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Romano R, Cristescu SM, Risby TH, Marczin N. Lipid peroxidation in cardiac surgery: towards consensus on biomonitoring, diagnostic tools and therapeutic implementation. J Breath Res 2018; 12:027109. [PMID: 29104182 DOI: 10.1088/1752-7163/aa9856] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
This review focuses on oxidative stress and more specifically lipid peroxidation in cardiac surgery, one of the fundamental theories of perioperative complications. We present the molecular pathways leading to lipid peroxidation and integrate analytical methods that allow detection of lipid peroxidation markers in the fluid phase with those focusing on volatile compounds in exhaled breath. In order to explore the accumulated data in the literature, we present a systematic review of quantitative analysis of malondialdehyde, a widely used lipid peroxidation product at various stages of cardiac surgery. This exploration reveals major limitations of existing studies in terms of variability of reported values and significant gaps due to discrete and variable sampling times during surgery. We also appraise methodologies that allow real-time and continuous monitoring of oxidative stress. Complimentary techniques highlight that beyond the widely acclaimed contribution of the cardiopulmonary bypass technology and myocardial reperfusion injury, the use of diathermy contributes significantly to intraoperative lipid peroxidation. We conclude that there is an urgent need to implement the theory of oxidative stress towards a paradigm change in the clinical practice. Firstly, we need to acquire definite and irrefutable information on the link between lipid peroxidation and post-operative complications by building international consensus on best analytical approaches towards generating qualitatively and quantitatively comparable datasets in coordinated multicentre studies. Secondly, we should move away from routine low-risk surgeries towards higher risk interventions where there is major unmet clinical need for improving patient journey and outcomes. There is also need for consensus on best therapeutic interventions which could be tested in convincing large scale clinical trials. As future directions, we propose combination of fluid phase platforms and 'metabography', an extended form of capnography-including real-time analysis of lipid peroxidation and volatile footprints of metabolism-for better patient phenotyping prior to and during high risk surgery towards molecular prediction, stratification and monitoring of the patient's journey.
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Affiliation(s)
- Rosalba Romano
- Section of Anaesthetics, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, United Kingdom
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Cristescu SM, Kiss R, Hekkert STL, Dalby M, Harren FJM, Risby TH, Marczin N. Real-time monitoring of endogenous lipid peroxidation by exhaled ethylene in patients undergoing cardiac surgery. Am J Physiol Lung Cell Mol Physiol 2014; 307:L509-15. [PMID: 25128523 DOI: 10.1152/ajplung.00168.2014] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Pulmonary and systemic organ injury produced by oxidative stress including lipid peroxidation is a fundamental tenet of ischemia-reperfusion injury, inflammatory response to cardiac surgery, and cardiopulmonary bypass (CPB) but is not routinely measured in a surgically relevant time frame. To initiate a paradigm shift toward noninvasive and real-time monitoring of endogenous lipid peroxidation, we have explored pulmonary excretion and dynamism of exhaled breath ethylene during cardiac surgery to test the hypothesis that surgical technique and ischemia-reperfusion triggers lipid peroxidation. We have employed laser photoacoustic spectroscopy to measure real-time trace concentrations of ethylene from the patient breath and from the CPB machine. Patients undergoing aortic or mitral valve surgery-requiring CPB (n = 15) or off-pump coronary artery bypass surgery (OPCAB) (n = 7) were studied. Skin and tissue incision by diathermy caused striking (> 30-fold) increases in exhaled ethylene resulting in elevated levels until CPB. Gaseous ethylene in the CPB circuit was raised upon the establishment of CPB (> 10-fold) and decreased over time. Reperfusion of myocardium and lungs did not appear to enhance ethylene levels significantly. During OPCAB surgery, we have observed increased ethylene in 16 of 30 documented reperfusion events associated with coronary and aortic anastomoses. Therefore, novel real-time monitoring of endogenous lipid peroxidation in the intraoperative setting provides unparalleled detail of endogenous and surgery-triggered production of ethylene. Diathermy and unprotected regional myocardial ischemia and reperfusion are the most significant contributors to increased ethylene.
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Affiliation(s)
- Simona M Cristescu
- Department of Molecular and Laser Physics, Institute of Molecules and Materials, Radboud University, Nijmegen, the Netherlands
| | - Rudolf Kiss
- Department of Anaesthesia, Royal Brompton and Harefield NHS Foundation Trust, Harefield, UK; Section of Anaesthesia, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK
| | | | - Miles Dalby
- Department of Cardiology, Royal Brompton and Harefield NHS Foundation Trust, Harefield, UK
| | - Frans J M Harren
- Department of Molecular and Laser Physics, Institute of Molecules and Materials, Radboud University, Nijmegen, the Netherlands
| | - Terence H Risby
- Department of Environmental Health Sciences, Bloomberg School of Public Health, The Johns Hopkins University, Baltimore, Maryland; and
| | - Nandor Marczin
- Department of Anaesthesia, Royal Brompton and Harefield NHS Foundation Trust, Harefield, UK; Section of Anaesthesia, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK; Centre of Anaesthesia and Intensive Care, Semmelweis University, Budapest, Hungary
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