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Banerjee D, Feng J, Sellke FW. Strategies to attenuate maladaptive inflammatory response associated with cardiopulmonary bypass. Front Surg 2024; 11:1224068. [PMID: 39022594 PMCID: PMC11251955 DOI: 10.3389/fsurg.2024.1224068] [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: 05/17/2023] [Accepted: 06/07/2024] [Indexed: 07/20/2024] Open
Abstract
Cardiopulmonary bypass (CPB) initiates an intense inflammatory response due to various factors: conversion from pulsatile to laminar flow, cold cardioplegia, surgical trauma, endotoxemia, ischemia-reperfusion injury, oxidative stress, hypothermia, and contact activation of cells by the extracorporeal circuit. Redundant and overlapping inflammatory cascades amplify the initial response to produce a systemic inflammatory response, heightened by coincident activation of coagulation and fibrinolytic pathways. When unchecked, this inflammatory response can become maladaptive and lead to serious postoperative complications. Concerted research efforts have been made to identify technical refinements and pharmacologic interventions that appropriately attenuate the inflammatory response and ultimately translate to improved clinical outcomes. Surface modification of the extracorporeal circuit to increase biocompatibility, miniaturized circuits with sheer resistance, filtration techniques, and minimally invasive approaches have improved clinical outcomes in specific populations. Pharmacologic adjuncts, including aprotinin, steroids, monoclonal antibodies, and free radical scavengers, show real promise. A multimodal approach incorporating technical, circuit-specific, and pharmacologic strategies will likely yield maximal clinical benefit.
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Affiliation(s)
| | | | - Frank W. Sellke
- Division of Cardiothoracic Surgery, Department of Surgery, Brown University/Rhode Island Hospital, Providence, RI, United States
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2
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Squiccimarro E, Stasi A, Lorusso R, Paparella D. Narrative review of the systemic inflammatory reaction to cardiac surgery and cardiopulmonary bypass. Artif Organs 2022; 46:568-577. [PMID: 35061922 PMCID: PMC9303696 DOI: 10.1111/aor.14171] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2021] [Revised: 11/14/2021] [Accepted: 12/29/2021] [Indexed: 12/11/2022]
Abstract
Background Data from large cardiac surgery registries have been depicting a downward trend of mortality and morbidities in the last 20 years. However, despite decades of medical evolution, cardiac surgery and cardiopulmonary bypass still provoke a systemic inflammatory response, which occasionally leads to worsened outcome. This article seeks to outline the mechanism of the phenomenon. Methods A thorough review of the literature has been performed. Criteria for considering studies for this non‐systematic review were as follows: observational and interventional studies investigating the systemic inflammatory response to cardiac surgery, experimental studies describing relevant molecular mechanisms, and essential review studies pertinent to the topic. Results The intrinsic variability of the inflammatory response to cardiac surgery, together with its heterogenous perception among clinicians, as well as the arduousness to early discriminate high‐responder patients from those who will not develop a clinically relevant reaction, concurred to hitherto unconclusive randomized controlled trials. Furthermore, peremptory knowledge about the pathophysiology of maladaptive inflammation following heart surgery is still lacking. Conclusions Systemic inflammation following cardiac surgery is a frequent entity that occasionally becomes clinically relevant. Specific genomic differences, age, and other preoperative factors influence the magnitude of the response, which elements display extreme redundancy and pleiotropism that the target of a single pathway cannot represent a silver bullet.
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Affiliation(s)
- Enrico Squiccimarro
- Division of Cardiac Surgery Department of Medical and Surgical Sciences University of Foggia Foggia Italy
- Cardio‐Thoracic Surgery Department, Heart & Vascular Centre Maastricht University Medical Centre Maastricht The Netherlands
| | - Alessandra Stasi
- Department of Emergency and Organ Transplantation University of Bari Bari Italy
| | - Roberto Lorusso
- Cardio‐Thoracic Surgery Department, Heart & Vascular Centre Maastricht University Medical Centre Maastricht The Netherlands
- Cardiovascular Research Institute Maastricht Maastricht The Netherlands
| | - Domenico Paparella
- Division of Cardiac Surgery Department of Medical and Surgical Sciences University of Foggia Foggia Italy
- Division of Cardiac Surgery Santa Maria Hospital, GVM Care & Research Bari Italy
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3
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Abstract
Just as the influence of genetic variation on patient outcomes is being discussed in many other areas of medicine, so too are its effects on cerebral outcome after cardiac surgery now being described. Whereas early studies focused on neurocognitive outcome, where the single nucleotide polymorphisms of APOE4 and PLA2 were the first investigated genetic targets, stroke is now being elaborated on with related single and multi-gene single nucleotide polymorphisms having been identified. Our work has established key links between post-cardiac surgery stroke and C-reactive protein (3’UTR 1846C/T) and interleukin-6 (-174 G/C) single nucleotide polymorphisms.
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Affiliation(s)
- Hilary P Grocott
- Department of Anesthesiology, Duke University Medical Center, Durham, NC 27710, USA.
