Inflammatory cytokine response and cardiac troponin I changes in cardiopulmonary bypass using two cardioplegia solutions; del Nido and modified St. Thomas': a randomized controlled trial

Does remote ischemic preconditioning affect the systemic inflammatory response by modulating presepsin levels?

OBJECTIVE

We investigated the effect of Remote Ischemic Preconditioning (RIPC) on the inflammatory response during CPB by means of serum presepsin levels at preoperative and postoperative 1st and 24th h.

METHODS

In this prospective, randomized, cross-sectional study we included 81 patients undergoing coronary artery bypass graft surgery with cardiopulmonary bypass (CPB). Patients were randomized and RIPC was applied to 40 patients in the study group before anesthesia. The remaining 41 patients were determined as the control group. The relationships between RIPC and factors such as presepsin, C-reactive protein (CRP), and leukocyte levels were investigated.

RESULTS

There was no significant difference between the groups in postoperative leukocyte and CRP values (p = 0.52, p = 0.13, respectively). When the preoperative and postoperative first hour presepsin values of the patients were compared, no significant difference was found in the control group (p = 0.17), but a significant difference was found in the study group (p < 0.05). When the presepsin values were compared between the groups, a significant difference was found only in the postoperative first hour value (p < 0.05).

CONCLUSIONS

It was observed that RIPC application caused to increase the presepsin levels in the postoperative first hour significantly in the study group (p < 0.05).

The effect of Del Nido versus custodiol cardioplegia on clinical outcomes and troponin-I changes among pediatrics with tetralogy of fallot undergoing cardiopulmonary bypass

BACKGROUND

Myocardial protection during operations with cardiopulmonary bypass (CPB) and aortic cross clamping is vital. For this purpose, Del Nido (DN) and Custodiol cardioplegia (CC) solutions are used for single-dose cardioplegia in cardiac surgical procedures with CPB. Present study aimed to compare the effects of DN and CC on peri-operative clinical outcomes in pediatrics with Tetralogy of Fallot (TF) undergoing cardiopulmonary bypass.

METHODS

Present randomized clinical trial was performed in two trial groups with parallel design. One group received DN and another group received CC. We assessed circulatory Troponin-I (cTnI) and coronary sinus lactate level as primary outcomes. Secondary outcomes were ventilation time, electrolytes levels, pump time, cross-clamp time and other clinical parameters.

RESULTS

Duration of CPB and cross-clamp were the same in both groups. There were no significant differences in hemodynamic parameters, left ventricular ejection fraction after the surgery and discharge time between the two trial groups. Ventilation time (8.5 vs. 18; p = 0.001), ICU stay, Troponin-I in ICU admission and Coronary sinus lactate level (p = 0.001) were significantly higher among patients of Custodiol group compared to other trial group. Electrolytes Na, Cl and K levels, during CPB, were significantly less in Custodiol group.

CONCLUSION

When used for inducing cardiac arrest during CPB, DN solution offers better maintenance of the electrolyte balance during CPB, and is associated with less circulatory cTnI and coronary sinus lactate level compared with the CC.

Which is better for pediatric and adult cardiac surgery: del Nido or St. Thomas cardioplegia? A systematic review and meta-analysis

Background

Although recently it has been extended for use in adult cardiac surgery, del Nido cardioplegia was originally indicated for pediatric cardiac surgery. In this meta-analysis, we compare del Nido cardioplegia vs St. Thomas cardioplegia in pediatric and adult cardiac surgery.

Methods

A comprehensive systematic literature review was performed to identify observational and randomized controlled trials (RCTs) comparing del Nido cardioplegia with St. Thomas cardioplegia. An analysis of both random and fixed effects was conducted. The measure of the effect was by the mean difference (MD) and the risk ratio (RR) with a 95% confidence interval (95% CI).

Results

A total of 1893 patients from 12 studies were included (5 RCTs and 7 observational studies). Compared to St. Thomas solution, del Nido cardioplegia was associated with a shorter aortic cross-clamp in adult cardiac surgery (RCT MD - 19.83, 95% CI - 21.89-17.78; observational - 5.85; 95% CI - 11.59, - 0.11 respectively), but no difference in pediatric cardiac surgery. Additionally, del Nido cardioplegia was associated with lower cardiopulmonary bypass time in both adults (observational, MD - 29.15; 95% CI - 31.76-26.55) and pediatric cardiac surgery (RCTs, MD - 7.15; 95% CI - 13.25-1.05). Defibrillation rates were also significantly lower with del Nido cardioplegia group in both adult (RR 0.35, 95% CI 0.24-0.50, I2 = 50%) and pediatric cardiac surgery (odds ratio (OR) 0.30, 95% CI 0.18-0.49, I2 = 92%).

