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Kamenshchikov NO, Podoksenov YK, Kozlov BN, Maslov LN, Mukhomedzyanov AV, Tyo MA, Boiko AM, Margolis NY, Boshchenko AA, Serebryakova ON, Dzyuman AN, Shirshin AS, Buranov SN, Selemir VD. The Nephroprotective Effect of Nitric Oxide during Extracorporeal Circulation: An Experimental Study. Biomedicines 2024; 12:1298. [PMID: 38927505 PMCID: PMC11201384 DOI: 10.3390/biomedicines12061298] [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: 04/23/2024] [Revised: 05/24/2024] [Accepted: 06/06/2024] [Indexed: 06/28/2024] Open
Abstract
This study aims to determine the effectiveness of administering 80 ppm nitric oxide in reducing kidney injury, mitochondrial dysfunction and regulated cell death in kidneys during experimental perfusion. Twenty-four sheep were randomized into four groups: two groups received 80 ppm NO conditioning with 90 min of cardiopulmonary bypass (CPB + NO) or 90 min of CPB and hypothermic circulatory arrest (CPB + CA + NO), while two groups received sham protocols (CPB and CPB + CA). Kidney injury was assessed using laboratory (neutrophil gelatinase-associated lipocalin, an acute kidney injury biomarker) and morphological methods (morphometric histological changes in kidney biopsy specimens). A kidney biopsy was performed 60 min after weaning from mechanical perfusion. NO did not increase the concentrations of inhaled NO2 and methemoglobin significantly. The NO-conditioning groups showed less severe kidney injury and mitochondrial dysfunction, with statistical significance in the CPB + NO group and reduced tumor necrosis factor-α expression as a trigger of apoptosis and necroptosis in renal tissue in the CPB + CA + NO group compared to the CPB + CA group. The severity of mitochondrial dysfunction in renal tissue was insignificantly lower in the NO-conditioning groups. We conclude that NO administration is safe and effective at reducing kidney injury, mitochondrial dysfunction and regulated cell death in kidneys during experimental CPB.
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Affiliation(s)
- Nikolay O. Kamenshchikov
- Cardiology Research Institute, Tomsk National Research Medical Center, Russian Academy of Sciences, 111a Kievskaya St., Tomsk 634012, Russia; (Y.K.P.); (B.N.K.); (L.N.M.); (A.V.M.); (M.A.T.); (A.M.B.); (N.Y.M.); (A.A.B.)
| | - Yuri K. Podoksenov
- Cardiology Research Institute, Tomsk National Research Medical Center, Russian Academy of Sciences, 111a Kievskaya St., Tomsk 634012, Russia; (Y.K.P.); (B.N.K.); (L.N.M.); (A.V.M.); (M.A.T.); (A.M.B.); (N.Y.M.); (A.A.B.)
| | - Boris N. Kozlov
- Cardiology Research Institute, Tomsk National Research Medical Center, Russian Academy of Sciences, 111a Kievskaya St., Tomsk 634012, Russia; (Y.K.P.); (B.N.K.); (L.N.M.); (A.V.M.); (M.A.T.); (A.M.B.); (N.Y.M.); (A.A.B.)
| | - Leonid N. Maslov
- Cardiology Research Institute, Tomsk National Research Medical Center, Russian Academy of Sciences, 111a Kievskaya St., Tomsk 634012, Russia; (Y.K.P.); (B.N.K.); (L.N.M.); (A.V.M.); (M.A.T.); (A.M.B.); (N.Y.M.); (A.A.B.)
| | - Alexander V. Mukhomedzyanov
- Cardiology Research Institute, Tomsk National Research Medical Center, Russian Academy of Sciences, 111a Kievskaya St., Tomsk 634012, Russia; (Y.K.P.); (B.N.K.); (L.N.M.); (A.V.M.); (M.A.T.); (A.M.B.); (N.Y.M.); (A.A.B.)
| | - Mark A. Tyo
- Cardiology Research Institute, Tomsk National Research Medical Center, Russian Academy of Sciences, 111a Kievskaya St., Tomsk 634012, Russia; (Y.K.P.); (B.N.K.); (L.N.M.); (A.V.M.); (M.A.T.); (A.M.B.); (N.Y.M.); (A.A.B.)
| | - Alexander M. Boiko
- Cardiology Research Institute, Tomsk National Research Medical Center, Russian Academy of Sciences, 111a Kievskaya St., Tomsk 634012, Russia; (Y.K.P.); (B.N.K.); (L.N.M.); (A.V.M.); (M.A.T.); (A.M.B.); (N.Y.M.); (A.A.B.)
| | - Natalya Yu. Margolis
- Cardiology Research Institute, Tomsk National Research Medical Center, Russian Academy of Sciences, 111a Kievskaya St., Tomsk 634012, Russia; (Y.K.P.); (B.N.K.); (L.N.M.); (A.V.M.); (M.A.T.); (A.M.B.); (N.Y.M.); (A.A.B.)
| | - Alla A. Boshchenko
- Cardiology Research Institute, Tomsk National Research Medical Center, Russian Academy of Sciences, 111a Kievskaya St., Tomsk 634012, Russia; (Y.K.P.); (B.N.K.); (L.N.M.); (A.V.M.); (M.A.T.); (A.M.B.); (N.Y.M.); (A.A.B.)
| | - Olga N. Serebryakova
- Department of Morphology and General Pathology, Siberian State Medical University, 2 Moskovsky trakt, Tomsk 634050, Russia; (O.N.S.); (A.N.D.)
| | - Anna N. Dzyuman
- Department of Morphology and General Pathology, Siberian State Medical University, 2 Moskovsky trakt, Tomsk 634050, Russia; (O.N.S.); (A.N.D.)