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Massad I, Abu-Ali H, Biron-Andreani C, Picot MC, Trinh-Duc P. Antithrombin and Protein C in Systemic Inflammatory Response Syndrome. Asian Cardiovasc Thorac Ann 2016; 15:39-44. [PMID: 17244921 DOI: 10.1177/021849230701500109] [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: 11/17/2022]
Abstract
Coronary artery bypass grafting with cardiopulmonary bypass can induce systemic inflammatory response syndrome. To assess the prevalence of preoperative antithrombin and protein C deficiencies in relation to the incidence of this syndrome, antithrombin and protein C levels were measured in 130 patients undergoing coronary artery bypass grafting with cardiopulmonary bypass. Systemic inflammatory response syndrome developed in 36 (27.7%) patients who were predominantly male, had a lower EuroSCORE, longer cardiopulmonary bypass time, higher pre-bypass temperature, and shorter activated coagulation time. Logistic regression showed that predictive factors included bypass duration and pre-bypass temperature; however, low antithrombin levels appeared to be a negative predictive factor. Antithrombin levels were < 80% in 33.8% of patients, and 11.6% had protein C levels < 80%. Postoperative antithrombin and protein C deficiencies are not uncommon in adults undergoing cardiac surgery with cardiopulmonary bypass, but detection of these deficits did not identify patients at increased risk of systemic inflammatory response syndrome.
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Affiliation(s)
- Islam Massad
- Division of Cardiac Anesthesia, Department of General Surgery, Anesthesia and Intensive Care, Jordan University Hospital, PO Box 13046, Amman 11942, Jordan.
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Matualatupauw JC, Radonjic M, van de Rest O, de Groot LCPGM, Geleijnse JM, Müller M, Afman LA. Apolipoprotein E genotype status affects habitual human blood mononuclear cell gene expression and its response to fish oil intervention. Mol Nutr Food Res 2016; 60:1649-60. [PMID: 27005961 DOI: 10.1002/mnfr.201500941] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2015] [Revised: 03/02/2016] [Accepted: 03/03/2016] [Indexed: 11/10/2022]
Abstract
SCOPE People who carry the apolipoprotein E4 (APOE4) single nucleotide polymorphism have an increased risk of cardiovascular disease (CVD). Fish-oil supplementation may help in the prevention of CVD, though interindividual differences in the response to n-3 PUFAs have been observed. We aimed to assess the impact of APOE genotype on peripheral blood mononuclear cell whole genome gene expression at baseline and following a fish-oil intervention. METHODS AND RESULTS Participants received 6 months of fish-oil supplementation containing 1800 mg of eicosapentaenoic acid and docosahexaenoic acid per day. APOE genotype and peripheral blood mononuclear cell whole genome gene expression before and after supplementation were measured. We characterized the differences in gene expression profiles in carriers of APOE4 (N = 8) compared to noncarriers (N = 15). At baseline, 1320 genes were differentially expressed and the fish-oil supplementation differentially regulated 866 genes between APOE4 carriers and noncarriers. Gene set enrichment analysis showed that carriers had a higher gene expression of cholesterol biosynthesis and IFN signaling pathways. Fish-oil supplementation reduced expression of IFN-related genes in carriers only. CONCLUSION The increased expression of IFN signaling and cholesterol biosynthesis pathways might explain part of the association between APOE4 and CVD. Fish-oil supplementation may particularly benefit APOE4 carriers by decreasing expression of IFN-related genes.
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Affiliation(s)
- Juri C Matualatupauw
- Division of Human Nutrition, Wageningen University, Wageningen, The Netherlands.,TNO, Department of Microbiology and Systems Biology, The Hague, The Netherlands
| | - Marijana Radonjic
- TNO, Department of Microbiology and Systems Biology, The Hague, The Netherlands
| | - Ondine van de Rest
- Division of Human Nutrition, Wageningen University, Wageningen, The Netherlands
| | | | - Johanna M Geleijnse
- Division of Human Nutrition, Wageningen University, Wageningen, The Netherlands
| | - Michael Müller
- Division of Human Nutrition, Wageningen University, Wageningen, The Netherlands
| | - Lydia A Afman
- Division of Human Nutrition, Wageningen University, Wageningen, The Netherlands
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Yun YW, Kweon SS, Choi JS, Rhee JA, Lee YH, Nam HS, Jeong SK, Park KS, Ryu SY, Choi SW, Kim HN, Cauley JA, Shin MH. APOE Polymorphism Is Associated with C-reactive Protein Levels but Not with White Blood Cell Count: Dong-gu Study and Namwon Study. J Korean Med Sci 2015; 30:860-5. [PMID: 26130946 PMCID: PMC4479937 DOI: 10.3346/jkms.2015.30.7.860] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2014] [Accepted: 02/17/2015] [Indexed: 01/06/2023] Open
Abstract
We evaluated the association of the APOE polymorphism with serum C-reactive protein levels and white blood cell count in two large population-based studies in Korean. The datasets included the Dong-gu study (n = 8,893) and the Namwon Study (n = 10,032). APOE genotypes were identified by polymerase chain reaction-restriction fragment length polymorphism. Multivariable linear regression analysis was performed to evaluate the relationship of APOE genotypes with C-reactive protein levels and white blood cell count with adjustments for age, sex, body mass index, smoking, diabetes, hypertension, and serum lipids. In the multivariate model, carriers of E3E4 or E4E4 genotype had significantly lower C-reactive protein levels compared with carriers of E3E3 genotype group (0.50 mg/L vs. 0.67 mg/L; 0.37 mg/L vs. 0.67 mg/L, respectively, for the Dong-gu Study and 0.47 mg/L vs. 0.66 mg/L; 0.45 mg/L vs. 0.66 mg/L, respectively, for the Namwon Study). However, there was no difference in white blood cell count among APOE genotypes. We found that the APOE E4 allele is associated with lower C-reactive protein levels, but not white blood cell count. Our results suggest that APOE genotype may influence C-reactive protein levels through non-inflammatory pathway.