Conclusion

In both adults and pediatric cardiac surgery, del Nido cardioplegia helps in lowering cardiopulmonary bypass duration, defibrillation rates, and hospital stay, compared to St. Thomas solution. Among adults, del Nido cardioplegia lessens the aortic cross clamp times with no difference observed in all-cause mortality, intensive care unit stay, or mechanical ventilation.

Comparison between Del Nido and conventional blood cardioplegia in pediatric open-heart surgery

BACKGROUND

Del Nido cardioplegia (DNc) was designed for superior myocardial protection during cardiopulmonary bypass (CPB). We conducted a retrospective review to explore if DNc was associated with increase in systemic ventricle dysfunction (sVD) following pediatric CPB.

METHODS AND RESULTS

This single-center, retrospective study included 1534 patients undergoing CPB between 2013 and 2016, 997 prior to center-wide conversion to DNc and 537 following. The primary outcome was new postoperative ≥moderate sVD by echocardiogram. Secondary outcomes included sVD of any severity and right ventricular dysfunction. Data was evaluated by interrupted time-series analysis. Groups had similar cardiac diagnoses and surgical complexity. Del Nido cardioplegia was associated with longer median (IQR) CPB [117 (84-158) vs 108 (81-154), p = 0.04], and aortic cross-clamp [83 (55-119) vs 76 (53-106), p = 0.03], and fewer cardioplegia doses [2 (1-2) vs 3 (2-4), p < 0.0001]. Mortality was similar in both groups. Frequency of sVD was unchanged following DNc, including predetermine subgroups (neonates, infants, and prolonged cross-clamp). Logistic regression showed a significant rise in right ventricular dysfunction (OR 5.886 [95% CI: 0.588, 11.185], p = 0.03) but similar slope.

CONCLUSIONS

Use of DNc was not associated with increased in reported sVD, and provided similar myocardical protection to the systemic ventricle compared to conventional cardioplegia but may possibly impact right ventricular function. Studies evaluating quantitative systolic and diastolic function are needed.

Cardioplegia in Open Heart Surgery: Age Matters

INTRODUCTION

Cardioplegia is a pharmacological approach essential for the protection of the heart from ischemia-reperfusion (I-R) injury. Over the years, numerous cardioplegic solutions have been developed, with each cardioplegic approach having its advantages and disadvantages. Cardioplegic solutions can be divided into crystalloid and blood cardioplegic solutions, and an experienced surgeon chooses the type of solution based on the individual needs of patients in order to provide optimal heart protection. Importantly, the pediatric immature myocardium is structurally, physiologically, and metabolically different from the adult heart, and consequently its needs to achieve cardioplegic arrest strongly differ. Therefore, the present review aimed to provide a summary of the cardioplegic solutions available to pediatric patients with a special focus on emphasizing differences in heart injury after various cardioplegic solutions, the dosing strategies, and regimens.

MATERIAL AND METHODS

The PubMed database was searched using the terms cardioplegia, I-R, and pediatric population, and studies that investigated the influence of cardioplegic strategies on markers of cardiac muscle damage were further analyzed in this review.

CONCLUSIONS

A large body of evidence suggested more prominent benefits achieved with blood compared to those with crystalloid cardioplegia in pediatric myocardium preservation. However, standardized and uniform protocols have not been established so far, and an experienced surgeon chooses the type of cardioplegia solution based on the individual needs of patients, while the severity of myocardial damage strongly depends on the type and duration of the surgical procedure, overall patient condition, and presence of comorbidities, etc.