| | - Alexander S. Shirshin
- Federal State Unitary Enterprise “Russian Federal Nuclear Center—All-Russian Research Institute of Experimental Physics”, 37, Mira Ave., Nizhny Novgorod Region, Sarov 607190, Russia; (A.S.S.); (S.N.B.); (V.D.S.)
| | - Sergey N. Buranov
- Federal State Unitary Enterprise “Russian Federal Nuclear Center—All-Russian Research Institute of Experimental Physics”, 37, Mira Ave., Nizhny Novgorod Region, Sarov 607190, Russia; (A.S.S.); (S.N.B.); (V.D.S.)
| | - Victor D. Selemir
- Federal State Unitary Enterprise “Russian Federal Nuclear Center—All-Russian Research Institute of Experimental Physics”, 37, Mira Ave., Nizhny Novgorod Region, Sarov 607190, Russia; (A.S.S.); (S.N.B.); (V.D.S.)
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Yan Y, Kamenshchikov N, Zheng Z, Lei C. Inhaled nitric oxide and postoperative outcomes in cardiac surgery with cardiopulmonary bypass: A systematic review and meta-analysis. Nitric Oxide 2024; 146:64-74. [PMID: 38556145 DOI: 10.1016/j.niox.2024.03.004] [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: 01/21/2024] [Revised: 03/06/2024] [Accepted: 03/21/2024] [Indexed: 04/02/2024]
Abstract
Cardiac surgeries under cardiopulmonary bypass (CPB) are complex procedures with high incidence of complications, morbidity and mortality. The inhaled nitric oxide (iNO) has been frequently used as an important composite of perioperative management during cardiac surgery under CPB. We conducted a meta-analysis of published randomized clinical trials (RCTs) to assess the effects of iNO on reducing postoperative complications, including the duration of postoperative mechanical ventilation, length of intensive care unit (ICU) stay, length of hospital stay, mortality, hemodynamic improvement (the composite right ventricular failure, low cardiac output syndrome, pulmonary arterial pressure, and vasoactive inotropic score) and myocardial injury biomarker (postoperative troponin I levels). Subgroup analyses were performed to assess the effect of modification and interaction. These included iNO dosage, the timing and duration of iNO therapy, different populations (children and adults), and comparators (other vasodilators and placebo or standard care). A comprehensive search for iNO and cardiac surgery was performed on online databases. Twenty-seven studies were included after removing the duplicates and irrelevant articles. The results suggested that iNO could reduce the duration of mechanical ventilation, but had no significance in the ICU stay, hospital stay, and mortality. This may be attributed to the small sample size of the most included studies and heterogeneity in timing, dosage and duration of iNO administration. Well-designed, large-scale, multicenter clinical trials are needed to further explore the effect of iNO in improving postoperative prognosis in cardiovascular surgical patients.
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Affiliation(s)
- Yun Yan
- Department of Anesthesiology and Perioperative Medicine, Xijing Hospital, The Fourth Military Medical University, Xi'an, 710032, China; Department of Anesthesiology, China-Japan Friendship Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100029, China
| | - Nikolay Kamenshchikov
- Laboratory of Critical Care Medicine, Department of Anesthesiology and Intensive Care, Cardiology Research Institute, Tomsk National Research Medical Center, Russian Academy of Sciences, 111a Kievskaya St., Tomsk, 634012, Russian Federation
| | - Ziyu Zheng
- Department of Anesthesiology and Perioperative Medicine, Xijing Hospital, The Fourth Military Medical University, Xi'an, 710032, China
| | - Chong Lei
- Department of Anesthesiology and Perioperative Medicine, Xijing Hospital, The Fourth Military Medical University, Xi'an, 710032, China.
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Orizondo RA, Bengur FB, Komatsu C, Strong KR, Federspiel WJ, Solari MG. Machine Perfusion Deters Ischemia-Related Derangement of a Rodent Free Flap: Development of a Model. J Surg Res 2024; 295:203-213. [PMID: 38035871 DOI: 10.1016/j.jss.2023.10.014] [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: 10/16/2022] [Revised: 09/12/2023] [Accepted: 10/27/2023] [Indexed: 12/02/2023]
Abstract
INTRODUCTION Machine perfusion can enable isolated support of composite tissues, such as free flaps. The goal of perfusion in this setting is to preserve tissues prior to transplantation or provide transient support at the wound bed. This study aimed to establish a rodent model of machine perfusion in a fasciocutaneous-free flap to serve as an affordable testbed and determine the potential of the developed support protocol to deter ischemia-related metabolic derangement. METHODS Rat epigastric-free flaps were harvested and transferred to a closed circuit that provides circulatory and respiratory support. Whole rat blood was recirculated for 8 h, while adjusting the flow rate to maintain arterial-like perfusion pressures. Blood samples were collected during support. Extracellular tissue lactate and glucose levels were characterized with a microdialysis probe and compared with warm ischemic, cold ischemic, and anastomosed-free flap controls. RESULTS Maintenance of physiologic arterial pressures (85-100 mmHg) resulted in average pump flow rates of 360-430 μL/min. Blood-based measurements showed maintained glucose and oxygen consumption throughout machine perfusion. Average normalized lactate to glucose ratio for the perfused flaps was 5-32-fold lower than that for the warm ischemic flap controls during hours 2-8 (P < 0.05). CONCLUSIONS We developed a rat model of ex vivo machine perfusion of a fasciocutaneous-free flap with maintained stable flow and tissue metabolic activity for 8 h. This model can be used to assess critical elements of support in this setting as well as explore other novel therapies and technologies to improve free tissue transfer.
