1
|
Sabe SA, Harris DD, Broadwin M, Sellke FW. Cardioprotection in cardiovascular surgery. Basic Res Cardiol 2024; 119:545-568. [PMID: 38856733 DOI: 10.1007/s00395-024-01062-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2024] [Revised: 05/31/2024] [Accepted: 06/01/2024] [Indexed: 06/11/2024]
Abstract
Since the invention of cardiopulmonary bypass, cardioprotective strategies have been investigated to mitigate ischemic injury to the heart during aortic cross-clamping and reperfusion injury with cross-clamp release. With advances in cardiac surgical and percutaneous techniques and post-operative management strategies including mechanical circulatory support, cardiac surgeons are able to operate on more complex patients. Therefore, there is a growing need for improved cardioprotective strategies to optimize outcomes in these patients. This review provides an overview of the basic principles of cardioprotection in the setting of cardiac surgery, including mechanisms of cardiac injury in the context of cardiopulmonary bypass, followed by a discussion of the specific approaches to optimizing cardioprotection in cardiac surgery, including refinements in cardiopulmonary bypass and cardioplegia, ischemic conditioning, use of specific anesthetic and pharmaceutical agents, and novel mechanical circulatory support technologies. Finally, translational strategies that investigate cardioprotection in the setting of cardiac surgery will be reviewed, with a focus on promising research in the areas of cell-based and gene therapy. Advances in this area will help cardiologists and cardiac surgeons mitigate myocardial ischemic injury, improve functional post-operative recovery, and optimize clinical outcomes in patients undergoing cardiac surgery.
Collapse
Affiliation(s)
- Sharif A Sabe
- Division of Cardiothoracic Surgery, Department of Surgery, Cardiovascular Research Center, Rhode Island Hospital, Rhode Island Hospital, Alpert Medical School of Brown University, 2 Dudley Street, MOC 360, Providence, RI, 02905, USA
| | - Dwight D Harris
- Division of Cardiothoracic Surgery, Department of Surgery, Cardiovascular Research Center, Rhode Island Hospital, Rhode Island Hospital, Alpert Medical School of Brown University, 2 Dudley Street, MOC 360, Providence, RI, 02905, USA
| | - Mark Broadwin
- Division of Cardiothoracic Surgery, Department of Surgery, Cardiovascular Research Center, Rhode Island Hospital, Rhode Island Hospital, Alpert Medical School of Brown University, 2 Dudley Street, MOC 360, Providence, RI, 02905, USA
| | - Frank W Sellke
- Division of Cardiothoracic Surgery, Department of Surgery, Cardiovascular Research Center, Rhode Island Hospital, Rhode Island Hospital, Alpert Medical School of Brown University, 2 Dudley Street, MOC 360, Providence, RI, 02905, USA.
| |
Collapse
|
2
|
Kot TKM, Chan JSK, Froghi S, Lau DHH, Morgan K, Magni F, Harky A. Warm versus cold cardioplegia in cardiac surgery: A meta-analysis with trial sequential analysis. JTCVS OPEN 2021; 6:161-190. [PMID: 36003589 PMCID: PMC9390447 DOI: 10.1016/j.xjon.2021.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 03/17/2021] [Indexed: 11/16/2022]
Abstract
Objective This meta-analysis aimed to compare clinical outcomes of warm and cold cardioplegia in cardiac surgeries in adult patients, with trial sequential analysis (TSA) used to determine the conclusiveness of the results. Methods Electronic searches were performed on PubMed, Medline, Scopus, EMBASE, and Cochrane library to identify all studies that compared warm and cold cardioplegia in cardiac surgeries. Primary end points were in-hospital or 30-day mortality, myocardial infarction, low cardiac output syndrome, intra-aortic balloon pump use, stroke, and new atrial fibrillation. Secondary end points were acute kidney injury, hospital length of stay, and intensive care unit length of stay. Prespecified subgroup analyses were performed for (1) studies published since publication of Fan and colleagues in 2010, (2) randomized controlled studies, (3) studies with low risk of bias, (4) coronary artery bypass graft surgeries, and (5) studies with cold blood versus those with cold crystalloid cardioplegia. TSA was performed to determine conclusiveness of the results, using on all outcomes without significant heterogeneity from studies of low risk of bias. Results No significant differences were found between post-operative rates of mortality, myocardial infarction, low cardiac output syndrome, intra-aortic balloon pump use, stroke, new atrial fibrillation, and acute kidney injury between warm and cold cardioplegia. TSA concluded that current evidence was sufficient to rule out a 20% relative risk reduction in these outcomes. Conclusions Concerning safety outcomes, current evidence suggests that the choice between warm and cold cardioplegia remains in the surgeon's preference.
