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Muenster S, Zarragoikoetxea I, Moscatelli A, Balcells J, Gaudard P, Pouard P, Marczin N, Janssens SP. Inhaled NO at a crossroads in cardiac surgery: current need to improve mechanistic understanding, clinical trial design and scientific evidence. Front Cardiovasc Med 2024; 11:1374635. [PMID: 38646153 PMCID: PMC11027901 DOI: 10.3389/fcvm.2024.1374635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 03/27/2024] [Indexed: 04/23/2024] Open
Abstract
Inhaled nitric oxide (NO) has been used in pediatric and adult perioperative cardiac intensive care for over three decades. NO is a cellular signaling molecule that induces smooth muscle relaxation in the mammalian vasculature. Inhaled NO has the unique ability to exert its vasodilatory effects in the pulmonary vasculature without any hypotensive side-effects in the systemic circulation. In patients undergoing cardiac surgery, NO has been reported in numerous studies to exert beneficial effects on acutely lowering pulmonary artery pressure and reversing right ventricular dysfunction and/or failure. Yet, various investigations failed to demonstrate significant differences in long-term clinical outcomes. The authors, serving as an advisory board of international experts in the field of inhaled NO within pediatric and adult cardiac surgery, will discuss how the existing scientific evidence can be further improved. We will summarize the basic mechanisms underlying the clinical applications of inhaled NO and how this translates into the mandate for inhaled NO in cardiac surgery. We will move on to the popular use of inhaled NO and will talk about the evidence base of the use of this selective pulmonary vasodilator. This review will elucidate what kind of clinical and biological barriers and gaps in knowledge need to be solved and how this has impacted in the development of clinical trials. The authors will elaborate on how the optimization of inhaled NO therapy, the development of biomarkers to identify the target population and the definition of response can improve the design of future large clinical trials. We will explain why it is mandatory to gain an international consensus for the state of the art of NO therapy far beyond this expert advisory board by including the different major players in the field, such as the different medical societies and the pharma industry to improve our understanding of the real-life effects of inhaled NO in large scale observational studies. The design for future innovative randomized controlled trials on inhaled NO therapy in cardiac surgery, adequately powered and based on enhanced biological phenotyping, will be crucial to eventually provide scientific evidence of its clinical efficacy beyond its beneficial hemodynamic properties.
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Affiliation(s)
- Stefan Muenster
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Iratxe Zarragoikoetxea
- Department of Anesthesiology and Intensive Care Medicine, Hospital Universitari I Politècnic Fe, Valencia, Spain
| | - Andrea Moscatelli
- Neonatal and Pediatric Intensive Care Unit, Emergency Department, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Joan Balcells
- Pediatric Intensive Care Unit, Vall d’Hebron Barcelona Campus Hospitalari, Universitari Vall d'Hebron, Barcelona, Spain
| | - Philippe Gaudard
- Department of Anesthesiology and Critical Care Medicine Arnaud de Villeneuve, CHU Montpellier, University of Montpellier, PhyMedExp, INSERM, CNRS, Montpellier, France
| | - Philippe Pouard
- Department of Anesthesiology and Critical Care, Assistance Publique-Hopitaux de Paris, Hopital Necker-Enfants Malades, Paris, France
| | - Nandor Marczin
- Department of Surgery and Cancer, Imperial College, London, United Kingdom
| | - Stefan P. Janssens
- Cardiac Intensive Care, Department of Cardiovascular Diseases, University Hospital Leuven, Leuven, Belgium
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Son KH, Kim WH, Kwak JG, Choi CH, Lee SI, Ko UW, Kim HS, Lee H, Chung ES, Kim JB, Jang WS, Jung JS, Kim J, Yoon YK, Song S, Sung M, Jang MH, Kim YS, Jeong IS, Kim DW, Kim TY, Kim SJ, Kim SW, Hong J, An H. Hyperglycemia and Hypoglycemia Are Associated with In-Hospital Mortality among Patients with Coronavirus Disease 2019 Supported with Extracorporeal Membrane Oxygenation. J Clin Med 2022; 11:jcm11175106. [PMID: 36079032 PMCID: PMC9457381 DOI: 10.3390/jcm11175106] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 08/24/2022] [Accepted: 08/29/2022] [Indexed: 11/16/2022] Open
Abstract
Metabolic abnormalities, such as preexisting diabetes or hyperglycemia or hypoglycemia during hospitalization aggravated the severity of COVID-19. We evaluated whether diabetes history, hyperglycemia before and during extracorporeal membrane oxygenation (ECMO) support, and hypoglycemia were risk factors for mortality in patients with COVID-19. This study included data on 195 patients with COVID-19, who were aged ≥19 years and were treated with ECMO. The proportion of patients with diabetes history among nonsurvivors was higher than that among survivors. Univariate Cox regression analysis showed that in-hospital mortality after ECMO support was associated with diabetes history, renal replacement therapy (RRT), and body mass index (BMI) < 18.5 kg/m2. Glucose at admission >200 mg/dL and glucose levels before ventilator >200 mg/dL were not associated with in-hospital mortality. However, glucose levels before ECMO >200 mg/dL and minimal glucose levels during hospitalization <70 mg/dL were associated with in-hospital mortality. Multivariable Cox regression analysis showed that glucose >200 mg/dL before ECMO and minimal glucose <70 mg/dL during hospitalization remained risk factors for in-hospital mortality after adjustment for age, BMI, and RRT. In conclusion, glucose >200 mg/dL before ECMO and minimal glucose level <70 mg/dL during hospitalization were risk factors for in-hospital mortality among COVID-19 patients who underwent ECMO.