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Affiliation(s)
- Ryan A Orizondo
- Department of Plastic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania; Department of Bioengineering, University of Pittsburgh, Pittsburgh, Pennsylvania; McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Fuat Baris Bengur
- Department of Plastic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Chiaki Komatsu
- Department of Plastic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Kelly R Strong
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - William J Federspiel
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, Pennsylvania; McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania; Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania; Department of Chemical Engineering, University of Pittsburgh, Pittsburgh, Pennsylvania; Department of Clinical and Translational Sciences, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Mario G Solari
- Department of Plastic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania; McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania.
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Clark JB. Commentary: Encouraging findings for the renal-protective effect of nitric oxide administration during cardiopulmonary bypass. J Thorac Cardiovasc Surg 2023; 166:e176-e177. [PMID: 37164057 DOI: 10.1016/j.jtcvs.2023.04.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 04/13/2023] [Indexed: 05/12/2023]
Affiliation(s)
- Joseph B Clark
- Department of Pediatrics, Penn State Health Children's Hospital, Hershey, Pa.
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Zhang J, Li J, An Z, Qi J. HYDROMORPHONE MITIGATES CARDIOPULMONARY BYPASS-INDUCED ACUTE LUNG INJURY BY REPRESSING PYROPTOSIS OF ALVEOLAR MACROPHAGES. Shock 2023; 60:92-99. [PMID: 37127893 DOI: 10.1097/shk.0000000000002138] [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: 05/03/2023]
Abstract
ABSTRACT Introduction: Acute lung injury (ALI) is a devastating pulmonary illness with diffuse inflammatory responses. Hydromorphone (Hyd) is an opioid agonist used for relieving moderate-to-severe pain. The present work investigated the effect of Hyd on cardiopulmonary bypass (CPB)-induced ALI by regulating pyroptosis of alveolar macrophages (AMs). Methods: Rats were subjected to CPB, followed by Hyd treatment. The lung injury in rat lung tissues was appraised by the ratio of lung wet/dry weight (weight), histological staining, and the total protein concentrations in bronchoalveolar lavage fluid, and lung function was assessed by oxygenation index and respiratory index, and lung macrophage pyroptosis was observed by fluorescence staining. Alveolar macrophages were separated and pyroptosis was determined by western blot assay and enzyme-linked immunosorbent assay. The expression patterns of nuclear factor erythroid 2-related factor 2/heme oxygenase 1 (Nrf2/HO-1), nod-like receptor protein 3 (NLRP3), N-terminal gasdermin-D, and cleaved caspase-1 were examined by real-time quantitative polymerase chain reaction, western blot, and immunohistochemistry assays. The impact of NLRP3 or Nrf2 on pyroptosis of AMs and CPB-induced ALI was observed after treatment of nigericin (NLRP3 agonist) or ML385 (Nrf2 inhibitor). Results: Hyd attenuated CPB-induced lung injury as manifested by reductions in lung inflammation and edema, the scores of lung injury, the ratio of lung wet/dry weight, and the total protein concentrations in bronchoalveolar lavage fluid. Besides, Hyd repressed NLRP3 inflammasome-mediated pyroptosis of AMs after CPB treatment. Hyd upregulated Nrf2/HO-1 expression levels to repress NLRP3 inflammasome-mediated pyroptosis. Treatment of nigericin or ML385 counteracted the role of Hyd in ameliorating pyroptosis of AMs and CPB-induced ALI. Conclusions: Hyd alleviated NLRP3 inflammasome-mediated pyroptosis and CPB-induced ALI via upregulating the Nrf2/HO-1 pathway, which may be achieved by AMs.
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Affiliation(s)
- Jun Zhang
- Department of Anesthesiology, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, China
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Nanodrugs alleviate acute kidney injury: Manipulate RONS at kidney. Bioact Mater 2023; 22:141-167. [PMID: 36203963 PMCID: PMC9526023 DOI: 10.1016/j.bioactmat.2022.09.021] [Citation(s) in RCA: 28] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 08/12/2022] [Accepted: 09/19/2022] [Indexed: 02/06/2023] Open
Abstract
Currently, there are no clinical drugs available to treat acute kidney injury (AKI). Given the high prevalence and high mortality rate of AKI, the development of drugs to effectively treat AKI is a huge unmet medical need and a research hotspot. Although existing evidence fully demonstrates that reactive oxygen and nitrogen species (RONS) burst at the AKI site is a major contributor to AKI progression, the heterogeneity, complexity, and unique physiological structure of the kidney make most antioxidant and anti-inflammatory small molecule drugs ineffective because of the lack of kidney targeting and side effects. Recently, nanodrugs with intrinsic kidney targeting through the control of size, shape, and surface properties have opened exciting prospects for the treatment of AKI. Many antioxidant nanodrugs have emerged to address the limitations of current AKI treatments. In this review, we systematically summarized for the first time about the emerging nanodrugs that exploit the pathological and physiological features of the kidney to overcome the limitations of traditional small-molecule drugs to achieve high AKI efficacy. First, we analyzed the pathological structural characteristics of AKI and the main pathological mechanism of AKI: hypoxia, harmful substance accumulation-induced RONS burst at the renal site despite the multifactorial initiation and heterogeneity of AKI. Subsequently, we introduced the strategies used to improve renal targeting and reviewed advances of nanodrugs for AKI: nano-RONS-sacrificial agents, antioxidant nanozymes, and nanocarriers for antioxidants and anti-inflammatory drugs. These nanodrugs have demonstrated excellent therapeutic effects, such as greatly reducing oxidative stress damage, restoring renal function, and low side effects. Finally, we discussed the challenges and future directions for translating nanodrugs into clinical AKI treatment. AKI is a common clinical acute syndrome with high morbidity and mortality but without effective clinical drug available. Hypoxia and accumulation of toxic substances are key pathological features of various heterogeneous AKI. Excessive RONS is the core of the pathological mechanism of AKI. The development of nanodrugs is expected to achieve successful treatment in AKI.