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Affiliation(s)
- Yong-Woon Yun
- Gwangju-Jeonnam Regional Cardiocerebrovascular Center, Chonnam National University Hospital, Gwangju, Korea
| | - Sun-Seog Kweon
- Department of Preventive Medicine, Chonnam National University Medical School, Gwangju, Korea
- Jeonnam Regional Cancer Center, Chonnam National University Hwasun Hospital, Hwasun, Korea
| | - Jin-Su Choi
- Department of Preventive Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Jung-Ae Rhee
- Department of Preventive Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Young-Hoon Lee
- Department of Preventive Medicine & Institute of Wonkwang Medical Science, Wonkwang University College of Medicine, Iksan, Korea
| | - Hae-Sung Nam
- Department of Preventive Medicine, Chungnam National University Medical School, Daejeon, Korea
| | - Seul-Ki Jeong
- Department of Neurology & Research Institute of Clinical Medicine, Chonbuk National University-Biomedical Institute of Chonbuk National University Hospital, Jeonju, Korea
| | - Kyeong-Soo Park
- Department of Preventive Medicine, Seonam University College of Medicine, Namwon, Korea
| | - So-Yeon Ryu
- Department of Preventive Medicine, Chosun University Medical School, Gwangju, Korea
| | - Seong-Woo Choi
- Department of Preventive Medicine, Chosun University Medical School, Gwangju, Korea
| | - Hee Nam Kim
- Center for Creative Biomedical Scientists, Chonnam National University, Gwangju, Korea
| | - Jane A. Cauley
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, USA
| | - Min-Ho Shin
- Department of Preventive Medicine, Chonnam National University Medical School, Gwangju, Korea
- Center for Creative Biomedical Scientists, Chonnam National University, Gwangju, Korea
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Gungor Z, Anuurad E, Enkhmaa B, Zhang W, Kim K, Berglund L. Apo E4 and lipoprotein-associated phospholipase A2 synergistically increase cardiovascular risk. Atherosclerosis 2012; 223:230-4. [PMID: 22632920 PMCID: PMC3389284 DOI: 10.1016/j.atherosclerosis.2012.04.021] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2012] [Revised: 04/13/2012] [Accepted: 04/24/2012] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Apolipoprotein E (apoE) has been implicated as conveying increased risk for coronary artery disease (CAD). Previous studies suggest a role of apoE as a modulator of immune response and inflammatory properties. We hypothesized that the presence of apo E4 is associated with an increased inflammatory burden in subjects with CAD as compared to subjects without CAD. METHODS ApoE genotypes, systemic (C-reactive protein [CRP], fibrinogen, serum amyloid-A [SAA]) and vascular inflammatory markers (Lipoprotein-associated phospholipase A(2) [Lp-PLA(2)] and pentraxin-3 [PTX-3]) were assessed in 324 Caucasians and 208 African Americans, undergoing coronary angiography. RESULTS For both ethnic groups, Lp-PLA(2) index, an integrated measure of Lp-PLA(2) mass and activity, increased significantly and stepwise across apoE isoforms (P = 0.009 and P = 0.026 for African Americans and Caucasians respectively). No differences were found for other inflammatory markers tested (CRP, fibrinogen, SAA and PTX-3). For the top cardiovascular score tertile, apo E4 carriers had a significantly higher level of Lp-PLA(2) index in both ethnic groups (P = 0.027 and P = 0.010, respectively). CONCLUSION The presence of the apo E4 isoform was associated with a higher level of Lp-PLA(2) index, a marker of vascular inflammation. Our results suggest that genetic variation at the apoE locus may impact cardiovascular disease risk through enhanced vascular inflammation.
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Affiliation(s)
- Zeynep Gungor
- Department of Biochemistry, Cerrahpasa Medical School, University of Istanbul, Istanbul, Turkey
| | | | | | - Wei Zhang
- Department of Medicine, University of California, Davis, CA
| | - Kyoungmi Kim
- Public Health Sciences, University of California, Davis, CA
| | - Lars Berglund
- Department of Medicine, University of California, Davis, CA
- VA Northern California Health Care System
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8
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ApoE genotype: from geographic distribution to function and responsiveness to dietary factors. Proc Nutr Soc 2012; 71:410-24. [DOI: 10.1017/s0029665112000249] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
ApoE is a key protein in lipid metabolism with three major isoforms.ApoEallele frequencies show non-random global distribution especially in Europe with highapoEε3frequency in the Mediterranean area, whereas theapoEε4genotype is enriched in Northern Europe. TheapoEε4genotype is one of the most important genetic risk factors for age-dependent chronic diseases, including CVD and Alzheimer's disease (AD). The apoE polymorphism has been shown to impact on blood lipids, biomarkers of oxidative stress and chronic inflammation, which all may contribute to the isoform-dependent disease risk. Studies in mice and human subjects indicate that theapoEε3but not theapoEε4genotype may significantly benefit from dietary flavonoids (e.g. quercetin) andn-3 fatty acids. Metabolism of lipid soluble vitamins E and D is likewise differentially affected by theapoEgenotype. Epidemiological and experimental evidence suggest a better vitamin D status inapoEε4than ε3subjects indicating a certain advantage of ε4over ε3. The present review aims at evaluation of current data available on interactions between apoE polymorphism and dietary responsiveness to flavonoids, fat soluble vitamins andn-3 fatty acids. Likewise, distinct geographic distribution and chronic disease risk of the different apoE isoforms are addressed.