High-sensitivity cardiac troponins in pediatric population

Apparently healthy children often complain of chest pain, especially after physical exercise. Cardiac biomarker levels are often measured, but the clinical relevance of these assays in children is still debated, even when a cardiac disease is present. Coronary artery disease is exceedingly rare in children, but elevated circulating levels of cardiac troponin I (cTnI) and T (cTnT) in an acute setting may help detect heart failure due to an unknown cardiac disorder, or worsening heart failure, particularly in combination with other biomarkers such as B-type natriuretic peptides. However, the interpretation of biomarkers is often challenging, especially when institutions transition from conventional cTn assays to high-sensitivity (hs-cTn) methods, as well demonstrated in the emergency setting for adult patients. From a clinical perspective, the lack of established reference values in the pediatric age is the main problem limiting the use of hs-cTn methods for the diagnosis and managements of cardiac diseases in infants, children and adolescents. This review aims to discuss the possibility to use hs-cTnI and hs-cTnT to detect cardiac disease and to explore age-related differences in biomarker levels in the pediatric age. We start from some analytical and pathophysiological considerations related to hs-cTn assays. Then, after a systematic literature search, we discuss the current evidence and possible limitations of hs-cTn assay as indicators of cardiac disease in the most frequently cardiac disease in pediatric setting.

Del Nido versus HTK cardioplegia for myocardial protection during adult complex valve surgery: a retrospective study

BACKGROUND

Histidine-tryptophan-ketoglutarate (HTK) and del Nido (DN) cardioplegia are intracellular-type and extracellular-type solution respectively, both can provide a long period of myocardial protection with single-dose infusion, but studies comparing the two are rare for adult cardiac surgery. This study aims to evaluate whether DN is suitable for cardioplegia in complex and high-risk valve surgery with long-term cardiac ischemia when compared with HTK.

METHODS

The perioperative records of adult patients infused with DN/HTK as a cardioplegic solution who underwent complex valve surgery with an expected myocardial ischaemic duration longer than 90 min between Oct 2018 and Oct 2019 were analysed retrospectively.

RESULTS

Of the 160 patients who received DN/HTK and underwent complex valve surgery, we propensity matched 73 pairs. Both groups achieved satisfactory cardiac arrest effects, and no significant difference was found in their cTnI and CK-MB levels within 12 to 72 h postoperatively. The DN group had a higher rate of return to spontaneous rhythm (0.88 v 0.52, P < 0.001), a lower frequency of postoperative severe arrythmias (12% v 26%, P = 0.036), a higher postoperative stroke volume (65 v 59 ml, P = 0.011) and a higher cardiac output (6.0 v 4.9 L/min, P = 0.007) as evaluated by echocardiography, fewer transfusions and shorter ICU stays (both P < 0.05). The two groups had similar inotrope usage and similar incidences of low cardiac output, morbidities and mortality. Subgroup analysis showed that when the aortic clamping time was greater than 120 min, the advantages of DN were weakened.

CONCLUSIONS

DN can be safely applied to complex valve surgery, and it has a similar myocardial protection effect as HTK. Further prospective studies are required to verify these retrospective findings. Trial registration retrospectively registered.

A Cardioplegic Solution with an Understanding of a Cardiochannelopathy

Cardiac surgeries have been improved by accompanying developing cardioplegia solutions. However, the cardioplegia application presents an ongoing challenge with a view of a sufficiently restored cardiac function. In this review, we focus on the cardioplegia-induced mechanism and summarize the findings of studies undertaken to improve cardioprotective strategies. Currently, and somewhat surprisingly, relatively little is known about cardiac electrolyte regulation through channel physiology. We hope that an improved understanding of the electrolyte transport through ion channels/transporters and modulations of water channel aquaporins will provide an insight into cardiac channel physiology and a channel-based cardiac pathology of a cardiochannelopathy.

Initial experience with del Nido cardioplegia solution at a Pediatric and Congenital Cardiac Surgery Program in Brazil

OBJECTIVE

The aim of this study was to evaluate outcome measures between our standard multidose cardioplegia protocol and a del Nido cardioplegia protocol in congenital heart surgery patients.

METHODS

Retrospective single-center study including 250 consecutive patients that received del Nido cardioplegia (DN group) with a mandatory reperfusion period of 30% of cross clamp time and 250 patients that received a modified St. Thomas' solution (ST group). Groups were matched by age, weight, gender, and Risk Adjustment for Congenital Heart Surgery (RACHS-1) scores. Preoperative hematocrit and oxygen saturation were also recorded. Outcomes analyzed were the vasoactive inotropic score (VIS), lactate, ventilation time, ventricular dysfunction with low cardiac output syndrome (LCOS), intensive care unit (ICU) length of stay (LOS), hospital LOS, bypass and aortic cross-clamp times, and in-hospital mortality.