Collapse
Key Words
- AF, atrial fibrillation
- AKI, acute kidney injury
- CABG, coronary artery bypass graft
- CI, confidence interval
- IABP, intra-aortic balloon pump
- ICU, intensive care unit
- LCOS, low cardiac output syndrome
- LOS, length of stay
- MI, myocardial infarction
- NOS, Newcastle–Ottawa Quality Assessment Scale
- PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses
- RCT, randomized controlled trial
- RR, risk ratio
- TSA, trial sequential analysis
- WMD, weighted mean difference
- cardiac surgeries
- cold cardioplegia
- meta-analysis
- trial sequential analysis
- warm cardioplegia
Collapse
Affiliation(s)
- Thompson Ka Ming Kot
- Faculty of Medicine, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong
- Department of Anaesthesia and Intensive Care, Prince of Wales Hospital, Shatin, New Territories, Hong Kong
| | - Jeffrey Shi Kai Chan
- Faculty of Medicine, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong
- Division of Cardiology, Department of Medicine and Therapeutics, Prince of Wales Hospital, Hong Kong
| | - Saied Froghi
- Division of Surgery and Interventional Sciences, Royal Free Hospital, University College London, London, United Kingdom
| | - Dawnie Ho Hei Lau
- Faculty of Medicine, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong
- Division of Cardiology, Department of Medicine and Therapeutics, Prince of Wales Hospital, Hong Kong
| | - Kara Morgan
- Department of Cardiology, Manchester Royal Infirmary, Manchester, United Kingdom
- Faculty of Biology, Medicine & Health, Division of Pharmacy & Optometry, School of Health Sciences, The University of Manchester, Manchester, United Kingdom
| | - Francesco Magni
- Faculty of Medicine, University College London, London, United Kingdom
| | - Amer Harky
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| |
Collapse
|
3
|
Higher Mortality in Women after Coronary Artery Bypass: Meta-analysis & Bias Analysis of Confounding. Ann Thorac Surg 2020; 113:674-680. [PMID: 33373588 DOI: 10.1016/j.athoracsur.2020.11.039] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 10/30/2020] [Accepted: 11/12/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND Some studies suggest the observed higher mortality in women than men after coronary artery bypass grafting (CABG) is due to confounding. Our meta-analysis aimed to 1) summarize the effect of sex on mortality following CABG and 2) identify whether unmeasured confounding likely explains the apparent higher mortality in women. METHODS MEDLINE, Embase, and CENTRAL databases were searched for studies examining sex and 30-day mortality following CABG. We used random-effects meta-analysis to estimate the summary odds ratio (OR) of mortality in women versus men using 1) unadjusted study results and 2) adjusted study results. Available confounders data from included studies was identified. Using the OR of measured confounders and the risk of death to inform unmeasured confounding effects, we performed bias analysis simulation to correct potential unmeasured confounding in our summary OR. RESULTS From 7138 retrieved studies, 112 were included (N=5,008,262 patients), 25 studies reported adjusted OR (N=770,450 patients). The overall 30-day mortality was 4.9% in women vs. 3.3% in men. The unadjusted summary OR (1.81, 95% CI 1.72 to 1.91) and adjusted summary OR (1.40, 95% CI 1.35 to 1.45) demonstrated that women had an increased risk of 30-day mortality compared to men. Simulations correcting for unmeasured confounding that mostly ranged from 1.05 to 1.80, supporting a higher risk of death in women after CABG. CONCLUSIONS The findings of this review suggest confounding is unlikely to account for the increased risk of mortality in women after CABG and that biological factors have a casual effect.
