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Chiari P, Fellahi JL. Myocardial protection in cardiac surgery: a comprehensive review of current therapies and future cardioprotective strategies. Front Med (Lausanne) 2024; 11:1424188. [PMID: 38962735 PMCID: PMC11220133 DOI: 10.3389/fmed.2024.1424188] [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: 04/27/2024] [Accepted: 05/23/2024] [Indexed: 07/05/2024] Open
Abstract
Cardiac surgery with cardiopulmonary bypass results in global myocardial ischemia-reperfusion injury, leading to significant postoperative morbidity and mortality. Although cardioplegia is the cornerstone of intraoperative cardioprotection, a number of additional strategies have been identified. The concept of preconditioning and postconditioning, despite its limited direct clinical application, provided an essential contribution to the understanding of myocardial injury and organ protection. Therefore, physicians can use different tools to limit perioperative myocardial injury. These include the choice of anesthetic agents, remote ischemic preconditioning, tight glycemic control, optimization of respiratory parameters during the aortic unclamping phase to limit reperfusion injury, appropriate choice of monitoring to optimize hemodynamic parameters and limit perioperative use of catecholamines, and early reintroduction of cardioprotective agents in the postoperative period. Appropriate management before, during, and after cardiopulmonary bypass will help to decrease myocardial damage. This review aimed to highlight the current advancements in cardioprotection and their potential applications during cardiac surgery.
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Affiliation(s)
- Pascal Chiari
- Service d’Anesthésie Réanimation, Hôpital Universitaire Louis Pradel, Hospices Civils de Lyon, Lyon, France
- Laboratoire CarMeN, Inserm UMR 1060, Université Claude Bernard Lyon 1, Lyon, France
| | - Jean-Luc Fellahi
- Service d’Anesthésie Réanimation, Hôpital Universitaire Louis Pradel, Hospices Civils de Lyon, Lyon, France
- Laboratoire CarMeN, Inserm UMR 1060, Université Claude Bernard Lyon 1, Lyon, France
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Milliken AS, Ciesla JH, Nadtochiy SM, Brookes PS. Distinct effects of intracellular vs. extracellular acidic pH on the cardiac metabolome during ischemia and reperfusion. J Mol Cell Cardiol 2023; 174:101-114. [PMID: 36481511 PMCID: PMC9868090 DOI: 10.1016/j.yjmcc.2022.11.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Revised: 11/22/2022] [Accepted: 11/25/2022] [Indexed: 12/10/2022]
Abstract
Tissue ischemia results in intracellular pH (pHIN) acidification, and while metabolism is a known driver of acidic pHIN, less is known about how acidic pHIN regulates metabolism. Furthermore, acidic extracellular (pHEX) during early reperfusion confers cardioprotection, but how this impacts metabolism is unclear. Herein we employed LCMS based targeted metabolomics to analyze perfused mouse hearts exposed to: (i) control perfusion, (ii) hypoxia, (iii) ischemia, (iv) enforced acidic pHIN, (v) control reperfusion, and (vi) acidic pHEX (6.8) reperfusion. Surprisingly little overlap was seen between metabolic changes induced by hypoxia, ischemia, and acidic pHIN. Acidic pHIN elevated metabolites in the top half of glycolysis, and enhanced glutathione redox state. Meanwhile, acidic pHEX reperfusion induced substantial metabolic changes in addition to those seen in control reperfusion. This included elevated metabolites in the top half of glycolysis, prevention of purine nucleotide loss, and an enhancement in glutathione redox state. These data led to hypotheses regarding potential roles for methylglyoxal inhibiting the mitochondrial permeability transition pore, and for acidic inhibition of ecto-5'-nucleotidase, as potential mediators of cardioprotection by acidic pHEX reperfusion. However, neither hypothesis was supported by subsequent experiments. In contrast, analysis of cardiac effluents revealed complex effects of pHEX on metabolite transport, suggesting that mildly acidic pHEX may enhance succinate release during reperfusion. Overall, each intervention had distinct and overlapping metabolic effects, suggesting acidic pH is an independent metabolic regulator regardless which side of the cell membrane it is imposed.