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Affiliation(s)
- Kuk Hui Son
- Department of Thoracic and Cardiovascular Surgery, Gachon University Gil Medical Center, Gachon University College of Medicine, Incheon 21565, Korea
| | - Woong-Han Kim
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Children’s Hospital, Seoul National University College of Medicine, Seoul 03080, Korea
- Correspondence: ; Tel.: +82-2-2072-3637
| | - Jae Gun Kwak
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Children’s Hospital, Seoul National University College of Medicine, Seoul 03080, Korea
| | - Chang-Hyu Choi
- Department of Thoracic and Cardiovascular Surgery, Gachon University Gil Medical Center, Gachon University College of Medicine, Incheon 21565, Korea
| | - Seok In Lee
- Department of Thoracic and Cardiovascular Surgery, Gachon University Gil Medical Center, Gachon University College of Medicine, Incheon 21565, Korea
| | - Ui Won Ko
- Pulmonary and Allergy Division, Department of Internal Medicine, Gachon University Gil Medical Center, Gachon University College of Medicine, Incheon 21565, Korea
| | - Hyoung Soo Kim
- Department of Thoracic and Cardiovascular Surgery, Hallym Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon 24252, Korea
| | - Haeyoung Lee
- Department of Thoracic and Cardiovascular Surgery, Kosin University Gospel Hospital, Kosin University College of Medicine, Busan 49267, Korea
| | - Euy Suk Chung
- Department of Thoracic and Cardiovascular Surgery, Kangbuk Samsung Hospital, Sungkyunkwan University, Seoul 03181, Korea
| | - Jae-Bum Kim
- Department of Thoracic and Cardiovascular Surgery, Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu 42601, Korea
| | - Woo Sung Jang
- Department of Thoracic and Cardiovascular Surgery, Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu 42601, Korea
| | - Jae Seung Jung
- Department of Thoracic and Cardiovascular Surgery, Korea University College of Medicine, Seoul 02841, Korea
| | - Jieon Kim
- Department of Thoracic and Cardiovascular Surgery, Korea University College of Medicine, Seoul 02841, Korea
| | - Young Kyung Yoon
- Division of Infectious Disease, Department of Internal Medicine, Korea University College of Medicine, Seoul 02841, Korea
| | - Seunghwan Song
- Department of Thoracic and Cardiovascular Surgery, Pusan National University Hospital, Biomedical Research Institute, Pusan National University School of Medicine, Busan 49241, Korea
| | - Minji Sung
- Health Convergence Medicine Laboratory, Biomedical Research Institute, Pusan National University Hospital, Busan 49241, Korea
| | - Myung Hun Jang
- Department of Rehabilitation Medicine, Biomedical Research Institute, Pusan National University Hospital, Busan 49241, Korea
| | - Young Sam Kim
- Department of Thoracic and Cardiovascular Surgery, Inha University Hospital, Inha University School of Medicine, Incheon 22332, Korea
| | - In-Seok Jeong
- Department of Thoracic and Cardiovascular Surgery, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju 61649, Korea
| | - Do Wan Kim
- Department of Thoracic and Cardiovascular Surgery, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju 61649, Korea
| | - Tae Yun Kim
- Department of Thoracic and Cardiovascular Surgery, Jeonbuk National University Hospital, Jeonju 54907, Korea
| | - Soon Jin Kim
- Department of Thoracic and Cardiovascular Surgery, Jeonbuk National University Hospital, Jeonju 54907, Korea
| | - Su Wan Kim
- Department of Thoracic and Cardiovascular Surgery, Jeju National University Hospital, Jeju National University School of Medicine, Jeju 63241, Korea
| | - Joonhwa Hong
- Department of Thoracic and Cardiovascular Surgery, Chung-Ang University Hospital, Seoul 06973, Korea
| | - Hyungmi An
- Institute of Convergence Medicine, Ewha Womans University Mokdong Hospital, Seoul 07985, Korea
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Fujii Y, Abe T, Ikegami K. Diabetic Pathophysiology Enhances Inflammation during Extracorporeal Membrane Oxygenation in a Rat Model. MEMBRANES 2021; 11:membranes11040283. [PMID: 33920465 PMCID: PMC8068986 DOI: 10.3390/membranes11040283] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 04/09/2021] [Accepted: 04/09/2021] [Indexed: 12/17/2022]
Abstract
Systemic inflammatory responses in patients undergoing extracorporeal membrane oxygenation (ECMO) contribute significantly to ECMO-associated morbidity and mortality. In recent years, the number of type 2 diabetes mellitus patients has increased, and the number of these patients undergoing ECMO has also increased. Type 2 diabetes mellitus is a high-risk factor for complications during ECMO. We studied the effects of ECMO on inflammatory response in a diabetic rat ECMO model. Twenty-eight rats were divided into 4 groups: normal SHAM group (normal rats: n = 7), diabetic SHAM group (diabetic rats: n = 7), normal ECMO group (normal rats: n = 7), and diabetic ECMO group (diabetic rats: n = 7). We measured the plasma levels of cytokines, tumor necrosis factor-α, and interleukin-6. Aspartate aminotransferase (AST), alanine aminotransferase (ALT), lactate dehydrogenase (LDH), blood urea nitrogen (BUN), creatinine (Cr), and liver-type fatty acid binding protein (L-FABP) were examined in the rat cardiopulmonary bypass model to ascertain organ damage. In addition, the lung wet-to-dry weight (W/D) ratio was measured as an index of pulmonary tissue edema. A pathologic evaluation of kidneys was conducted by hematoxylin-eosin (HE) and periodic-acid-methenamine-silver (PAM) staining. In the diabetic ECMO group, levels of cytokines, AST, ALT, LDH, and L-FABP increased significantly, reaching a maximum at the end of ECMO in comparison with other groups (p < 0.05). In addition, hematoxylin-eosin and periodic acid-methenamine-silver staining of renal tissues showed marked injury in the ECMO group (normal ECMO and diabetic ECMO groups). Furthermore, when the normal ECMO and diabetic ECMO groups were compared, severe organ injury was seen in the diabetic ECMO group. There was remarkable organ injury in the diabetic ECMO group. These data demonstrate that diabetes enhances proinflammatory cytokine release, renal damage, and pulmonary edema during ECMO in an animal model.
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Affiliation(s)
- Yutaka Fujii
- Department of Clinical Engineering and Medical Technology, Niigata University of Health and Welfare, Niigata 950-3198, Japan;
- Correspondence:
| | - Takuya Abe
- Department of Clinical Engineering and Medical Technology, Niigata University of Health and Welfare, Niigata 950-3198, Japan;
| | - Kikuo Ikegami
- Department of Health and Medical Sciences, Chiba Institute of Science, Choshi 288-0025, Japan;
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Sun H, Zhao X, Tai Q, Xu G, Ju Y, Gao W. Endothelial colony-forming cells reduced the lung injury induced by cardiopulmonary bypass in rats. Stem Cell Res Ther 2020; 11:246. [PMID: 32586365 PMCID: PMC7318475 DOI: 10.1186/s13287-020-01722-7] [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: 02/21/2020] [Revised: 04/28/2020] [Accepted: 05/11/2020] [Indexed: 12/03/2022] Open
Abstract
Background Cardiopulmonary bypass (CPB) results in severe lung injury via inflammation and endothelial injury. The aim of this study was to evaluate the effect of endothelial colony-forming cells (ECFCs) on lung injury in rats subjected to CPB. Methods Thirty-two rats were randomized into the sham, CPB, CPB/ECFC and CPB/ECFC/L-NIO groups. The rats in the sham group received anaesthesia, and the rats in the other groups received CPB. The rats also received PBS, ECFCs and L-NIO-pre-treated ECFCs. After 24 h of CPB, pulmonary capillary permeability, including the PaO2/FiO2 ratio, protein levels in bronchoalveolar lavage fluid (BALF) and lung tissue wet/dry weight were evaluated. The cell numbers and cytokines in BALF and peripheral blood were tested. Endothelial injury, lung histological injury and apoptosis were assessed. The oxidative stress response and apoptosis-related proteins were analysed. Results After CPB, all the data deteriorated compared with those obtained in the S group (sham vs CPB vs CPB/ECFC vs CPB/ECFC/L-NIO: histological score 1.62 ± 0.51 vs 5.37 ± 0.91 vs 3.37 ± 0.89 vs 4.37 ± 0.74; PaO2/FiO2 389 ± 12 vs 233 ± 36 vs 338 ± 28 vs 287 ± 30; wet/dry weight 3.11 ± 0.32 vs 6.71 ± 0.73 vs 4.66 ± 0.55 vs 5.52 ± 0.57; protein levels in BALF: 134 ± 22 vs 442 ± 99 vs 225 ± 41 vs 337 ± 53, all P < 0.05). Compared to the CPB treatment, ECFCs significantly improved pulmonary capillary permeability and PaO2/FiO2. Similarly, ECFCs also decreased the inflammatory cell number and pro-inflammatory factors in BALF and peripheral blood, as well as the oxidative stress response in the lung tissue. ECFCs reduced the lung histological injury score and apoptosis and regulated apoptosis-related proteins in the lung tissue. Compared with the CPB/ECFC group, all the indicators were partly reversed by the L-NIO. Conclusions ECFCs significantly reduced lung injury induced by inflammation after CPB.