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Zhao SJ, Guo CN, Wang MQ, Chen WJ, Zhao YB. Serum levels of inflammation factors and cognitive performance in amnestic mild cognitive impairment: a Chinese clinical study. Cytokine 2011; 57:221-5. [PMID: 22154514 DOI: 10.1016/j.cyto.2011.11.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2010] [Revised: 10/10/2011] [Accepted: 11/04/2011] [Indexed: 10/14/2022]
Abstract
Early diagnosis of Alzheimer's disease (AD) is important for initiating timely therapy to block or slow the rate of disease progression. This study was designed to investigate the potential of inflammation-related biomarkers in peripheral blood to accurately reflect AD onset and progression. Individuals (n=150) with amnestic mild cognitive impairment (aMCI) were divided into two subgroups (low- and high-risk) based on APOEε4 allele carrier status, and administered a battery of neuropsychological tests and tested for serum levels of IL-6, IL-10, TNF-α, and IFN-γ by using specific enzyme-linked immunosorbent assays. Results were compared with those from age-matched healthy controls (n=150). The levels of IL-6 were significantly higher in the aMCI group than in controls (P<0.01). When the aMCI group was stratified by APOEε4 status, significant differences were found between the low- and high-risk groups and controls in the levels of IL-6 and IFN-γ (P<0.01 and P=0.041, respectively). Moreover, the IL-6 level in the low-risk aMCI group was higher than that in the high-risk aMCI group (P=0.028). A weak but significant negative correlation was found between IL-6 and cognitive performance. Taken together, these findings indicate that IL-6, while not useful alone, has potential in combination with other biomarkers to support early diagnosis of aMCI due to its association with the progression of cognitive impairment.
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Affiliation(s)
- Sheng-Jie Zhao
- Department of Neurology, Shanghai Jiaotong University Affiliated First People's Hospital, Shanghai 200080, China
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Vasunilashorn S, Finch CE, Crimmins EM, Vikman SA, Stieglitz J, Gurven M, Kaplan H, Allayee H. Inflammatory gene variants in the Tsimane, an indigenous Bolivian population with a high infectious load. BIODEMOGRAPHY AND SOCIAL BIOLOGY 2011; 57:33-52. [PMID: 21845926 PMCID: PMC3529658 DOI: 10.1080/19485565.2011.564475] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Abstract
The Tsimane of lowland Bolivia are an indigenous forager-farmer population living under conditions resembling pre-industrial European populations, with high infectious morbidity, high infection and inflammation, and shortened life expectancy. Analysis of 917 persons ages 5 to 60+ showed that allele frequencies of 9 SNPs examined in the apolipoprotein E (apoE), C-reactive protein (CRP), and interleukin-6 (IL-6) genes differed from some European, African, and north Asian-derived populations. The apoE2 allele was absent, whereas four SNPs related to CRP and IL-6 were monomorphic: CRP (rs1800947, rs3093061, and rs3093062) and IL-6 (rs1800795). No significant differences in apoE, CRP, and IL-6 variants across age were found CRP levels were higher in carriers of two CRP proinflammatory SNPs, whereas they were lower in carriers of apoE4. Taken together the evidence for (1) different allele frequencies between the Tsimane and other populations and (2) the correlations of CRP and apoE alleles with blood CRP may suggest that these variants are under selection in response to a high infection environment.
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Trotter JH, Liebl AL, Weeber EJ, Martin LB. Linking ecological immunology and evolutionary medicine: the case for apolipoprotein E. Funct Ecol 2010. [DOI: 10.1111/j.1365-2435.2010.01780.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Justin H. Trotter
- Department of Molecular Pharmacology and Physiology, University of South Florida, Tampa, Florida 33613, USA
- USF Health Byrd Alzheimer’s Institute, University of South Florida, Tampa, Florida 33613, USA
| | - Andrea L. Liebl
- Department of Integrative Biology, University of South Florida, Tampa Florida 33620, USA
| | - Edwin J. Weeber
- Department of Molecular Pharmacology and Physiology, University of South Florida, Tampa, Florida 33613, USA
- USF Health Byrd Alzheimer’s Institute, University of South Florida, Tampa, Florida 33613, USA
| | - Lynn B. Martin
- Department of Integrative Biology, University of South Florida, Tampa Florida 33620, USA
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Welsby IJ, Podgoreanu MV, Phillips-Bute B, Morris R, Mathew JP, Smith PK, Newman MF, Schwinn DA, Stafford-Smith M. Association of the 98T ELAM-1 polymorphism with increased bleeding after cardiac surgery. J Cardiothorac Vasc Anesth 2010; 24:427-33. [PMID: 20056442 DOI: 10.1053/j.jvca.2009.10.030] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2009] [Indexed: 01/04/2023]
Abstract
OBJECTIVE Hemorrhage continues to be a major problem after cardiac surgery despite the routine use of antifibrinolytic drugs, with striking inter-patient variability poorly explained by already known risk factors. The authors tested the hypothesis that genetic polymorphisms of inflammatory mediators and cellular adhesion molecules are associated with bleeding after cardiac surgery. DESIGN Prospective, observational study. SETTING Single, tertiary referral university heart center. PARTICIPANTS Adult patients undergoing aortocoronary surgery with cardiopulmonary bypass. INTERVENTIONS Patients (n = 759) had 10 mL of blood drawn preoperatively and genomic DNA isolated then genotyped for 17 polymorphisms in 7 candidate genes: tumor necrosis factor, interleukins 1beta and 6, interleukin 1 receptor antagonist, intercellular adhesion molecule-1 (ICAM-1), P-selectin and endothelial leucocyte adhesion molecule-1 (E-selectin). Multivariate analyses were used to relate clinical and genetic factors to bleeding and transfusion. MEASUREMENTS AND MAIN RESULTS The 98G/T polymorphism of the E-selectin gene was independently associated with bleeding after cardiac surgery (p = 0.002), after adjusting for significant clinical predictors (patient size and baseline hemoglobin concentration). There was a gene dose effect according to the number of minor alleles in the genotype; carriers of the minor allele bled 17% (GT) and 54% (TT) more than wild type (GG) genotypes, respectively (p = 0.01). Carriers of the minor allele also had longer activated partial thromboplastin times (p = 0.0023) and increased fresh frozen plasma transfusion (p = 0.03) compared with wild type. CONCLUSIONS The authors found a dose-related association between the 98T E-selectin polymorphism and bleeding after cardiac surgery, independent of and additive to standard clinical risk factors.
