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Pieri M, Dormio S, Morosato M, Belletti A, Silvestri D, Montorfano M, Monaco F. Shaping the Anesthetic Approach to TricValve Implantation: Insights From a Case Series. J Cardiothorac Vasc Anesth 2024; 38:911-917. [PMID: 38281824 DOI: 10.1053/j.jvca.2024.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 11/29/2023] [Accepted: 01/03/2024] [Indexed: 01/30/2024]
Abstract
OBJECTIVES Caval valve implantation (CAVI) represents a minimally invasive strategy for managing severe tricuspid regurgitation in high-risk patients unsuitable for surgical or transcatheter tricuspid valve implantation. This case series aimed to assess the anesthesia management challenges and outcomes associated with this procedure, seeking to generate insights that can inform and refine anesthesia protocols. DESIGN A case series. SETTING At a cardiac catheterization laboratory of a teaching hospital. PARTICIPANTS Eight patients undergoing CAVI with the Tricvalve system INTERVENTIONS: The anesthetic protocol included preprocedural planning, fast-track general anesthesia, and postprocedural debriefing. Intraoperative management involved anesthesia depth monitoring, real-time guidance via transesophageal echocardiography, and hemodynamic stability maintenance. Postoperative analgesia involved preemptive intravenous paracetamol and morphine as needed. MEASUREMENTS AND MAIN RESULTS No anesthesia-related or implantation-related complications were observed, with a mean procedure duration of 112 ± 44 minutes. The median hospital stay was 4 days, and only 1 patient required brief intensive care unit monitoring. Postoperative right shoulder pain was reported by half of the patients, and was managed with morphine bolus administration (average dose 4.75 ± 3.6 mg). All patients had the device correctly positioned, as confirmed by postoperative transthoracic echocardiograms. None of the patients required outpatient analgesic therapy upon discharge. CONCLUSIONS The authors' study demonstrated the potential of TricValve implantation in effectively managing severe tricuspid regurgitation with no procedure-related complications and a 100% survival rate. A collaborative, interdisciplinary approach and targeted anesthesia management proved crucial for this success. Postoperative shoulder pain emerged as a frequent complication, whose pathogenesis is still not clear, and successfully was managed using targeted analgesic therapy.
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Affiliation(s)
- Marina Pieri
- Department of Cardiothoracic and Vascular Surgery, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Sara Dormio
- Department of Cardiothoracic and Vascular Surgery, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Michele Morosato
- Cardiothoracic Department, IRCCS San Raffaele Hospital, Milan, Italy
| | - Alessandro Belletti
- Department of Cardiothoracic and Vascular Surgery, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Dario Silvestri
- Interventional Cardiology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Matteo Montorfano
- Vita-Salute San Raffaele University, Milan, Italy; Interventional Cardiology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Fabrizio Monaco
- Department of Cardiothoracic and Vascular Surgery, IRCCS San Raffaele Scientific Institute, Milan, Italy.