Collapse
|
4
|
Kiss A, Heber S, Kramer AM, Hackl M, Skalicky S, Hallström S, Podesser BK, Santer D. MicroRNA Expression Profile Changes after Cardiopulmonary Bypass and Ischemia/Reperfusion-Injury in a Porcine Model of Cardioplegic Arrest. Diagnostics (Basel) 2020; 10:diagnostics10040240. [PMID: 32326306 PMCID: PMC7236010 DOI: 10.3390/diagnostics10040240] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Revised: 04/10/2020] [Accepted: 04/16/2020] [Indexed: 12/22/2022] Open
Abstract
Identification of microRNAs (miRNA) associated with cardiopulmonary bypass, cardiac arrest and subsequent myocardial ischemia/reperfusion may unravel novel therapeutic targets and biomarkers. The primary aim of the present study was to investigate the effects of cardiopulmonary bypass and temperature of cardioplegic arrest on myocardial miRNA profile in pigs' left ventricular tissue. We employed next-generation sequencing to analyse miRNA profiles in the following groups: (1) hearts were arrested with antegrade warm St Thomas Hospital No. 2 (STH2) cardioplegia (n = 5; STH2-warm, 37 °C) and (2) cold STH2 (n = 6; STH2-cold, 4 °C) cardioplegia. Sixty min of ischemia was followed by 60 min of on-pump reperfusion with an additional 90 min of off-pump reperfusion. In addition, two groups without cardiac arrest (off-pump and on-pump group; n = 3, respectively) served as additional controls. STH2-warm and STH2-cold cardioplegia revealed no hemodynamic differences. In contrast, coronary venous creatine kinase-myocardial band (CK-MB) levels were significantly lower in pigs receiving STH2-warm cardioplegia (p < 0.05). Principal component analysis revealed that cardiopulmonary bypass and cardioplegic arrest markedly affected miRNAs in left ventricular tissue. Accordingly, ssc-miR-122, ssc-miR-10a-5p, ssc-miR-193a-3p, ssc-miR-499-3p, ssc-miR-374a-5p, ssc-miR-345-5p, ssc-miR-142-3p, ssc-miR-424-5p, ssc-miR-545-3p, ssc-miR-30b-5p, ssc-miR-145-5p, ssc-miR-374b-5p and ssc-miR-139-3p were differently regulated by cardiopulmonary bypass (false discovery rate (FDR) < 0.05 versus off-pump group). However, only ssc-miR-451 was differently expressed between STH2-warm and STH2-cold (FDR < 0.05). These data demonstrate for the first time that cardiopulmonary bypass and temperature of cardioplegic solution affected the expression of miRNAs in left ventricular tissue. In conclusion, specific miRNAs are potential therapeutic targets for limiting ischemia-reperfusion injury in patients undergoing cardiac surgery.
Collapse
Affiliation(s)
- Attila Kiss
- Ludwig Boltzmann Institute for Cardiovascular Research at Center for Biomedical Research, Medical University of Vienna, 1090 Vienna, Austria; (A.K.); (A.-M.K.); (D.S.)
| | - Stefan Heber
- Institute of Physiology, Center for Physiology and Pharmacology, Medical University of Vienna, 1090 Vienna, Austria;
| | - Anne-Margarethe Kramer
- Ludwig Boltzmann Institute for Cardiovascular Research at Center for Biomedical Research, Medical University of Vienna, 1090 Vienna, Austria; (A.K.); (A.-M.K.); (D.S.)
| | | | | | - Seth Hallström
- Division of Physiological Chemistry, Otto Loewi Research Center, Medical University of Graz, 8010 Graz, Austria;
| | - Bruno K. Podesser
- Ludwig Boltzmann Institute for Cardiovascular Research at Center for Biomedical Research, Medical University of Vienna, 1090 Vienna, Austria; (A.K.); (A.-M.K.); (D.S.)
