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Abdel Twab SM, Kamal F, Fouad A. Comparison Between Histidine-Tryptophan-Ketoglutarate Cardioplegia and Cold Blood Cardioplegia for Myocardial Protection in Tetralogy of Fallot Patients Undergoing Surgical Repair: A Randomized Clinical Trial. J Cardiothorac Vasc Anesth 2024:S1053-0770(24)00497-X. [PMID: 39174372 DOI: 10.1053/j.jvca.2024.07.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2024] [Revised: 07/19/2024] [Accepted: 07/21/2024] [Indexed: 08/24/2024]
Abstract
OBJECTIVES This study was conducted to compare the efficacy of histidine-tryptophan-ketoglutarate (HTK) cardioplegia and cold blood cardioplegia (CBC), especially for postoperative right ventricular (RV) function after tetralogy of Fallot repair. DESIGN Randomized, double-blinded, parallel-group, controlled clinical trial. SETTING Ain Shams University Hospitals. PARTICIPANTS A total of 100 children (1 to 5 years old) scheduled for tetralogy of Fallot repair. INTERVENTIONS Patients were allocated (double-blinded 1:1 allocation ratio) to either the HTK group that received HTK cardioplegia (30 mL/kg via antegrade route) or the CBC group that received cold blood cardioplegia with blood-to-Ringer solution (4:1) in a volume of 20 mL/kg. MEASUREMENTS AND MAIN RESULTS The HTK group showed a statistically significant reduction of the vasoactive inotropic score on admission to the pediatric intensive care unit (13.0 ± 4.1) in comparison to the CBC group (15.5 ± 5.4), with a p value of 0.011. However, after 24 hours, the vasoactive-inotropic score was comparable. Lactate level during the first 24 hours was 6.2 ± 0.7 mmol/L in the HTK group and 6.9 ± 0.4 mmol/L in the CBC group (p < 0.0001). Serial troponin measurements were lower in the HTK group (1.49 ± 0.45) compared to the CBC group (1.69 ± 0.18) at the first 72 hours postoperatively (p = 0.005). Postoperative echocardiographic assessment of RV function by means of tricuspid annular plane systolic excursion and myocardial performance index were better in the HTK group than in the CBC grpup (p < 0.05). CONCLUSIONS HTK cardioplegia may offer better cardiac protection to pediatric patients undergoing tetralogy of Fallot repair than our institutional standard CBC with better recovery for the hypertrophic RV.
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Affiliation(s)
- Samar M Abdel Twab
- Department of Anaesthesiology, Intensive Care, and Pain Management, Faculty of Medicine, Ain Shams University, Cairo, Egypt.
| | - Farouk Kamal
- Department of Anaesthesiology, Intensive Care, and Pain Management, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Amr Fouad
- Department of Anaesthesiology, Intensive Care, and Pain Management, Faculty of Medicine, Ain Shams University, Cairo, Egypt
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Yu X, Xiong W, Zhang J, Lin J, Wang B, Huang H, Du L, Xiong J. Comparison of "Huaxi-1" or "histidine-tryptophan-ketoglutarate" cardioplegia in an animal model. Front Cardiovasc Med 2024; 11:1385253. [PMID: 38903973 PMCID: PMC11188422 DOI: 10.3389/fcvm.2024.1385253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Accepted: 05/22/2024] [Indexed: 06/22/2024] Open
Abstract
Background Using a pig model of cardiopulmonary bypass, we compared outcomes after cardioplegia either with our in-house "Huaxi-1" solution containing natural blood and crystalloid or with the entirely crystalloid, commercially available "histidine-tryptophan-ketoglutarate" solution. Methods Cardiopulmonary bypass was established in 12 healthy male pigs, who were randomized to receive a single dose of either Huaxi-1 or entirely crystalloid. All animals were then subjected to whole-heart ischemia for 90 min, followed by 2 h of reperfusion, after which myocardial injury was assessed in terms of cardiac function, myocardial pathology and levels of biomarkers in plasma, while levels of high-energy phosphate in myocardium were assayed using liquid chromatography. Results Animals given Huaxi-1 cardioplegia required significantly less time to be weaned off bypass, they received significantly lower doses of norepinephrine, and they showed significantly higher levels (mean ± SD) of adenosine triphosphate (14 ± 4 vs. 8 ± 2 µg/mg, P = 0.005), adenosine diphosphate (16 ± 2 vs. 13 ± 2 µg/mg, P = 0.046), and total adenine nucleotide (37 ± 4 vs. 30 ± 3 µg/mg, P = 0.006) in myocardium after 2 h of reperfusion. They also showed less severe bleeding, edema and injury to mitochondria and myofibers in myocardium. The two groups did not differ significantly in doses of inotropic drugs received, cardiac output or levels of biomarkers in plasma. Conclusions In this animal model of healthy hearts subjected to 90 min of ischemia, Huaxi-1 cardioplegia may be superior to entirely crystalloid cardioplegia for promoting energy generation and attenuating ischemia/reperfusion injury in myocardium.