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Affiliation(s)
- Alexander S Milliken
- Department of Pharmacology and Physiology, University of Rochester Medical Center, USA
| | - Jessica H Ciesla
- Department of Biochemistry, University of Rochester Medical Center, USA
| | - Sergiy M Nadtochiy
- Department of Anesthesiology and Perioperative Medicine, University of Rochester Medical Center, USA
| | - Paul S Brookes
- Department of Pharmacology and Physiology, University of Rochester Medical Center, USA; Department of Anesthesiology and Perioperative Medicine, University of Rochester Medical Center, USA.
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Cuomo O, Vinciguerra A, Cerullo P, Anzilotti S, Brancaccio P, Bilo L, Scorziello A, Molinaro P, Di Renzo G, Pignataro G. Ionic homeostasis in brain conditioning. Front Neurosci 2015; 9:277. [PMID: 26321902 PMCID: PMC4530315 DOI: 10.3389/fnins.2015.00277] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2015] [Accepted: 07/23/2015] [Indexed: 12/26/2022] Open
Abstract
Most of the current focus on developing neuroprotective therapies is aimed at preventing neuronal death. However, these approaches have not been successful despite many years of clinical trials mainly because the numerous side effects observed in humans and absent in animals used at preclinical level. Recently, the research in this field aims to overcome this problem by developing strategies which induce, mimic, or boost endogenous protective responses and thus do not interfere with physiological neurotransmission. Preconditioning is a protective strategy in which a subliminal stimulus is applied before a subsequent harmful stimulus, thus inducing a state of tolerance in which the injury inflicted by the challenge is mitigated. Tolerance may be observed in ischemia, seizure, and infection. Since it requires protein synthesis, it confers delayed and temporary neuroprotection, taking hours to develop, with a pick at 1–3 days. A new promising approach for neuroprotection derives from post-conditioning, in which neuroprotection is achieved by a modified reperfusion subsequent to a prolonged ischemic episode. Many pathways have been proposed as plausible mechanisms to explain the neuroprotection offered by preconditioning and post-conditioning. Although the mechanisms through which these two endogenous protective strategies exert their effects are not yet fully understood, recent evidence highlights that the maintenance of ionic homeostasis plays a key role in propagating these neuroprotective phenomena. The present article will review the role of protein transporters and ionic channels involved in the control of ionic homeostasis in the neuroprotective effect of ischemic preconditioning and post-conditioning in adult brain, with particular regards to the Na+/Ca2+ exchangers (NCX), the plasma membrane Ca2+-ATPase (PMCA), the Na+/H+ exchange (NHE), the Na+/K+/2Cl− cotransport (NKCC) and the acid-sensing cation channels (ASIC). Ischemic stroke is the third leading cause of death and disability. Up until now, all clinical trials testing potential stroke neuroprotectants failed. For this reason attention of researchers has been focusing on the identification of brain endogenous neuroprotective mechanisms activated after cerebral ischemia. In this context, ischemic preconditioning and ischemic post-conditioning represent two neuroprotecive strategies to investigate in order to identify new molecular target to reduce the ischemic damage.
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Affiliation(s)
- Ornella Cuomo
- Division of Pharmacology, Department of Neuroscience, Reproductive and Dentistry Sciences, School of Medicine, Federico II University of Naples Naples, Italy
| | - Antonio Vinciguerra
- Division of Pharmacology, Department of Neuroscience, Reproductive and Dentistry Sciences, School of Medicine, Federico II University of Naples Naples, Italy
| | - Pierpaolo Cerullo
- Division of Pharmacology, Department of Neuroscience, Reproductive and Dentistry Sciences, School of Medicine, Federico II University of Naples Naples, Italy
| | | | - Paola Brancaccio
- Division of Pharmacology, Department of Neuroscience, Reproductive and Dentistry Sciences, School of Medicine, Federico II University of Naples Naples, Italy
| | - Leonilda Bilo
- Division of Neurology, Department of Neuroscience, Reproductive and Dentistry Sciences, School of Medicine, Federico II University of Naples Naples, Italy
| | - Antonella Scorziello
- Division of Pharmacology, Department of Neuroscience, Reproductive and Dentistry Sciences, School of Medicine, Federico II University of Naples Naples, Italy
| | - Pasquale Molinaro
- Division of Pharmacology, Department of Neuroscience, Reproductive and Dentistry Sciences, School of Medicine, Federico II University of Naples Naples, Italy
| | - Gianfranco Di Renzo
- Division of Pharmacology, Department of Neuroscience, Reproductive and Dentistry Sciences, School of Medicine, Federico II University of Naples Naples, Italy
| | - Giuseppe Pignataro