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Affiliation(s)
- Haibin Sun
- Department of Anesthesiology, The Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Xiaoqing Zhao
- Department of Anesthesiology, The Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Qihang Tai
- Department of Anesthesiology, The Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Guangxiao Xu
- Department of Anesthesiology, The Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Yingnan Ju
- Department of ICU, Tumor Hospital of Harbin Medical University, Harbin, China.
| | - Wei Gao
- Department of Anesthesiology, The Second Affiliated Hospital of Harbin Medical University, Harbin, China.
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Kahraman A, Mutlu E, Aldağ M. ADMA, SDMA and L-arginine may be Novel Targets in Pharmacotherapy for Complications due to Cardiopulmonary Bypass. J Med Biochem 2017; 36:8-17. [PMID: 28680344 PMCID: PMC5471654 DOI: 10.1515/jomb-2016-0025] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2016] [Accepted: 07/15/2016] [Indexed: 12/29/2022] Open
Abstract
Background In this study, the effects of olmesartan therapy on asymmetric dimethylarginine (ADMA), symmetric dimethylarginine (SDMA), L-arginine and inducible nitric oxide synthase (iNOS) levels were investigated in patients undergoing cardiopulmonary bypass. Methods Patients were randomly allocated to two groups, control and olmesartan. Olmesartan was administered 30 mg once a day beginning from preoperative day 5 to postoperative day 28 and on operation day. Blood was drawn from all patients and ADMA, SDMA, L-arginine and iNOS levels were analyzed at six time points (T1: before anesthesia induction, T2: during cardiopulmonary bypass, T3: five min after the cross-clamp was removed, T4: after protamine infusion, T5: on postoperative day 3 and T6: on postoperative day 28). Results In the olmesartan treated group, iNOS levels exhibited significant decreases at T2, T3, T4, T5 and T6 time points compared with control group (p<0.001, p<0.05, p<0.001, p<0.01, p<0.05 respectively). ADMA levels were significantly lower in olmesartan treated group than in control group at T3, T4, T5 and T6 time points (p<0.05, p<0.05, p<0.05, p<0.01 respectively). SDMA levels at T2, T3 and T6 time points were higher in control group than olmesartan group. L-Arginine levels were significantly higher at T2 and T3 time points in olmesartan treated group than control group (p<0.001, p<0.01). Conclusions It was concluded that administration of olmesartan reduced plasma ADMA, SDMA, iNOS levels and enhanced L-arginine level in CPB time and it could reduce potential postoperative complications through reducing oxidative stress and inflammatory response in the postoperative period after coronary bypass surgery.
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Affiliation(s)
- Aydın Kahraman
- Firat University, Faculty of Medicine, Department of Cardiovascular Surgery, Elazig, Turkey
| | - Emre Mutlu
- Firat University, Faculty of Medicine, Department of Pharmacology, Elazig, Turkey
| | - Mustafa Aldağ
- Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
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Murakami T, Iwagaki H, Saito S, Ohtani S, Kuroki K, Kuinose M, Tanaka N, Tanemoto K. Equivalence of the Acute Cytokine Surge and Myocardial Injury after Coronary Artery Bypass Grafting with and without a Novel Extracorporeal Circulation System. J Int Med Res 2016; 33:133-49. [PMID: 15790125 DOI: 10.1177/147323000503300201] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Cardiopulmonary bypass (CPB) contributes to a morbidity-inducing systemic Inflammatory response after cardiac surgery. We compared this response in patients receiving coronary artery bypass grafting (CABG) with (CPB group; n = 7) or without (off-pump group; n = 8) the Minimal Extracorporeal Circulation (MECC®) system. Serum concentrations of tumour necrosis factor (TNF)-α, soluble TNF receptors, pro- and anti-inflammatory interleukins (ILs) and other myocardial injury markers were measured after anaesthetic induction, at 1 h, 4 h and 24 h after completing all anastomoses or serially. Soluble TNF receptor type I (sTNFRI) and IL-8 peaked early after CABG in both groups and did not decline. Serum sTNFRI was significantly higher in the CPB compared with the off-pump group at 1 h, whereas IL-8 was significantly lower in the CPB group throughout. The MECC® system, therefore, produces an equivalent acute cytokine response and degree of myocardial injury to off-pump CABG, and may be useful when CABG cannot be performed without CPB.
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Affiliation(s)
- T Murakami
- Division of Cardiovascular Surgery, National Hospital Organization, Iwakuni Medical Centre, Iwakuni, Japan
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Sokolowska E, Kalaska B, Miklosz J, Mogielnicki A. The toxicology of heparin reversal with protamine: past, present and future. Expert Opin Drug Metab Toxicol 2016; 12:897-909. [DOI: 10.1080/17425255.2016.1194395] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Emilia Sokolowska
- Department of Pharmacodynamics, Medical University of Bialystok, Bialystok, Poland
| | - Bartlomiej Kalaska
- Department of Pharmacodynamics, Medical University of Bialystok, Bialystok, Poland
| | - Joanna Miklosz
- Department of Pharmacodynamics, Medical University of Bialystok, Bialystok, Poland
| | - Andrzej Mogielnicki
- Department of Pharmacodynamics, Medical University of Bialystok, Bialystok, Poland
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Hussein AAM, Barakat N, Awadalla A, Shokeir AA. Systemic and renal haemodynamic changes in renal schemia/reperfusion injury: impact of erythropoietin. Can J Physiol Pharmacol 2012. [PMID: 23181281 DOI: 10.1139/y2012-120] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The objective of this study was to investigate the effects of erythropoietin (EPO) on systemic and renal hemodynamics in a rat model of renal ischemic/reperfusion (I/R) injury. We used 30 male Sprague-Dawley rats distributed among the following 3 groups (10 rats per group): (i) the sham-operated group, (ii) the control group (I/R injury only), and (iii) the EPO-treated group (I/R injury with 1500 U EPO·(kg body mass)⁻¹ on day 0, and 500 U·kg⁻¹ on days 2 and 4 after ischemia). Renal function, arterial blood pressure (ABP), renal plasma flow (RPF), renal blood flow (RBF), and renal vascular resistance (RVR) were measured on days 1, 2, and 7 after ischemia. The expression of endothelial NO synthase (eNOS) and histopathology of kidney were evaluated on day 7. The contractility of aortic strips was recorded from the different groups. The results show that renal function and histopathology were significantly improved after treatment with EPO. Compared with the control group, the EPO-treated group showed a significant increase in RPF, RBF, haematocrite, ABP, eNOS expression, and a decrease in RVR (p < 0.05).The response of aortic strips to the relaxant effect of acetylcholine was improved in the EPO-treated group. In conclusion, treatment with EPO improves renal function and renal haemodynamics in renal I/R injury, and causes significant rise of ABP and haematocrite value.
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Affiliation(s)
- Abdel-Aziz M Hussein
- Department of Physiology, Faculty of Medicine, Mansoura University, Mansoura, Egypt.
