Cytokine responses and myocardial injury in coronary artery bypass grafting

Effect of Perioperative Nicorandil on Myocardial Protection in Patients Undergoing Cardiac Surgery with Cardiopulmonary Bypass, a Retrospective Study

Background

The potential myocardial protective effect of nicorandil (NICD) in patients undergoing percutaneous coronary intervention has been established. However, its efficacy in the context of cardiac surgery remains controversial. The present study aimed to evaluate the myocardial protective effect of perioperative NICD use in patients undergoing cardiac surgery with cardiopulmonary bypass (CPB).

Methods

We retrospectively gathered data from patients undergoing cardiac bypass surgery between 12/2018 and 04/2021 in Fuwai Hospital. Subsequently, the patients were divided into two groups, NICD group and non-nicorandil (non-NICD) group. A 1, 3 propensity score matching (PSM) was conducted. The primary outcome was the incidence of myocardial injury. The secondary outcomes included the mechanical ventilation (MV) duration, intensive care unit (ICU) length of stay (LOS), hospital LOS, duration of chest drainage, the drainage volume, the total cost, the incidence of acute kidney injury (AKI), and the incidence of acute liver injury (ALI). Subsequently, we divided the entire population into two distinct subgroups based on their administration of NICD, and performed a comprehensive subgroup analysis.

Results

A total of 2406 patients were ultimately included in the study. After PSM, 250 patients in NICD group and 750 patients in non-NICD group were included in the analysis. Perioperative NICD reduced the incidence of myocardial injury (47.2% versus 38.8%, P=0.025). Our subgroup analysis revealed that preoperative NICD administration not only provided myocardial protection benefits (45.7% vs 35.8%, OR 0.66, 95% CI [0.45-0.97], P=0.041), but also demonstrated statistically significant reduction in ALI, the ICU and hospital LOS, and the duration of chest drainage (all P<0.05).

Conclusion

The perioperative NICD administration may confer myocardial protection in patients undergoing cardiac surgery with CPB. Furthermore, the preoperative utilization of NICD has the potential to mitigate the incidence of postoperative ALI, a reduction in the ICU and hospital LOS, and the duration of chest drainage.

Nandrolone Decanoate: Use, Abuse and Side Effects

Background and Objectives: Androgens play a significant role in the development of male reproductive organs. The clinical use of synthetic testosterone derivatives, such as nandrolone, is focused on maximizing the anabolic effects and minimizing the androgenic ones. Class II anabolic androgenic steroids (AAS), including nandrolone, are rapidly becoming a widespread group of drugs used both clinically and illicitly. The illicit use of AAS is diffused among adolescent and bodybuilders because of their anabolic proprieties and their capacity to increase tolerance to exercise. This systematic review aims to focus on side effects related to illicit AAS abuse, evaluating the scientific literature in order to underline the most frequent side effects on AAS abusers’ bodies. Materials and Methods: A systematic review of the scientific literature was performed using the PubMed database and the keywords “nandrolone decanoate”. The inclusion criteria for articles or abstracts were English language and the presence of the following words: “abuse” or “adverse effects”. After applying the exclusion and inclusion criteria, from a total of 766 articles, only 148 were considered eligible for the study. Results: The most reported adverse effects (found in more than 5% of the studies) were endocrine effects (18 studies, 42%), such as virilization, gynecomastia, hormonal disorders, dyslipidemia, genital alterations, and infertility; cardiovascular dysfunctions (six studies, 14%) such as vascular damage, coagulation disorders, and arteriosus hypertension; skin disorders (five studies, 12%) such as pricking, acne, and skin spots; psychiatric and mood disorders (four studies, 9%) such as aggressiveness, sleep disorders and anxiety; musculoskeletal disorders (two studies, 5%), excretory disorders (two studies, 5%), and gastrointestinal disorders (two studies, 5%). Conclusions: Based on the result of our study, the most common adverse effects secondary to the abuse of nandrolone decanoate (ND) involve the endocrine, cardiovascular, skin, and psychiatric systems. These data could prove useful to healthcare professionals in both sports and clinical settings.