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Balakhnin DG, Chermnykh II, Ivkin AA, Borisenko DV, Grigoryev EV. The Issue of Acute Kidney Injury in Patients after Cardiac Surgery. MESSENGER OF ANESTHESIOLOGY AND RESUSCITATION 2022. [DOI: 10.21292/2078-5658-2022-19-5-93-101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Cardiac surgery associated acute kidney injury (CSA-AKI) is a common complication of cardiac surgery resulting from the patient's exposure to a complex combination of factors in the perioperative period. Current diagnostic criteria for AKI may underestimate the incidence of this complication due to certain specific features of cardiac surgery patients. The introduction of new diagnostic biomarkers of kidney injury into clinical practice has shown the prospective of identifying patients in the early stages of CSA-AKI development. Accurate and timely identification of patients at high risk of developing CSA-AKI can also allow performing comprehensive interventions to prevent it. When diagnosed, CSA-AKI management limited to symptomatic treatment.
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Li S, A L. The hidden blood loss and its factors in patients undergoing minimally invasive knee arthroscopy. Front Surg 2022; 9:944481. [PMID: 36111226 PMCID: PMC9468242 DOI: 10.3389/fsurg.2022.944481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Accepted: 07/22/2022] [Indexed: 11/17/2022] Open
Abstract
Background With respect to knee arthroscopy, assessing the amount of hidden blood loss is of great importance to avoid potential complications such as fever, anemia, difficulty in wound healing and wound infection. The current study aims to investigate the hidden blood loss and its factors in patients who underwent minimally invasive knee arthroscopy. Methods Consecutive patients with knee joint injury, who underwent arthroscopic minimally invasive treatment, were enrolled from January 2019 to November 2020 and were retrospectively studied. Demographic information on these patients, such as medical history and biochemical parameters, was collected. The hidden blood loss was calculated. Multivariate linear regression analysis was used to confirm independent factors associated with hidden blood loss. Results Finally, a total of 100 patients aged 44.78 ± 13.67 (range 17–66) years were reviewed, and it was found that a substantial amount of [387.02 ± 252.56 (range 18.89–1130.06) ml] hidden blood loss occurred after minimally invasive knee arthroscopy. Univariate analysis showed that this hidden blood loss was negatively correlated with age, gender, postoperative hemoglobin, and postoperative hematocrit (all P < 0.05), while it was positively correlated with body mass index (BMI), length of hospital stay, preoperative red blood cells, preoperative hemoglobin, preoperative hematocrit, blood volume, and the presence of medical conditions (all P < 0.05). Further multivariate linear regression indicated that preoperative hematocrit, blood volume, and postoperative hematocrit were independent factors associated with actual blood loss, and preoperative hematocrit, blood volume, postoperative hematocrit, and gender were independent factors associated with hidden blood loss, respectively (all P < 0.05). Conclusion Preoperative hematocrit, preoperative blood volume, postoperative hematocrit, and gender are the influencing factors of hidden blood loss in patients undergoing minimally invasive treatment under knee arthroscopy. More attention should be paid to hidden blood loss and its factors during the perioperative period.
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Affiliation(s)
- Sheng Li
- Department of Orthopaedics, Affiliated Central Hospital of Shenyang Medical College, Shenyang, China
- Shenyang Hand Foot Clinical Research Center, Shenyang, China
| | - Liang A
- Department of Orthopaedics, Affiliated Central Hospital of Shenyang Medical College, Shenyang, China
- Shenyang Hand Foot Clinical Research Center, Shenyang, China
- Correspondence: Liang A
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Risk Factors for Acute Kidney Injury Following Cardiac Surgery and Performance of Leicester Score in a Spanish Cohort. J Clin Med 2022; 11:jcm11040904. [PMID: 35207177 PMCID: PMC8876028 DOI: 10.3390/jcm11040904] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 01/29/2022] [Accepted: 02/03/2022] [Indexed: 12/04/2022] Open
Abstract
The incidence of acute kidney injury following cardiac surgery (CSA-AKI) is up to 30%, and it places patients at an increased risk of death. The Leicester score (LS) is a new score that predicts CSA-AKI of any stage with better discrimination compared to previous scores. The aim of this study was to identify risk factors for CSA-AKI and to assess the performance of LS. A unicentric retrospective study of patients that required cardiac surgery with cardio-pulmonary bypass (CPB) in 2015 was performed. The inclusion criteria were patients over 18 years old who were operated on for cardiac surgery (valve substitution (VS), Coronary Artery Bypass Graft (CABG), or a combination of both procedures and requiring CPB). CSA-AKI was defined with the Kidney Disease Improving Global Outcomes (KDIGO) criteria. In the multivariate analysis, hypertension (odds ratio 1.883), estimated glomerular filtration rate (EGFR) <60 mL/min (2.365), and peripheral vascular disease (4.66) were associated with the outcome. Both discrimination and calibration were better when the LS was used compared to the Cleveland Clinic Score and Euroscore II, with an area under the curve (AUC) of 0.721. In conclusion, preoperative hypertension in patients with CKD with or without peripheral vasculopathy can identify patients who are at risk of CSA-AKI. The LS was proven to be a valid score that could be used to identify patients who are at risk and who could benefit from intervention studies.