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Affiliation(s)
- Xiang Yu
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
| | - Wen Xiong
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
- Department of Anesthesiology, The First Affiliated Hospital of Hunan University of Chinese Medicine, Changsha, Hunan, China
| | - Jie Zhang
- Key Laboratory of Transplant Engineering and Immunology, West China Hospital, Sichuan University, Chengdu, China
| | - Jing Lin
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
| | - Bo Wang
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
| | - Hong Huang
- Chengdu Qingshan Likang Pharmaceutical Co. Ltd., Research and Development Department, Chengdu, Sichuan, China
| | - Lei Du
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
| | - Jiyue Xiong
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
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Lira KB, Delvaux RS, Spadini FA, Hauschild LH, Ceron RO, Anschau F, Kopittke L, Rode J, Rey RAW, Wittke EI, Rombaldi AR, Cambruzzi E, Lopes ERC, Almeida AS. Myocardial protection: comparing histological effects of single-dose cardioplegic solutions-study protocol for a secondary analysis of the CARDIOPLEGIA trial. J Thorac Dis 2024; 16:1480-1487. [PMID: 38505015 PMCID: PMC10944752 DOI: 10.21037/jtd-23-1442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 12/15/2023] [Indexed: 03/21/2024]
Abstract
Background Myocardial protection is crucial for successful cardiac surgery, as it prevents heart muscle damage that can occur during the procedure. Prolonged hypoxia without proper protection can lead to adenosine triphosphate consumption, microvilli loss, blister formation, and edema. Custodiol, del Nido, and modified del Nido are single-dose cardioplegic solutions with proven safety and significance in modern surgery. While each has been independently assessed for patient outcomes, limited research directly compares them. This study aims to compare their myocardial protection using histological analysis. Methods In a double-blind clinical trial, at least 90 patients will be randomly assigned to receive one of the three cardioplegic solutions. Myocardial biopsies will be collected before cardiopulmonary bypass and 15 minutes after reperfusion. The surgical, anesthetic and perfusion techniques will be the same for all patients, following the Institution's standard protocols. Discussion The ideal cardioplegic solution does not exist, and its selection remains challenging for surgeons. In modern surgical practice, understanding the behavior of these solutions and the ischemic tissue damage caused during induced cardiac arrest allows for safer surgical procedures. The results of this clinical trial can help in understanding the behavior of cardioplegic solutions and their tissue effects. Thus, by selecting the best cardioplegic solution, ischemic damage can be minimized, enhancing the effectiveness of this essential technique in cardiac procedures. The study may aid in implementing clinical protocols in several institutions, aiming to choose the solution with a superior myocardial protection profile, increasing safety, and reducing expenses. Trial Registration Brazilian Clinical Trials Registry (ReBEC, http://ensaiosclinicos.gov.br/): RBR-997tqhh. Registered: January 26th, 2022.