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Le Guillou V, Tamion F, Jouet I, Richard V, Mulder P, Bessou JP, Doguet F. Mesenteric endothelial dysfunction in a cardiopulmonary bypass rat model: the effect of diabetes. Diab Vasc Dis Res 2012; 9:270-9. [PMID: 22278737 DOI: 10.1177/1479164111434432] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Diabetes is a risk factor for perioperative complications after cardiac surgery. We studied its effects on mesenteric endothelial function in a cardiopulmonary bypass (CPB) model. METHODS Forty Wistar rats were divided into four groups: sham (D-CPB-), cardiopulmonary bypass (D-CPB+), diabetic (D+CPB-) and diabetic that have undergone CPB (D+CPB+). Two samples of mesenteric artery were used for nitric oxide synthase (NOS) Western blot analysis, and two others for assessing contractile response and endothelium relaxations. Nitrite products and tumour necrosis factor-alpha (TNF-α) were assessed as markers of inflammatory response. RESULTS We observed an enhanced contractile response to the α-adrenergic agonist associated with impairment of mesenteric vasorelaxation in D+CPB+ rats. Western immunoblot analysis of D+CPB+ highlighted an additive effect of hyper-expression of inducible NOS. A significantly increased inflammatory response was observed after CPB in diabetic animals. CONCLUSIONS This work confirms the potential deleterious impact of diabetes on the mesenteric endothelium during CPB in cardiac surgery.
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Affiliation(s)
- Vincent Le Guillou
- Department of Thoracic and Cardiovascular Surgery, Rouen University Hospital, France
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Yeh CB, Lin PY, Hwang JM, Su CJ, Yeh YT, Yang SF, Chou MC. Study on synthesis of thalidomide analogues and their bioactivities; inhibition on iNOS pathway and cytotoxic effects. Med Chem Res 2011. [DOI: 10.1007/s00044-011-9603-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Osaka M, Aoyagi K, Hirakawa A, Nakajima M, Jikuya T, Shigeta O, Sakakibara Y. Comparison of hydroxyl radical generation in patients undergoing coronary artery bypass grafting with and without cardiopulmonary bypass. Free Radic Res 2009; 40:127-33. [PMID: 16390821 DOI: 10.1080/10715760500428705] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
We measured the hydroxyl radical (.OH) generation in fourteen patients undergoing coronary artery bypass grafting (CABG), of whom seven patients underwent on-pump CABG with cardiopulmonary bypass (CPB) and seven patients underwent off-pump CABG without CPB. To detect .OH generation, we measured the urinary excretion of .OH products of creatinine (Cr), creatol (CTL; 5-hydroxycreatinine) and methylguanidine (MG) with HPLC using the one point sampling and collected urine during and after the operation. The urinary CTL value corrected urinary Cr value of on-pump CABG significantly increased about 3-5 times from the beginning of CPB to 4 h after operation compared to the baseline value before CPB in both the collected urine and the one point sampling urine. The urinary MG/Cr value in both groups did not change significantly. Significantly increased .OH generation was found during and soon after on-pump CABG.
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Affiliation(s)
- Motoo Osaka
- Graduated School of Comprehensive Human Sciences, University of Tsukuba, and Tsukuba Medical Center Hospital, Department of Cardiovascular Surgery, Tsukuba, Japan
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Sun YJ, Chen WM, Zhang TZ, Cao HJ, Zhou J. Effects of cardiopulmonary bypass on tight junction protein expressions in intestinal mucosa of rats. World J Gastroenterol 2008; 14:5868-75. [PMID: 18855986 PMCID: PMC2751897 DOI: 10.3748/wjg.14.5868] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
AIM: To investigate the tight junction protein expressions of intestinal mucosa in an experimental model of cardiopulmonary bypass (CPB) in rats.
METHODS: Thirty anesthetized rats were randomly divided into two groups: Group S (n = 10) served as sham operation and group C (n = 20) served as CPB which underwent CPB for 1 h. Expression of occludin and zonula occludens-1 (ZO-1) were determined by Western blotting and immunocytochemistry, respectively. Plasma levels of diamine oxidase (DAO) and d-lactate were determined using an enzymatic spectrophotometry.
RESULTS: Immunohistochemical localization of occludin and ZO-1 showed disruption of the tight junctions in enterocytes lining villi at the end of CPB and 2 h after CPB. The intensities of the occludin and ZO-1 at the end of CPB were lower than those of control group (76.4% ± 22.5% vs 96.5% ± 28.5% and 62.4% ± 10.1% vs 85.5% ± 25.6%, P < 0.05) and were further lower at 2 h after CPB (50.5% ± 10.5% and 45.3% ± 9.5%, P < 0.05). Plasma d-lactate and DAO levels increased significantly (8.688 ± 0.704 vs 5.745 ± 0.364 and 0.898 ± 0.062 vs 0.562 ± 0.035, P < 0.05) at the end of CPB compared with control group and were significantly higher at 2 h after CPB than those at the end of CPB (9.377 ± 0.769 and 1.038 ± 0.252, P < 0.05). There were significant negative correlations between occludin or ZO-1 expression and DAO (r2 = 0.5629, r2 = 0.5424, P < 0.05) or d-lactate levels (r2 = 0.6512, r2 = 0.7073, P < 0.05) both at the end of CPB and 2 h after CPB.
CONCLUSION: CPB markedly down-regulates the expression of occludin and ZO-1 proteins in intestinal mucosa of rats. The close correlation between expression of tight junctions (TJs) and plasma levels of DAO or d-lactate supports the hypothesis that intestinal permeability increases during and after CPB because of decreases in the expressions of TJs.
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Lisle TC, Gazoni LM, Fernandez LG, Sharma AK, Bellizzi AM, Shifflett GD, Schifflett GD, Laubach VE, Kron IL. Inflammatory lung injury after cardiopulmonary bypass is attenuated by adenosine A(2A) receptor activation. J Thorac Cardiovasc Surg 2008; 136:1280-7; discussion 1287-8. [PMID: 19026816 DOI: 10.1016/j.jtcvs.2008.07.010] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2008] [Revised: 06/06/2008] [Accepted: 07/05/2008] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Cardiopulmonary bypass has been shown to exert an inflammatory response within the lung, often resulting in postoperative pulmonary dysfunction. Several studies have shown that adenosine A(2A) receptor activation attenuates lung ischemia-reperfusion injury; however, the effect of adenosine A(2A) receptor activation on cardiopulmonary bypass-induced lung injury has not been studied. We hypothesized that specific adenosine A(2A) receptor activation by ATL313 would attenuate inflammatory lung injury after cardiopulmonary bypass. METHODS Adult male Sprague-Dawley rats were randomly divided into 3 groups: 1) SHAM group (underwent cannulation + heparinization only); 2) CONTROL group (underwent 90 minutes of normothermic cardiopulmonary bypass with normal whole-blood priming solution; and 3) ATL group (underwent 90 minutes of normothermic cardiopulmonary bypass with ATL313 added to the normal priming solution). RESULTS There was significantly less pulmonary edema and lung injury in the ATL group compared with the CONTROL group. The ATL group had significant reductions in bronchoalveolar lavage interleukin-1, interleukin-6, interferon-gamma, and myeloperoxidase levels compared with the CONTROL group. Similarly, lung tissue interleukin-6, tumor necrosis factor-alpha, and interferon-gamma were significantly decreased in the ATL group compared with the CONTROL group. There was no significant difference between the SHAM and ATL groups in the amount of pulmonary edema, lung injury, or levels of proinflammatory cytokines. CONCLUSION The addition of a potent adenosine A(2A) receptor agonist to the normal priming solution before the initiation of cardiopulmonary bypass significantly protects the lung from the inflammatory effects of cardiopulmonary bypass and reduces the amount of lung injury. Adenosine A(2A) receptor agonists could represent a new therapeutic strategy for reducing the potentially devastating consequences of the inflammatory response associated with cardiopulmonary bypass.