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Vuong TA, Rana MS, Moore B, Cronin J, Ceneri NM, Sinha P, Deutsch N, Matisoff AJ. Association Between Exogenous Nitric Oxide Given During Cardiopulmonary Bypass and the Incidence of Postoperative Kidney Injury in Children. J Cardiothorac Vasc Anesth 2021; 36:2352-2357. [PMID: 34776350 DOI: 10.1053/j.jvca.2021.10.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 10/03/2021] [Accepted: 10/06/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To compare the incidence and severity of acute kidney injury (AKI) after cardiac surgery with cardiopulmonary bypass and the administration of exogenous nitric oxide in children. DESIGN A retrospective cohort study. SETTING A single institution, university hospital. PARTICIPANTS All children younger than 18 years of age who underwent surgery with cardiopulmonary bypass. INTERVENTIONS Medical records of all eligible patients between January 4, 2017, and June 28, 2019, were reviewed. Patients were divided into two groups based on whether they received exogenous nitric oxide. MEASUREMENTS AND MAIN RESULTS The primary endpoint was a change in serum creatinine level, defined as the difference between the preoperative creatinine and peak postoperative creatinine. The secondary endpoint was the incidence and severity of postoperative AKI. A difference-in-difference method using fixed-effect multiple linear regression was carried out to compare the difference in maximum serum creatinine changes between the control and intervention groups. Five hundred ninety-one patients were included in the analysis: 298 (50.5%) in the control group and 293 (49.5%) in the intervention group. Control and intervention groups did not vary significantly in terms of baseline characteristics except for bypass time. After adjusting for all baseline variables, there was no statistically significant difference in the increase in serum creatinine between the control and the intervention groups (0.01 [95% CI: -0.03, 0.05], p = 0.545). CONCLUSIONS This single-center, retrospective, cohort study found no change in the incidence and severity of postoperative AKI after the administration of nitric oxide into the cardiopulmonary bypass circuit in children.
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Affiliation(s)
- Thoai A Vuong
- The George Washington University School of Medicine and Health Sciences, Division of Cardiac Anesthesia, Children's National Hospital, Washington, DC.
| | - Md Sohel Rana
- Children's National Hospital, Joseph E. Robert, Jr., Center for Surgical Care, Washington, DC
| | - Brenna Moore
- The George Washington University School of Medicine and Health Sciences, MD Candidate, Washington, DC
| | - Jessica Cronin
- The George Washington University School of Medicine and Health Sciences, Division of Anesthesia and Perioperative Medicine, Children's National Hospital, Washington, DC
| | - Nicolle M Ceneri
- The George Washington University School of Medicine and Health Sciences, MD Candidate, Washington, DC
| | - Pranava Sinha
- The George Washington University School of Medicine and Health Sciences, Division of Cardiovascular Surgery, Children's National Hospital, Washington, DC
| | - Nina Deutsch
- The George Washington University School of Medicine and Health Sciences, Division of Cardiac Anesthesia, Children's National Hospital, Washington, DC
| | - Andrew J Matisoff
- The George Washington University School of Medicine and Health Sciences, Division of Cardiac Anesthesia, Children's National Hospital, Washington, DC
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Hu J, Rezoagli E, Zadek F, Bittner EA, Lei C, Berra L. Free Hemoglobin Ratio as a Novel Biomarker of Acute Kidney Injury After On-Pump Cardiac Surgery: Secondary Analysis of a Randomized Controlled Trial. Anesth Analg 2021; 132:1548-1558. [PMID: 33481401 DOI: 10.1213/ane.0000000000005381] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Cardiac surgery with cardiopulmonary bypass (CPB) is associated with a high risk of postoperative acute kidney injury (AKI). Due to limitations of current diagnostic strategies, we sought to determine whether free hemoglobin (fHb) ratio (ie, levels of fHb at the end of CPB divided by baseline fHb) could predict AKI after on-pump cardiac surgery. METHODS This is a secondary analysis of a randomized controlled trial comparing the effect of nitric oxide (intervention) versus nitrogen (control) on AKI after cardiac surgery (NCT01802619). A total of 110 adult patients in the control arm were included. First, we determined whether fHb ratio was associated with AKI via multivariable analysis. Second, we verified whether fHb ratio could predict AKI and incorporation of fHb ratio could improve predictive performance at an early stage, compared with prediction using urinary biomarkers alone. We conducted restricted cubic spline in logistic regression for model development. We determined the predictive performance, including area under the receiver-operating-characteristics curve (AUC) and calibration (calibration plot and accuracy, ie, number of correct predictions divided by total number of predictions). We also used AUC test, likelihood ratio test, and net reclassification index (NRI) to compare the predictive performance between competing models (ie, fHb ratio versus neutrophil gelatinase-associated lipocalin [NGAL], N-acetyl-β-d-glucosaminidase [NAG], and kidney injury molecule-1 [KIM-1], respectively, and incorporation of fHb ratio with NGAL, NAG, and KIM-1 versus urinary biomarkers alone), if applicable. RESULTS Data stratified by median fHb ratio showed that subjects with an fHb ratio >2.23 presented higher incidence of AKI (80.0% vs 49.1%; P = .001), more need of renal replacement therapy (10.9% vs 0%; P = .036), and higher in-hospital mortality (10.9% vs 0%; P = .036) than subjects with an fHb ratio ≤2.23. fHb ratio was associated with AKI after adjustment for preestablished factors. fHb ratio outperformed urinary biomarkers with the highest AUC of 0.704 (95% confidence interval [CI], 0.592-0.804) and accuracy of 0.714 (95% CI, 0.579-0.804). Incorporation of fHb ratio achieved better discrimination (AUC test, P = .012), calibration (likelihood ratio test, P < .001; accuracy, 0.740 [95% CI, 0.617-0.832] vs 0.632 [95% CI, 0.477-0.748]), and significant prediction increment (NRI, 0.638; 95% CI, 0.269-1.008; P < .001) at an early stage, compared with prediction using urinary biomarkers alone. CONCLUSIONS Results from this exploratory, hypothesis-generating retrospective, observational study shows that fHb ratio at the end of CPB might be used as a novel, widely applicable biomarker for AKI. The use of fHb ratio might help for an early detection of AKI, compared with prediction based only on urinary biomarkers.
