Heart rate limitation and cardiac unloading in sevoflurane post-conditioning

Anesthesia Protocols used to Create Ischemia Reperfusion Myocardial Infarcts in Swine

The porcine ischemia-reperfusion model is one of the most commonly used for cardiology research and for testing interventions for myocardial regeneration. In creating ischemic reperfusion injury, the anesthetic protocol is important for assuring hemodynamic stability of the animal during the induction of the experimental lesion and may affect its postoperative survival. This paper reviews the many drugs and anesthetic protocols used in recent studies involving porcine models of ischemiareperfusion injury. The paper also summarizes the most important characteristics of some commonly used anesthetic drugs. Literature was selected for inclusion in this review if the authors described the anesthetic protocol used and also reported the mortality rate attributed to the creation of the model. This information is an important consideration because the anesthetic protocol can influence hemodynamic stability during the experimental induction of an acute myocardial infarction, thereby impacting the survival rate and affecting the number of animals needed for each study.

The mechanisms of cardio-protective effects of desflurane and sevoflurane at the time of reperfusion: anaesthetic post-conditioning potentially translatable to humans?

Myocardial conditioning is actually an essential strategy in the management of ischaemia-reperfusion injury. The concept of anaesthetic post-conditioning is intriguing, its action occurring at a pivotal moment (that of reperfusion when ischaemia reperfusion lesions are initiated) where the activation of these cardio-protective mechanisms could overpower the mechanisms leading to ischaemia reperfusion injuries. Desflurane and sevoflurane are volatile anaesthetics frequently used during cardiac surgery. This review focuses on the efficacy of desflurane and sevoflurane administered during early reperfusion as a potential cardio-protective strategy. In the context of experimental studies in animal models and in human atrial tissues in vitro, the mechanisms underlying the cardio-protective effect of these agents and their capacity to induce post-conditioning have been reviewed in detail, underlining the role of reactive oxygen species generation, the activation of the cellular signalling pathways, and the actions on mitochondria along with the translatable actions in humans; this might well be sufficient to set the basis for launching randomized clinical studies, actually needed to confirm this strategy as one of real impact.

Impact of Heart Rate on Myocardial Salvage in Timely Reperfused Patients with ST-Segment Elevation Myocardial Infarction: New Insights from Cardiovascular Magnetic Resonance

BACKGROUND

Previous studies evaluating the progression of the necrotic wave in relation to heart rate were carried out only in animal models of ST-elevated myocardial infarction (STEMI). Aim of the study was to investigate changes of myocardial salvage in relation to different heart rates at hospital admission in timely reperfused patients with STEMI by using cardiovascular magnetic resonance (CMR).

METHODS

One hundred-eighty-seven patients with STEMI successfully and timely treated with primary coronary angioplasty underwent CMR five days after hospital admission. According to the heart rate at presentation, patients were subcategorized into 5 quintiles: <55 bpm (group I, n = 44), 55-64 bpm (group II, n = 35), 65-74 bpm (group III, n = 35), 75-84 bpm (group IV, n = 37), ≥85 bpm (group V, n = 36). Area at risk, infarct size, microvascular obstruction (MVO) and myocardium salvaged index (MSI) were assessed by CMR using standard sequences.

RESULTS

Lower heart rates at presentation were associated with a bigger amount of myocardial salvage after reperfusion. MSI progressively decreased as the heart rates increased (0.54 group I, 0.46 group II, 0.38 group III, 0.34 group IV, 0.32 group V, p<0.001). Stepwise multivariable analysis showed heart rate, peak troponin and the presence of MVO were independent predictor of myocardial salvage. No changes related to heart rate were observed in relation to area at risk and infarct size.

CONCLUSIONS

High heart rates registered before performing coronary angioplasty in timely reperfused patients with STEMI are associated with a reduction in salvaged myocardium. In particular, salvaged myocardium significantly reduced when heart rate at presentation is ≥85 bpm.

Sevoflurane postconditioning protects rat hearts against ischemia-reperfusion injury via the activation of PI3K/AKT/mTOR signaling

Phosphatidylinositol 3-kinase (PI3K)/protein kinase B (AKT) pathway plays a key role in myocardial ischemia-reperfusion (I/R) injury. Mammalian target of rapamycin (mTOR), a downstream target of PI3K/AKT signaling, is necessary and sufficient to protect the heart from I/R injury. Inhaled anesthetic sevoflurane is widely used in cardiac surgeries because its induction and recovery are faster and smoother than other inhaled anesthetics. Sevoflurane proved capable of inducing postconditioning effects in the myocardium. However, the underlying molecular mechanisms for sevoflurane-induced postconditioning (SPC) were largely unclear. In the present study, we demonstrated that SPC protects myocardium from I/R injury with narrowed cardiac infarct focus, increased ATP content, and decreased cardiomyocyte apoptosis, which are mainly due to the activation of PI3K/AKT/mTOR signaling and the protection of mitochondrial energy metabolism. Application of dactolisib (BEZ235), a PI3K/mTOR dual inhibitor, abolishes the up-regulation of pho-AKT, pho-GSK, pho-mTOR, and pho-p70s6k induced by SPC, hence abrogating the anti-apoptotic effect of sevoflurane and reducing SPC-mediated protection of heart from I/R injury. As such, this study proved that PI3K/AKT/mTOR pathway plays an important role in SPC induced cardiac protection against I/R injury.