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Affiliation(s)
- Ian J Welsby
- Department of Anesthesiology, Duke University Medical Center, Durham, NC 27710, USA.
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James ML, Blessing R, Bennett E, Laskowitz DT. Apolipoprotein E modifies neurological outcome by affecting cerebral edema but not hematoma size after intracerebral hemorrhage in humans. J Stroke Cerebrovasc Dis 2009; 18:144-9. [PMID: 19251191 DOI: 10.1016/j.jstrokecerebrovasdis.2008.09.012] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2008] [Revised: 09/10/2008] [Accepted: 09/12/2008] [Indexed: 01/06/2023] Open
Abstract
INTRODUCTION To address the mechanisms by which apoE polymorphism affects functional outcome after intracerebral hemorrhage in humans, we tested the hypothesis that the presence of the APOE4 allele results in amplified inflammatory responses and increased cerebral edema. METHODS We prospectively enrolled and collected data on 21 adult patients consecutively admitted to Duke University Hospital with supratentorial intracerebral hematoma including hemorrhage volume, midline shift, modified Rankin Score, Glasgow Outcome Score, and APOE genotype. Hemorrhage size (cm(3)) and midline shift (mm), at the level of the thalamus, were measured by computed tomography within 36 hours of admission. Rankin and Glasgow Scores were determined at discharge. Student's t-test was used to analyze hemorrhage size, midline shift, and Glasgow Outcome Score and logistical regression were used to measure allele affect on modified Rankin Score. When analyzing modified Rankin Score, patients were grouped by favorable outcome (0-2) or unfavorable (3-6). RESULTS Out of 21 patients, 11 possessed at least 1 APOE4 allele (APOE4+). There was no difference in hemorrhage volume (25.8 v 38.3 mm for APOE4- v APOE4+, respectively) between the groups, but there was a significant difference in midline shift (P = .04, 0.7 v 4 mm). Functional outcomes were worse for the patients possessing at least 1 APOE4 allele (P = .04) CONCLUSION The presence of APOE4 is associated with poor functional outcomes in humans after intracerebral hemorrhage. Our data suggest that the mechanism for this may be increased cerebral edema and not larger hematoma volume.
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Affiliation(s)
- Michael L James
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina 27710, USA.
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Wang H, Christensen DJ, Vitek MP, Sullivan PM, Laskowitz DT. APOE genotype affects outcome in a murine model of sepsis: implications for a new treatment strategy. Anaesth Intensive Care 2009; 37:38-45. [PMID: 19157344 DOI: 10.1177/0310057x0903700111] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
In this study, we assessed whether apolipoprotein E (APOE) polymorphism affects inflammatory responses and mortality in the caecal ligation and puncture model of peritonitis. In addition, we determined the effects of APOE mimetic peptide administration in this sepsis model. Differences in survival between targeted replacement mice expressing the human APOE3 allele (APOE3TR) and the APOE4 allele (APOE4TR) mice were assessed. In a separate series of experiments, COG1410, an apoE-mimetic peptide, was administered intravenously at 12-hour intervals for 72 hours and compared to vehicle-treated control animals. End-points included mortality and serum levels of interleukin-1beta, interleukin-6, interleukin-12 and tumour necrosis factor-alpha. Mice expressing the human APOE4 allele (n = 16) demonstrated an increase in mortality following caecal ligation and puncture compared with APOE3TR mice (n = 22; P = 0.039). Administration of the apolipoprotein E mimetic COG1410 was well tolerated and APOE3TR mice treated with peptide (n = 20) demonstrated a significant reduction in mortality compared with vehicle treated animals (n = 20; P = 0.007). A similar effect was also observed in APOE4TR animals, in which treatment with COG1410 was associated with reduced mortality compared with vehicle treatment (n =16 animals/group; P = 0.027). COG1410 was also associated with a reduction in TNFalpha, interleukin-1beta, interleukin-6 and interleukin-12 levels in both APOE3TR and APOE4TR (n = 5 animals/group) assessed at 24 hours. Thus, administration of an apolipoprotein E-mimetic peptide is well tolerated, suppresses inflammatory responses, and improves mortality in a caecal ligation and puncture model of sepsis.
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Affiliation(s)
- H Wang
- Department of Medicine, Duke University Medical Center, Durham, North Carolina 27710, USA
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Abstract
Delirium, or acute brain dysfunction, is a life-threatening global disturbance in cognitive functioning that frequently manifests in critically ill patients. This review examines the current status of knowledge regarding the pathophysiology of delirium in the ICU, in particular, evaluating the role of iatrogenic factors such as sedatives and analgesic administration in brain dysfunction. This hypothesis is considered along with several other plausible mechanisms of ICU delirium, including sepsis, postoperative cognitive dysfunction, and changes in biomarkers and neurotransmitters. The review concludes by highlighting potential future directions in molecular genetics for the elucidation of delirium and its long-term consequences.
