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Drury NE, van Doorn C, Woolley RL, Amos-Hirst RJ, Bi R, Spencer CM, Morris KP, Montgomerie J, Stickley J, Crucean A, Gill A, Hill M, Weber RJ, Najdekr L, Jankevics A, Southam AD, Lloyd GR, Jaber O, Kassai I, Pelella G, Khan NE, Botha P, Barron DJ, Madhani M, Dunn WB, Ives NJ, Kirchhof P, Jones TJ. Bilateral remote ischemic conditioning in children: A two-center, double-blind, randomized controlled trial in young children undergoing cardiac surgery. JTCVS OPEN 2024; 18:193-208. [PMID: 38690427 PMCID: PMC11056492 DOI: 10.1016/j.xjon.2024.02.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Revised: 01/30/2024] [Accepted: 02/20/2024] [Indexed: 05/02/2024]
Abstract
Objective The study objective was to determine whether adequately delivered bilateral remote ischemic preconditioning is cardioprotective in young children undergoing surgery for 2 common congenital heart defects with or without cyanosis. Methods We performed a prospective, double-blind, randomized controlled trial at 2 centers in the United Kingdom. Children aged 3 to 36 months undergoing tetralogy of Fallot repair or ventricular septal defect closure were randomized 1:1 to receive bilateral preconditioning or sham intervention. Participants were followed up until hospital discharge or 30 days. The primary outcome was area under the curve for high-sensitivity troponin-T in the first 24 hours after surgery, analyzed by intention-to-treat. Right atrial biopsies were obtained in selected participants. Results Between October 2016 and December 2020, 120 eligible children were randomized to receive bilateral preconditioning (n = 60) or sham intervention (n = 60). The primary outcome, area under the curve for high-sensitivity troponin-T, was higher in the preconditioning group (mean: 70.0 ± 50.9 μg/L/h, n = 56) than in controls (mean: 55.6 ± 30.1 μg/L/h, n = 58) (mean difference, 13.2 μg/L/h; 95% CI, 0.5-25.8; P = .04). Subgroup analyses did not show a differential treatment effect by oxygen saturations (pinteraction = .25), but there was evidence of a differential effect by underlying defect (pinteraction = .04). Secondary outcomes and myocardial metabolism, quantified in atrial biopsies, were not different between randomized groups. Conclusions Bilateral remote ischemic preconditioning does not attenuate myocardial injury in children undergoing surgical repair for congenital heart defects, and there was evidence of potential harm in unstented tetralogy of Fallot. The routine use of remote ischemic preconditioning cannot be recommended for myocardial protection during pediatric cardiac surgery.
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Affiliation(s)
- Nigel E. Drury
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom
- Department of Paediatric Cardiac Surgery, Birmingham Children's Hospital, Birmingham, United Kingdom
| | - Carin van Doorn
- Department of Congenital Cardiac Surgery, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Rebecca L. Woolley
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, United Kingdom
- Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom
| | - Rebecca J. Amos-Hirst
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, United Kingdom
- Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom
| | - Rehana Bi
- Department of Paediatric Cardiac Surgery, Birmingham Children's Hospital, Birmingham, United Kingdom
| | - Collette M. Spencer
- Department of Congenital Cardiac Surgery, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Kevin P. Morris
- Department of Paediatric Intensive Care, Birmingham Children's Hospital, Birmingham, United Kingdom
| | - James Montgomerie
- Department of Paediatric Cardiac Anesthesia, Birmingham Children's Hospital, Birmingham, United Kingdom
| | - John Stickley
- Department of Paediatric Cardiac Surgery, Birmingham Children's Hospital, Birmingham, United Kingdom
| | - Adrian Crucean
- Department of Paediatric Cardiac Surgery, Birmingham Children's Hospital, Birmingham, United Kingdom
| | - Alicia Gill
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, United Kingdom
- Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom
| | - Matt Hill
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, United Kingdom
- Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom
