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Coronary ostial assessment of myeloperoxidase level correlated to severity of coronary artery disease. COR ET VASA 2021. [DOI: 10.33678/cor.2021.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Chowdhury UK, Sheil A, Kapoor PM, Narang R, Gharde P, Malik V, Kalaivani M, Chaudhury A. Short-term prognostic value of perioperative coronary sinus-derived-serum cardiac troponin-I, creatine kinase-MB, lactate, pyruvate, and lactate-pyruvate ratio in adult patients undergoing open heart surgery. Ann Card Anaesth 2017; 19:439-53. [PMID: 27397448 PMCID: PMC4971972 DOI: 10.4103/0971-9784.185526] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES To investigate the release pattern of different cardiac metabolites and biomarkers directly from the coronary sinus (CS) and to establish the diagnostic discrimination limits of each marker protein and metabolites to evaluate perioperative myocardial injury in patients undergoing cardiac surgery under cardiopulmonary bypass (CPB). PATIENTS AND METHODS Sixty-eight patients undergoing first mitral and/or aortic valve replacements with/without coronary artery bypass grafting and Bentall procedure under CPB and blood cardioplegic arrest were studied. All cardiac metabolites and biomarkers were measured in serial CS-derived blood samples at pre-CPB, immediate post aortic declamping, 10 minutes post-CPB and 12 hrs post-CPB. RESULTS Receiver operating characteristic curve analysis of cardiac biomarkers indicated lactate-pyruvate ratio as the superior diagnostic discriminator of myocardial injury with an optimal "cut-off" value >10.8 immediately after aortic declamping (AUC, 0.92; 95% CI: 0.85-0.98). Lactate was the second best diagnostic discriminator of myocardial injury with an optimal "cut-off" value >2mmol/l at immediately after aortic declamping (AUC, 0.89; 95% CI: 0.80-0.96). Cardiac troponin-I was the third best diagnostic discriminator of myocardial injury with an optimal "cut-off" value >2.1ng/ml at immediately after aortic declamping (AUC, 0.88; 95% CI: 0.80-0.95). Creatine kinase-MB was the fourth best diagnostic discriminator of myocardial injury with an optimal "cut-off" value >58 log units/ml prior to decanulation (AUC, 0.85; 95% CI: 0.78-0.94). CONCLUSIONS Measurable cardiac damage exists in all patients undergoing cardiac surgery under cardioplegic arrest. The degree of myocardial injury is more in patients with poor ventricular function and those requiring longer aortic clamp time. CS-derived lactate-pyruvate ratio, lactate, cTn-I served as superior diagnostic discriminators of peri-operative myocardial damage.
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Affiliation(s)
- Ujjwal Kumar Chowdhury
- Department of Cardiothoracic and Vascular Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Avneesh Sheil
- Department of Cardiothoracic and Vascular Surgery, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
| | - Poonam Malhotra Kapoor
- Department of Cardiovascular Anaesthesia, All India Institute of Medical Sciences, New Delhi, India
| | - Rajiv Narang
- Department of Cardiology, CNC, All India Institute of Medical Sciences, New Delhi, India
| | - Parag Gharde
- Department of Cardiovascular Anaesthesia, All India Institute of Medical Sciences, New Delhi, India
| | - Vishwas Malik
- Department of Cardiovascular Anaesthesia, All India Institute of Medical Sciences, New Delhi, India
| | - Mani Kalaivani
- Department of Baiostatistics, All India Institute of Medical Sciences, New Delhi, India
| | - Arindam Chaudhury