Serum levels of interleukin-6, interleukin-8, interleukin-10, and tumor necrosis factor-α, renal function biochemical parameters and clinical outcomes in pediatric cardiopulmonary bypass surgery

BACKGROUND

Cardiopulmonary bypass causes detrimental effects on remote organs due to inflammatory response. One of these organs is kidney that is frequently affected by cardiac surgery. Acute kidney injury is a post-cardiopulmonary bypass complication, which may result in increased post-operative morbidity and mortality. Post-cardiopulmonary bypass inflammatory response may contribute to remote organ dysfunction. In the present study, we investigated the relation between cytokines including interleukin-6, interleukin-8, interleukin-10, and tumor necrosis factor-α, and renal function tests such as creatinine and blood urea nitrogen (BUN).

METHODS

In total, 91 patients between the ages of 4 and 60 months were enrolled for elective cardiac surgery with cardiopulmonary bypass after informed consent. Data regarding renal function tests and clinical outcomes were carefully recorded until 24 hours after admission to intensive care unit and analyzed.

RESULTS

Our findings support that there is a direct correlation between cytokines including interleukin-6, interleukin-8, interleukin-10, and tumor necrosis factor-α and cardiopulmonary bypass time, duration of operation, and intensive care unit stay. Longer cardiopulmonary bypass time was associated with higher interleukin-8 at cross-clamp removal and 24 hours post- intensive care unit as well as higher interleukin-10 at declamp time. Higher interleukin-6 at declamp time was directly correlated with higher post-operative BUN. Interleukin-8 level after anesthesia induction was directly correlated with intensive care unit stay duration. Higher blood interleukin-6 and tumor necrosis factor-α levels following 24 hours of admission to intensive care unit were associated with longer mechanical ventilation time.

CONCLUSION

Higher circulatory pro-inflammatory cytokine level is associated with adverse outcomes such as increased intensive care unit stay and longer mechanical ventilation time in pediatric patients. It is also correlated with unfavorable biochemical parameter of renal function, BUN. Findings hint that proper control of the inflammatory response is vital for the control of unfavorable clinical and pathological outcomes.

Elevated Levels of Procalcitonin and Interleukin-6 are Linked with Postoperative Complications in Cardiac Surgery

BACKGROUND

Cardiac surgery-associated acute kidney injury is a frequent and serious postoperative complication of cardiac surgery and is associated with an increased risk of morbidity, mortality, and length stay. In this study, we hypothesized that persistent elevation in inflammation in the first 48 h might be a powerful predictor of clinical outcome. Our aim was to elucidate the usefulness of interleukin-6 and procalcitonin postoperative levels in predicting mortality and renal complications in cardiac surgery patients.

METHODS

A total of 122 cardiac surgery patients were enrolled. Procalcitonin and interleukin-6 concentrations were measured on the second postoperative day, and their levels were evaluated versus a number of conditions and endpoints.

RESULTS

Procalcitonin has a good predictive value for adverse renal outcome (p < 0.05). Interleukin-6 has a good predictive value for 30 days and overall mortality in cardiac surgery population (p < 0.05). We did not observe a significant difference in procalcitonin and interleukin-6 levels among patients with different types of surgery and different extracorporeal circulation time, but the levels of both the molecules increase significantly depending on number of transfusions received by patients (p < 0.01).

CONCLUSION

We speculated that procalcitonin and interleukin-6 could be two effective biomarkers. There is a possibility of having a combined inflammatory multi-biomarker panel, with procalcitonin for predicting renal outcome and interleukin-6 for predicting mortality.

Equivalence of the Acute Cytokine Surge and Myocardial Injury after Coronary Artery Bypass Grafting with and without a Novel Extracorporeal Circulation System

Cardiopulmonary bypass (CPB) contributes to a morbidity-inducing systemic Inflammatory response after cardiac surgery. We compared this response in patients receiving coronary artery bypass grafting (CABG) with (CPB group; n = 7) or without (off-pump group; n = 8) the Minimal Extracorporeal Circulation (MECC®) system. Serum concentrations of tumour necrosis factor (TNF)-α, soluble TNF receptors, pro- and anti-inflammatory interleukins (ILs) and other myocardial injury markers were measured after anaesthetic induction, at 1 h, 4 h and 24 h after completing all anastomoses or serially. Soluble TNF receptor type I (sTNFRI) and IL-8 peaked early after CABG in both groups and did not decline. Serum sTNFRI was significantly higher in the CPB compared with the off-pump group at 1 h, whereas IL-8 was significantly lower in the CPB group throughout. The MECC® system, therefore, produces an equivalent acute cytokine response and degree of myocardial injury to off-pump CABG, and may be useful when CABG cannot be performed without CPB.