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Affiliation(s)
- Max L Gunther
- VA Tennessee Valley Geriatric Research, Education and Clinical Center, Nashville, TN 37212-2637, USA
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16
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Jofre-Monseny L, Minihane AM, Rimbach G. Impact of apoE genotype on oxidative stress, inflammation and disease risk. Mol Nutr Food Res 2008; 52:131-45. [PMID: 18203129 DOI: 10.1002/mnfr.200700322] [Citation(s) in RCA: 225] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Although in developing countries an apolipoprotein E4 (apoE4) genotype may offer an evolutionary advantage, as it has been shown to offer protection against certain infectious disease, in Westernised societies it is associated with increased morbidity and mortality, and represents a significant risk factor for cardiovascular disease, late-onset Alzheimer's disease and other chronic disorders. ApoE is an important modulator of many stages of lipoprotein metabolism and traditionally the increased risk was attributed to higher lipid levels in E4 carriers. However, more recent evidence demonstrates the multifunctional nature of the apoE protein and the fact that the impact of genotype on disease risk may be in large part due to an impact on oxidative status or the immunomodulatory/anti-inflammatory properties of apoE. An increasing number of studies in cell lines, targeted replacement rodents and human volunteers indicate higher oxidative stress and a more pro-inflammatory state associated with the epsilon4 allele. The impact of genotype on the antioxidant and immunomodulatory/anti-inflammatory properties of apoE is the focus of the current review. Furthermore, current information on the impact of environment (diet, exercise, smoking status, alcohol) on apoE genotype-phenotype associations are discussed with a view to identifying particular lifestyle strategies that could be adapted to counteract the 'at-risk' E4 genotype.
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Affiliation(s)
- Laia Jofre-Monseny
- Institute of Human Nutrition and Food Science, Christian Albrechts University of Kiel, Kiel, Germany
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Laskowitz DT, Vitek MP. Apolipoprotein E and neurological disease: therapeutic potential and pharmacogenomic interactions. Pharmacogenomics 2008; 8:959-69. [PMID: 17716229 DOI: 10.2217/14622416.8.8.959] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
The apolipoprotein E (apoE) polymorphism is emerging as a uniquely important genetic modifier that affects functional outcome from both acute and chronic neurological injuries. Recent attention has focused on common denominator mechanisms by which apoE might affect brain injury and/or brain repair responses in clinically diverse diseases. Although endogenous apoE likely serves several adaptive functions in the injured CNS, there is growing evidence that its effect on modifying brain inflammatory responses and providing protection from excitotoxic injury may be central to its protective properties. A more complete understanding of the role that apoE plays in the injured brain has led to novel therapeutic strategies for both acute and chronic neurological disease.
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Affiliation(s)
- Daniel T Laskowitz
- Duke University Medical Center, Department of Medicine (Neurology), Box 2900, Durham, NC 27710, USA.
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Ak K, Isbir S, Tekeli A, Ergen A, Atalan N, Dogan S, Civelek A, Arsan S. Presence of lipoprotein lipase S447X stop codon affects the magnitude of interleukin 8 release after cardiac surgery with cardiopulmonary bypass. J Thorac Cardiovasc Surg 2007; 134:477-83. [PMID: 17662793 DOI: 10.1016/j.jtcvs.2007.03.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2007] [Revised: 03/01/2007] [Accepted: 03/12/2007] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Current data suggest that individual genetic predisposition may influence the magnitude of cytokine response and the degree of organ dysfunction after cardiopulmonary bypass. Lipoprotein lipase S447X polymorphism has been shown to be protective against atherosclerosis. The aim of the study was to investigate the effect of lipoprotein lipase S447X polymorphism on cytokine release and early outcome after cardiopulmonary bypass. METHODS Forty patients who underwent coronary artery bypass grafting with cardiopulmonary bypass were included. Genotyping for lipoprotein lipase S447X polymorphism was performed by polymerase chain reaction. Levels of interleukins 6 and 8 were measured before induction and 6, 24, and 72 hours after operation by enzyme-linked immunosorbent assay. Clinical data were collected prospectively. Daily assessment of organ dysfunction was done according to the cardiac surgery scoring (CASUS) system. RESULTS The allele frequency of lipoprotein lipase S447X stop codon was 17.5%. S447X carriers revealed significantly lower interleukin 8 levels at the sixth and 24th postoperative hours than the noncarrier group (P = .005 and P = .041, respectively). Patients in the S447X carrier group had significantly shorter ventilation times than the noncarrier group (P = .048). Also, the S447X carrier group revealed significantly lower postoperative 6-hour lactate levels, operative day, and postoperative day 1 organ dysfunction scores than the other group (P = .001, .005 and .002, respectively). CONCLUSION Lipoprotein lipase S447X stop codon mutation is associated with lower levels of interleukin 8 after coronary artery bypass grafting. Identification of high-risk patients for cardiopulmonary bypass-related systemic inflammation by detecting lipoprotein lipase S447X stop codon polymorphism may improve early postoperative outcome, especially in patients with limited organ reserves.
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Affiliation(s)
- Koray Ak
- Marmara University School of Medicine, Department of Cardiovascular Surgery, Istanbul, Turkey.
