury requiring renal replacement therapy. A logistic regression was used to assess relationships between variables.

RESULTS

There were 602 patients recruited for this study. The main end-point occurred in 40 patients. Preoperative NT-proBNP (OR 1.026; 95% CI 1.012-1.041; p = 0.001) and hemoglobin (OR 0.653; 95% CI 0.503-0.847; p = 0.003) are independent predictors of the primary end-point in a multivariate regression analysis. The cut-off point for the NT-proBNP value for postoperative MODS was calculated at 1300 pg/mL.

CONCLUSIONS

A high preoperative level of NTpro-BNP may be associated with the onset of MODS in the early postoperative period. The results of the study may also suggest that earlier cardiac surgery for significant valvular heart disease may be associated with an improved prognosis in this group of patients.

Risk Factors of Sudden Cardiac Arrest during the Postoperative Period in Patient Undergoing Heart Valve Surgery

BACKGROUND

Sudden cardiac arrest (SCA) is the sudden cessation of normal cardiac activity with hemodynamic collapse. This usually leads to sudden cardiac death (SCD) when cardiopulmonary resuscitation is not undertaken. In patients undergoing heart valve surgery, postoperative SCA is a complication with a high risk of death, cerebral hypoxia and multiple organ dysfunction syndrome (MODS). Therefore, knowledge of the predictors of postoperative SCA is extremely important as it enables the identification of patients at risk of this complication and the application of the special surveillance and therapeutic management in this group of patients. The aim of the study was to evaluate the usefulness of selected biomarkers in predicting postoperative SCA in patients undergoing heart valve surgery.

METHODS

This prospective study was conducted on a group of 616 consecutive patients with significant valvular heart disease that underwent elective valve surgery with or without coronary artery bypass surgery. The primary end-point at the intra-hospital follow-up was postoperative SCA. The secondary end-point was death from all causes in patients with postoperative SCA. Patients were observed until discharge from the hospital or until death. Logistic regression was used to assess the relationships between variables.

RESULTS

The postoperative SCA occurred in 14 patients. At multivariate analysis, only NT-proBNP (odds ratio (OR) 1.022, 95% confidence interval (CI) 1.012-1.044; p = 0.03) remained independent predictors of the primary end-point. Age and NT-proBNP were associated with an increased risk of death in patients with postoperative SCA.

CONCLUSIONS

The results of the presented study indicate that SCA in the early postoperative period in patients undergoing heart valve surgery is an unpredictable event with high mortality. The potential predictive ability of the preoperative NT-proBNP level for the occurrence of postoperative SCA and death in patients after SCA demonstrated in the study may indicate that the overloaded and damaged myocardium in patients undergoing heart valve surgery is particularly sensitive to non-physiological conditions prevailing in the perioperative period, which may cause serious hemodynamic disturbances in the postoperative period and lead to death.

N-Terminal of the Prohormone Brain Natriuretic Peptide Predicts Postoperative Cardiogenic Shock Requiring Extracorporeal Membrane Oxygenation

Aims: Heart valve surgery is associated with a risk of serious postoperative complications including postoperative cardiogenic shock (described as postcardiotomy shock (PCS)). The indication for extracorporeal membrane oxygenation (ECMO) is cardiogenic shock, which is resistant to optimal causal and pharmacological treatment, including the supply of catecholamines and/or an intra-aortic balloon pump (IABP). The aim of this study was to assess the usefulness of the selected preoperative biomarkers in the prediction of postoperative cardiogenic shock requiring ECMO in patients undergoing heart valve surgery. Methods: A prospective study was conducted on a group of consecutive patients with significant valvular heart disease that underwent elective valve surgery. The primary endpoint at the intra-hospital follow-up was postoperative cardiogenic shock requiring ECMO. Univariate analysis, followed by multivariate regression analysis, were performed. Results: The study included 610 patients. The primary endpoint occurred in 15 patients. At multivariate analysis, the preoperative N-terminal of the prohormone brain natriuretic peptide (NT-proBNP) level (OR 1.022; 95% CI 1.011–1.034; p = 0.001) remained an independent predictor of the primary endpoint. Conclusions: An elevated NT-proBNP level was associated with a higher risk of postoperative cardiogenic shock requiring the use of ECMO.

Postoperative complications associated with coronary artery bypass graft surgery and their therapeutic interventions

Coronary artery disease is one of the commonest surgery demanding cardiovascular diseases. Coronary artery bypass graft surgery is practiced all over the world for the treatment of coronary artery disease. Systemic trauma during the surgery is associated with a wide range of complications, some of which are fatal. Preoperative risk factors such as age, previous illness and obesity are common predictors of these adverse events. Advances in therapeutic medicine have allowed timely treatment of these adverse events and co-morbidities. This review summarizes some of the most occurring complications associated with coronary artery bypass graft and corresponding treatment options.