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Affiliation(s)
- Kathize Betti Lira
- Department of Cardiovascular Surgery-Postgraduate Program in Cardiovascular Surgery, Nossa Senhora da Conceição Hospital, Porto Alegre, RS, Brazil
- Department of Education and Research-Postgraduate Program in Technology Assessment for the Brazilian National Health System, Conceição Hospital Group, Porto Alegre, RS, Brazil
| | - Renan Senandes Delvaux
- Department of Cardiovascular Surgery-Postgraduate Program in Cardiovascular Surgery, Nossa Senhora da Conceição Hospital, Porto Alegre, RS, Brazil
| | - Felipe Abatti Spadini
- Department of Cardiovascular Surgery-Postgraduate Program in Cardiovascular Surgery, Nossa Senhora da Conceição Hospital, Porto Alegre, RS, Brazil
- Department of Education and Research-Postgraduate Program in Technology Assessment for the Brazilian National Health System, Conceição Hospital Group, Porto Alegre, RS, Brazil
| | - Luis Henrique Hauschild
- Department of Cardiovascular Surgery-Postgraduate Program in Cardiovascular Surgery, Nossa Senhora da Conceição Hospital, Porto Alegre, RS, Brazil
- Department of Education and Research-Postgraduate Program in Technology Assessment for the Brazilian National Health System, Conceição Hospital Group, Porto Alegre, RS, Brazil
| | - Rafael Oliveira Ceron
- Department of Cardiovascular Surgery-Postgraduate Program in Cardiovascular Surgery, Nossa Senhora da Conceição Hospital, Porto Alegre, RS, Brazil
- Department of Cardiovascular Surgery, Nossa Senhora da Conceição Hospital, Porto Alegre, RS, Brazil
| | - Fernando Anschau
- Department of Education and Research-Postgraduate Program in Technology Assessment for the Brazilian National Health System, Conceição Hospital Group, Porto Alegre, RS, Brazil
- Health Technology Assessment Center, Conceição Hospital Group, Porto Alegre, RS, Brazil
| | - Luciane Kopittke
- Department of Education and Research-Postgraduate Program in Technology Assessment for the Brazilian National Health System, Conceição Hospital Group, Porto Alegre, RS, Brazil
- Health Technology Assessment Center, Conceição Hospital Group, Porto Alegre, RS, Brazil
| | - Juarez Rode
- Department of Cardiovascular Surgery-Postgraduate Program in Cardiovascular Surgery, Nossa Senhora da Conceição Hospital, Porto Alegre, RS, Brazil
- Department of Cardiovascular Surgery, Nossa Senhora da Conceição Hospital, Porto Alegre, RS, Brazil
| | - Rafael Antônio Widholzer Rey
- Department of Cardiovascular Surgery-Postgraduate Program in Cardiovascular Surgery, Nossa Senhora da Conceição Hospital, Porto Alegre, RS, Brazil
- Department of Cardiovascular Surgery, Nossa Senhora da Conceição Hospital, Porto Alegre, RS, Brazil
| | - Estefania Inez Wittke
- Department of Cardiovascular Surgery-Postgraduate Program in Cardiovascular Surgery, Nossa Senhora da Conceição Hospital, Porto Alegre, RS, Brazil
- Department of Education and Research-Postgraduate Program in Technology Assessment for the Brazilian National Health System, Conceição Hospital Group, Porto Alegre, RS, Brazil
- Department of Cardiovascular Surgery, Nossa Senhora da Conceição Hospital, Porto Alegre, RS, Brazil
| | - Alfeu Roberto Rombaldi
- Department of Cardiovascular Surgery-Postgraduate Program in Cardiovascular Surgery, Nossa Senhora da Conceição Hospital, Porto Alegre, RS, Brazil
- Department of Cardiovascular Surgery, Nossa Senhora da Conceição Hospital, Porto Alegre, RS, Brazil
| | - Eduardo Cambruzzi
- Department of Pathology, Nossa Senhora da Conceição Hospital, Porto Alegre, RS, Brazil
| | | | - Adriana Silveira Almeida
- Department of Cardiovascular Surgery-Postgraduate Program in Cardiovascular Surgery, Nossa Senhora da Conceição Hospital, Porto Alegre, RS, Brazil
- Department of Education and Research-Postgraduate Program in Technology Assessment for the Brazilian National Health System, Conceição Hospital Group, Porto Alegre, RS, Brazil