RESULTS

Both groups were comparable demographically. Statistically significant differences (p ⩽ 0.05) were noted for cardiac dysfunction with LCOS, hematocrit at end of surgery (p = 0.0038), VIS on ICU admission and at end of surgery (p = 0.0111), and ICU LOS (p = 0.00118) with patients in the DN group having more desirable values for those parameters. Other outcome measures did not reach statistical significance.

CONCLUSION

In our congenital cardiac surgery population, del Nido cardioplegia strategy was associated with less ventricular dysfunction with LCOS, a lower VIS and decreased ICU LOS compared with patients that received our standard myocardial protection using a modified St. Thomas' solution. Despite the limitation of this study, including its retrospective nature and cohort size, these data supported our transition to incorporate del Nido cardioplegia solution with a mandatory reperfusion period as the preferred myocardial protection method in our program.

International Pediatric Perfusion Practice: 2016 Survey Results

New cardiopulmonary bypass device techniques emerge and are reported in the scientific literature. The extent to which they are actually adopted into clinical practice is not well known. Since 1989, we have periodically surveyed pediatric cardiac centers to ascertain practice patterns. In December 2016, a 186-question perfusion survey was distributed to pediatric cardiac surgery centers all over the world using a Web-based survey tool. Responses were received from 93 North American (NA) centers (the United States and Canada) and 67 non-NA (NNA) centers, representing 19,645 cumulative annual procedures in NA and 27,776 in NNA centers on patients <18 years. Wide variation in practice was evident across geographic regions. However, the most common pediatric circuit consisted of a hard-shell (open) venous reservoir, an arterial roller pump, and a hollow-fiber membrane oxygenator with a separate or integrated arterial filter. Compared with our previous surveys, there was increased utilization of all types of safety devices. The use of an electronic perfusion record was reported by 50% of NA centers and 31% of NNA centers. There was wide regional variation in cardioplegia delivery systems and cardioplegia solutions. Seventy-nine percent of the centers reported the use of some form of modified ultrafiltration. The survey demonstrated that there remains variation in perfusion practice for pediatric patients. Future surveys will be useful to evaluate the adoption of emerging perfusion practice guidelines.

Remote ischemic preconditioning effects on inflammatory markers and myocardial protection in coronary artery bypass graft surgery

BACKGROUND

Induction of short episodes of ischemia to remote organs, namely upper or lower limbs, literally known as remote ischemic preconditioning (RIPC) has been suggested as a preconditioning approach to ameliorate ischemia/reperfusion injury (IRI). RIPC has been demonstrated to effectively protect various vital organs, including heart, against the next ischemic events in preclinical studies. However, human studies are required to approve its clinical applicability. Present study was performed to evaluate the effect of RIPC on the myocardial protection and inflammatory response markers in patients undergoing coronary artery bypass graft surgery.

METHODS

In this randomized clinical trial, 43 coronary artery bypass graft (CABG) patients from Imam Hossein educational hospital were allocated in two groups, RIPC (21 patients) and control (22 patients). Serum level of interleukin (IL)-4, IL-8, and IL-10, interferon (IFN)-γ and Cardiac Troponin-I (cTnI) were measured in (1) after induction of anesthesia (before incision of skin), (2) after separation from CPB and (3) 24 hours after ICU arrival.Results:increase pack cell transfusions were observed in control group in ICU. Serum level of IL-10 at 24 hours after ICU admission was significantly higher in the RIPC group. Significantly lower amounts of IL-8 at post-CPB time were observed in the RIPC group in comparison with control.Conclusion:RIPC regulates the circulatory inflammatory cytokines, IL-8 decrement and IL-10 elevation, which could be translated into protection against IRI. However, further studies with larger sample sizes with careful consideration of parameters such as use of propofol as an anesthetic in the patients should be conducted to consolidate the findings from the current study.

Safety and Effectiveness of Del Nido Cardioplegia in Comparison to Blood-Based St. Thomas Cardioplegia in Congenital Heart Surgeries: A Prospective Randomized Controlled Study

Background:

To compare the safety and effectiveness of del Nido cardioplegia with blood-based St Thomas Hospital (BSTH) cardioplegia in myocardial protection in congenital heart surgery.

Methods:

It is a prospective, open-labeled, randomized controlled study conducted at National Heart Institute, Kuala Lumpur from July 2018 to July 2019. All patients with simple and complex congenital heart diseases (CHD) with good left ventricular function (left ventricular ejection fraction [LVEF] >50%) were included while those with LVEF <50% were excluded. A total of 100 patients were randomized into two groups of 50 each receiving either del Nido or BSTH cardioplegia. Primary end points were the spontaneous return of activity following aortic cross-clamp release and ventricular function between two groups. Secondary end point was myocardial injury as assessed by troponin T levels.