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Affiliation(s)
- Turner C Lisle
- Department of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, VA 22908, USA.
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14
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Exogenous melatonin ameliorates hepatic injury in a rat cardiopulmonary bypass model. Eur J Pharmacol 2008; 580:416-24. [DOI: 10.1016/j.ejphar.2007.09.045] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2007] [Revised: 08/20/2007] [Accepted: 09/07/2007] [Indexed: 11/22/2022]
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Huang H, Yin R, Zhu J, Feng X, Wang C, Sheng Y, Dong G, Li D, Jing H. Protective effects of melatonin and N-acetylcysteine on hepatic injury in a rat cardiopulmonary bypass model. J Surg Res 2007; 142:153-61. [PMID: 17628600 DOI: 10.1016/j.jss.2006.12.553] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2006] [Revised: 12/18/2006] [Accepted: 12/21/2006] [Indexed: 10/23/2022]
Abstract
BACKGROUND An increasing number of patients were undergoing cardiac surgery with cardiopulmonary bypass (CPB) and more attention had been paid to hepatic injury after CPB. This study was designed to test the hypothesis that melatonin and N-acetylcysteine (NAC) could attenuate hepatic injury induced by CPB in rats. MATERIALS AND METHODS Male Sprague Dawley rats were randomly divided into four groups: sham, control (CPB + placebo), NAC (CPB + 250 mg/kg N-acetylcysteine), and melatonin (CPB + 20 mg/kg melatonin). Blood samples were collected at the beginning, at the end of CPB, and at 0.5, 1, 2, 3, and 24 h postoperation. Liver samples were harvested at 24 h after the operation. RESULTS In the control group, the levels of serum liver enzymes and tumor necrosis factor-alpha, activities of inducible nitric oxide synthase, malondialdehyde, and myeloperoxidase in liver tissue were significantly increased. In addition, swollen hepatocytes, vacuolization, and congestion in sinusoids were observed. These changes were markedly reversed in both NAC and melatonin groups. Furthermore, the glutathione content and liver antioxidative enzymes activities were significantly decreased in the control group compared with the sham group. However, the levels of these antioxidants were markedly elevated after NAC or melatonin treatment compared with placebo treatment. CONCLUSIONS Our findings showed that NAC and melatonin had acceptably beneficial effects against the CPB-induced hepatic injury.
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Affiliation(s)
- Hairong Huang
- Department of Cardiothoracic Surgery, Jinling Hospital, Clinical Medicine School of Nanjing University, Nanjing, China
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16
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Mazer CD, Briet F, Blight KR, Stewart DJ, Robb M, Wang Z, Harrington AM, Mak W, Li X, Hare GMT. Increased cerebral and renal endothelial nitric oxide synthase gene expression after cardiopulmonary bypass in the rat. J Thorac Cardiovasc Surg 2007; 133:13-20. [PMID: 17198775 DOI: 10.1016/j.jtcvs.2006.06.047] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2005] [Revised: 05/17/2006] [Accepted: 06/13/2006] [Indexed: 11/21/2022]
Abstract
OBJECTIVE Hemodilution and endothelial nitric oxide synthase genetic polymorphism may contribute to cerebral and renal injury after cardiopulmonary bypass. This study tested the hypothesis that cardiopulmonary bypass and anemia stimulate an increase in cerebral and renal endothelial nitric oxide synthase gene expression in an experimental model of cardiopulmonary bypass. METHODS Anesthetized rats underwent a sham procedure without cardiopulmonary bypass (sham, n = 5), normothermic bypass for 1 hour (CPB, n = 7), or bypass plus hemodilutional anemia (CPB anemia, n = 9). After 24 hours of recovery, RNA was extracted from the cerebral cortex, renal cortex, and renal medulla. Quantitative reverse transcriptase polymerase chain reaction was used to assess endothelial nitric oxide synthase messenger RNA levels in brain and kidney tissues. RESULTS The hemoglobin concentration of anemic CPB rats was significantly lower than that of nonanemic rats on bypass (64 +/- 5 vs 99 +/- 8 g x L(-1), P < .001). Cerebral cortical endothelial nitric oxide synthase messenger RNA levels were increased after cardiopulmonary bypass relative to those of the sham group (11.2 +/- 4.2 vs 6.3 +/- 1.5 fg, P = .031), without a further increase in anemic rats. Renal medullary endothelial nitric oxide synthase messenger RNA levels were significantly higher in the CPB anemia group than in the sham and CPB groups (7.1 +/- 4.4 fg vs 1.8 +/- 0.4 fg vs 3.0 +/- 0.6 fg, P < .001). Renal cortical endothelial nitric oxide synthase messenger RNA levels did not change significantly. CONCLUSIONS Normothermic cardiopulmonary bypass was associated with higher endothelial nitric oxide synthase messenger RNA levels in kidney and brain than was the sham procedure 24 hours after cardiopulmonary bypass. Anemia accentuated the increase in renal medullary, but not cerebral cortical, endothelial nitric oxide synthase expression. These data provide an approach for exploring potential mechanisms by which endothelial nitric oxide synthase may contribute to renal and cerebral dysfunction after cardiopulmonary bypass and anemia.
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Affiliation(s)
- C David Mazer
- Department of Anesthesia, University of Toronto, St. Michael's Hospital, Seneca College, Toronto, Ontario, Canada.
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Toprak V, Sirin BH, Tok D, Ozbilgin K, Saribülbül O. The Effect of Cardiopulmonary Bypass on the Expression of Inducible Nitric Oxide Synthase, Endothelial Nitric Oxide Synthase, and Vascular Endothelial Growth Factor in the Internal Mammary Artery. J Cardiothorac Vasc Anesth 2006; 20:63-7. [PMID: 16458216 DOI: 10.1053/j.jvca.2005.02.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2004] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Endothelial function of a vessel may be impaired by local or systemic inflammation initiated by cardiopulmonary bypass (CPB) during coronary artery bypass graft (CABG) surgery. The present study was designed to investigate the early effects of CPB on nitric oxide production and vascular endothelial growth factor (VEGF) expression in internal mammary artery (IMA). DESIGN Prospective study. SETTING University hospital. PARTICIPANTS Twenty patients who were scheduled for elective CABG with CPB. INTERVENTIONS IMA sections were studied immunohistochemically from these patients. The samples were taken from the distal end of the IMA before the institution of CPB and just before the construction of the IMA-left anterior descending artery anastomosis. MEASUREMENT AND MAIN RESULTS After CPB, VEGF and endothelial nitric oxide synthase immunoreactivity increased significantly when compared with baseline values in the endothelium (p = 0.0156, p = 0.0313) and adventitia (p = 0.0313, p = 0.0001), respectively. No significant change was observed in inducible nitric oxide synthase immunoreactivity. CONCLUSIONS The increase in eNOS expression may have been induced by the inflammation caused by CPB.
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Affiliation(s)
- Verda Toprak
- Department of Anaesthesiology and Reanimation, School of Medicine, Celal Bayar University, Manisa, Turkey.