- Division of Pharmacology, Department of Neuroscience, Reproductive and Dentistry Sciences, School of Medicine, Federico II University of Naples Naples, Italy
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Inserte J, Garcia-Dorado D. The cGMP/PKG pathway as a common mediator of cardioprotection: translatability and mechanism. Br J Pharmacol 2015; 172:1996-2009. [PMID: 25297462 DOI: 10.1111/bph.12959] [Citation(s) in RCA: 72] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2014] [Revised: 09/16/2014] [Accepted: 09/26/2014] [Indexed: 12/24/2022] Open
Abstract
Cardiomyocyte cell death occurring during myocardial reperfusion (reperfusion injury) contributes to final infarct size after transient coronary occlusion. Different interrelated mechanisms of reperfusion injury have been identified, including alterations in cytosolic Ca(2+) handling, sarcoplasmic reticulum-mediated Ca(2+) oscillations and hypercontracture, proteolysis secondary to calpain activation and mitochondrial permeability transition. All these mechanisms occur during the initial minutes of reperfusion and are inhibited by intracellular acidosis. The cGMP/PKG pathway modulates the rate of recovery of intracellular pH, but has also direct effect on Ca(2+) oscillations and mitochondrial permeability transition. The cGMP/PKG pathway is depressed in cardiomyocytes by ischaemia/reperfusion and preserved by ischaemic postconditioning, which importantly contributes to postconditioning protection. The present article reviews the mechanisms and consequences of the effect of ischaemic postconditioning on the cGMP/PKG pathway, the different pharmacological strategies aimed to stimulate it during myocardial reperfusion and the evidence, limitations and promise of translation of these strategies to the clinical practice. Overall, the preclinical and clinical evidence suggests that modulation of the cGMP/PKG pathway may be a therapeutic target in the context of myocardial infarction.
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Affiliation(s)
- Javier Inserte
- Cardiology Department, Vall d'Hebron University Hospital and Research Institute, Universitat Autònoma de Barcelona, Barcelona, Spain
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Myocardial protection in cardiac surgery: a historical review from the beginning to the current topics. Gen Thorac Cardiovasc Surg 2013; 61:485-96. [PMID: 23877427 DOI: 10.1007/s11748-013-0279-4] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2012] [Indexed: 02/01/2023]
Abstract
Myocardial protection has become an essential adjunctive measure in cardiac surgery for a couple of decades, because since the 1950s, the methods of cardioprotection (cardioplegic solutions and related procedures) have been improved by the mechanism of myocardial ischemia/reperfusion-induced damage being unveiled through the untiring efforts of researchers and clinicians. The concept of myocardial protection in cardiac surgery was proposed along with introduction of hypothermic crystalloid potassium cardioplegia in the beginning and has been diversified by pharmacological additives, blood cardioplegia, temperature modulation (warm; tepid), retrograde cardioplegia, controlled reperfusion, integrated cardioplegia, and pre-and postconditioning. This historical review summarized experimental and clinical studies dealing with the methods and results of myocardial protection in cardiac surgery, introducing the newly developed concepts for the last decade and the current topics.
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Xin Duan, Bingyang Ji, Kun Yu, Feilong Hei, Jinping Liu, Cun Long. Acidic buffer or plus cyclosporine A post-conditioning protects isolated rat hearts against ischemia-reperfusion injury. Perfusion 2011; 26:245-52. [PMID: 21490080 DOI: 10.1177/0267659110398733] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: It is well documented that transient acidosis during reperfusion is protective. The aim of this study was to evaluate the cardioprotection of acidic buffer or plus cyclosporine A in isolated rat hearts after cardioplegic arrest. Methods: Langendorff-perfused Sprague—Dawley rat hearts were perfused for 20 min with Krebs—Henseleit (K-H) buffer followed by 30 min of crystalloid cardioplegia and 60 min of reperfusion. Control hearts were perfused with Krebs—Henseleit buffer. Acidic buffer post-conditioning hearts were perfused with acidic K-H buffer (pH 6.8) for the first 3 min of reperfusion. Acidic buffer plus cyclosporine A hearts were perfused with K-H acidic buffer (pH 6.8) containing cyclosporine A (0.2 μmol/L) for the first 3 min of reperfusion. Results: Compared with the control group, acidic buffer or plus cyclosporine A post-conditioning significantly improved myocardial performance, decreased cytochrome C release into the cytosol, increased Bcl-2 expression and decreased Bax expression, decreased sensitivity of mPTP-opening to [Ca2+] and the rate of apoptosis after reperfusion. Conclusion: These findings suggested that acidic buffer or plus cyclosporine A post-conditioning prevented apoptosis-related mitochondrial permeabilization and provided the myocardial protection after cardioplegic arrest.