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Affiliation(s)
- Jie Hu
- From the Department of Critical Care Medicine, Chinese PLA General Hospital, Beijing, China.,Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Emanuele Rezoagli
- School of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy
| | - Francesco Zadek
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Edward A Bittner
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Chong Lei
- Department of Anesthesiology and Perioperative Medicine, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Lorenzo Berra
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
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12
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McNair ED, Bezaire J, Moser M, Mondal P, Conacher J, Franczak A, Sawicki G, Reid D, Khani-Hanjani A. The Association of Matrix Metalloproteinases With Acute Kidney Injury Following CPB-Supported Cardiac Surgery. Can J Kidney Health Dis 2021; 8:20543581211019640. [PMID: 34350005 PMCID: PMC8287351 DOI: 10.1177/20543581211019640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 04/19/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Cardiac surgery-associated acute kidney injury (AKI) is an adverse outcome that increases morbidity and mortality in patients undergoing cardiac surgical procedures. To date, the use of serum creatinine levels as an early indicator of AKI has limitations because of its slow rise and poor predictive accuracy for renal injury. This delay in diagnosis may lead to prolonged initiation in treatment and increased risk for adverse outcomes. OBJECTIVE This pilot study explores serum and urine matrix metalloproteinases (MMPs)-2 and MMP-9 and their association, and potentially earlier detection of AKI in patients following cardiopulmonary bypass (CPB)-supported cardiac surgery. We hypothesize that increased activity of serum and urine levels MMP-2 and/ or MMP-9 are associated with AKI. Furthermore, MMP-2 and/ or MMP-9 may provide earlier identification of AKI as compared with serum levels of creatinine. METHODS During the study period, there were 150 CPB-supported surgeries, 21 of which developed AKI according to the Kidney Disease Improving Global Outcomes criteria. We then selected a sample of 21 matched cases from those patients who went through the surgery without developing AKI. Primary outcomes were the measurement via gel zymography of the serum and urine activity of MMP-2 and MMP-9 drawn at the following intervals: pre-CPB; 10-minute post-CPB; and 4-hour post-CPB time points. Secondary variables were the measurement of serum creatinine, intensive care unit (ICU) fluid balance, and length of ICU stay. RESULTS At the 10-minute and 4-hour post-CPB time points, the serum MMP-2 activity of AKI patients were significantly higher as compared with non-AKI patients (P < .001 and P = .004), respectively. Similarly, at the 10-minute and 4-hour post-CPB time points, the serum MMP-9 activity of AKI patients was significantly higher as compared with non-AKI patients (P = .001 and P = .014), respectively. The activity of urine MMP-2 and MMP-9 of AKI patients was significantly higher as compared with non-AKI patients at all 3 time points (P = .004, P < .001, P < .001), respectively. CONCLUSION Although the pilot study may have limitations, it has demonstrated that the serum and urine levels of activity of MMP-2 and MMP-9 are associated with the clinical endpoint of AKI and appear to have earlier rising levels as compared with those of serum creatinine. Furthermore, in depth, exploration is underway with a larger sample size to attempt validation of the analytical performance and reproducibility of the assay for MMP-2 and MMP-9 to aid in earlier diagnosis of AKI following CPB-supported cardiac surgery.