- Correspondence: ; Tel.: +43-1-40400-52210
| | - David Santer
- Ludwig Boltzmann Institute for Cardiovascular Research at Center for Biomedical Research, Medical University of Vienna, 1090 Vienna, Austria; (A.K.); (A.-M.K.); (D.S.)
- Department of Cardiac Surgery, University Hospital Basel, 4031 Basel, Switzerland
| |
Collapse
|
5
|
James TM, Nores M, Rousou JA, Lin N, Stamou SC. Warm Blood Cardioplegia for Myocardial Protection: Concepts and Controversies. Tex Heart Inst J 2020; 47:108-116. [PMID: 32603472 DOI: 10.14503/thij-18-6909] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Warm blood cardioplegia has been an established cardioplegic method since the 1990s, yet it remains controversial in regard to myocardial protection. This review will describe the physiologic and technical concepts behind warm blood cardioplegia, as well as outline the current basic and clinical research that evaluates its usefulness. Controversies regarding this technique will also be reviewed. A long history of experimental data indicates that warm blood cardioplegia is safe and effective and thus suitable myocardial protection during cardiopulmonary bypass surgeries.
Collapse
Affiliation(s)
- Taylor M James
- Graduate Medical Education MD/MPH Program, University of Miami Miller School of Medicine, Miami, Florida 33130
| | - Marcos Nores
- Department of Cardiothoracic Surgery, JFK Medical Center, Atlantis, Florida 33462
| | - John A Rousou
- Department of Cardiothoracic Surgery, Baystate Medical Center, Springfield, Massachusetts 01199
| | - Nicole Lin
- Graduate Medical Education MD/MPH Program, University of Miami Miller School of Medicine, Miami, Florida 33130
| | - Sotiris C Stamou
- Department of Cardiothoracic Surgery, JFK Medical Center, Atlantis, Florida 33462
| |
Collapse
|
6
|
Boening A, Assling-Simon L, Heep M, Boengler K, Niemann B, Schipke J, Mühlfeld C, Grieshaber P. Blood cardioplegia for cardiac surgery in acute myocardial infarction: rat experiments with two widely used solutions. Interact Cardiovasc Thorac Surg 2019; 27:88-94. [PMID: 29452370 DOI: 10.1093/icvts/ivy011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Accepted: 01/06/2018] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVES Blood cardioplegia (BCP) can be used in different ways to protect the heart from ischaemia-reperfusion injury during cardiac surgery. Because there could be differences between warm and cold intermittent cardioplegia with or without warm reperfusion, we investigated the influence of 2 blood cardioplegia solutions on cardiac function, metabolism and infarct size in stable and infarcted rat hearts. METHODS The hearts of 32 male Wistar rats were excised and inserted into a blood-perfused isolated heart apparatus. In 16 hearts, an acute myocardial infarction was induced by ligation of the left anterior descending coronary artery at least 30 min before aortic clamping. After aortic clamping, either Calafiore or Buckberg BCP was administered. During reperfusion, coronary blood flow, left ventricular developed pressure and dp/dt max were recorded, and oxygen consumption and lactate production were determined. The infarct size after 90 min of reperfusion was measured by triphenyl tetrazolium chloride staining. The hearts of rats without infarction were investigated using transmission electron microscopy. RESULTS In hearts without infarction, haemodynamic recovery was similar for Calafiore and Buckberg solutions: left ventricular developed pressure [Cala 62% of baseline (BL), Buck 58% BL] and dp/dt max (Cala 83% BL, Buck 89% BL). Coronary flow, which was slightly less in infarcted hearts, also recovered similarly after the administration of the 2 BCP solutions (Cala 65% BL, Buck 68% BL). During reperfusion, lactate production was similar (Cala 0.85 ml/min, Buck 1.0 ml/min), and the cellular oedema index and mitochondrial swelling were comparable between the 2 groups. In hearts with infarction, left ventricular developed pressure (Cala 58% BL, Buck 56% BL) and dp/dt max (Cala 79% BL, Buck 72% BL) showed similar recovery for reperfusion with Calafiore or Buckberg BCP. In addition, coronary flow recovered similarly (Cala 54% BL, Buck 57% BL). During reperfusion, myocardial oxygen consumption was lower in the Cala (67% BL) than in the Buck (82% BL) group, but lactate production was similar between the Cala (1.1 ml/min) and the Buck (1.1 ml/min) groups. Myocardial infarct size was also similar in the Cala group (24%) and in the Buck group (26%). CONCLUSIONS In stable perfused rat hearts and in an in vitro model of acute myocardial infarction, the 2 BCP solutions offer equally good myocardial protection.