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Heusch G, Andreadou I, Bell R, Bertero E, Botker HE, Davidson SM, Downey J, Eaton P, Ferdinandy P, Gersh BJ, Giacca M, Hausenloy DJ, Ibanez B, Krieg T, Maack C, Schulz R, Sellke F, Shah AM, Thiele H, Yellon DM, Di Lisa F. Health position paper and redox perspectives on reactive oxygen species as signals and targets of cardioprotection. Redox Biol 2023; 67:102894. [PMID: 37839355 PMCID: PMC10590874 DOI: 10.1016/j.redox.2023.102894] [Citation(s) in RCA: 24] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 09/04/2023] [Accepted: 09/15/2023] [Indexed: 10/17/2023] Open
Abstract
The present review summarizes the beneficial and detrimental roles of reactive oxygen species in myocardial ischemia/reperfusion injury and cardioprotection. In the first part, the continued need for cardioprotection beyond that by rapid reperfusion of acute myocardial infarction is emphasized. Then, pathomechanisms of myocardial ischemia/reperfusion to the myocardium and the coronary circulation and the different modes of cell death in myocardial infarction are characterized. Different mechanical and pharmacological interventions to protect the ischemic/reperfused myocardium in elective percutaneous coronary interventions and coronary artery bypass grafting, in acute myocardial infarction and in cardiotoxicity from cancer therapy are detailed. The second part keeps the focus on ROS providing a comprehensive overview of molecular and cellular mechanisms involved in ischemia/reperfusion injury. Starting from mitochondria as the main sources and targets of ROS in ischemic/reperfused myocardium, a complex network of cellular and extracellular processes is discussed, including relationships with Ca2+ homeostasis, thiol group redox balance, hydrogen sulfide modulation, cross-talk with NAPDH oxidases, exosomes, cytokines and growth factors. While mechanistic insights are needed to improve our current therapeutic approaches, advancements in knowledge of ROS-mediated processes indicate that detrimental facets of oxidative stress are opposed by ROS requirement for physiological and protective reactions. This inevitable contrast is likely to underlie unsuccessful clinical trials and limits the development of novel cardioprotective interventions simply based upon ROS removal.
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Affiliation(s)
- Gerd Heusch
- Institute for Pathophysiology, West German Heart and Vascular Center, University of Duisburg-Essen, Essen, Germany.
| | - Ioanna Andreadou
- Laboratory of Pharmacology, Faculty of Pharmacy, National and Kapodistrian University of Athens, Athens, Greece
| | - Robert Bell
- The Hatter Cardiovascular Institute, University College London, London, United Kingdom
| | - Edoardo Bertero
- Chair of Cardiovascular Disease, Department of Internal Medicine and Specialties, University of Genova, Genova, Italy
| | - Hans-Erik Botker
- Department of Cardiology, Institute for Clinical Medicine, Aarhus University, Aarhus N, Denmark
| | - Sean M Davidson
- The Hatter Cardiovascular Institute, University College London, London, United Kingdom
| | - James Downey
- Department of Physiology, University of South Alabama, Mobile, AL, USA
| | - Philip Eaton
- William Harvey Research Institute, Queen Mary University of London, Heart Centre, Charterhouse Square, London, United Kingdom
| | - Peter Ferdinandy
- Department of Pharmacology and Pharmacotherapy, Semmelweis University, Budapest, Hungary; Pharmahungary Group, Szeged, Hungary
| | - Bernard J Gersh
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Mauro Giacca
- School of Cardiovascular and Metabolic Medicine & Sciences, King's College, London, United Kingdom
| | - Derek J Hausenloy
- The Hatter Cardiovascular Institute, University College London, London, United Kingdom; Cardiovascular & Metabolic Disorders Program, Duke-National University of Singapore Medical School, National Heart Research Institute Singapore, National Heart Centre, Yong Loo Lin School of Medicine, National University Singapore, Singapore
| | - Borja Ibanez
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), IIS-Fundación Jiménez Díaz University Hospital, and CIBERCV, Madrid, Spain
| | - Thomas Krieg
- Department of Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Christoph Maack
- Department of Translational Research, Comprehensive Heart Failure Center, University Clinic Würzburg, Würzburg, Germany
| | - Rainer Schulz
- Institute for Physiology, Justus-Liebig -Universität, Giessen, Germany
| | - Frank Sellke
- Division of Cardiothoracic Surgery, Alpert Medical School of Brown University and Rhode Island Hospital, Providence, RI, USA
| | - Ajay M Shah
- King's College London British Heart Foundation Centre of Excellence, London, United Kingdom
| | - Holger Thiele
- Heart Center Leipzig at University of Leipzig and Leipzig Heart Science, Leipzig, Germany
| | - Derek M Yellon
- The Hatter Cardiovascular Institute, University College London, London, United Kingdom
| | - Fabio Di Lisa
- Dipartimento di Scienze Biomediche, Università degli studi di Padova, Padova, Italy.