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Affiliation(s)
- Erick D. McNair
- Department of Pathology and Laboratory
Medicine, College of Medicine, University of Saskatchewan, Saskatoon, Canada
- Department of Surgery/Division of
Cardiac Surgery, College of Medicine, University of Saskatchewan, Saskatoon,
Canada
| | - Jennifer Bezaire
- Department of Pathology and Laboratory
Medicine, College of Medicine, University of Saskatchewan, Saskatoon, Canada
| | - Michael Moser
- Department of Medicine, College of
Medicine, University of Saskatchewan, Saskatoon, Canada
| | - Prosanta Mondal
- Department of Community Health and
Epidemiology, College of Medicine, University of Saskatchewan, Saskatoon,
Canada
| | - Josie Conacher
- Department of Pathology and Laboratory
Medicine, College of Medicine, University of Saskatchewan, Saskatoon, Canada
| | - Aleksandra Franczak
- Department of Medicine, College of
Medicine, University of Saskatchewan, Saskatoon, Canada
| | - Greg Sawicki
- Department of Pharmacology, College of
Medicine, University of Saskatchewan, Saskatoon, Canada
| | - David Reid
- Department of Medicine, College of
Medicine, University of Saskatchewan, Saskatoon, Canada
| | - Abass Khani-Hanjani
- Department of Surgery/Division of
Cardiac Surgery, College of Medicine, University of Saskatchewan, Saskatoon,
Canada
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13
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Nakane T, Esaki J, Ueda R, Honda M, Okabayashi H. Inhaled nitric oxide improves pulmonary hypertension and organ functions after adult heart valve surgeries. Gen Thorac Cardiovasc Surg 2021; 69:1519-1526. [PMID: 34033007 DOI: 10.1007/s11748-021-01651-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 05/17/2021] [Indexed: 01/31/2023]
Abstract
OBJECTIVES Pulmonary hypertension during cardiac surgery is associated with increased morbidity and mortality. Inhaled nitric oxide serves as a selective pulmonary vasodilator and has other potential extrapulmonary protective roles. Its effects on pulmonary hypertension and organ functions after adult valve surgeries were evaluated. METHODS From April 2017 to March 2000, 30 patients received inhaled nitric oxide therapy for pulmonary hypertension during weaning from cardiopulmonary bypass in valvular surgery (iNO group). The group was compared with a control group of 65 patients who developed pulmonary hypertension during weaning from cardiopulmonary bypass in valvular surgery and received conventional therapy from April 2014 to March 2017. Intraoperative hemodynamic changes and postoperative Sequential Organ Failure Assessment (SOFA) score were evaluated. RESULTS The inhalation of nitric oxide lowered the pulmonary-to-systemic pressure ratio (Pp/Ps) (p < 0.0001) in the iNO group, and this ratio after the inhalation was significantly lower than that in the control group (p = 0.015). Moreover, norepinephrine requirement was lower in the iNO group than in the control group (p = 0.0060). The SOFA total scores, respiratory scores, coagulation scores, and the increase of renal scores within postoperative 2 days were lower in the iNO group than in the control group (p < 0.0001, p = 0.0002, p = 0.0013, and p = 0.037). CONCLUSIONS Inhaled nitric oxide therapy ameliorated pulmonary hypertension and improved postoperative respiratory, coagulation, and renal functions in adult valve surgeries.
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Affiliation(s)
- Takeichiro Nakane
- Department of Cardiovascular Surgery, Mitsubishi Kyoto Hospital, 1 Katsuragosho-cho, Nishikyo-ku, Kyoto, 615-8087, Japan.
| | - Jiro Esaki
- Department of Cardiovascular Surgery, Mitsubishi Kyoto Hospital, 1 Katsuragosho-cho, Nishikyo-ku, Kyoto, 615-8087, Japan
| | - Ryoma Ueda
- Department of Cardiovascular Surgery, Mitsubishi Kyoto Hospital, 1 Katsuragosho-cho, Nishikyo-ku, Kyoto, 615-8087, Japan
| | - Masanori Honda
- Department of Cardiovascular Surgery, Mitsubishi Kyoto Hospital, 1 Katsuragosho-cho, Nishikyo-ku, Kyoto, 615-8087, Japan
| | - Hitoshi Okabayashi
- Department of Cardiovascular Surgery, Mitsubishi Kyoto Hospital, 1 Katsuragosho-cho, Nishikyo-ku, Kyoto, 615-8087, Japan
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14
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Liu K, Wang H, Yu SJ, Tu GW, Luo Z. Inhaled pulmonary vasodilators: a narrative review. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:597. [PMID: 33987295 PMCID: PMC8105872 DOI: 10.21037/atm-20-4895] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 07/30/2020] [Indexed: 02/05/2023]
Abstract
Pulmonary hypertension (PH) is a severe disease that affects people of all ages. It can occur as an idiopathic disorder at birth or as part of a variety of cardiovascular and pulmonary disorders. Inhaled pulmonary vasodilators (IPV) can reduce pulmonary vascular resistance (PVR) and improve RV function with minimal systemic effects. IPV includes inhaled nitric oxide (iNO), inhaled aerosolized prostacyclin, or analogs, including epoprostenol, iloprost, treprostinil, and other vasodilators. In addition to pulmonary vasodilating effects, IPV can also be used to improve oxygenation, reduce inflammation, and protect cell. Off-label use of IPV is common in daily clinical practice. However, evidence supporting the inhalational administration of these medications is limited, inconclusive, and controversial regarding their safety and efficacy. We conducted a search for relevant papers published up to May 2020 in four databases: PubMed, Google Scholar, EMBASE and Web of Science. This review demonstrates that the clinical using and updated evidence of IPV. iNO is widely used in neonates, pediatrics, and adults with different cardiopulmonary diseases. The limitations of iNO include high cost, flat dose-response, risk of significant rebound PH after withdrawal, and the requirement of complex technology for monitoring. The literature suggests that inhaled aerosolized epoprostenol, iloprost, treprostinil and others such as milrinone and levosimendan may be similar to iNO. More research of IPV is needed to determine acceptable inclusion criteria, long-term outcomes, and management strategies including time, dose, and duration.
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Affiliation(s)
- Kai Liu
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Huan Wang
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Shen-Ji Yu
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Guo-Wei Tu
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Zhe Luo
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
- Department of Critical Care Med, Xiamen Branch, Zhongshan Hospital, Fudan University, Xiamen, China
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15
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Wu B, Zheng C, Ding K, Huang X, Li M, Zhang S, Lei Y, Guo Y, Wang Y. Cross-Linking Porcine Pericardium by 3,4-Dihydroxybenzaldehyde: A Novel Method to Improve the Biocompatibility of Bioprosthetic Valve. Biomacromolecules 2020; 22:823-836. [PMID: 33375781 DOI: 10.1021/acs.biomac.0c01554] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Heart valve replacement is an effective therapy for patients with moderate to severe valvular stenosis or regurgitation. Most bioprosthetic heart valves applied clinically are based on cross-linking with glutaraldehyde (GLUT), but they have some drawbacks like high cytotoxicity, severe calcification, and poor hemocompatibility. In this study, we focused on enhancing the properties of bioprosthetic heart valves by cross-linking with 3,4-dihydroxybenzaldehyde (DHBA). The experiment results revealed that compared with GLUT cross-linked porcine pericardium (PP), the relative amount of platelets absorbed on the surface of DHBA cross-linked PP decreased from 0.294 ± 0.034 to 0.176 ± 0.028, and the activated partial thromboplastin time (APTT) increased from 9.9 ± 0.1 to 15.2 ± 0.1 s, indicating improved hemocompatibility. Moreover, anticalcification performance and cytocompatibility were greatly enhanced by DHBA cross-linking. In conclusion, the properties of bioprosthetic valves could be effectively improved by processing valves with a DHBA-based cross-linking method.