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Affiliation(s)
- Xin Duan
- Fuwai Hospital and Cardiovascular Institute, Chinese Academy of Medical Science, Peking Union Medical College, Beijing, Peoples Republic of China
| | - Bingyang Ji
- Department of Cardiopulmonary Bypass, Fuwai Hospital and Cardiovascular Institute, Chinese Academy of Medical Science, Peking Union Medical College, Beijing, Peoples Republic of China
| | - Kun Yu
- Department of Cardiopulmonary Bypass, Fuwai Hospital and Cardiovascular Institute, Chinese Academy of Medical Science, Peking Union Medical College, Beijing, Peoples Republic of China
| | - Feilong Hei
- Department of Cardiopulmonary Bypass, Fuwai Hospital and Cardiovascular Institute, Chinese Academy of Medical Science, Peking Union Medical College, Beijing, Peoples Republic of China
| | - Jinping Liu
- Department of Cardiopulmonary Bypass, Fuwai Hospital and Cardiovascular Institute, Chinese Academy of Medical Science, Peking Union Medical College, Beijing, Peoples Republic of China
| | - Cun Long
- Department of Cardiopulmonary Bypass, Fuwai Hospital and Cardiovascular Institute, Chinese Academy of Medical Science, Peking Union Medical College, Beijing, Peoples Republic of China
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Inserte J, Ruiz-Meana M, Rodríguez-Sinovas A, Barba I, Garcia-Dorado D. Contribution of delayed intracellular pH recovery to ischemic postconditioning protection. Antioxid Redox Signal 2011; 14:923-39. [PMID: 20578958 DOI: 10.1089/ars.2010.3312] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Ischemic postconditioning (PoCo) has been proven to be a feasible approach to attenuate reperfusion injury and enhance myocardial salvage in patients with acute myocardial infarction, but its mechanisms have not been completely elucidated yet. Recent studies demonstrate that PoCo may delay the recovery of intracellular pH during initial reperfusion, and that its ability to limit infarct size critically depends on this effect. Prolongation of postischemic intracellular acidosis inhibits hypercontracture, mitochondrial permeability transition, calpain-mediated proteolysis, and gap junction-mediated spread of injury during the first minutes of reflow. This role of prolonged acidosis does not exclude the participation of other pathways in PoCo-induced cardioprotection. On the contrary, it may allow these pathways to act by preventing immediate reperfusion-induced cell death. Moreover, the existence of interactions between intracellular acidosis and endogenous protection signaling cannot be excluded and needs to be investigated. The role of prolonged acidosis in PoCo cardioprotection has important implications in the design of optimal PoCo protocols and in the translation of cardioprotective strategies to patients with on-going myocardial infarction receiving coronary reperfusion.
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Affiliation(s)
- Javier Inserte
- Department of Cardiology, Vall d'Hebron University Hospital and Research Institute, Universitat Autònoma de Barcelona, Barcelona, Spain
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Intracoronary acid infusion as an alternative to ischemic postconditioning in pigs. Basic Res Cardiol 2009; 104:761-71. [DOI: 10.1007/s00395-009-0032-4] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2009] [Revised: 04/27/2009] [Accepted: 04/27/2009] [Indexed: 12/14/2022]
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López D, Rodríguez-Sinovas A, Agulló L, Inserte J, Cabestrero A, García-Dorado D. Acidic reoxygenation protects against endothelial dysfunction in rat aortic rings submitted to simulated ischemia. Am J Physiol Heart Circ Physiol 2008; 295:H2409-16. [PMID: 18931032 DOI: 10.1152/ajpheart.00409.2008] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Ischemia-reperfusion causes endothelial dysfunction. Prolongation of acidosis during initial cardiac reperfusion limits infarct size in animal models, but the effects of acidic reperfusion on vascular function are unknown. The present work analyzes the effects of acidic reoxygenation on vascular responses to different agonists in rat aortic rings. Arterial rings obtained from Sprague-Dawley rat aorta were placed in organ baths containing a Krebs solution oxygenated at 37 degrees C (pH 7.4). After equilibration (30 mN, 1 h), the effects of acidosis (pH 6.4) on aortic responses to acetylcholine and norepinephrine were initially assessed under normoxic conditions. Thereafter, the effects of acidosis during hypoxia (1 h) or reoxygenation on aortic responses to acetylcholine, norepinephrine, or sodium nitroprusside were analyzed and compared with those observed in control rings. Acidosis did not modify aortic responses to acetylcholine or adrenaline during normoxia. In contrast, rings submitted to hypoxia and reoxygenated at pH 7.4 showed a reduction in vasodilator responses to acetylcholine and in contractions to norepinephrine with no change in responses to sodium nitroprusside. Reoxygenation at pH 6.4 did not modify the depressed response to norepinephrine but enhanced the recovery of acetylcholine-induced vasorelaxation. Cumulative concentration-response curves to acetylcholine showed an increased responsiveness to this drug in rings reoxygenated at a low pH. This functional improvement was associated with the preservation of aortic cGMP content after stimulation of reoxygenated rings with acetylcholine. In conclusion, acidic reoxygenation preserves endothelial function in arterial rings submitted to simulated ischemia, likely through the preservation of cGMP signaling.