- Department of Cardiovascular Anaesthesia, All India Institute of Medical Sciences, New Delhi, India
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Kapoor P, Mandal B, Chowdhury U, Singh S, Kiran U. Changes in myocardial lactate, pyruvate and lactate-pyruvate ratio during cardiopulmonary bypass for elective adult cardiac surgery: Early indicator of morbidity. J Anaesthesiol Clin Pharmacol 2013; 27:225-32. [PMID: 21772685 PMCID: PMC3127304 DOI: 10.4103/0970-9185.81819] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Myocardial lactate assays have been established as a standard method to compare various myocardial protection strategies. This study was designed to test whether coronary sinus (CS) lactates, pyruvate and lactate-pyruvate (LP) ratio correlates with myocardial dysfunction and predict postoperative outcomes. MATERIALS AND METHODS This prospective observational study was conducted on 40 adult patients undergoing elective cardiac surgery with the aid of cardiopulmonary bypass (CPB). CS blood sampling was done for estimation of myocardial lactate (ML), pyruvate (MP) and lactate-pyruvate ratio (MLPR) namely: pre-CPB (T(1)), after removal of aortic cross clamp (T(2)) and 30 minutes post-CPB (T(3)). RESULTS Baseline myocardial LPR strongly correlated with Troponin-I at T1 (σ: 0.6). Patients were sub grouped according to the median value of myocardial lactate (2.9) at baseline T1 into low myocardial lactate (LML) group, mean (2.39±0.4 mmol/l), n=19 and a high myocardial lactate (HML) group, mean (3.65±0.9 mmol/l), n = 21. A significant increase in PL, ML, MLPR and TropI occurred in both groups as compared to baseline. Patients in HML group had significant longer period of ICU stay. Patients with higher inotrope score had significantly higher ML (T2, T3). ML with a baseline value of 2.9 mmol/l had 70.83% sensitivity and 62.5% specificity (ROC area: 0.7109 Std error: 0.09) while myocardial pyruvate with a baseline value of 0.07 mmol/l has 79.17% sensitivity and 68.75% specificity (ROC area: 0.7852, Std error: 0.0765) for predicting inotrope requirement after CPB. CONCLUSION CS lactate, pyruvate and LP ratio correlate with myocardial function and can predict postoperative outcome.
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Affiliation(s)
- Pm Kapoor
- Department of Cardiac Anaesthesia and CTVS, CN Centre, All India Institute of Medical Sciences, New Delhi, India
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Mohan Rao PS, Simha PP. Myocardial preservation: controlled reperfusion. Semin Thorac Cardiovasc Surg 2012; 23:318-21. [PMID: 22443652 DOI: 10.1053/j.semtcvs.2011.12.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/20/2011] [Indexed: 11/11/2022]
Abstract
Reperfusion injury after reestablishing coronary flow by releasing the aortic cross clamp after cardiac surgery with cardioplegic arrest causes myocardial damage and even death. Attenuation of this reperfusion response by controlling the biochemical and physical environment can avoid morbidity and mortality. Use of a warm reperfusate with addition of drugs that are known to decrease reperfusion injury with manipulation of coronary vascular resistance and the physical parameters of the reperfusion environment helps the heart to reestablish coronary perfusion while decreasing the harm produced by the period of ischemia that occurs during cardiac surgery with intermittent cardioplegic arrest.
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Affiliation(s)
- Prasanna Simha Mohan Rao
- Department of Cardiothoracic and Vascular Surgery, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bangalore, Karnataka, India.