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Affiliation(s)
- Binggang Wu
- National Engineering Research Center for Biomaterials, Sichuan University, No. 29 Wangjiang Road, Chengdu 610064, P. R. China.,Department of Cardiovascular Surgery, West China Hospital, Sichuan University, No. 37 Guoxue Alley, Chengdu 610041, P. R. China
| | - Cheng Zheng
- National Engineering Research Center for Biomaterials, Sichuan University, No. 29 Wangjiang Road, Chengdu 610064, P. R. China
| | - Kailei Ding
- National Engineering Research Center for Biomaterials, Sichuan University, No. 29 Wangjiang Road, Chengdu 610064, P. R. China
| | - Xueyu Huang
- National Engineering Research Center for Biomaterials, Sichuan University, No. 29 Wangjiang Road, Chengdu 610064, P. R. China
| | - Meiling Li
- National Engineering Research Center for Biomaterials, Sichuan University, No. 29 Wangjiang Road, Chengdu 610064, P. R. China
| | - Shumang Zhang
- National Engineering Research Center for Biomaterials, Sichuan University, No. 29 Wangjiang Road, Chengdu 610064, P. R. China
| | - Yang Lei
- National Engineering Research Center for Biomaterials, Sichuan University, No. 29 Wangjiang Road, Chengdu 610064, P. R. China
| | - Yingqiang Guo
- Department of Cardiovascular Surgery, West China Hospital, Sichuan University, No. 37 Guoxue Alley, Chengdu 610041, P. R. China
| | - Yunbing Wang
- National Engineering Research Center for Biomaterials, Sichuan University, No. 29 Wangjiang Road, Chengdu 610064, P. R. China
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16
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Hornik CP. Efficacy of Nitric Oxide Administration During Neonatal Cardiopulmonary Bypass. World J Pediatr Congenit Heart Surg 2020; 11:NP424-NP425. [PMID: 32645765 DOI: 10.1177/2150135120920625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This editorial accompanies an original research article by Dr Elzein and colleagues describing findings of a randomized, placebo-controlled trial of nitric oxide administration during cardiopulmonary bypass surgery in infants undergoing the Norwood procedure.
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17
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Eghtesady P. Invited Commentary. Ann Thorac Surg 2019; 109:1494-1495. [PMID: 31843635 DOI: 10.1016/j.athoracsur.2019.10.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Accepted: 10/15/2019] [Indexed: 10/25/2022]
Affiliation(s)
- Pirooz Eghtesady
- Pediatric Cardiothoracic Surgery, Washington University in St Louis and St Louis Children's Hospital, One Children's Place, Ste 5S50, St Louis, MO 63110.
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18
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Merkle J, Sunny J, Ehlscheid L, Sabashnikov A, Weber C, Eghbalzadeh K, Djordjevic I, Liakopoulos O, Choi YH, Wahlers T, Zeriouh M. Early and long-term outcomes of coronary artery bypass surgery with and without use of heart-lung machine and with special respect to renal function - A retrospective study. PLoS One 2019; 14:e0223806. [PMID: 31600308 PMCID: PMC6786630 DOI: 10.1371/journal.pone.0223806] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2019] [Accepted: 09/27/2019] [Indexed: 01/18/2023] Open
Abstract
The aim of our study was to compare early and long-term outcome of patients undergoing either on-pump or off-pump coronary artery bypass grafting with special focus on impairment of renal function. Five hundred ninety-three consecutive patients undergoing coronary artery bypass grafting were retrospectively analyzed. They were assigned either to on-pump (n = 281) or to off-pump (n = 312) group. Early and long-term outcomes were analyzed with special focus on renal function. Basic demographics and preoperative characteristics did not differ between groups (p>0.05) as well as postoperative renal parameters (p>0.05). Postoperative odds ratios (OR) of off-pump group in comparison to on-pump group were higher without reaching significance in terms of incidence of gastrointestinal complications and pneumonia (OR = 2.23 and 1.61, respectively) as well as hazard ratios (HR) on long-term follow-up for mortality and incidence of myocardial infarction (HR = 1.50 and 2.29, respectively). Kaplan-Meier estimation analysis also revealed similar results for both groups in terms of mid- and long-term survival (Breslow p = 0.062 and Log-Rank p = 0.064, respectively) and for incidence of myocardial infarction (Breslow p = 0.102 and Log-Rank p = 0.103, respectively). Our study suggests that use or not use of coronary artery bypass did not influence postoperative renal function. Odds of early outcomes were similar in both groups as well as incidence of myocardial infarction and mortality in long-term follow-up.
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Affiliation(s)
- Julia Merkle
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
- * E-mail:
| | - Jaison Sunny
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | - Laura Ehlscheid
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | - Anton Sabashnikov
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | - Carolyn Weber
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | - Kaveh Eghbalzadeh
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | - Ilija Djordjevic
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | - Oliver Liakopoulos
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | - Yeong-Hoon Choi
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | - Thorsten Wahlers
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | - Mohamed Zeriouh
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
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