Collapse
Affiliation(s)
- Andreas Boening
- Department of Cardiovascular Surgery, University Hospital Giessen, Giessen, Germany
| | - Lena Assling-Simon
- Department of Cardiovascular Surgery, University Hospital Giessen, Giessen, Germany
| | - Martina Heep
- Department of Cardiovascular Surgery, University Hospital Giessen, Giessen, Germany
| | - Kerstin Boengler
- Department of Physiology, Justus Liebig University, Giessen, Germany
| | - Bernd Niemann
- Department of Cardiovascular Surgery, University Hospital Giessen, Giessen, Germany
| | - Julia Schipke
- Institute of Functional and Applied Anatomy, Hannover Medical School, Hannover, Germany
| | - Christian Mühlfeld
- Institute of Functional and Applied Anatomy, Hannover Medical School, Hannover, Germany
| | - Philippe Grieshaber
- Department of Cardiovascular Surgery, University Hospital Giessen, Giessen, Germany
| |
Collapse
|
7
|
Bouma HR, Mungroop HE, de Geus AF, Huisman DD, Nijsten MW, Mariani MA, Scheeren TW, Burgerhof JG, Henning RH, Epema AH. Acute Kidney Injury Classification Underestimates Long-Term Mortality After Cardiac Valve Operations. Ann Thorac Surg 2018; 106:92-98. [DOI: 10.1016/j.athoracsur.2018.01.066] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Revised: 12/19/2017] [Accepted: 01/22/2018] [Indexed: 10/17/2022]
|
8
|
Abstract
BACKGROUND Despite substantial success in the anesthetic and surgical management of cardiac surgery, patients frequently show postoperative complications and organ dysfunctions. This is highly relevant for mid- to long-term outcomes. OBJECTIVES To evaluate cardioprotective strategies that may offer effective protection in vulnerable cardiac surgery patients. METHODS To demonstrate recent cardioprotective approaches for cardiac surgery patients, aiming to modulate the body's own protective mechanisms in cardiac surgery patients. RESULTS Both cardioplegia and hypothermia belong to the well-established protective strategies during myocardial ischemia. Volatile anesthetics have been repeatedly shown to improve the left ventricular function and reduce the extent of myocardial injury compared to a control group with intravenous anesthesia. Furthermore, patients receiving volatile anesthetics showed a significantly shortened stay in the ICU and in hospital after cardiac surgery. In contrast, numerous other protective strategies failed translation into the clinical practice. Despite the published reduction of troponin release after remote ischemic preconditioning, two recent large-scale randomized multicenter trials were unable to demonstrate a clinical benefit. CONCLUSIONS Beside the use of cardioplegia and hypothermia, the use of volatile anesthetics is well-established during cardiac surgery because of its conditioning and protective properties. Regardless of the promising results derived from experimental studies and small clinical trials, the majority of other approaches failed to translate their findings into the clinic. Therefore, systematic experimental studies are needed to identify potential confounding factors that may affect the protective effects.
Collapse
|