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Affiliation(s)
- Diego López
- Laboratorio de Cardiología Experimental, Servicio de Cardiologia, Hospital Universitario Vall d'Hebron, Barcelona, Spain
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Inserte J, Barba I, Hernando V, Garcia-Dorado D. Delayed recovery of intracellular acidosis during reperfusion prevents calpain activation and determines protection in postconditioned myocardium. Cardiovasc Res 2008; 81:116-22. [DOI: 10.1093/cvr/cvn260] [Citation(s) in RCA: 90] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Inserte J, Barba I, Hernando V, Abellan A, Ruiz-Meana M, Rodriguez-Sinovas A, Garcia-Dorado D. Effect of acidic reperfusion on prolongation of intracellular acidosis and myocardial salvage. Cardiovasc Res 2007; 77:782-90. [DOI: 10.1093/cvr/cvm082] [Citation(s) in RCA: 84] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
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Tritto FP, Inserte J, Garcia-Dorado D, Ruiz-Meana M, Soler-Soler J. Sodium/hydrogen exchanger inhibition reduces myocardial reperfusion edema after normothermic cardioplegia. J Thorac Cardiovasc Surg 1998; 115:709-15. [PMID: 9535460 DOI: 10.1016/s0022-5223(98)70337-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE The hypothesis was that Na+/H+ exchange occurring during normothermic cardioplegia contributes to the development of myocardial edema during subsequent reperfusion and impairs functional recovery. METHODS Rat hearts were perfused in a Langendorff apparatus and submitted to 60 minutes of normothermic cardioplegia and 90 minutes of reperfusion. Hearts were allocated to one of four groups (n = 8): inhibition of Na+/H+ exchanger with HOE642 throughout the whole experiment (HOE group), only during cardioplegia (HOE-C) or during reperfusion (HOE-R), and a control group. RESULTS In HOE and HOE-C groups, myocardial water content at the end of reperfusion was lower than in the HOE-R and control groups (526 +/- 19 and 533 +/- 18 ml/100 gm dry tissue vs 632 +/- 25 and 634 +/- 17 ml/100 gm dry tissue, respectively, p = 0.001), left ventricular end-diastolic pressure increased less after reperfusion (46.6 +/- 9.7 and 63.2 +/- 10.0 mm Hg vs 75.1 +/- 4.3 mm Hg and 85.7 +/- 8.9 mm Hg, respectively, p = 0.006), and recovery of left ventricular developed pressure was better (46.7% and 45.8% vs 4.5% and 9.8%, p = 0.048). Relative to the control group, total lactate dehydrogenase release during reperfusion was reduced by 80.2%, 69.3% and 36% in HOE, HOE-C, and HOE-R groups, respectively. CONCLUSION Inhibition of the Na+/H+ exchange during normothermic cardioplegia reduces myocardial edema and necrosis during subsequent reperfusion, improving functional recovery. Inhibition of Na+/H+ exchange during reperfusion only has a much smaller effect.
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Affiliation(s)
- F P Tritto
- Laboratorio de Cardiologia Experimental B. Servicio de Cardiologia, Hospital General Universitari Vall d'Hebron, Barcelona, Spain
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