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Kleinbongard P, Lieder HR, Skyschally A, Heusch G. No robust reduction of infarct size and no-reflow by metoprolol pretreatment in adult Göttingen minipigs. Basic Res Cardiol 2023; 118:23. [PMID: 37289247 PMCID: PMC10250284 DOI: 10.1007/s00395-023-00993-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 05/09/2023] [Accepted: 05/20/2023] [Indexed: 06/09/2023]
Abstract
Whereas prior experiments in juvenile pigs had reported infarct size reduction by intravenous metoprolol early during myocardial ischaemia, two major clinical trials in patients with reperfused acute myocardial infarction were equivocal. We, therefore, went back and tested the translational robustness of infarct size reduction by metoprolol in minipigs. Using a power analysis-based prospective design, we pretreated 20 anaesthetised adult Göttingen minipigs with 1 mg kg-1 metoprolol or placebo and subjected them to 60-min coronary occlusion and 180-min reperfusion. Primary endpoint was infarct size (triphenyl tetrazolium chloride staining) as a fraction of area at risk; no-reflow area (thioflavin-S staining) was a secondary endpoint. There was no significant reduction in infarct size (46 ± 8% of area at risk with metoprolol vs. 42 ± 8% with placebo) or area of no-reflow (19 ± 21% of infarct size with metoprolol vs. 15 ± 23% with placebo). However, the inverse relationship between infarct size and ischaemic regional myocardial blood flow was modestly, but significantly shifted downwards with metoprolol, whereas ischaemic blood flow tended to be reduced by metoprolol. With an additional dose of 1 mg kg-1 metoprolol after 30-min ischaemia in 4 additional pigs, infarct size was also not reduced (54 ± 9% vs. 46 ± 8% in 3 contemporary placebo, n.s.), and area of no-reflow tended to be increased (59 ± 20% vs. 29 ± 12%, n.s.).Infarct size reduction by metoprolol in pigs is not robust, and this result reflects the equivocal clinical trials. The lack of infarct size reduction may be the result of opposite effects of reduced infarct size at any given blood flow and reduced blood flow, possibly through unopposed alpha-adrenergic coronary vasoconstriction.
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Affiliation(s)
- Petra Kleinbongard
- Institute for Pathophysiology, West German Heart and Vascular Center, University of Essen Medical School, University of Duisburg-Essen, Hufelandstr. 55, 45147, Essen, Germany
| | - Helmut Raphael Lieder
- Institute for Pathophysiology, West German Heart and Vascular Center, University of Essen Medical School, University of Duisburg-Essen, Hufelandstr. 55, 45147, Essen, Germany
| | - Andreas Skyschally
- Institute for Pathophysiology, West German Heart and Vascular Center, University of Essen Medical School, University of Duisburg-Essen, Hufelandstr. 55, 45147, Essen, Germany
| | - Gerd Heusch
- Institute for Pathophysiology, West German Heart and Vascular Center, University of Essen Medical School, University of Duisburg-Essen, Hufelandstr. 55, 45147, Essen, Germany.