Nandrolone decanoate determines cardiac remodelling and injury by an imbalance in cardiac inflammatory cytokines and ACE activity, blunting of the Bezold-Jarisch reflex, resulting in the development of hypertension

The aims of this study were to evaluate the effects of nandrolone (ND) on cardiac inflammatory cytokines, ACE activity, troponin I, and the sensitivity of the Bezold-Jarisch reflex (BJR). Male Wistar rats were administered either ND (20 mg/kg; DECA) or vehicle (control animals; CONT) for 4 weeks. BJR was analyzed by measuring the bradycardia and hypotension responses elicited by serotonin administration (2-32 μg/kg). Mean arterial pressure (MAP) was assessed and myocyte hypertrophy was determined by the heart weight/body weight ratio and by morphometric analysis. Matrix collagen deposition was assessed by histological analysis of the picrosirius red-stained samples. Mesenteric vascular reactivity was performed and central venous pressure (CVP) evaluated. Cardiac inflammatory cytokine levels and angiotensin-converting enzyme (ACE) activity were studied as well the biomarker of cardiac lesion, troponin I. DECA group showed enhancement of matrix type I collagen deposition (p < 0.01) and cardiac ACE activity (p < 0.01) compared with the CONT. Interleukin (IL)-10 was reduced (p < 0.01) and pro-inflammatory cytokines (TNF-α and IL-6; p < 0.01) were increased in the DECA group compared with CONT. Cardiac injury was observed in the DECA group shown by the reduction in cardiac troponin I (p < 0.01) compared with the CONT group. Animals in the DECA group also developed myocyte hypertrophy and reduction of BJR sensitivity. The MAP of animals treated with ND reached hypertensive levels (p < 0.01; compared with CONT). No changes in CVP and vascular reactivity were observed in both experimental groups. We conclude that high doses of ND elicit cardiotoxic effects with cardiac remodelling and injury. Cardiac changes reduce the BJR sensitivity. Together, these abnormalities contributed to the development of hypertension in animals in the DECA group.

Remote ischaemic preconditioning does not alter perioperative cytokine production in high-risk cardiac surgery

RATIONALE

Remote ischaemic preconditioning (RIPC) is a novel cardioprotective strategy that uses brief intermittent limb ischaemia to protect the myocardium and other organs from perioperative ischaemic damage. The precise mechanism through which this protective effect occurs is unknown, but potentially could be related to changes in blood-borne mediators such as cytokines.

OBJECTIVE

To determine whether RIPC alters inflammatory cytokine expression in a double-blind, randomised, controlled trial of patients undergoing high-risk cardiac surgery.

METHODS AND RESULTS

Serum interleukin (IL)-6, IL-8, and IL-10 levels from 95 patients randomised to RIPC (n=47) or control treatment (n=48) were measured preoperatively, and 1, 2, 3, 6 and 12 h after cross-clamp removal. Systemic concentrations of all cytokines were increased from baseline following surgery, and, compared with simple procedures, complex surgeries were associated with significantly higher release of IL-6 (ratio of mean area under the curves 1.54 (95% CI 1.02 to 2.34), p=0.04) and IL-10 (1.97 (1.16 to 3.35), p=0.012). No significant difference in mean cytokine levels between the RIPC and control groups was detected at any time point, irrespective of the type of surgery undergone.

CONCLUSIONS

High levels of IL-6, IL-8 and IL-10 are produced during high-risk cardiac surgery, and RIPC does not alter these elevated perioperative cytokine concentrations. Identification of factors that influence the ability to induce RIPC-mediated cardioprotection should be the priority of future research.

TRIAL REGISTRATION

is in the Australian New Zealand Clinical Trials Registry (http://www.anzctr.org.au; ACTRN12609000965202).