Results:

Cardiopulmonary bypass and aortic cross-clamp time, return of spontaneous cardiac activity following the aortic cross-clamp release, the duration of mechanical ventilation, and intensive care unit stay were comparable between two groups. Statistically significant difference was seen in the amount and number of cardioplegia doses delivered ( P < .001). The hemodilution was significantly less in the del Nido complex CHD group compared to BSTH cardioplegia ( P = .001) but no difference in blood usage ( P = .36). The myocardial injury was lesser (lower troponin T release) with del Nido compared to BSTH cardioplegia ( P = .6).

Conclusion:

Our study showed that both del Nido and BSTH cardioplegia are comparable in terms of myocardial protection. However, single, less frequent, and lesser volume of del Nido cardioplegia makes it more suitable for complex repair.

Serial ultrastructural evaluation of myocardial ischemic injury after infusion of del Nido cardioplegia in the human heart

OBJECTIVES

The safe ischemic time after a single-dose del Nido cardioplegia (DNC) infusion has not yet been established. This study evaluated the progression of myocardial ischemic injury to establish the safe ischemic time after a single-dose DNC infusion in the human heart using a transmission electron microscope.

METHODS

Seven hearts extracted from heart transplant recipients after infusion of 1000 mL single-dose DNC were evaluated. Serial left ventricular myocardial tissue samples were collected every 30 minutes for 180 minutes. Ischemic injuries in the mitochondria and nuclei were scored from 0 to 3 (0 = normal, 0.5 = slight, 1 = moderate, 2 = severe, and 3 = irreversible).

RESULTS

At the time of extraction, 83.5% of the mitochondria were normal. The proportion of mitochondria with moderate ischemic injury increased gradually from 1.4% at extraction to 52.5% at 180 minutes. From 90 minutes to 180 minutes, the proportion of mitochondria with severe and irreversible injury increased from 0.8% to 4.4% and 0.3% to 1.3%, respectively. A significant linear correlation was identified between the average ischemic injury score of mitochondria and ischemic time (P < .001). Most nuclei showed moderate to severe ischemic injury at every time point (61.0%-85.2%). A significant linear correlation was also found between the average ischemic injury score of nuclei and ischemic time (P < .001).

CONCLUSIONS

Myocardial ischemic injury progresses gradually, and irreversible ischemic injury begins to occur 90 minutes after initial DNC infusion in the adult human heart. Therefore, redosing of DNC may be required after 90 minutes of aortic crossclamp time during adult cardiac surgery.

Effect of single-dose crystalloid cardioplegic agent compared to bloody cardioplegic agent in cardiac surgery in children with Tetralogy of Fallot

BACKGROUND

Cardioplegia is one of the main post-operative cardiac protective factors widely used in recent decades in the form of crystalloid (St. Thomas) and bloody solutions [del Nido (DN)]. The purpose of this study was to compare the effect of a crystalloid cardioplegic agent (St. Thomas) with that of a bloody cardioplegic agent (DN) in pediatric cardiac surgery among children with Tetralogy of Fallot (TOF).

METHODS

This study was performed on 60 children with TOF, who were candidates for heart repair surgery. The participants were randomly divided into two groups of crystalloid cardioplegic agent and bloody cardioplegic agent. Operative outcomes such as required time for onset of heart arrest, duration of returning to normal heart rhythm, and cardiopulmonary bypass (CPB) time, and operative complications were compared between the two groups.

RESULTS

The duration of returning to normal heart rhythm (50.43 ± 10.93 seconds vs. 43.03 ± 16.35 seconds; P = 0.044) and duration of inotropy (80.40 ± 27.14 hours vs. 63.20 ± 26.91 hours; P = 0.017) were significantly higher in the DN group compared to the St. Thomas group. However, there were no significant differences between the two groups in terms of heart arrest time, cross-clamp time, CPB time, supplementary lasix time, duration of intubation, and intensive care unit (ICU) and hospital length of stay (LOS) (P > 0.050).

CONCLUSION

The use of St. Thomas cardioplegic solution was more effective in reducing the duration of returning to normal heart rhythm and inotropy compared with DN cardioplegic agent, and a single dose of these two cardioplegic agents can keep the mean cardiac arrest duration within the range of 50-70 minutes. It seems that the use of St. Thomas cardioplegic solution can be suggested in pediatric heart surgery.