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Li J, Wang X, Liu W, Wen S, Li X. Remote ischemic preconditioning and clinical outcomes after pediatric cardiac surgery: a systematic review and meta-analysis. BMC Anesthesiol 2023; 23:105. [PMID: 37005591 PMCID: PMC10067320 DOI: 10.1186/s12871-023-02064-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Accepted: 03/22/2023] [Indexed: 04/04/2023] Open
Abstract
BACKGROUND The benefit of remote ischemia preconditioning (RIPreC) in pediatric cardiac surgery is unclear. The objective of this systematic review and meta-analysis was to examine the effectiveness of RIPreC in reducing the duration of mechanical ventilation and intensive care unit (ICU) length of stay after pediatric cardiac surgery. METHODS We searched PubMed, EMBASE and the Cochrane Library from inception to December 31, 2022. Randomized controlled trials comparing RIPreC versus control in children undergoing cardiac surgery were included. The risk of bias of included studies was assessed using the Risk of Bias 2 (RoB 2) tool. The outcomes of interest were postoperative duration of mechanical ventilation and ICU length of stay. We conducted random-effects meta-analysis to calculate weighted mean difference (WMD) with 95% confidence interval (CI) for the outcomes of interest. We performed sensitivity analysis to examine the influence of intraoperative propofol use. RESULTS Thirteen trials enrolling 1,352 children were included. Meta-analyses of all trials showed that RIPreC did not reduce postoperative duration of mechanical ventilation (WMD -5.35 h, 95% CI -12.12-1.42) but reduced postoperative ICU length of stay (WMD -11.48 h, 95% CI -20.96- -2.01). When only trials using propofol-free anesthesia were included, both mechanical ventilation duration (WMD -2.16 h, 95% CI -3.87- -0.45) and ICU length of stay (WMD -7.41 h, 95% CI -14.77- -0.05) were reduced by RIPreC. The overall quality of evidence was moderate to low. CONCLUSIONS The effects of RIPreC on clinical outcomes after pediatric cardiac surgery were inconsistent, but both postoperative mechanical ventilation duration and ICU length of stay were reduced in the subgroup of children not exposed to propofol. These results suggested a possible interaction effect of propofol. More studies with adequate sample size and without intraoperative propofol use are needed to define the role of RIPreC in pediatric cardiac surgery.
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Affiliation(s)
- Jianwen Li
- Departments of Anesthesiology, DongGuan SongShan Lake Tungwah Hospital, DongGuan, China
| | - Xiwen Wang
- Departments of Anesthesiology, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Wengui Liu
- Departments of Anesthesiology, DongGuan SongShan Lake Tungwah Hospital, DongGuan, China
| | - Shihong Wen
- Departments of Anesthesiology, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China.
| | - Xueping Li
- Departments of Anesthesiology, DongGuan SongShan Lake Tungwah Hospital, DongGuan, China.
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Kleinbongard P, Lieder HR, Skyschally A, Alloosh M, Gödecke A, Rahmann S, Sturek M, Heusch G. Non-responsiveness to cardioprotection by ischaemic preconditioning in Ossabaw minipigs with genetic predisposition to, but without the phenotype of the metabolic syndrome. Basic Res Cardiol 2022; 117:58. [PMID: 36374343 PMCID: PMC9652280 DOI: 10.1007/s00395-022-00965-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 10/05/2022] [Accepted: 10/13/2022] [Indexed: 11/13/2022]
Abstract
The translation of successful preclinical and clinical proof-of-concept studies on cardioprotection to the benefit of patients with reperfused acute myocardial infarction has been difficult so far. This difficulty has been attributed to confounders which patients with myocardial infarction typically have but experimental animals usually not have. The metabolic syndrome is a typical confounder. We hypothesised that there may also be a genuine non-responsiveness to cardioprotection and used Ossabaw minipigs which have the genetic predisposition to develop a diet-induced metabolic syndrome, but before they had developed the diseased phenotype. Using a prospective study design, a reperfused acute myocardial infarction was induced in 62 lean Ossabaw minipigs by 60 min coronary occlusion and 180 min reperfusion. Ischaemic preconditioning by 3 cycles of 5 min coronary occlusion and 10 min reperfusion was used as cardioprotective intervention. Ossabaw minipigs were stratified for their single nucleotide polymorphism as homozygous for valine (V/V) or isoleucine (I/I)) in the γ-subunit of adenosine monophosphate-activated protein kinase. Endpoints were infarct size and area of no-reflow. Infarct size (V/V: 54 ± 8, I/I: 54 ± 13% of area at risk, respectively) was not reduced by ischaemic preconditioning (V/V: 55 ± 11, I/I: 46 ± 11%) nor was the area of no-reflow (V/V: 57 ± 18, I/I: 49 ± 21 vs. V/V: 57 ± 21, I/I: 47 ± 21% of infarct size). Bioinformatic comparison of the Ossabaw genome to that of Sus scrofa and Göttingen minipigs identified differences in clusters of genes encoding mitochondrial and inflammatory proteins, including the janus kinase (JAK)-signal transducer and activator of transcription (STAT) pathway. The phosphorylation of STAT3 at early reperfusion was not increased by ischaemic preconditioning, different from the established STAT3 activation by cardioprotective interventions in other pig strains. Ossabaw pigs have not only the genetic predisposition to develop a metabolic syndrome but also are not amenable to cardioprotection by ischaemic preconditioning.