On-versus Off-Pump Coronary Artery Bypass Grafting: No Difference in Early Postoperative Kidney Function Based on TNF-α or C-Reactive Protein

BACKGROUND/AIMS: There are controversial data about renal function following off-pump coronary artery bypass grafting (CABG). The present study aimed to evaluate renal function changes 24 h after on- and off-pump CABG, as well as renal function correlated with high-sensitivity C-reactive protein (hs-CRP) and tumor necrosis factor-α (TNF-α). METHODS: Ninety patients with coronary artery disease referred to our center for CABG from July 2006 to November 2007 were enrolled in the study. Patients were equally and randomly divided in two groups, on- and off-pump. Serum levels of creatinine (Cr), blood urea nitrogen, creatinine clearance (CrCl), hs-CRP, and TNF-α were determined immediately before and 24 h after surgery. RESULTS: Cr and CrCl changes after surgery were not significantly different between the two groups; however, blood urea nitrogen levels after surgery were significantly higher in the on-pump group (p = 0.035). No statistically significant difference was noted between the two groups in terms of changes in levels of hs-CRP and TNF-α (p = 0.350 and 0.805, respectively). The changes in CrCl levels had no significant correlation with hs-CRP and TNF-α. CONCLUSIONS: The early Cr and CrCl levels after surgery are not significantly different in on- and off-pump groups. The early renal function after on- or off-pump CABG is not correlated with the levels of inflammatory markers including hs-CRP and TNF-α.

Left heart pump-assisted myocardial revascularization favorably affects neutrophil apoptosis

OBJECTIVES

Granulocyte apoptosis is a key control process in the clearance of neutrophils from inflammatory sites, and its rate is modulated by a number of inflammatory mediators. In this study, we investigated whether the use of left ventricular-assisted technique (LVA) in beating heart myocardial revascularization would exert less impact on neutrophil apoptosis compared with conventional cardiopulmonary bypass (CPB).

METHODS

Forty consecutive patients who underwent myocardial revascularization were randomly assigned to LVA (group A, 21 patients) or CPB (group B, 19 patients). Blood samples for detection of interleukin-6, interleukin-8, and tumor necrosis factor-alpha were measured at baseline and at various time points postoperatively. Neutrophil apoptosis was detected by light microscopy as well as by the annexin-V assays together with the activity of caspase 3 on postoperative samples.

RESULTS

Preoperative clinical and demographic data did not differ between the two groups. The two groups also were similar with respect to mortality, number of grafts performed, duration of extracorporeal circulation, and need for inotropes. However postoperatively, spontaneous apoptosis was significantly delayed in neutrophils from CPB patients compared with LVA patients. Neutrophils were activated, as indicated by increased surface expression of CD11b. Caspase 3 activity was found to be significantly reduced in neutrophils from CPB patients after 18 and 24 hours of culture.

CONCLUSIONS

Patients who underwent beating heart myocardial revascularization with LVA show a better preserved neutrophil apoptosis than patients treated with the CPB.

Early blood biomarkers predict organ injury and resource utilization following complex cardiac surgery

BACKGROUND

Patients undergoing complex cardiac surgery (thoracic aorta and valve) are at risk for organ failure and increased resource utilization. Neutrophil gelatinase-associated lipocalin (NGAL) has been found to be an early biomarker for renal injury. Multiplex cytokine immunoassays allow the evaluation of the early inflammatory response. We examined the relationship between early biomarker appearance (NGAL and multiplex cytokines) and organ injury and resource utilization.

MATERIALS AND METHODS

NGAL and multiplex cytokine immunoassays were performed at baseline, 1, 6, and 24 h following surgery on 38 patients undergoing thoracic aorta and valve operations. The mean age was 65 y with 26 males and 12 females. Acute kidney injury (AKIN definition), pulmonary failure (>24 h ventilation), and intensive care unit and hospital stays were examined.

RESULTS

One hour following complex cardiac surgery, the quartile of patients with the greatest IL-6 response had higher serum NGAL levels compared with the lowest quartile (347 versus 145 ng/mL, P=0.002), and 70% of these patients progressed to clinical kidney injury. Six hours following surgery, the quartile of patients with the greatest IL-10 response had higher serum NGAL compared with the lowest quartile (271 versus 160, P =0.04), more pulmonary failure (60% versus 10%, P =0.01), and longer ICU and hospital stays (P =0.001).