Comparison of outcomes of the use of Del Nido and St. Thomas cardioplegia in adult and paediatric cardiac surgery: a systematic review and meta-analysis

Background:

In recent years, the use of del Nido cardioplegia, initially intended for paediatric cardiac surgery, has been extended to adult cardiac surgery in many institutions. Our aim was thus to compare the outcomes of the use of del Nido cardioplegia with that of conventional cardioplegia and discuss its role in both adult and paediatric cardiac surgery.

Method:

A systematic literature search was conducted in August 2019 on Medline (via PubMed), Embase and Cochrane electronic databases according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Any retrospective studies and randomised controlled trials that reported findings comparing the outcomes of the use of del Nido cardioplegia with that of St. Thomas cardioplegia were included.

Results:

We observed shorter aortic cross-clamp time (mean difference: −15.18, confidence interval: −27.21 to −3.15, p = 0.01) and cardiopulmonary bypass time (mean difference: −13.52, confidence interval: −20.64 to −6.39, p = 0.0002) associated with the use of del Nido cardioplegia in adult cardiac surgery as compared to St. Thomas cardioplegia. Defibrillation rates were significantly lower in patients who had been given del Nido cardioplegia, in both adult (relative risk: 0.28, confidence interval: 0.12 to 0.64, p = 0.003) and paediatric patients (relative risk: 0.25, confidence interval: 0.08 to 0.79, p = 0.02).

Conclusion:

Del Nido cardioplegia may be a viable alternative to the use of St. Thomas cardioplegia in both adult and paediatric patients, providing similar postoperative outcomes while also affording the additional advantage of shorter aortic cross-clamp time and cardiopulmonary bypass time (in adult cardiac surgery) and decreased rates of defibrillation (in both adult and paediatric cardiac surgery).

Would Colloidal Gold Nanocarriers Present An Effective Diagnosis Or Treatment For Ischemic Stroke?

INTRODUCTION

This study was conducted to evaluate OX26-PEG-coated gold nanoparticles (GNPs) (OX26@GNPs) as a novel targeted nanoparticulate system on cell survival after ischemic stroke.

MATERIALS AND METHODS

Dynamic light scattering (DLS), zeta sizer, and transmission electron microscopy (TEM) were performed to characterize the OX26@GNPs. The effect of OX26@GNPs on infarct volume, neuronal loss, and necroptosis was evaluated 24 h after reperfusion using 2, 3,5-Triphenyltetrazolium chloride (TTC) staining, Nissl staining and Western blot assay, respectively.

RESULTS

Conjugation of OX26-PEG to the surface of the 25 nm colloidal gold particles increased their size to 32±2 nm, while a zeta potential change of -40.4 to 3.40 mV remarkably increased the stability of the nanoparticles. Most importantly, OX26@GNPs significantly increased the infarcted brain tissue, while bare GNPs and PEGylated GNPs had no effect on the infarct volume. However, our results indicated an extension of necroptotic cell death, followed by cell membrane damage.

CONCLUSION

Collectively, our results showed that the presently formulated OX26@GNPs are not suitable nanocarriers nor contrast agents under oxidative stress for the diagnosis and treatment of ischemic stroke. Moreover, our findings suggest that the cytotoxicity of GNPs in the brain is significantly associated with their surface charge.

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.

Combination therapy profoundly improved skin flap survival by modulating KATP channels and nitric oxide

PURPOSE

A potential therapeutic approach on skin flap necrosis is to target parallel pathways involved in necrosis. Azelaic Acid, Minoxidil and Caffeine combination was tried on skin flap survival by their possible interaction with ATP sensitive potassium (KATP) channels and nitric oxide pathway.

MATERIAL AND METHODS

Sprauge-Dawley rats were divided into 8 groups for skin flap surgery. Azelaic acid, minoxidil, caffeine, or their combination were applied topically in different groups. Two additional groups were treated with L-NAME or glibenclamide in addition to the combination therapy. Percentage of flap necrosis was calculated and flap samples were removed to measure tissue malondialdehyde (MDA) and nitric oxide (NO) and expression of inducible nitric oxide synthase (iNOS), Bcl-2 and Bax proteins.