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Takakura K, Mizogami M, Fukuda S. Protamine sulfate causes endothelium-indepen-dent vasorelaxation via inducible nitric oxide syn-thase pathway. Can J Anaesth 2006; 53:162-7. [PMID: 16434757 DOI: 10.1007/bf03021822] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
PURPOSE The precise mechanism of systemic hypotension frequently observed with the use of protamine is unclear. Although it has been reported that protamine stimulates the release of nitric oxide (NO) from endothelium NO synthase (eNOS), the association with inducible NOS (iNOS) remains unknown, despite the induction of iNOS by lipopolysaccharides (LPS) and/or inflammatory cytokines during cardiopulmonary bypass (CPB). The purpose of this study was to determine whether protamine stimulates the release of NO from iNOS induced by LPS. METHODS We performed prospective and controlled functional examinations with isolated endothelium-denuded thoracic aortas from 21 male Wister rats. Aortic strips were mounted in Krebs solution and treated with LPS (1 microg x mL(-1)) for six hours to induce iNOS. Changes in tension caused by L-arginine (a substrate of NOS), protamine or a heparin-protamine complex (heparin: protamine = 1 unit: 10 microg) were measured in strips pre-contracted by phenylephrine. RESULTS No drug relaxed the strips before LPS-treatment, but each drug relaxed the strips in a dose-dependent manner after LPS-treatment (P < 0.05). Aminoguanidine (an iNOS inhibitor) and methylene blue (a guanylyl cyclase inhibitor) inhibited the relaxations. CONCLUSION These results indicate that protamine and the heparin-protamine complex stimulated the release of NO from iNOS. As iNOS is induced during CPB, protamine or a heparin-protamine complex might cause systemic hypotension, at least in part, by stimulating iNOS.
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Affiliation(s)
- Ko Takakura
- Department of Anesthesiology, Asahi University, 1851-1 Hozumi, Mizuho, Gifu 501-0296, Japan.
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Dong GH, Xu B, Wang CT, Qian JJ, Liu H, Huang G, Jing H. A rat model of cardiopulmonary bypass with excellent survival. J Surg Res 2005; 123:171-5. [PMID: 15680374 DOI: 10.1016/j.jss.2004.08.007] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2003] [Indexed: 11/20/2022]
Abstract
BACKGROUND Elucidating the underlying mechanisms and developing protective strategies for the pathophysiological consequences of cardiopulmonary bypass (CPB) have been hampered due to the absence of a satisfactory long-term recovery animal model. The objective of this study was to establish a survival experimental model of CPB in rats to meet the requirement of these studies. MATERIALS AND METHODS Male SD rats (450-550 g) were randomly divided into CPB (n = 10) group and Sham group (n = 10). All rats were anaesthetized and mechanically ventilated. The femoral artery and vein were cannulated for continuous blood pressure recordings and fluid replacement, respectively. The CPB circuit comprised a venous reservoir, a membrane oxygenator, and a roller pump. Blood was drained from the right atrium via a jugular vein catheter and returned to the right carotid artery. Priming consisted of 8 ml of homologous blood and 8 ml of colloid. CPB was conducted for 60 min at a flow rate of 100-150 ml/kg/min in the CPB group. Haemodynamic investigations, blood gas analysis, and survival studies were performed subsequently. RESULTS Our data show that the rat model principally simulated the clinical setting of CPB in terms of its construction, configuration, performance, material surface area, and priming volume to blood volume ratio. All CPB rats survived and the 2-week follow-up period remained uneventful. CONCLUSIONS The rat model of CPB was easy to establish and was associated with excellent survival. This model should facilitate the investigation of the pathophysiological processes concerning CPB-related multiple organ dysfunction and possible protective interventions.
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Affiliation(s)
- Guo-Hua Dong
- Department of Cardiovascular and Thoracic Surgery, Jinling Hospital, Clinical Medicine School of Nanjing University, Nanjing, Jiangsu, China.
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Andrási TB, Blázovics A, Szabó G, Vahl CF, Hagl S. Poly(ADP-ribose) polymerase inhibitor PJ-34 reduces mesenteric vascular injury induced by experimental cardiopulmonary bypass with cardiac arrest. Am J Physiol Heart Circ Physiol 2005; 288:H2972-8. [PMID: 15681711 DOI: 10.1152/ajpheart.01039.2004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The aim of this study was to investigate effects of poly(ADP-ribose) polymerase (PARP) inhibition on mesenteric vascular function and metabolism in an experimental model of cardiopulmonary bypass (CPB) with cardiac arrest. Twelve anesthetized dogs underwent 90-min hypothermic CPB. After 60 min of cardiac arrest, reperfusion was started for 40 min following application of either saline vehicle (control, n = 6) or a potent PARP inhibitor, PJ-34 (10 mg/kg iv bolus and 0.5 mg.kg(-1).min(-1) infusion for 20 min, n = 6). PJ-34 led to better recovery of cardiac output (2.2 +/- 0.1 vs. 1.8 +/- 0.2 l/min in control) and mesenteric blood flow (175 +/- 38 vs. 83 +/- 4 ml/min, P < 0.05 vs. control) after reperfusion. The impaired vasodilator response of the superior mesenteric artery to acetylcholine, assessed in the control group after CPB (-32.8 +/- 3.3 vs. -57.6 +/- 6.6% at baseline, P < 0.05), was improved by PJ-34 (-50.3 +/- 3.6 vs. -54.3 +/- 4.1% at baseline, P < 0.05 vs. control). Although plasma nitrate/nitrite concentrations were not significantly different between groups, mesenteric nitric oxide synthase activity was increased in the PJ-34 group (P < 0.05). Moreover, the treated group showed a marked attenuation of mesenteric venous plasma myeloperoxidase levels after CPB compared with the control group (75 +/- 1 vs. 135 +/- 9 ng/ml, P < 0.05). Pharmacological PARP inhibition protects against development of post-CPB mesenteric vascular dysfunction by improving hemodynamics, restoring nitric oxide production, and reducing neutrophil adhesion.
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Affiliation(s)
- Terézia B Andrási
- Dept. of Visceral, Thoracic and Vascular Surgery, Carl Gustav Carus Univ. Hospital, Fetscherstrasse 74, Haus 59, 01307 Dresden, Germany.
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21
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de Vroege R, Stooker W, van Oeveren W, Bakker EWM, Huybregts RAJM, van Klarenbosch J, van Kamp GJ, Hack CE, Eijsman L, Wildevuur CRH. The Impact of Heparin Coated Circuits Upon Metabolism in Vital Organs: Effect Upon Cerebral and Renal Function During and After Cardiopulmonary Bypass. ASAIO J 2005; 51:103-9. [PMID: 15745143 DOI: 10.1097/01.mat.0000151147.24915.49] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
During cardiopulmonary bypass (CPB), the brain and the kidneys may be damaged because of microemboli, ischemia, and inflammation. The latter has been reduced by the use of heparin coated circuits. We questioned whether heparin coated circuits could also reduce cerebral and renal damage and whether inflammatory markers correlate with damage to the brain and the kidneys. Fifty-one patients scheduled for coronary artery bypass grafting were perfused with either a heparin coated or an uncoated circuit. To compare the effect of a heparin coated circuit with an uncoated circuit upon cerebral and renal function in relation to inflammation, we assessed markers of cerebral (S100beta) and renal (N-acetyl-beta-D-glucosaminidase [NAG], creatinine, and urea) function, inflammation, and oxygen metabolism. S100beta levels and NAG levels increased during CPB in both groups as compared with baseline levels (p < 0.01), without differences between the groups. After 15 minutes on CPB, C4b/c levels were significantly higher in the coated group compared with the uncoated group (p < 0.02). C4b/c correlated with S100beta (p < 0.01). Total body oxygen delivery (DO2) and consumption (VO2) decreased significantly in both groups during CPB (p < 0.01), but recovery was better in the coated group. After protamine infusion, total body oxygen delivery and consumption correlated negatively with S100beta levels (both p < 0.05) and with NAG levels (both p < 0.01). This study suggests that, if adequate tissue perfusion is not maintained, the use of a heparin coated circuit gives no additional benefit beyond that of the uncoated circuit. The inverse relationship of both cerebral and renal markers with DO2 and VO2 suggests that increased levels of S100beta and NAG during CPB may primarily be caused by an oxygen deficit and secondary to the inflammatory response.