| | - Ralf J.M. Weber
- Phenome Centre Birmingham, School of Biosciences, University of Birmingham, Birmingham, United Kingdom
| | - Lukas Najdekr
- Phenome Centre Birmingham, School of Biosciences, University of Birmingham, Birmingham, United Kingdom
| | - Andris Jankevics
- Phenome Centre Birmingham, School of Biosciences, University of Birmingham, Birmingham, United Kingdom
| | - Andrew D. Southam
- Phenome Centre Birmingham, School of Biosciences, University of Birmingham, Birmingham, United Kingdom
| | - Gavin R. Lloyd
- Phenome Centre Birmingham, School of Biosciences, University of Birmingham, Birmingham, United Kingdom
| | - Osama Jaber
- Department of Congenital Cardiac Surgery, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Imre Kassai
- Department of Congenital Cardiac Surgery, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Giuseppe Pelella
- Department of Congenital Cardiac Surgery, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Natasha E. Khan
- Department of Paediatric Cardiac Surgery, Birmingham Children's Hospital, Birmingham, United Kingdom
| | - Phil Botha
- Department of Paediatric Cardiac Surgery, Birmingham Children's Hospital, Birmingham, United Kingdom
| | - David J. Barron
- Division of Cardiovascular Surgery, Hospital for Sick Children, Toronto, Canada
- Department of Surgery, University of Toronto, Toronto, Canada
| | - Melanie Madhani
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Warwick B. Dunn
- Phenome Centre Birmingham, School of Biosciences, University of Birmingham, Birmingham, United Kingdom
- Department of Biochemistry and Systems Biology, Institute of Systems, Molecular, and Integrative Biology, University of Liverpool, Liverpool, United Kingdom
| | - Natalie J. Ives
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, United Kingdom
- Institute of Applied Health Research, University of Birmingham, Birmingham, United Kingdom
| | - Paulus Kirchhof
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom
- Department of Cardiology, University Heart and Vascular Centre, UKE Hamburg, Hamburg, Germany
- German Centre for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Timothy J. Jones
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom
- Department of Paediatric Cardiac Surgery, Birmingham Children's Hospital, Birmingham, United Kingdom
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Drury NE. Myocardial protection in paediatric cardiac surgery: building an evidence-based strategy. Ann R Coll Surg Engl 2024; 106:277-282. [PMID: 37249560 PMCID: PMC10904256 DOI: 10.1308/rcsann.2023.0004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/24/2023] [Indexed: 05/31/2023] Open
Abstract
Cardioplegia is fundamental to the surgical repair of congenital heart defects by protecting the heart against ischaemia/reperfusion injury, characterised by low cardiac output and troponin release in the early postoperative period. The immature myocardium exhibits structural, physiological and metabolic differences from the adult heart, with a greater sensitivity to calcium overload-mediated injury during reperfusion. Del Nido cardioplegia was designed specifically to protect the immature heart, is widely used in North America and may provide better myocardial protection in children; however, it has not been commercially available in the UK, where most centres use St Thomas' blood cardioplegia. There are no phase 3 clinical trials in children to support one solution over another and this lack of evidence, combined with variations in practice, suggests the presence of clinical equipoise. The best cardioplegia solution for use in children, and the impact of age and other clinical factors remain unknown. In this Hunterian lecture, I propose an evidence-based strategy to improve myocardial protection during cardiac surgery in children through: (1) conducting multicentre clinical trials of established techniques; (2) improving our knowledge of ischaemia/reperfusion injury in the setting of cardioplegic arrest; (3) applying this to drive innovation, moving beyond current cardioplegia solutions; (4) empowering personalised medicine, through combining clinical and genomic data, including ethnic diversity; and (5) understanding the impact of cardioplegic arrest on the late outcomes that matter to patients and their families.