CONCLUSIONS

Patients with early elevated biomarkers of inflammation exhibited higher NGAL, more pulmonary failure, and greater resource utilization. Earlier identification of patients at risk for organ injury may allow for earlier intervention and reduce resource utilization.

Off-pump surgery does not eliminate microalbuminuria or other markers of systemic inflammatory response to coronary artery bypass surgery

OBJECTIVE

To evaluate whether off-pump surgery attenuates microalbuminuria and other markers of systemic inflammatory response to coronary artery bypass surgery as compared to surgery performed using cardiopulmonary bypass.

DESIGN

Forty-three adult patients undergoing elective coronary artery bypass grafting surgery were operated on with or without cardiopulmonary bypass (CPB). Microalbuminuria, serum C-reactive protein, and oxygenation and lung function parameters were measured at several time points until the first postoperative morning.

RESULTS

The urinary albumin/creatinine ratio was low in both groups before surgery, but reached a maximum level at the end of CPB or just after opening the last coronary artery clamp in the off-pump group (p<0.05). The urinary albumin/creatinine ratio remained slightly elevated in both groups until the morning after the operation (p<0.05). There were no statistical differences between groups. Serum C-reactive protein remained at the initial level the evening after the operation, but increased by the first postoperative morning in both groups (p<0.001). The alveolar-arterial gradient for oxygen partial pressure rose significantly after the operation in the intensive care unit in both groups (p<0.0001). The shunt fraction of the pulmonary circulation did not change in either group.

CONCLUSIONS

Off-pump coronary artery surgery did not prevent the acute phase inflammatory response measured in the present study. The acute phase inflammatory response after coronary artery bypass surgery is more likely a response to the surgical trauma itself rather than to CPB.

Deleterious effects of cardiopulmonary bypass in coronary artery surgery and scientific interpretation of off-pump's logic

Cardiopulmonary bypass (CPB) has been suggested to be a cause of complex systemic inflammatory response that significantly contributes to several adverse postoperative complications. In the last few years, off-pump coronary artery bypass grafting (OPCAB) has gained widespread attention as an alternative technique to conventional on-pump coronary artery bypass grafting (ONCAB). However, a degree of uncertainty regarding the relative merits of ONCAB and OPCAB continues to be a significant issue. Surgeons supporting off-pump surgery, state that the avoidance of the CPB leads to significantly reduced myocardial ischemia-reperfusion injury, postoperative systemic inflammatory response and other biological derangements, a feature that may improve the clinical outcomes. However, perfection in perioperative care, surgical technique and methods of attenuating the untoward effects of CPB has resulted in better clinical outcome of ONCAB as well. Possible reasons of these controversial opinions are that high-quality studies have not comprehensively examined relevant patient outcomes and have enrolled a limited range of patients. Some studies may have been too small to detect clinically important differences in patient outcomes between these two modalities. We present a review of the available scientific interpretation of the literature on OPCAB with regard to safety, hemodynamic changes, inflammation, myocardial preservation and oxidative stress. We also sought to determine from different reported retrospective and randomized control studies, the initial and the long-term benefits of this approach, despite the substantial learning curve associated with OPCAB.

Prospective randomized study comparing coronary artery bypass grafting with the new mini-extracorporeal circulation Jostra System or with a standard cardiopulmonary bypass

BACKGROUND

To assess the potential benefits of a new concept of cardiopulmonary bypass (CPB), the mini-extracorporeal circulation (MECC) Jostra System, we conducted a prospective randomized study among patients who underwent coronary artery bypass grafting (CABG) with a MECC Jostra System or with a standard CPB.

METHODS

In a prospective randomized study, 400 patients underwent elective CABG using a standard CPB (200 patients) or a Jostra MECC System (200 patients). The patients were randomly assigned to have preoperative data similar for both groups.

RESULTS

The operative mortality rate (< 30 days) was 1.5% for the MECC group and 2.5% for the CPB group (P = NS). Low-cardiac-output syndrome occurred in 0.66% and 4% for the CPB group (P < .001.). The inflammatory response was significantly reduced with the MECC. Likewise, C-reactive protein release was significantly higher in group B at 24 hours (69.6 +/- 38.5 vs 40.8 +/- 21.8 mg/L for the group A, P < .01) and at 48 hours (116.7 +/- 47.0 vs 65.4 +/- 39.5 mg/L, P < .05) postoperatively. In the CPB group, there was a significantly higher decrease of hematocrit and hemoglobin rate. So, the intraoperative transfusion rate amounted to 6% for the MECC group and 12.8% for the CPB group (P < .001). Patients in the CPB group had significantly higher levels of postoperative blood creatinine and urea.