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Affiliation(s)
- Petra Kleinbongard
- Institute for Pathophysiology, West German Heart and Vascular Center, University of Essen Medical School, University of Duisburg-Essen, Hufelandstr. 55, 45147, Essen, Germany
| | - Helmut Raphael Lieder
- Institute for Pathophysiology, West German Heart and Vascular Center, University of Essen Medical School, University of Duisburg-Essen, Hufelandstr. 55, 45147, Essen, Germany
| | - Andreas Skyschally
- Institute for Pathophysiology, West German Heart and Vascular Center, University of Essen Medical School, University of Duisburg-Essen, Hufelandstr. 55, 45147, Essen, Germany
| | - Mouhamad Alloosh
- Department of Anatomy, Cell Biology, and Physiology, Indiana University School of Medicine, Indianapolis, USA
| | - Axel Gödecke
- Institute for Cardiovascular Physiology, University Hospital and Heinrich-Heine University, Düsseldorf, Germany
| | - Sven Rahmann
- Algorithmic Bioinformatics, Center for Bioinformatics and Department of Computer Science, Saarland University, Saarbrücken, Germany
| | - Michael Sturek
- Department of Anatomy, Cell Biology, and Physiology, Indiana University School of Medicine, Indianapolis, USA
| | - Gerd Heusch
- Institute for Pathophysiology, West German Heart and Vascular Center, University of Essen Medical School, University of Duisburg-Essen, Hufelandstr. 55, 45147, Essen, Germany.
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Makkad B, Heinke TL, Kertai MD. Inhalational or total intravenous anesthetic for cardiac surgery: does the debate even exist? Curr Opin Anaesthesiol 2022; 35:18-35. [PMID: 34873076 DOI: 10.1097/aco.0000000000001087] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW Perioperative myocardial injury related to cardiac surgery is associated with organ dysfunction and increased mortality. Volatile anesthetics (VA) have been used during cardiac surgery for decades because of their direct and indirect preconditioning and protection against ischemia-reperfusion injury. The current review provides a summary of the latest literature comparing pharmacological preconditioning and the potential benefits of using VA versus total intravenous anesthesia (TIVA) for general anesthesia to improve outcomes after cardiac surgery. RECENT FINDINGS Recent literature reports lower mortality and better outcomes when VA is used alone or in combination with remote ischemic preconditioning compared with groups receiving TIVA. However, inconsistent research findings over the years have led to continued debate regarding the anesthetic technique considered more favorable for cardiac surgery. SUMMARY Research findings regarding the use of volatile anesthetic versus TIVA for better outcomes after cardiac surgery are inconsistent. Variability in timing, duration, dosing, and type of VA as well as surgical and patient-related factors may have influenced these results. Therefore, either technique can reasonably be adopted depending on provider and institutional preference and used safely in patients undergoing cardiac surgery.