RESULTS

Combination therapy profoundly decreased skin flap necrosis, tissue MDA contents, and expression of the pro-apoptotic protein Bax (p < 0.05 vs. single treatments). These effects were reversed by L-NAME and glibenclamide pre-treatments. Further evaluations showed combination therapy increases flap tissue NO content and iNOS expression (p < 0.05 vs. single treatments).

CONCLUSION

Beneficial effect of the combination therapy with azelaic acid, minoxidil and caffeine therapy on rescuing the flap from necrosis by targeting parallel signaling pathways suggested potential applications in clinical practice.

Comparison of del Nido Cardioplegia with Blood Cardioplegia in Coronary Artery Bypass Grafting Combined with Mitral Valve Replacement

OBJECTIVE

To compare del Nido cardioplegia (DNC) with blood cardioplegia (BC) in coronary artery bypass grafting (CABG) combined with mitral valve replacement.

METHODS

A 3-year single-center retrospective cohort study was carried out. Subjects who underwent CABG (up to triple bypass) combined with mitral valve replacement were divided into DNC and BC groups. Each group had thirty subjects.

RESULTS

Both groups demonstrated similar baseline characteristics, including age, gender, cardiac/non-cardiac comorbidity, and preoperative echocardiographic parameters. Compared with the BC group, the DNC group demonstrated significantly lower cardioplegia volume (BC = 1130.00±194.1 mL, DNC = 884.33±156.8 mL, P=0.001), cardiopulmonary bypass time (DNC = 110.90±12.52 min, BC = 121.70±13.57 min, P=0.002), aortic clamp time (DNC = 91.37±11.58 min, BC = 101.37±13.87 min, P=0.004), and need for intraoperative defibrillation (DNC = 6 events, BC = 21 events, P=0.001). Postoperative creatine kinase-MB levels and troponin levels were significantly lower in the DNC group than in the BC group. Postoperative haemoglobin and haematocrit levels were significantly higher in the DNC group than in the BC group. The intubation period (hours) in intensive care unit (ICU) was significantly small in the BC group (DNC = 8.13±12.21, BC = 6.82±1.57, P=0.037); however, ICU stay, total hospital stay, and postoperative complication rates were not significantly different between them. At pre-discharge echocardiography, the DNC group demonstrated significantly higher ejection fraction rates than the BC group (47.79±5.50 and 45.72±5.86, respectively, P=0.005).

CONCLUSION

DNC presented better intraoperative and postoperative parameters and it is an effective and safe alternative to BC for CABG combined with mitral valve replacement.

Mesenchymal stem cells from human amniotic membrane differentiate into cardiomyocytes and endothelial-like cells without improving cardiac function after surgical administration in rat model of chronic heart failure

Introduction: Human amnion-derived mesenchymal stem cells (hAMSCs) have been used in the treatment of acute myocardial infarction. In the current study, we investigated the efficacy of hAMSCs for the treatment of chronic model of myocardial ischemia and heart failure (HF) in rats. Methods: Male Wistar rats weighing between 250 to 350 g were randomized into three groups: sham, HF control and HF+hAMSCs. For HF induction, animals were anesthetized and underwent left anterior descending artery ligation. In HF+hAMSCs group, 2×106 cells were injected into the left ventricular muscle four weeks post ischemia in the border zone of the ischemic area. Cardiac function was studied using echocardiography. Masson's trichrome staining was used for studying tissue fibrosis. Cells were transduced with green fluorescent protein (GFP) coding lentiviral vector. Immunohistochemistry was used for detecting GFP, vascular-endothelial growth factor (VEGF) and troponin T markers in the tissue sections. Results: Assessment of the cardiac function revealed no improvement in the myocardial function compared to the control HF group. Moreover, tissue fibrosis was similar in two groups. Immunohistochemical study revealed the homing of the injected hAMSCs to the myocardium. Cells were stained positive for VEGF and troponin T markers. Conclusion: injection of hAMSCs 4 weeks after ischemia does not improve cardiac function and cardiac muscle fibrosis, although the cells show markers of differentiation into vascular endothelial cells and cardiomyocytes. In sum, it appears that hAMSCs are effective in the early phases of myocardial ischemia and does not offer a significant advantage in patients with chronic HF.

Del Nido cardioplegia - what is the current evidence?

Del Nido cardioplegia is believed to be both clinically and economically efficient. The interest in this myocardial protection method has been continuously growing. However, the evidence is not clear. The article summarizes recent reports regarding del Nido cardioplegia.