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Ravingerova T, Adameova A, Lonek L, Farkasova V, Ferko M, Andelova N, Kura B, Slezak J, Galatou E, Lazou A, Zohdi V, Dhalla NS. Is Intrinsic Cardioprotection a Laboratory Phenomenon or a Clinically Relevant Tool to Salvage the Failing Heart? Int J Mol Sci 2023; 24:16497. [PMID: 38003687 PMCID: PMC10671596 DOI: 10.3390/ijms242216497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 11/13/2023] [Accepted: 11/13/2023] [Indexed: 11/26/2023] Open
Abstract
Cardiovascular diseases, especially ischemic heart disease, as a leading cause of heart failure (HF) and mortality, will not reduce over the coming decades despite the progress in pharmacotherapy, interventional cardiology, and surgery. Although patients surviving acute myocardial infarction live longer, alteration of heart function will later lead to HF. Its rising incidence represents a danger, especially among the elderly, with data showing more unfavorable results among females than among males. Experiments revealed an infarct-sparing effect of ischemic "preconditioning" (IPC) as the most robust form of innate cardioprotection based on the heart's adaptation to moderate stress, increasing its resistance to severe insults. However, translation to clinical practice is limited by technical requirements and limited time. Novel forms of adaptive interventions, such as "remote" IPC, have already been applied in patients, albeit with different effectiveness. Cardiac ischemic tolerance can also be increased by other noninvasive approaches, such as adaptation to hypoxia- or exercise-induced preconditioning. Although their molecular mechanisms are not yet fully understood, some noninvasive modalities appear to be promising novel strategies for fighting HF through targeting its numerous mechanisms. In this review, we will discuss the molecular mechanisms of heart injury and repair, as well as interventions that have potential to be used in the treatment of patients.
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Affiliation(s)
- Tanya Ravingerova
- Institute for Heart Research, Centre of Experimental Medicine, Slovak Academy of Sciences, 9 Dubravska cesta, 841 04 Bratislava, Slovakia; (A.A.); (L.L.); (V.F.); (M.F.); (N.A.); (B.K.); (J.S.)
| | - Adriana Adameova
- Institute for Heart Research, Centre of Experimental Medicine, Slovak Academy of Sciences, 9 Dubravska cesta, 841 04 Bratislava, Slovakia; (A.A.); (L.L.); (V.F.); (M.F.); (N.A.); (B.K.); (J.S.)
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Comenius University in Bratislava, 10 Odbojárov St., 832 32 Bratislava, Slovakia
| | - Lubomir Lonek
- Institute for Heart Research, Centre of Experimental Medicine, Slovak Academy of Sciences, 9 Dubravska cesta, 841 04 Bratislava, Slovakia; (A.A.); (L.L.); (V.F.); (M.F.); (N.A.); (B.K.); (J.S.)
| | - Veronika Farkasova
- Institute for Heart Research, Centre of Experimental Medicine, Slovak Academy of Sciences, 9 Dubravska cesta, 841 04 Bratislava, Slovakia; (A.A.); (L.L.); (V.F.); (M.F.); (N.A.); (B.K.); (J.S.)
| | - Miroslav Ferko
- Institute for Heart Research, Centre of Experimental Medicine, Slovak Academy of Sciences, 9 Dubravska cesta, 841 04 Bratislava, Slovakia; (A.A.); (L.L.); (V.F.); (M.F.); (N.A.); (B.K.); (J.S.)
| | - Natalia Andelova
- Institute for Heart Research, Centre of Experimental Medicine, Slovak Academy of Sciences, 9 Dubravska cesta, 841 04 Bratislava, Slovakia; (A.A.); (L.L.); (V.F.); (M.F.); (N.A.); (B.K.); (J.S.)
| | - Branislav Kura
- Institute for Heart Research, Centre of Experimental Medicine, Slovak Academy of Sciences, 9 Dubravska cesta, 841 04 Bratislava, Slovakia; (A.A.); (L.L.); (V.F.); (M.F.); (N.A.); (B.K.); (J.S.)
| | - Jan Slezak
- Institute for Heart Research, Centre of Experimental Medicine, Slovak Academy of Sciences, 9 Dubravska cesta, 841 04 Bratislava, Slovakia; (A.A.); (L.L.); (V.F.); (M.F.); (N.A.); (B.K.); (J.S.)
| | - Eleftheria Galatou
- School of Biology, Aristotle University of Thessaloniki, 541 24 Thessaloniki, Greece; (E.G.); (A.L.)