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Affiliation(s)
- Roel de Vroege
- Department of Extracorporeal Circulation, Room 6A 149, Vrije Universiteit Medisch Centrum, PO Box 7057, 1007 MB Amsterdam, The Netherlands
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22
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Hubble CL, Cheifetz IM, Craig DM, Quick G, Meliones JN, Clark RH. Inhaled nitric oxide results in deteriorating hemodynamics when administered during cardiopulmonary bypass in neonatal swine. Pediatr Crit Care Med 2004; 5:157-62. [PMID: 14987346 DOI: 10.1097/01.pcc.0000112377.90107.97] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To evaluate if inhaled nitric oxide (iNO) has a lung-protective effect when it is delivered during the ischemic phase of neonatal cardiopulmonary bypass (CPB). DESIGN Prospective, randomized, controlled study. SETTING Surgical research laboratory in a university hospital. SUBJECTS Thirty-five neonatal swine. INTERVENTIONS One-week-old swine (2.1-3.4 kg) were exposed to cool, low-flow CPB bypass designed to mimic the bypass used during neonatal congenital heart repair. Animals were randomized to four groups: a) CPB without exposure to iNO (n = 9); b) iNO delivery only during CPB with discontinuation of iNO at the start of reperfusion (n = 7); c) iNO delivery both during CPB and during the 90-min post-CPB observation period (n = 7); and d) iNO delivery only after separation from CPB (n = 7). Each animal was placed on nonpulsatile CPB and cooled to a nasopharyngeal temperature of 18 degrees C (64 degrees F). Low-flow CPB (35 mL.kg(-1).min(-1)) was instituted for 90 mins. The blood flow then was returned to 100 mL.kg(-1).min(-1), and the animals were warmed to 36 degrees C (96.8 degrees F) before separation from CPB. Animals were followed 90 mins post-CPB. Lung tissue was harvested and evaluated for myeloperoxidase activity, wet/dry weight, and lung pathology. Five animals underwent sham protocol, receiving instrumentation but not exposure to CPB or iNO. MEASUREMENTS AND MAIN RESULTS We measured pulmonary vascular resistance, right ventricular output, and pulmonary artery pressure in all animals at 30, 60, and 90 mins following separation from CPB. Study animals that received iNO during the ischemic period of CPB were not protected against CPB-induced lung injury. Those animals treated with iNO both during and after CPB trended worse than those receiving iNO only after CPB. Inhaled nitric oxide delivered only after separation from CPB improved the hemodynamic variables compared with all other groups. Differences in lung wet/dry weight, myeloperoxidase, and pathology were not significantly different among groups. CONCLUSIONS The delivery of iNO during the ischemic period of CPB does not protect against CPB-induced lung injury in a neonatal piglet CPB model. Delivery of iNO during this phase of CPB may, in fact, worsen the post-CPB hemodynamic condition. Inhaled nitric oxide should be used with caution during periods of low pulmonary blood flow CPB. Inhaled nitric oxide remains effective for reducing pulmonary vascular resistance after CPB.
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Affiliation(s)
- Christopher L Hubble
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Duke University Medical Center, Durham, NC, USA
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23
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Zegdi R, Fabre O, Cambillau M, Fornès P, Tazi KA, Shen M, Hervé P, Carpentier A, Fabiani JN. Exhaled Nitric Oxide and Acute Lung Injury in a Rat Model of Extracorporeal Circulation. Shock 2003; 20:569-74. [PMID: 14625483 DOI: 10.1097/01.shk.0000094765.36694.92] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Exhaled nitric oxide (NO) concentration, a marker of pulmonary inflammation, has been shown to be elevated in various models of acute lung injury (ALI). This study was undertaken to evaluate the pulmonary NO production in a rat model of postextracorporeal circulation (ECC) ALI. Wistar rats underwent either a partial femorofemoral ECC in normothermia for 3 h (n = 10) or a sham procedure (n = 10). The extracorporeal circuit consisted of a roller pump and a membrane oxygenator. Exhaled NO concentration was monitored with a chemiluminescence analyzer. After sacrifice, lungs were harvested for microscopic studies and to analyze the inducible nitric oxide synthase (iNOS) activity and expression (Western blot). ECC was responsible for an ALI characterized by a decreased arterial blood oxygen saturation (88.9% [51.7-94.2] vs. 93.7% [91.4-98.6] P = 0.005) and pulmonary histological changes (marked alveolar neutrophil infiltration; interstitial edema; intraalveolar hemorrhage). The lung injury score was significantly higher in the ECC group (n = 5; 3.0 [2-4]) in comparison to the sham group (n = 5; 1.0 [0-2]). Exhaled NO concentration remained stable throughout the experiment in all sham rats whereas it significantly increased in the ECC group from baseline (2 ppb [1-5]) until the end of experiment (33.5 ppb [1-47]). Lung iNOS activity and expression were also significantly increased in the ECC group. An increase in exhaled NO, however, did not correlate with the decrease in arterial oxygen pressure. ECC was responsible for an ALI in rats and for an elevated pulmonary NO production. Determination of the relationship between exhaled NO and the severity of the inflammatory process in ALI will require further studies.
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Affiliation(s)
- Rachid Zegdi
- Laboratoire d'Etudes des Greffes et Prothèses Cardiaques, Hôspital Broussais, 75014 Paris, France.
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Gessler P, Pfenninger J, Pfammatter JP, Carrel T, Baenziger O, Dahinden C. Plasma levels of interleukin-8 and expression of interleukin-8 receptors on circulating neutrophils and monocytes after cardiopulmonary bypass in children. J Thorac Cardiovasc Surg 2003; 126:718-25. [PMID: 14502144 DOI: 10.1016/s0022-5223(03)00685-8] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
OBJECTIVE Cardiopulmonary bypass induces a systemic inflammatory response that causes substantial clinical morbidity. This study sought to determine cellular and humoral variables of inflammation. We hypothesized that chemokines are a major source of stimulation of neutrophils and monocytes in pediatric cardiac surgery. METHODS We performed an observational prospective clinical study of 20 pediatric patients before and after cardiopulmonary bypass. Plasma levels of interleukin-6, interleukin-8, myeloperoxidase, and nitric oxide were measured by immunoassays. Expression of interleukin-8 receptors (CXCR1, CXCR2) and CD14 of circulating neutrophils and monocytes was assessed by flow cytometry. Clinical evaluations included length of inotropic support and mechanical ventilation as well as oxygenation. RESULTS Two hours after cardiopulmonary bypass, plasma levels of interleukin-6 and interleukin-8 were strongly increased (P =.0001 and P =.0032, respectively). Interleukin-6 and interleukin-8 concentrations correlated with the length of inotropic support, as well as with the length of mechanical ventilation (r >.70, P </=.0006), and were inversely related to the ratio of arterial oxygen tension to fraction of inspired oxygen. There was a strong association between the postoperative levels of interleukin-6 and nitric oxide, as well as between interleukin-6 and CD14 expression on monocytes (r >.62, P </=.0031). The expression of CXCR2 but not CXCR1 on neutrophils and monocytes correlated negatively with the levels of interleukin-8 and myeloperoxidase. CONCLUSIONS After cardiopulmonary bypass, impairment of cardiovascular and respiratory function correlated with the levels of interleukin-6 and interleukin-8 as mediators of an inflammatory response. The negative correlation of CXCR2 expression with interleukin-8 and myeloperoxidase indicates that myeloid cells were stimulated by CXC chemokines with Glu-Leu-Arg (ELR) motif and thereby contributed to tissue damage, leading to impairment of cardiovascular and respiratory function.