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Schroeder MA, Clarke K, Neubauer S, Tyler DJ. Hyperpolarized magnetic resonance: a novel technique for the in vivo assessment of cardiovascular disease. Circulation 2011; 124:1580-94. [PMID: 21969318 DOI: 10.1161/circulationaha.111.024919] [Citation(s) in RCA: 101] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Marie A Schroeder
- Department of Physiology, Anatomy, and Genetics, Sherrington Bldg, University of Oxford, Parks Rd, Oxford, UK OX1 3PT
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Onorati F, Santarpino G, Cristodoro L, Scalas C, Costanzo FS, Renzulli A. Continuous Coronary Sinus Perfusion Reverses Ongoing Myocardial Damage in Acute Ischemia. Artif Organs 2009; 33:788-97. [DOI: 10.1111/j.1525-1594.2009.00811.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Rangaraj AT, Ghanta RK, Umakanthan R, Soltesz EG, Laurence RG, Fox J, Cohn LH, Bolman RM, Frangioni JV, Chen FY. Real-time visualization and quantification of retrograde cardioplegia delivery using near infrared fluorescent imaging. J Card Surg 2009; 23:701-8. [PMID: 19016995 DOI: 10.1111/j.1540-8191.2008.00767.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND AIM Homogeneous delivery of cardioplegia is essential for myocardial protection during cardiac surgery. Presently, there exist no established methods to quantitatively assess cardioplegia distribution intraoperatively and determine when retrograde cardioplegia is required. In this study, we evaluate the feasibility of near infrared (NIR) imaging for real-time visualization of cardioplegia distribution in a porcine model. METHODS A portable, intraoperative, real-time NIR imaging system was utilized. NIR fluorescent cardioplegia solution was developed by incorporating indocyanine green (ICG) into crystalloid cardioplegia solution. Real-time NIR imaging was performed while the fluorescent cardioplegia solution was infused via the retrograde route in five ex vivo normal porcine hearts and in five ex vivo porcine hearts status post left anterior descending (LAD) coronary artery ligation. Horizontal cross-sections of the hearts were obtained at proximal, middle, and distal LAD levels. Videodensitometry was performed to quantify distribution of fluorophore content. RESULTS The progressive distribution of cardioplegia was clearly visualized with NIR imaging. Complete visualization of retrograde distribution occurred within 4 minutes of infusion. Videodensitometry revealed retrograde cardioplegia, primarily distributed to the left ventricle (LV) and anterior septum. In hearts with LAD ligation, antegrade cardioplegia did not distribute to the anterior LV. This deficiency was compensated for with retrograde cardioplegia supplementation. CONCLUSIONS Incorporation of ICG into cardioplegia allows real-time visualization of cardioplegia delivery via NIR imaging. This technology may prove useful in guiding intraoperative decisions pertaining to when retrograde cardioplegia is mandated.
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Affiliation(s)
- Aravind T Rangaraj
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts 02115, USA
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Häggmark S, Haney MF, Johansson G, Reiz S, Näslund U. Contributions of myocardial ischemia and heart rate to ST segment changes in patients with or without coronary artery disease. Acta Anaesthesiol Scand 2008; 52:219-28. [PMID: 17999710 DOI: 10.1111/j.1399-6576.2007.01507.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND ST changes related to ischemia at different heart rates (HRs) have not been well described. We aimed to analyze ST dynamic changes by vectorcardiography (VCG) during pacing-induced HR changes for subjects with proven coronary artery disease (CAD) and without (non-CAD). METHODS Symptomatic CAD patients scheduled for elective surgery were enrolled along with a non-CAD group. During anesthesia, both groups were placed at multiple ascending levels. VCG ST data, and in particular in ST change vector magnitude (STC-VM) from baseline, along with arterial and great coronary artery vein (GCV) blood samples were collected to determine regional myocardial lactate production. RESULTS A total of 35 CAD and 10 non-CAD patients were studied over six incremental 10 beat/min HR increases. STC-VM mean levels increased in the CAD group from 9+/-5 to 131+/-37 microV (standard deviation) compared with non-CAD subjects with 8+/-3-76+/-34 microV. Myocardial ischemia (lactate production) was noted at higher HRs and the positive predictive value for STC-VM to detect ischemia was 58% with the negative predictive value being 88%. STC-VM at 54 microV showed a sensitivity of 88% and a specificity of 75% for identification of ischemia. CONCLUSIONS Both HR and ischemia at higher HRs contribute to VCG ST elevation. Established ST ischemia detection concerning HR levels is suboptimal, and further attention to the effects of HR on ST segments is needed to improve electrocardiographic ischemia criteria.