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Baufreton C, Corbeau JJ, Pinaud F. [Inflammatory response and haematological disorders in cardiac surgery: toward a more physiological cardiopulmonary bypass]. ACTA ACUST UNITED AC 2006; 25:510-20. [PMID: 16488106 DOI: 10.1016/j.annfar.2005.12.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2005] [Accepted: 12/23/2005] [Indexed: 10/25/2022]
Abstract
The systemic inflammatory response in cardiac surgery is closely related to the haemostasis disturbances. It is responsible of a significant morbidity and mortality that was previously suspected to be caused by cardiopulmonary bypass alone. However, it is time now to clearly identify the factors that are material-dependent from that material-independent. From this point of view, off-pump surgery allowed for better comprehension of the multiple sources of the inflammatory response. Numerous pathways are activated, involving complement, platelets, neutrophiles and monocytes. The tissue pathway of the coagulation system, through tissue factor, is of major importance and has to be surgically considered in order to reduce the whole body inflammatory response postoperatively. The quality of the extracorporeal perfusion through its consequences on organ perfusion, particularly in the splanchnic area, also participates to this pathophysiological process. Beyond the progress of technology provided by the industry, particularly the minimally extracorporeal circulation derived from off-pump surgery evolution, the surgical approach is of major importance in the control of the systemic inflammatory response and must not be ignored yet.
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Affiliation(s)
- C Baufreton
- Service de Chirurgie Cardiaque et Département d'Anesthésie-Réanimation, CHU d'Angers, 4, rue Larrey, 49933 Angers cedex 09, France.
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Moretti EW, Morris RW, Podgoreanu M, Schwinn DA, Newman MF, Bennett E, Moulin VG, Mba UU, Laskowitz DT. APOE polymorphism is associated with risk of severe sepsis in surgical patients. Crit Care Med 2005; 33:2521-6. [PMID: 16276176 DOI: 10.1097/01.ccm.0000186368.96146.fb] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To test for an association between apolipoprotein E (APOE) genotypes and the occurrence of severe sepsis in an elective surgical cohort. DESIGN Prospective, observational, single cohort study. SETTING Sixteen-bed surgical intensive care unit (ICU) at a university hospital. PATIENTS Patients were 343 patients with planned admission to the ICU after major elective noncardiac surgery. INTERVENTIONS Blood samples, together with demographic data, baseline clinical data, and Acute Physiology and Chronic Health Evaluation II scores, were collected on admission to the ICU and on each subsequent ICU day. APOE genotyping was conducted using a polymerase chain reaction-based assay. The primary outcome was diagnosis of severe sepsis; secondary outcomes included time on mechanical ventilation, ICU length of stay, and ICU mortality. MEASUREMENTS AND MAIN RESULTS Severe sepsis was diagnosed in 34 of 343 patients (9.9%). Carriers of the APOepsilon3 allele (one or two copies) had a lower incidence of severe sepsis than patients with no APOepsilon3 allele (p = .014), with a relative risk of 0.284 (95% confidence interval 0.127-0.635). The protective effect of APOepsilon3 genotype on the incidence of severe sepsis remained significant (p < .01) after adjusting for age, gender, or race in a logistic regression model. Supporting our findings, presence of the APOepsilon3 allele was also associated with fewer days spent in the ICU (p = .007). In contrast, APOE genotypes were not associated with duration of mechanical ventilation or ICU mortality. CONCLUSIONS In an elective surgical cohort, presence of the APOepsilon3 allele is associated with decreased incidence of severe sepsis and a shorter ICU length of stay.
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Affiliation(s)
- Eugene W Moretti
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
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Huang HC, Wang CL, Huang LT, Chuang H, Liu CA, Hsu TY, Ou CY, Yang KD. Association of cord blood cytokines with prematurity and cerebral palsy. Early Hum Dev 2004; 77:29-36. [PMID: 15113629 DOI: 10.1016/j.earlhumdev.2004.01.001] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/09/2004] [Indexed: 10/26/2022]
Abstract
BACKGROUND Many studies have shown that certain cytokines in amniotic fluids are correlated to premature labor and neonatal brain insults. AIMS We investigated whether different fetal phagocyte and vascular mediators including IL-8, myeloperoxidase (MPO), PGE(2) and soluble vascular cell adhesion molecule-1 (sVCAM-1) levels were correlated to prematurity and cerebral palsy (CP) of premature infants. SUBJECTS Umbilical cord blood samples from 96 preterm babies from 2250 cord blood collections were studied. METHOD The enzyme-linked immunoassay (ELISA) technique was used to determine concentrations of cord blood IL-8, MPO, PGE(2) and sVCAM-1. RESULTS Preterm babies with gestational age (GA) < or =32 weeks had significant higher cord blood IL-8, MPO and PGE(2) levels than full-term babies. These mediators, however, were not correlated to gestational age, suggesting that increases of these mediators are more related to preterm delivery but not fetal maturation. Further analysis showed that IL-8, a mediator mainly from monocytes, but not MPO, another mediator mostly from granulocytes, was correlated to cerebral palsy. CONCLUSIONS Taken together, these results suggest that both premature monocytes and granulocytes activation are involved in preterm delivery, but maybe only monocytes activation is correlated to premature infants' cerebral palsy. Selective manipulation of monocytes activation may be useful to prevent premature-related cerebral palsy.