- Department of Life and Health Sciences, University of Nicosia, 2417 Nicosia, Cyprus
| | - Antigone Lazou
- School of Biology, Aristotle University of Thessaloniki, 541 24 Thessaloniki, Greece; (E.G.); (A.L.)
| | - Vladislava Zohdi
- Department of Anatomy, Faculty of Medicine, Comenius University in Bratislava, 24 Špitalska, 813 72 Bratislava, Slovakia;
- Department of Anatomy and Developmental Biology, Monash Biomedicine Discovery Institute, Monash University, 19 Innovation Walk, Clayton, VIC 3800, Australia
| | - Naranjan S. Dhalla
- Institute of Cardiovascular Sciences St. Boniface Hospital Albrechtsen Research Centre, 351 Tache Avenue, Winnipeg, MB R2H 2A6, Canada;
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Menzies J, Tooke C, Jones T, Lavis A, Drury N. 'Just one interview': making visible the hidden workload associated with qualitative research. Nurse Res 2023; 31:36-43. [PMID: 37102315 DOI: 10.7748/nr.2023.e1872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/13/2023] [Indexed: 04/28/2023]
Abstract
BACKGROUND Appropriate costing and allocation of resources is vital to ensure that recruitment to a study is achieved on time and on target. However, there is little guidance concerning the workload associated with qualitative research. AIM To review the planned versus actual workloads in a qualitative sub-study following elective cardiac surgery in children. DISCUSSION Parents of children approached for a clinical trial were invited to participate in a semi-structured interview to explore their views about making decisions concerning their children's participation in the trial. A workload audit was conducted using anticipated points of contact with participants, and the duration of activities identified in the protocol and Health Research Authority statement of activities; these were compared with timed activities documented by the research team. CONCLUSION The current system did not anticipate or capture the workload associated with conducting a relatively straightforward qualitative sub-study of a clinical trial with a research-engaged patient group. IMPLICATIONS FOR PRACTICE Understanding the hidden workload associated with qualitative research is vital in ensuring that project timelines, recruitment targets and funding for research staff are realistic.
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Affiliation(s)
- Julie Menzies
- Paediatric Intensive Care Unit, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, England
| | - Carly Tooke
- Paediatric Intensive Care Unit, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, England
| | - Timothy Jones
- Department of Paediatric Cardiac Surgery, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, England
| | - Anna Lavis
- Institute of Applied Health Research, University of Birmingham Edgbaston Campus: University of Birmingham, Birmingham, England
| | - Nigel Drury
- Department of Paediatric Cardiac Surgery, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, England
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Drury NE, Menzies JC, Taylor CJ, Jones TJ, Lavis AC. Understanding parents' decision-making on participation in clinical trials in children's heart surgery: a qualitative study. BMJ Open 2021; 11:e044896. [PMID: 33622954 PMCID: PMC7907877 DOI: 10.1136/bmjopen-2020-044896] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES Few children undergoing heart surgery are recruited to clinical trials and little is known about the views and attitudes of parents towards trials. This study explored parents' perspectives on decision-making about their child's participation in a clinical trial during their elective cardiac surgery. DESIGN Qualitative interview study. SETTING Single-centre substudy of a multicentre, double-blind, randomised controlled trial to investigate the effects of remote ischaemic preconditioning in children undergoing cardiac surgery. PARTICIPANTS Parents of children approached to participate in the trial, both consenters and decliners. METHODS Semistructured interviews were conducted face-to-face or by telephone following discharge, digitally audio-recorded, transcribed and thematically analysed. RESULTS Of 46 patients approached for the trial, 24 consenting and 2 declining parents agreed to participate in an interview (21 mothers, 5 fathers). Parental decision-making about research was influenced by (1) potential risks or additional procedures; (2) personal benefit and altruism for the 'cardiac community'; (3) information, preparation, timing and approach; and (4) trust in the clinical team and collaboration with researchers. All of these were placed within the context of their understanding of the trial and knowledge of research. CONCLUSIONS Parents of children undergoing cardiac surgery attach value to clinical research and are supportive of clinical trials when there is no or minimal perceived additional risk. These findings enhance our understanding of the factors that influence parents' decision-making and should be used to inform the design and conduct of future paediatric surgical trials. TRIAL REGISTRATION NUMBER ISRCTN12923441; Pre-results.
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Affiliation(s)
- Nigel E Drury
- Paediatric Cardiac Surgery, Birmingham Children's Hospital, Birmingham, UK
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| | - Julie C Menzies
- Paediatric Intensive Care, Birmingham Children's Hospital, Birmingham, UK
| | - Clare J Taylor
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Timothy J Jones
- Paediatric Cardiac Surgery, Birmingham Children's Hospital, Birmingham, UK
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| | - Anna C Lavis
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
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