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Affiliation(s)
- S Häggmark
- Heart Centre, University Hospital, Umeå, Sweden.
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Molter GP, Silomon M, Bauer C, Ziegeler S, Soltesz S. Effects of hyperoncotic or hypertonic-hyperoncotic solutions on polymorphonuclear neutrophil count, elastase- and superoxide-anion production: a randomized controlled clinical trial in patients undergoing elective coronary artery bypass grafting. Acta Anaesthesiol Scand 2007; 51:914-21. [PMID: 17578462 DOI: 10.1111/j.1399-6576.2007.01341.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Hypertonic-hyperoncotic solutions may be an effective treatment for systemic inflammatory response syndrome (SIRS). With regard to the immunomodulatory effects of these drugs, previous studies demonstrated controversial results. Therefore, the present study investigated the influence of different hyperoncotic and hypertonic-hyperoncotic solutions on polymorphonuclear neutrophil leukocyte (PMNL) count, elastase and superoxide-anion production in patients undergoing elective coronary artery bypass grafting (CABG) with cardiopulmonary bypass. METHODS Fifty patients scheduled for elective CABG with cardiopulmonary bypass were randomly assigned to five groups: (i) NaCl 0.9%, 750 ml/m(2) body surface area (BSA); (ii) hydroxyethylic starch 10%, 250 ml/m(2) BSA and NaCl 0.9%, 400 ml/m(2) BSA; (iii) dextran 10%, 250 ml/m(2) BSA and NaCl 0.9%, 300 ml/m(2) BSA; (iv) hypertonic sodium chloride 7.2%/hyperoncotic hydroxyethylic starch 10%, 150 ml/m(2) BSA; and (v) hypertonic sodium chloride 7.2%/hyperoncotic dextran 10%, 150 ml/m(2) BSA. Blood samples were drawn from arterial, central venous and coronary artery sinus catheters peri-operatively. PMNL count, superoxide-anion production and elastase were recorded. RESULTS PMNL counts and elastase activity increased in all groups after reperfusion. Superoxide-anion production showed only minor changes. Between groups, no significant differences were demonstrated. CONCLUSIONS Infusion of clinically relevant doses of hypertonic-hyperoncotic solution did not affect PMNL count, elastase- or superoxide-anion production during elective CABG with cardiopulmonary bypass.
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Affiliation(s)
- G P Molter
- Department of Anesthesia and Intensive Care, Klinikum Leverkusen, Leverkusen, Germany
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Onorati F, Cristodoro L, Caroleo S, Esposito A, Amantea B, Santangelo E, Renzulli A. Troponin I and Lactate From Coronary Sinus Predict Cardiac Complications After Myocardial Revascularization. Ann Thorac Surg 2007; 83:1016-23. [PMID: 17307451 DOI: 10.1016/j.athoracsur.2006.10.103] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2006] [Revised: 10/19/2006] [Accepted: 10/23/2006] [Indexed: 11/20/2022]
Abstract
BACKGROUND Postoperative troponin I and lactate elevation are related to cardiac complications after myocardial revascularization. We sought to evaluate earlier predictive value for acute myocardial infarction (AMI) and myocardial damage of troponin I and lactate after myocardial revascularization. METHODS In all, 183 consecutive isolated myocardial revascularizations were prospectively enrolled in the study. Troponin I and lactate were sampled preoperatively and intraoperatively from the coronary sinus, and at 12, 24, 48, and 72 hours. Hospital outcome was recorded. Receiver operating curves for coronary sinus troponin I and lactate were constructed to differentiate patients with or without AMI and myocardial damage. RESULTS Acute myocardial infarction developed in 6 patients (3.2%), with higher troponin I and lactate at all time points (p < 0.05), longer intubation time (p = 0.003), intensive care unit stay (p = 0.001), hospital stay (p = 0.001), higher atrial fibrillation (p = 0.001), and worse ventricular function (p = 0.001). Myocardial damage developed in 6 patients (3.2%), showing higher troponin I at all time points (p < 0.001), higher intraoperative lactate (p = 0.04), longer intubation time (p = 0.005), and intensive care unit stay (p = 0.03). Receiver operating characteristic curves demonstrated coronary sinus troponin I greater than 0.94 microg/L (area under the curve [AUC] 0.820 +/- 0.075; sensitivity 90.0%, specificity 68.9%) as a better discriminator between patients with or without AMI than lactate level greater than 2.85 mmol/L (AUC 0.686 +/- 0.090; sensitivity 80.0%; specificity 72.9%); troponin I greater than 0.65 microg/L was a better discriminator between patients with or without myocardial damage (AUC 0.834 +/- 0.061; sensitivity 93.8%, specificity 71.5%), than lactate greater than 2.05 mmol/L (AUC 0.627 +/- 0.067; sensitivity 87.5%; specificity 70.7%). CONCLUSIONS Coronary sinus troponin I and lactate are predictive for cardiac complications after myocardial revascularization. Intraoperative biochemical assays should be routinely performed to establish preventative strategies to reduce further myocardial damage.