CONCLUSION

The MECC system is a new concept of CPB that seems to be reliable and safe. To perform CABG, the MECC provides an excellent surgical exposure like a standard CPB and a better biologic profile like CABG without CPB.

Intraoperative Transit Time Flow Measurement: Off-Pump Versus On-Pump Coronary Artery Bypass

BACKGROUND

Off-pump coronary artery bypass grafting (OPCAB) has attracted increasing attention. Performing the anastomosis off-pump is technically more demanding. The objective of the study is to assess the quality of anastomosis in OPCAB in comparison with conventional on-pump coronary artery bypass grafting using the transit time flow measurement.

METHODS

Four hundred forty-five patients operated on using OPCAB technique were included in the study. For each patient in this group a similar patient from the on-pump coronary artery bypass grafting population was selected according to the number of grafts, bypass material, and target coronary arteries. The mean flow and the pulsatile index were measured in every bypass graft in both groups.

RESULTS

The average pulsatile index in OPCAB was 2.09 +/- 1.03 (mean flow, 39 +/- 22.63 mL/min), whereas with on-pump coronary artery bypass grafting it was 1.9 +/- 0.98 (mean flow, 44.19 +/- 23.58 mL/min); p = 0.005. Subgroup analysis showed significantly lower mean flows and higher pulsatile index with OPCAB in grafts to the obtuse marginal, diagonal, and right coronary artery, but not to the left anterior descending territory.

CONCLUSIONS

The quality of the anastomosis performed using the OPCAB technique might be jeopardized by less accessibility as in the case of lateral and posterior wall coronary arteries. Techniques to optimize the accessibility of the coronary artery like combining sling support with cup stabilizers, together with systematic training, should be strongly considered in OPCAB. Whenever there is good accessibility of the coronary artery as in the case of the left anterior descending, the anastomosis performed under OPCAB has a quality as good as that performed using the conventional technique.

Relationship between cerebral injury and inflammatory responses in patients undergoing cardiac surgery with cardiopulmonary bypass

This study was performed to evaluate whether cytokines, adhesion molecules, ghrelin and S-100B are useful markers in predicting the cerebral infarction after cardiac surgery with cardioplumomary bypass (CPB). The patients (n=20) were classified into two groups; group A (n=4) showed postoperative organized cerebral damage, while group B (n=16) consisted of patients without occurrence of postoperative strokes. Before CPB, serum levels of S-100B in both groups A and B were low (<0.5 ng/mL), while ghrelin concentrations in group A (all patients had history of strokes) were much higher than those in group B. After CPB, when serum levels of S-100B in group A at 24h were higher than those in group B, ghrelin in group A at same time point showed high levels in comparison to group B. At 12 and 24h after CPB, levels of tumor necrosis factor (TNF)-alpha, interleukin-10 and soluble TNF-receptor I in group A were significantly higher than those in group B. In conclusion, it is considered that ghrelin as well as S-100B can be a useful marker for the prediction of stoke after CPB. Increase of TNF-alpha, interleukin-10 and soluble TNF-receptor I after CPB may be involved in the pathogenesis of stroke after CPB.

Soluble adhesion molecules in coronary artery bypass surgery

Plasma levels of sE-selectin, sP-selectin, and sICAM-1 were measured before anesthesia and at 0.5, 4, and 20 hours after cardiopulmonary bypass in 37 men undergoing coronary artery bypass surgery. Plasma sE-selectin remained close to the preoperative levels. The levels of sP-selectin increased significantly from 46.5 +/- 15.3 ng x mL(-1) to 69.3 +/- 39.6 ng x mL(-1) at 0.5 hours, 84.1 +/- 45.5 ng x mL(-1) at 4 hours, and 79.6 +/- 35.5 ng x mL(-1) at 20 hours. Plasma sICAM-1 levels decreased 0.5 hours after cardiopulmonary bypass, recovered at 4 hours, and showed a significant increase at 20 hours. The changes in plasma levels of adhesion molecules did not correlate with the duration of bypass or aortic crossclamping, hemodynamics, or creatine kinase-MB levels. However, sE-selectin and sICAM-1 levels increased considerably more in patients who needed norepinephrine in the intensive care unit. These results indicate that the transient changes in plasma levels of soluble adhesion molecules are not associated with postoperative myocardial injury in low-risk coronary grafting, although they correlate with the need for a vasopressor.