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Affiliation(s)
- Hsin-Chun Huang
- Department of Pediatrics, Chang Gung Memorial Hospital and Graduate Institute of Clinical Medical Science, Chang Gung University at Kaohsiung, No. 123 Ta-Pei Road, Niau-Sung Hsiang, Kaohsiung 833, Taiwan
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Colton CA, Needham LK, Brown C, Cook D, Rasheed K, Burke JR, Strittmatter WJ, Schmechel DE, Vitek MP. APOE genotype-specific differences in human and mouse macrophage nitric oxide production. J Neuroimmunol 2004; 147:62-7. [PMID: 14741429 DOI: 10.1016/j.jneuroim.2003.10.015] [Citation(s) in RCA: 57] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Individuals expressing an APOE4 genotype demonstrate increased Alzheimer's disease (AD) neuropathology and a decreased onset age. The APOE4 gene may act by modulating the CNS immune response. Using human monocyte-derived macrophages (MDM), we show a significantly greater increase in NO production during immune activation in MDM from APOE4 AD patients compared to normal, age-matched individuals or to AD patients with an APOE 3/3 genotype. Microglia and peritoneal macrophages from APOE4 targeted replacement mice demonstrate a similar increase in NO compared to the APOE3 targeted replacement mice. The enhanced macrophage responsiveness and the increased production of NO in APOE4 AD patients may predispose the CNS to an increased potential for nitration and nitrosation, consistent with the redox imbalance and neuroinflammatory state seen in AD.
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Affiliation(s)
- Carol A Colton
- Division of Neurology and the Alzheimer's Disease Research Center, Duke University Medical Center, Durham, NC 27710, USA.
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Gaynor JW, Gerdes M, Zackai EH, Bernbaum J, Wernovsky G, Clancy RR, Newman MF, Saunders AM, Heagerty PJ, D'Agostino JA, McDonald-McGinn D, Nicolson SC, Spray TL, Jarvik GP. Apolipoprotein E genotype and neurodevelopmental sequelae of infant cardiac surgery. J Thorac Cardiovasc Surg 2003; 126:1736-45. [PMID: 14688681 DOI: 10.1016/s0022-5223(03)01188-7] [Citation(s) in RCA: 167] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND There has been increasing recognition of adverse neurodevelopmental sequelae in some children after repair of congenital heart defects. Even among children with the same cardiac defect, significant interindividual variation exists in developmental outcome. Polymorphisms of apolipoprotein E have been identified as a risk factor for worse neurologic recovery after central nervous system injury. METHODS A single-institution prospective study of patients <or=6 months of age undergoing cardiopulmonary bypass for repair of congenital heart defects was undertaken to evaluate the association between apolipoprotein E genotype and postoperative neurodevelopmental dysfunction. Developmental outcomes were evaluated at 1 year of age by using the Bayley Scales of Infant Development. RESULTS One-year evaluation was performed in 244 patients. After adjustment for preoperative and postoperative covariates-including gestational age, age at operation, sex, race, socioeconomic status, cardiac defect, and use of deep hypothermic circulatory arrest-the apolipoprotein E epsilon2 allele was associated with a worse neurologic outcome as assessed by the Psychomotor Developmental Index of the Bayley Scales of Infant Development (P =.036). Patients with the apolipoprotein E epsilon2 allele had approximately a 7-point decrease in the Psychomotor Developmental Index. CONCLUSIONS Apolipoprotein E epsilon2 allele carriers had significantly lower Psychomotor Development Index scores at 1 year of age after infant cardiac surgery. The effect was independent of ethnicity, socioeconomic status, cardiac defect, and use of deep hypothermic circulatory arrest. An effect of the apolipoprotein E epsilon4 allele was not detected. Genetic polymorphisms that decrease neuroresiliency and impair neuronal repair after central nervous system injury are important risk factors for neurodevelopmental dysfunction after infant cardiac surgery.
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Affiliation(s)
- J William Gaynor
- Division of Cardiothoracic Surgery, The Children's Hospital of Philadelphia, PA 19104, USA.
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Menasché P. The systemic factor: the comparative roles of cardiopulmonary bypass and off-pump surgery in the genesis of patient injury during and following cardiac surgery. Ann Thorac Surg 2001; 72:S2260-5; discussion S2265-6, S2267-70. [PMID: 11789850 DOI: 10.1016/s0003-4975(01)03286-6] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
There is compelling evidence that off-pump coronary artery bypass operations are associated with reduced circulating levels of inflammatory mediators. Whereas complement activation and release of acute-phase reactants such as interleukin-6 are still expected to occur as consequences of a nonbypass-related general surgical trauma, a major feature of off-pump surgery seems to be a decreased production of interleukin-8, which may have important practical implications because of the participation of this cytokine in neutrophil trafficking and myocardial injury. The scarcity of carefully controlled, randomized trials precludes firm conclusions regarding the extent to which these biological changes translate into meaningful improvements in clinical outcomes. The problem is further complicated by the fact that the adverse effects of cardiopulmonary bypass largely depend on a genetically controlled balance between proinflammatory and antiinflammatory mediators. Currently, it is still impossible to predict, in a given patient, the side toward which this balance will be shifted. Nevertheless, accumulating experience identifies patient subgroups who may greatly benefit from avoiding extracorporeal circulation. These subsets include patients with severe extracardiac comorbidities (in particular, renal failure) and, possibly, patients with advanced left ventricular dysfunction, who may poorly tolerate superimposed, bypass-related, inflammatory tissue injuries.
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Affiliation(s)
- P Menasché
- Department of Cardiovascular Surgery, Hôpital Bichat, Paris, France.
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