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Affiliation(s)
- Benu Makkad
- Department of Anesthesiology, University of Cincinnati Medical Center, Cincinnati, Ohio
| | - Timothy Lee Heinke
- Department of Anesthesia and Perioperative Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Miklos D Kertai
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Lieder HR, Tüller P, Braczko F, Zandi A, Kamler M, Thielmann M, Heusch G, Kleinbongard P. Bioassays of Humoral Cardioprotective Factors Released by Remote Ischemic Conditioning in Patients Undergoing Coronary Artery Bypass Surgery. J Cardiovasc Pharmacol Ther 2022; 27:10742484221097273. [PMID: 35510644 DOI: 10.1177/10742484221097273] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Remote ischemic conditioning (RIC) induces the release of circulating cardioprotective factors and attenuates myocardial ischemia/reperfusion injury. Evidence for such humoral cardioprotective factor(s) is derived from transfer with plasma (derivatives) from one individual undergoing RIC to another individual's heart, even across species. With transfer into an isolated perfused heart, only a single plasma (derivative) sample can be studied with infarct size as endpoint, and therefore the comparison of samples before and after RIC or between RIC and placebo is hampered by the inter-individual variation of infarct sizes in isolated perfused hearts. We therefore developed a preparation of cardiomyocytes from a single mouse heart, where aliquots of the same heart can undergo hypoxia/reoxygenation (H/R) with exposure to buffer, RIC, or placebo samples without or with pharmacological blockade. To validate this approach, we used plasma dialysates taken before and after RIC from patients undergoing coronary bypass grafting who had experienced protection by RIC (troponin release ↓ by 28% vs placebo). The cardiomyocyte bioassay had little variation after H/R with buffer (mean ± standard deviation; 7% ± 2% viable cells) and demonstrated preserved viability after RIC (15% ± 5% vs 6% ± 3% before). For comparison, infarct size in isolated mouse hearts after global ischemia and reperfusion was 22% ± 14% of left ventricular mass after versus 42% ± 14% before RIC. Stattic, an inhibitor of signal transducer and activator of transcription (STAT)3 protein, abrogated protection in the cardiomyocytes. We have thus established a cardiomyocyte bioassay to analyze RIC's protection which minimizes inter-individual variation and the use of animals.
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Affiliation(s)
- Helmut Raphael Lieder
- Institute for Pathophysiology, West German Heart and Vascular Center, 123109University of Essen Medical School, Essen, Germany
| | - Pia Tüller
- Institute for Pathophysiology, West German Heart and Vascular Center, 123109University of Essen Medical School, Essen, Germany
| | - Felix Braczko
- Institute for Pathophysiology, West German Heart and Vascular Center, 123109University of Essen Medical School, Essen, Germany
| | - Afsaneh Zandi
- Heart Center Essen-Huttrop, West German Heart and Vascular Center, 123109University of Essen Medical School, Essen, Germany
| | - Markus Kamler
- Heart Center Essen-Huttrop, West German Heart and Vascular Center, 123109University of Essen Medical School, Essen, Germany.,Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center, 123109University of Essen Medical School, Essen, Germany
| | - Matthias Thielmann
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center, 123109University of Essen Medical School, Essen, Germany
| | - Gerd Heusch
- Institute for Pathophysiology, West German Heart and Vascular Center, 123109University of Essen Medical School, Essen, Germany
| | - Petra Kleinbongard
- Institute for Pathophysiology, West German Heart and Vascular Center, 123109University of Essen Medical School, Essen, Germany
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Response to the Comment on "Effect of Remote Ischemic Preconditioning Conducted in Living Liver Donors on Postoperative Liver Function in Donors and Recipients Following Liver Transplantation: A Randomized Clinical Trial". Ann Surg 2021; 274:e710-e711. [PMID: 32224735 DOI: 10.1097/sla.0000000000003865] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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9
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Comità S, Femmino S, Thairi C, Alloatti G, Boengler K, Pagliaro P, Penna C. Regulation of STAT3 and its role in cardioprotection by conditioning: focus on non-genomic roles targeting mitochondrial function. Basic Res Cardiol 2021; 116:56. [PMID: 34642818 PMCID: PMC8510947 DOI: 10.1007/s00395-021-00898-0] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 09/23/2021] [Accepted: 09/27/2021] [Indexed: 12/11/2022]
Abstract
Ischemia–reperfusion injury (IRI) is one of the biggest challenges for cardiovascular researchers given the huge death toll caused by myocardial ischemic disease. Cardioprotective conditioning strategies, namely pre- and post-conditioning maneuvers, represent the most important strategies for stimulating pro-survival pathways essential to preserve cardiac health. Conditioning maneuvers have proved to be fundamental for the knowledge of the molecular basis of both IRI and cardioprotection. Among this evidence, the importance of signal transducer and activator of transcription 3 (STAT3) emerged. STAT3 is not only a transcription factor but also exhibits non-genomic pro-survival functions preserving mitochondrial function from IRI. Indeed, STAT3 is emerging as an influencer of mitochondrial function to explain the cardioprotection phenomena. Studying cardioprotection, STAT3 proved to be crucial as an element of the survivor activating factor enhancement (SAFE) pathway, which converges on mitochondria and influences their function by cross-talking with other cardioprotective pathways. Clearly there are still some functional properties of STAT3 to be discovered. Therefore, in this review, we highlight the evidence that places STAT3 as a promoter of the metabolic network. In particular, we focus on the possible interactions of STAT3 with processes aimed at maintaining mitochondrial functions, including the regulation of the electron transport chain, the production of reactive oxygen species, the homeostasis of Ca2+ and the inhibition of opening of mitochondrial permeability transition pore. Then we consider the role of STAT3 and the parallels between STA3/STAT5 in cardioprotection by conditioning, giving emphasis to the human heart and confounders.