Myocardial and lung injury after cardiopulmonary bypass: role of interleukin (IL)-10

BACKGROUND

Proinflammatory cytokines, such as tumor necrosis factor-alpha (TNF-alpha), interleukin (IL)-6, and IL-8 play a key role in the inflammatory cascade after cardiopulmonary bypass (CPB) and may induce cardiac and lung dysfunction. Antiinflammatory cytokines such as IL-10 may also significantly limit these complications. Corticosteroid administration before CPB increases blood IL-10 levels and prevents proinflammatory cytokine release. This study examined the association of increased release of IL-10, stimulated by steroid pretreatment, with reduced myocardial and lung injury after CPB.

METHODS

Twenty patients undergoing coronary artery bypass grafting (CABG) received either preoperative steroid (n = 10, protocol group) or no steroid (n = 10, control group). Perioperative care was standardized, and all caregivers were blinded to treatment group. Seven intervals of blood samples were obtained and assayed for TNF-alpha, IL-6, IL-8, and IL-10. Various hemodynamic and pulmonary measurements were obtained perioperatively. Levels of MB isoenzyme creatine kinase (CK-MB) were also measured.

RESULTS

In the protocol group, proinflammatory cytokines were significantly reduced while IL-10 levels were much higher after CPB. The protocol group had a lower alveolar-arterial oxygen gradient and higher ratio of arterial oxygen pressure to fraction of inspired oxygen after CPB. Creatine kinase (CK) and CK-MB were reduced in the patients treated with steroid. Correlations were found between plasma cytokines levels and cardiac index, and CK-MB.

CONCLUSIONS

This study confirms that corticosteroids abolish proinflammatory cytokines release and increase blood IL-10 levels after CPB. Our findings demonstrate a greater release of IL-10 induced by steroid pretreatment, and better heart and lung protection after CPB.

Cariporide (HOE-642) improves cardiac allograft preservation in a porcine model of orthotopic heart transplantation

BACKGROUND

Acute graft dysfunction caused by ischemia-reperfusion injury is recognized as a major source of morbidity and mortality following adult heart transplantation. The aim of this study was to determine whether treating the donor and recipient with cariporide, an inhibitor of the sodium-hydrogen exchanger, could reduce ischemia-reperfusion injury.

METHODS

A porcine model of donor brain death, hypothermic ischemic preservation, and orthotopic cardiac transplantation was used. Allografts in both the control group (CON, n=6) and treatment group (CAR, n=6) were arrested and stored for 4 hours in the extracellular crystalloid cardioplegia currently used in the clinical transplantation program at our institution. In addition, both the donor and recipient animals in the CAR group received a single intravenous dose of cariporide (2 mg/kg) 15 minutes before harvesting and reperfusion, respectively.

RESULTS

The initial rate of troponin I release was significantly lower in recipients of CAR hearts than in recipients of CON hearts (P =0.020). All hearts were weaned successfully from bypass. More CAR hearts were weaned successfully at the first attempt, at 1 hour post-reperfusion, than CON hearts (6 of 6 vs 3 of 6), but this did not achieve statistical significance. Left ventricular contractility (preload recruitable stroke-work relationship) and left ventricular compliance (end-diastolic pressure-volume relationship) were significantly better preserved in CAR hearts than CON hearts (both P <0.0001).

CONCLUSIONS

Myocardial injury was reduced, and contractile function was better preserved in allografts that received cariporide, compared with allografts that received conventional preservation alone.

Lazaroid (U74389G)-supplemented cardioplegia: results of a double-blind, randomized, controlled trial in a porcine model of orthotopic heart transplantation

BACKGROUND

U74389G (16-desmethyl tirilazad), a 21-aminosteroid or "lazaroid," inhibits lipid peroxidation, which is an important element of ischemia-reperfusion injury. The aim of this study was to determine whether the addition of U74389G to the cardioplegic preservation solution could improve early cardiac allograft function.