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Kwak YL. Reduction of Ischemia During Off-Pump Coronary Artery Bypass Graft Surgery. J Cardiothorac Vasc Anesth 2005; 19:667-77. [PMID: 16202908 DOI: 10.1053/j.jvca.2005.04.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2005] [Indexed: 12/11/2022]
Affiliation(s)
- Young Lan Kwak
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, 134 Shinchon-Dong, Seodaemun-Ku, Seoul, Korea.
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Son HS, Sun K, Fang YH, Park SY, Hwang CM, Park SM, Lee SH, Kim KT, Lee IS. The effects of pulsatile versus non-pulsatile extracorporeal circulation on the pattern of coronary artery blood flow during cardiac arrest. Int J Artif Organs 2005; 28:609-16. [PMID: 16015571 DOI: 10.1177/039139880502800610] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND In sudden cardiac arrest, the effective maintenance of coronary artery blood flow is of paramount importance for myocardial preservation as well as cardiac recovery and patient survival. The purpose of this study was to directly compare the effects of pulsatile versus non-pulsatile circulation to coronary artery flow and myocardial preservation in a cardiac arrest condition. METHODS A cardiopulmonary bypass circuit was constructed in a ventricular fibrillation model using fourteen Yorkshire swine weighing 25-35 kg each. The animals were randomly assigned to group I (n=7, non-pulsatile centrifugal pump) or group II (n=7, pulsatile T-PLS pump). Extracorporeal circulation was maintained for two hours at a pump flow of 2 L/min. The left anterior descending coronary artery flow was measured with an ultrasonic coronary artery flow measurement system at baseline (before bypass) and at every 20 minutes after bypass. Serologic parameters were collected simultaneously at baseline, 1 hour, and 2 hours after bypass in the systemic arterial and coronary sinus venous blood. The Mann-Whitney U test of STATISTICA 6.0 was used to determine intergroup significances using a p value of <0.05. RESULTS The resistance index of the coronary artery was lower in group II and the difference was significant at 40 min, 80 min, 100 min and 120 min (p<0.05). The mean velocity of the coronary artery was higher in group II throughout the study, and the difference was significant from 20 min after starting the pump (p<0.05). The coronary artery blood flow was higher in group II throughout the study, and the difference was significant from 40 min to 120 min (p<0.05) except at 80 min. Serologic parameters showed no differences between the groups at 1 hour and 2 hours after bypass in the systemic and coronary sinus blood (p=NS). CONCLUSION In the cardiac arrest condition, pulsatile extracorporeal circulation provides more blood flow, higher flow velocity and less resistance to coronary artery than non-pulsatile circulation.