Natriuretic Peptides in Cardiac Anesthesia and Intensive Care

Natriuretic peptides, predominantly B-type, are widely used in cardiology as prognostic and diagnostic biomarkers or, much less often, as a substantive treatment tool. They are hormones that are produced mainly in the myocardium in response to overload and ischemia, and their level quite accurately reflects the degree of myocardial dysfunction. Although their use in cardiac anesthesia and intensive care setting seems to be very beneficial for assessing the risk of acute disturbance of myocardial function or its laboratory monitoring, the actual significance of natriuretic peptides in this area is not yet recognized. This is due to the lack of clear diagnostic and prognostic values for these biomarkers supported by high-quality researches. On the basis of the available data, main advantages, existing difficulties, and most effective ways of using natriuretic peptides for determining the risk of heart surgery and assessing the severity of sepsis, pneumonia, and other critical conditions have been discussed in this review. In addition, the expediency of using natriuretic peptides as target parameters for goal-oriented therapy and as a substantive tool for treatment is considered.

Natriuretic Peptides and Normal Body Fluid Regulation

Natriuretic peptides are structurally related, functionally diverse hormones. Circulating atrial natriuretic peptide (ANP) and brain natriuretic peptide (BNP) are delivered predominantly by the heart. Two C-type natriuretic peptides (CNPs) are paracrine messengers, notably in bone, brain, and vessels. Natriuretic peptides act by binding to the extracellular domains of three receptors, NPR-A, NPR-B, and NPR-C of which the first two are guanylate cyclases. NPR-C is coupled to inhibitory proteins. Atrial wall stress is the major regulator of ANP secretion; however, atrial pressure changes plasma ANP only modestly and transiently, and the relation between plasma ANP and atrial wall tension (or extracellular volume or sodium intake) is weak. Absence and overexpression of ANP-related genes are associated with modest blood pressure changes. ANP augments vascular permeability and reduces vascular contractility, renin and aldosterone secretion, sympathetic nerve activity, and renal tubular sodium transport. Within the physiological range of plasma ANP, the responses to step-up changes are unimpressive; in man, the systemic physiological effects include diminution of renin secretion, aldosterone secretion, and cardiac preload. For BNP, the available evidence does not show that cardiac release to the blood is related to sodium homeostasis or body fluid control. CNPs are not circulating hormones, but primarily paracrine messengers important to ossification, nervous system development, and endothelial function. Normally, natriuretic peptides are not powerful natriuretic/diuretic hormones; common conclusions are not consistently supported by hard data. ANP may provide fine-tuning of reno-cardiovascular relationships, but seems, together with BNP, primarily involved in the regulation of cardiac performance and remodeling. © 2017 American Physiological Society. Compr Physiol 8:1211-1249, 2018.

Effect of carperitide on in-hospital mortality of patients admitted for heart failure: propensity score analyses

Although a previous randomized study showed that the use of atrial natriuretic peptide (carperitide) improved the long-term prognosis of patients with heart failure, its effect on short-term prognosis remains unclear. We retrospectively identified patients who were admitted to our tertiary-care center with acute decompensated heart failure (ADHF) between April 2009 and December 2013.We divided the eligible patients into two groups: patients who started receiving carperitide on the day of admission (carperitide group) and those who did not receive carperitide during hospitalization (control group). We compared the in-hospital mortality between the two groups using propensity scores derived from 40 baseline variables. We identified 879 eligible patients (mean age, 75.2 years; male, 56.7%), including 336 (38.2%) in the carperitide group and 543 (61.8%) in the control group. One-to-one propensity score matching created 177 pairs. Although the unmatched analysis found a significantly lower in-hospital mortality in the carperitide group than in the control group (3.3% vs. 7.9%, respectively, p = 0.005), the propensity score-matched analysis found no significant difference in in-hospital mortality between the two groups [4.0% vs. 5.1%, p = 0.609; risk difference, -1.1%, 95% confidence interval (CI), -5.5-3.2%]. Logistic regression analysis with adjustment for propensity scores also found no significant association between carperitide use and in-hospital mortality (adjusted odds ratio, 0.61; 95% CI, 0.29 to 1.28; p = 0.605). The present retrospective study showed that carperitide use as the initial treatment was not significantly associated with lower in-hospital mortality in patients with ADHF.

Recent Perioperative Pharmacological Prevention of Acute Kidney Injury after Cardiac Surgery: A Narrative Review

Acute kidney injury (AKI) is a common and severe complication of cardiac surgery, and related rates of both hospitalization and long-term mortality are increasing. A number of studies have explored the preventive effects of perioperative pharmacological therapy on AKI after cardiac surgery. However, the mechanisms of AKI are multifaceted, and no universal treatment has been confirmed as beneficial. We review and analyze several current perioperative pharmacological therapies for AKI after cardiac surgery to identify promising preventive strategies.