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Affiliation(s)
- Stefano Comità
- Department of Clinical and Biological Sciences, University of Turin, Regione Gonzole 10, Orbassano, 10043, Torino, TO, Italy
| | - Saveria Femmino
- Department of Medical Sciences, University of Turin, Torino, Italy
| | - Cecilia Thairi
- Department of Clinical and Biological Sciences, University of Turin, Regione Gonzole 10, Orbassano, 10043, Torino, TO, Italy
| | | | - Kerstin Boengler
- Institute of Physiology, University of Giessen, Giessen, Germany
| | - Pasquale Pagliaro
- Department of Clinical and Biological Sciences, University of Turin, Regione Gonzole 10, Orbassano, 10043, Torino, TO, Italy.
| | - Claudia Penna
- Department of Clinical and Biological Sciences, University of Turin, Regione Gonzole 10, Orbassano, 10043, Torino, TO, Italy.
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Abel F, Giebel B, Frey UH. Agony of choice: How anesthetics affect the composition and function of extracellular vesicles. Adv Drug Deliv Rev 2021; 175:113813. [PMID: 34029645 DOI: 10.1016/j.addr.2021.05.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 04/22/2021] [Accepted: 05/20/2021] [Indexed: 02/07/2023]
Abstract
The choice of the anesthetic regime is suggested to affect clinical outcomes following major surgery. Propofol was shown to exert beneficial effects on different cancer outcomes, while volatile anesthetics may be favorable in cardiac surgery. Recently, extracellular vesicles (EVs) were discovered as essential signal mediators in physiological and pathophysiological processes including carcinogenesis and metastasis. Furthermore, depending on their cell source, EVs fulfill therapeutic functions. In addition to extracorporally produced EVs, appropriate systemic intervention such as remote ischemic preconditioning (RIPC) is considered to promote endogenous release of therapeutically active EVs to mediate cardioprotective effects. EVs are assembled in cell-type specific manners and the composition of EVs is not only affected by the disease, but also by the applied anesthetic of anesthetized patients. Here, we compare known impacts of anesthetic agents on outcomes in cancer surgery and cardioprotection and link these effects to the composition and therapeutic potential of EVs.
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Affiliation(s)
- Frederik Abel
- Klinik für Anästhesiologie und Intensivmedizin, Universitätsklinikum Essen, Universität Duisburg-Essen, Hufelandstrasse 55, 45147 Essen, Germany
| | - Bernd Giebel
- Institut für Transfusionsmedizin, Universitätsklinikum Essen, Universität Duisburg-Essen, Virchowstraße 179, 45147 Essen, Germany.