METHODS

A porcine model of donor brain death and orthotopic cardiac transplantation was used. Hearts were arrested and preserved for 6 hours in an aspartate-enriched extracellular cardioplegia that had been supplemented with either U74389G and its carrier (n = 7) or the carrier alone (n = 9). Epicardial sonomicrometry and transmyocardial micromanometry were used to obtain pressure-volume loops before and after transplantation. Left ventricular wall volume was measured by volume displacement.

RESULTS

A higher proportion of U74389G-treated hearts were weaned successfully from cardiopulmonary bypass, but this difference did not achieve statistical significance (86% [6 of 7] vs 56% [5 of 9]; p = 0.308). In the hearts that were weaned successfully, preservation of left ventricular contractility, as judged by the pre-load recruitable stroke work relationship, was significantly better in the U74389G-treated hearts (p = 0.0271). In contrast, left ventricular compliance, as judged by the end-diastolic pressure-volume relationship, was significantly better preserved in the control group (p < 0.0001). U74389G-treated hearts developed less myocardial edema, as judged by the post-transplant left ventricular wall volume/baseline steady-state epicardial end-diastolic volume ratio (64 +/- 9% vs 76 +/- 11%; p = 0.045).

CONCLUSIONS

The benefit obtained from U74389G-supplemented cardioplegic preservation solution was marginal for hearts stored for 6 hours. After longer ischemic times, the benefit may be clearer.

Does aprotinin influence the inflammatory response to cardiopulmonary bypass in patients?

OBJECTIVES

Aprotinin has been shown to have anti-inflammatory properties, but its effects on the inflammatory reaction to cardiopulmonary bypass remain controversial. This prospective, randomized, double-blind study evaluated the influence of aprotinin on various blood markers of inflammation during and after cardiopulmonary bypass.

METHODS

Sixty male patients underwent coronary artery bypass grafting. The patients were randomized into 3 groups: a placebo group, a second group receiving 2,000,000 KIU of aprotinin followed by an infusion of 500,000 KIU/h and 2,000,000 KIU in the pump prime, and a third group receiving half this dosage. Measurements of tumor necrosis factor, interleukin 6, interleukin 8, interleukin 10, endotoxin, histamine, complement factors, prekallikrein, and prostaglandin D(2) were obtained at baseline, 30 minutes after study drug loading, 10 minutes after the beginning of cardiopulmonary bypass, before the end of bypass, 4 hours after bypass, and on the first and second postoperative days.

RESULTS

Aprotinin had no significant effect on any of these parameters. As expected, aprotinin reduced early blood loss in both treated groups.

CONCLUSIONS

These results indicate that aprotinin at doses currently used to reduce blood loss has no significant influence on the systemic inflammatory response during moderate hypothermic cardiopulmonary bypass in human subjects, as assessed by the mediators measured in this study.

Soluble adhesion molecules in coronary surgery and cardiopulmonary bypass with pump prime aprotinin

OBJECTIVE

The purpose of the present study was to establish whether pump prime aprotinin could influence soluble adhesion molecules in patients undergoing elective coronary artery bypass surgery.

DESIGN

Thirty patients admitted for first-time elective coronary artery bypass surgery were randomized into control or aprotinin groups. Patients in the aprotinin group received 280 mg of aprotinin in the pump prime. Plasma levels of soluble adhesion molecules were analyzed perioperatively.

RESULTS

There were no significant changes in plasma sE-selectin after the operation in either group. Plasma sP-selectin increased significantly up to 20 h after reperfusion to the myocardium. Plasma sICAM-1 decreased in the early stage after cardiopulmonary bypass (CPB), then recovered at 4 h after reperfusion and a significant increase in sICAM-1 was observed 20 h later. There were no significant differences between the groups in postoperative changes in sP-selectin (p = 0.21) and sICAM-1 (p = 0.91).

CONCLUSION

Pump prime aprotinin did not influence plasma levels of E-selectin, P-selectin and ICAM-1 in the present patients. The present results do not support the concept of an anti-inflammatory effect of pump prime aprotinin.