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Affiliation(s)
- Peter Gessler
- University Children's Hospital, Steinweisstrasse 75, CH 8032 Zurich, Switzerland.
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25
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Hayashi Y, Sawa Y, Nishimura M, Satoh H, Ohtake S, Matsuda H. Avoidance of full-sternotomy: effect on inflammatory cytokine production during cardiopulmonary bypass in rats. J Card Surg 2003; 18:390-5. [PMID: 12974923 DOI: 10.1046/j.1540-8191.2003.02046.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND AND AIM OF THE STUDY Although open heart operations via a mini-sternotomy or mini-thoracotomy are considered "less invasive" cosmetically and are hopeful for early social recovery, clinical experiences have not shown less invasiveness toward systemic inflammatory response, because of the wide variety of patients and operative procedures encountered. We examined the effect of a mini-sternotomy on an inflammatory response during a cardiopulmonary bypass (CPB) procedure performed in rats. METHODS Thirty-two adult Sprague-Dawley (SD) rats, each of which underwent a 120-minute CPB, were randomly divided into four groups according to the method of exposing the pericardial cavity; no sternotomy (Group N [0 cm], n = 8), right para-sternal thoracotomy (Group P [2 cm], n = 8), lower mini-sternotomy (Group M [2 cm], n = 8), and full-sternotomy (Group F [4 cm], n = 8). Blood samples were obtained (1) just prior to the initiation of CPB, and then (2) 30, (3) 60, and (4) 120 minutes after the initiation of CPB. RESULTS Thirty minutes after the initiation of CPB, there were significant differences in plasma interleukin [IL]-6 levels between groups, except for Groups P and M; whereas at 60 minutes the only significant difference occurred between Groups N and F, and at 120 minutes there were no significant differences between any of the groups. Further, plasma IL-8 levels were not significantly different at each sampling point between all of the groups. CONCLUSIONS These results first demonstrate experimentally that the avoidance of a full-sternotomy can be considered a less invasive strategy in terms of reducing the systemic inflammatory response that accompanies a shorter CPB duration.
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Affiliation(s)
- Yoshitaka Hayashi
- Department of Surgery, Course of Interventional Medicine (E1), Osaka University Graduate School of Medicine, 2-2 Yamada-oka, Suita, Osaka 565-0871, Japan
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Chello M, Mastroroberto P, Patti G, D'Ambrosio A, Morichetti MC, Di Sciascio G, Covino E. Simvastatin attenuates leucocyte-endothelial interactions after coronary revascularisation with cardiopulmonary bypass. Heart 2003; 89:538-43. [PMID: 12695460 PMCID: PMC1767656 DOI: 10.1136/heart.89.5.538] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/09/2003] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To investigate the effects of preoperative simvastatin treatment on leucocyte-endothelial interactions following coronary artery bypass surgery with cardiopulmonary bypass. DESIGN Double blind crossover study. Experiments on polymorphonuclear cells (neutrophils) were done at the end of cardiopulmonary bypass and one hour postoperatively. Endothelial P-selectin expression and neutrophil/endothelial adhesion were evaluated under either normoxic or hypoxic conditions. SETTING University hospital (tertiary referral centre). PATIENTS Three groups of patients undergoing coronary bypass surgery: 20 patients taking simvastatin for cholesterol control, 16 patients not responsive to simvastatin, and 20 controls. MAIN OUTCOME MEASURES Expression of neutrophil CD11b and endothelial P-selectin; adhesion of neutrophils to endothelium. RESULTS Cardiopulmonary bypass resulted in a significant increase in neutrophil CD11b expression in all groups. Similarly, the exposure of saphenous vein to hypoxia/reoxygenation induced an augmentation of endothelial P-selectin. However, both neutrophil CD11b expression and endothelial P-selectin exocytosis were less in the simvastatin groups than in the controls. Cardiopulmonary bypass and controlled hypoxia/reoxygenation stimulated neutrophil/endothelial adhesion, but the number of adhering cells was less in the simvastatin groups than in the controls, irrespective of the cholesterol concentration. Treatment of endothelial cells with L-NAME completely reversed the effects of simvastatin. CONCLUSIONS Pretreatment with simvastatin reduces neutrophil adhesion to the venous endothelium in patients undergoing coronary surgery, irrespective of its efficacy at lowering cholesterol concentration.
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Affiliation(s)
- M Chello
- Interdisciplinary Centre for Biomedical Research (CIR), Department of Cardiovascular Sciences, University Campus Bio-Medico di Roma, Rome, Italy.
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Hayashi Y, Sawa Y, Fukuyama N, Nakazawa H, Matsuda H. Preoperative glutamine administration induces heat-shock protein 70 expression and attenuates cardiopulmonary bypass-induced inflammatory response by regulating nitric oxide synthase activity. Circulation 2002; 106:2601-7. [PMID: 12427658 DOI: 10.1161/01.cir.0000035651.72240.07] [Citation(s) in RCA: 73] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Heat-shock protein 70 (HSP70) plays a major role in the pathophysiology of inflammation, and the induction of HSP70 before the onset of inflammation can reduce organ damage through a self-protective system. Glutamine is known to be an inducer of HSP70, and its preoperative administration seems useful in attenuating cardiopulmonary bypass (CPB)-induced inflammatory response. METHODS AND RESULTS Adult male Sprague-Dawley rats (group G, received 100 mg/kg of glutamine via the right jugular vein 3 times per day for 1 week and just before the initiation of CPB; group C served as control) underwent CPB (60 minutes, 100 mL/kg per minute, 34 degrees C) and were killed 3 hours after the termination of CPB. Group G showed significantly lower plasma concentrations of interleukin-6 and interleukin-8 after CPB termination. Myocardial and respiratory damages were significantly attenuated in group G, as evidenced by Langendorff perfusion, respiratory index, and neutrophil adherence. HSP70 expressions in the heart, lung, and liver were detected only in group G before CPB and were markedly stronger in group G 3 hours after CPB termination. Although plasma nitrate+nitrite concentrations were not significantly different between the groups, endothelial-constitutive nitric oxide synthase (NOS) activity was markedly preserved and inducible NOS activity was markedly attenuated in the tissues of group G. CONCLUSIONS These results suggest that preoperative glutamine administration induces HSP70 expression before CPB and attenuates CPB-induced inflammation by regulating NOS activity, which may be a prospective management for conferring tolerance to CPB-induced inflammatory response through a self-protective mechanism.
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Affiliation(s)
- Yoshitaka Hayashi
- Department of Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan.
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