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Affiliation(s)
- H S Son
- Department of Thoracic and Cardiovascular Surgery, Korea University, Seoul, Korea
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Gutierrez G, Chawla LS, Seneff MG, Katz NM, Zia H. Lactate concentration gradient from right atrium to pulmonary artery. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2005; 9:R425-9. [PMID: 16137356 PMCID: PMC1269463 DOI: 10.1186/cc3741] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/26/2005] [Revised: 05/16/2005] [Accepted: 05/20/2005] [Indexed: 11/10/2022]
Abstract
INTRODUCTION We compared simultaneous measurements of blood lactate concentration ([Lac]) in the right atrium (RA) and in the pulmonary artery (PA). Our aim was to determine if the mixing of right atrial with coronary venous blood, having substantially lower [Lac], results in detectable decreases in [Lac] from the RA to the PA. METHODS A prospective, sequential, observational study was conducted in a medical-surgical intensive care unit. We enrolled 45 critically ill adult individuals of either sex requiring pulmonary artery catheters (PACs) to guide fluid therapy. Immediately following the insertion of the PAC, one paired set of blood samples per patient was drawn in random order from the PAC's proximal and distal ports for measurement of hemoglobin concentration, O2 saturation (SO2) and [Lac]. We defined Delta[Lac] as ([Lac]ra - [Lac]pa), DeltaSO2 as (SraO2 - SpaO2) and the change in O2 consumption (DeltaVO2) as the difference in systemic VO2 calculated using Fick's equation with either SraO2 or SpaO2 in place of mixed venous SO2. Data were compared by paired Student's t-test, Spearman's correlation analysis and by the method of Bland and Altman. RESULTS We found SraO2 > SpaO2 (74.2 +/- 9.1 versus 69.0 +/- 10.4%; p < 0.001) and [Lac]ra > [Lac]pa (3.9 +/- 3.0 versus 3.7 +/- 3.0 mmol x l-1; p < 0.001). Delta[Lac] correlated with DeltaVO2 (r2 = 0.34; p < 0.001). CONCLUSION We found decreases in [Lac] from the RA to PA in this sample of critically ill individuals. We conclude that parallel decreases in SO2 and [Lac] from the RA to PA support the hypothesis that these gradients are produced by mixing RA with coronary venous blood of lower SO2 and [Lac]. The present study is a preliminary observation of this phenomenon and further work is needed to define the physiological and clinical significance of Delta[Lac].
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Affiliation(s)
- Guillermo Gutierrez
- Professor of Medicine and Anesthesiology, Pulmonary and Critical Care Medicine Division and Department of Medicine, The George Washington University Medical Center Washington, DC, USA
| | - Lakhmir S Chawla
- Assistant Professor of Anesthesiology and Medicine, Critical Care Medicine Division, Department of Anesthesiology, The George Washington University Medical Center Washington, DC, USA
| | - Michael G Seneff
- Associate Professor Anesthesiology, Critical Care Medicine Division, Department of Anesthesiology, The George Washington University Medical Center Washington, DC, USA
| | - Nevin M Katz
- Clinical Professor of Surgery, Cardio-Thoracic Critical Care, Department of Surgery, The George Washington University Medical Center Washington, DC, USA
| | - Hasan Zia
- Senior Resident, Division of General Surgery, Department of Surgery, The George Washington University Medical Center Washington, DC, USA
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Bortone F, Mazzoni M, Repossini A, Campolo J, Ceriani R, Devoto E, Parolini M, De Maria R, Arena V, Parodi O. Myocardial lactate metabolism in relation to preoperative regional wall motion and to early functional recovery after coronary revascularization. J Cardiothorac Vasc Anesth 2003; 17:478-85. [PMID: 12968236 DOI: 10.1016/s1053-0770(03)00153-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To evaluate myocardial lactate metabolism as a marker of functional status after surgical coronary revascularization. DESIGN Single-center, prospective, cohort study. SETTING Tertiary care teaching hospital. PARTICIPANTS Fifty patients with stable angina, ejection fraction >0.40, undergoing coronary artery bypass surgery for multiple-vessel disease. MEASUREMENTS AND MAIN RESULTS Before (T1) and 30 minutes (T2) after coronary artery bypass