- Department of Cardiovascular Surgery, Nossa Senhora da Conceição Hospital, Porto Alegre, RS, Brazil
- Health Technology Assessment Center, Conceição Hospital Group, Porto Alegre, RS, Brazil
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Sun M, Zhang Z, Yin Y, Yu L, Jiang W, Zhang C, Gu C, Ma H, Wang Y. Melatonin enhanced the cardioprotective effects of HTK solution on Langendorff-perfused mouse hearts subjected to ischemia/reperfusion. IRANIAN JOURNAL OF BASIC MEDICAL SCIENCES 2024; 27:366-374. [PMID: 38333753 PMCID: PMC10849209 DOI: 10.22038/ijbms.2023.74152.16109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 10/18/2023] [Indexed: 02/10/2024]
Abstract
Objectives Cardiac arrest is a crucial procedure in various cardiac surgeries, during which the heart is subjected to an ischemic state. The occurrence of ischemia/reperfusion (I/R) injury is inevitable due to aortic blockage and opening. The Histidine-tryptophan-ketoglutarate (HTK) solution is commonly used as an organ protection liquid to mitigate cardiac injury during cardiac surgery. Despite its widespread use, there is significant potential for improving its protective efficacy. Materials and Methods The cardioprotective effect of HTK solution with and without melatonin was evaluated using the isolated Langendorff-perfused mouse heart model. The isolated C57bL/6 mouse hearts were randomly divided into four groups: control, I/R, HTK solution treatment before reperfusion (HTK+I/R), and HTK solution combined with melatonin before reperfusion (HTK+M+I/R). Cardiac function and myocardial injury markers were then measured. AMP-activated protein kinase α2 (AMPKα2) KO mice were used to investigate the underlying mechanism. Results In our study, we found that melatonin significantly improved the protective effects of HTK solution in an isolated Langendorff-perfused mouse model, mechanistically by reducing mitochondrial damage, improving energy metabolism, inhibiting cardiomyocyte apoptosis, and reducing myocardial infarction size. We also observed that the HTK solution alone was ineffective in inhibiting ER stress, but when melatonin was added, there was a significant reduction in ER stress. Furthermore, melatonin was found to alleviate carbonyl stress during cardiac I/R. Interestingly, our results showed that the cardioprotective properties of melatonin were dependent on AMPKα2. Conclusion The findings presented in this study offer a valuable empirical foundation for the development of perioperative cardioprotective strategies.
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Affiliation(s)
- Mingchu Sun
- Institute of Medical Research, Northwestern Polytechnical University, Xi’an Shaanxi, 710072 China
| | - Zihui Zhang
- Institute of Medical Research, Northwestern Polytechnical University, Xi’an Shaanxi, 710072 China
| | - Yue Yin
- Department of Physiology and Pathophysiology, School of Basic Medicine, Fourth Military Medical University, Xi’an, 710032 China
| | - Lu Yu
- Department of Pathology, Xijing Hospital, Fourth Military Medical University, Xi’an 710032, China
| | - Wenhua Jiang
- Institute of Medical Research, Northwestern Polytechnical University, Xi’an Shaanxi, 710072 China
| | - Chan Zhang
- Institute of Medical Research, Northwestern Polytechnical University, Xi’an Shaanxi, 710072 China
| | - Chunhu Gu
- Department of Cardiovascular Surgery, Xijing Hospital, Fourth Military Medical University, Xi’an 710032, China
| | - Heng Ma
- Department of Physiology and Pathophysiology, School of Basic Medicine, Fourth Military Medical University, Xi’an, 710032 China
| | - Yishi Wang
- Department of Physiology and Pathophysiology, School of Basic Medicine, Fourth Military Medical University, Xi’an, 710032 China
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