grafting, the authors simultaneously sampled blood from artery and coronary sinus to determine myocardial lactate dynamics and performed transesophageal echocardiography (TEE) to assess segmental wall motion. Wall motion score index (WMSI) was calculated with an online/offline comparison. At T2, WMSI improved from 1.40 +/- 0.31 to 1.17 +/- 0.23 (p = 0.0001). Preoperatively, 2 patterns of lactate balance were found: 39 patients were lactate extractors (17% +/- 10%) and 11 were lactate producers (-11% +/- 11%). At T2, lactate metabolism was shifted towards a pattern opposite to the baseline: delta lactate extraction was -8% +/- 16% in extractors at T1 versus 7% +/- 9% in producers at T1 (p = 0.003). Changes in WMSI were not correlated with changes in lactate utilization. No single preoperative variable predicted postoperative WMSI or its changes from baseline. Cardiopulmonary bypass (CPB) time was the only significant predictor of postoperative lactate extraction by multivariate regression (r = -0.46, p = 0.001): at T2, patients in the highest CPB time quartile showed frank lactate production (-6% +/- 13%) when compared with those in the lowest quartile (15% +/- 11%, p = 0.005). However, postoperative WMSI was similar in different CPB time groups. CONCLUSIONS Myocardial lactate metabolism pattern is not associated with functional status before and early after successful coronary revascularization. CPB time was the only significant predictor of postoperative lactate extraction. Measurement of lactate does not appear to be a valuable tool to assess the coupling of myocardial regional function and metabolism in the setting of coronary artery surgery and mild-to-moderate functional impairment.
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Affiliation(s)
- Franco Bortone
- Department of Anesthesia and Cardiac Surgery, Humanitas Gavazzeni, Bergamo, Italy
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Vassiliades TA, Nielsen JL, Lonquist JL. Coronary perfusion methods during off-pump coronary artery bypass: results of a randomized clinical trial. Ann Thorac Surg 2002; 74:S1383-9. [PMID: 12400822 DOI: 10.1016/s0003-4975(02)03912-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Several techniques are being used to perform off-pump coronary artery bypass (OPCAB) grafting. This three-armed clinical trial was performed to determine whether one OPCAB method of coronary perfusion was superior over the others with respect to myocardial protection and performance. METHODS Over the course of 11 months, 151 consecutive unselected patients underwent elective first-time OPCAB grafting by sternotomy performed by a single surgeon. Patients were prospectively randomized to receive one of three OPCAB coronary perfusion treatments: (1) no coronary perfusion (NCP), ie, OPCAB using no coronary perfusion during the distal anastomosis or graft perfusion after the distal anastomosis until all the proximal anastomoses were completed; (2) passive coronary perfusion (PCP), providing distal coronary perfusion during the anastomosis and immediate graft perfusion after the distal anastomosis by means of a passive cannula from the aorta; or (3) active coronary perfusion (ACP), providing assisted distal coronary perfusion and graft perfusion by means of an in-line pump (perfusion-assisted direct coronary artery bypass. Hemodynamic and biochemical data were recorded to disc continuously throughout the operation and postoperatively. RESULTS With no statistically significant differences in the three treatment groups with respect to patient age, left ventricular systolic or diastolic function, and extent and distribution of coronary disease or grafts performed, cardiac performance postoperatively was superior in the active coronary perfusion group compared to the groups receiving either passive coronary perfusion or no coronary perfusion (p < 0.001). In addition, troponin I levels were lower in the coronary perfusion groups (PCP and ACP) (p = 0.023). CONCLUSIONS Providing active coronary perfusion during the anastomosis and after each distal anastomosis by using an in-line pump resulted in superior myocardial protection and performance during OPCAB surgery when compared to either no coronary perfusion or passive coronary perfusion.
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