| | - Ulrich H Frey
- Klinik für Anästhesiologie, operative Intensivmedizin, Schmerz- und Palliativmedizin, Marien Hospital Herne, Universitätsklinikum der Ruhr-Universität Bochum, Hölkeskampring 40, 44625 Herne, Germany
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Nistal-Nuño B. Machine learning applied to a Cardiac Surgery Recovery Unit and to a Coronary Care Unit for mortality prediction. J Clin Monit Comput 2021; 36:751-763. [PMID: 33860407 DOI: 10.1007/s10877-021-00703-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Accepted: 04/05/2021] [Indexed: 12/23/2022]
Abstract
Most established severity-of-illness systems used for prediction of intensive care unit (ICU) mortality were developed targeted at the general ICU population, based on logistic regression (LR). To date, no dynamic predictive tool for ICU mortality has been developed targeted at the Cardiac Surgery Recovery Unit (CSRU) and Coronary Care Unit (CCU) using machine learning (ML). CSRU and CCU adult patients from the MIMIC-III critical care database were studied. The ML methods developed extract ICU data during a 5-h window and demographic features to produce mortality predictions and were compared to six established severity-of-illness systems and LR. In a secondary experiment, additional procedure/surgery and ICU features were added to the models. The ML models developed were the Tree Ensemble (TE), Random Forest, XGBoost Tree Ensemble (XGB), Naive Bayes (NB), and Bayesian network. The discrimination, calibration and accuracy statistics were assessed. The AUROC values were superior for the ML models reaching 0.926 and 0.924 for the XGB, and 0.904 and 0.908 for the TE for ICU mortality prediction in the primary and secondary experiments respectively. Among the conventional systems, the serial SOFA obtained the highest AUROC (0.8405). The Brier score was better for the ML models except the NB over the conventional systems. The accuracy statistics less sensitive to unbalanced cohorts were higher for all the ML models. In conclusion, the predictive power of XGB was excellent, substantially outperforming the conventional systems and LR. The ML models developed in this work offer promising results that could benefit CSRU and CCU.
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Affiliation(s)
- Beatriz Nistal-Nuño
- Department of Anesthesiology, Complejo Hospitalario Universitario de Pontevedra, Mourente s/n, 36071, Pontevedra, Spain.
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Volatile Anesthetics versus Propofol for Cardiac Surgery with Cardiopulmonary Bypass. Anesthesiology 2020; 132:1429-1446. [DOI: 10.1097/aln.0000000000003236] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Abstract
Background
The aim of this systematic review and meta-analysis was to assess the effect of anesthesia maintenance with volatile agents compared with propofol on both short- and long-term mortality (primary outcomes) and major clinical events in adults undergoing cardiac surgery with cardiopulmonary bypass.
Methods
Randomized clinical trials on the effects of current volatile anesthetics versus propofol in adults undergoing cardiac surgery with cardiopulmonary bypass were searched (1965 to September 30, 2019) in PubMed, the Cochrane Library, and article reference lists. A random effect model on standardized mean difference for continuous outcomes and odds ratio for dichotomous outcomes were used to meta-analyze data.
Results
In total, 37 full-text articles (42 studies, 8,197 participants) were included. The class of volatile anesthetics compared with propofol was associated with lower 1-yr mortality (5.5 vs. 6.8%; odds ratio, 0.76 [95% CI, 0.60 to 0.96]; P = 0.023), myocardial infarction (odds ratio, 0.60 [95% CI, 0.39 to 0.92]; P = 0.023), cardiac troponin release (standardized mean difference, −0.39 [95% CI, −0.59 to −0.18], P = 0.0002), need for inotropic medications (odds ratio, 0.40 [95% CI, 0.24 to 0.67]; P = 0.0004), extubation time (standardized mean difference, −0.35 [95% CI, −0.68 to −0.02]; P = 0.038), and with higher cardiac index/output (standardized mean difference, 0.70 [95% CI, 0.37 to 1.04]; P < 0.0001). The class of volatile anesthetics was not associated with changes in short-term mortality (1.63 vs. 1.65%; odds ratio, 1.04 [95% CI, 0.73 to 1.49]; P = 0.820) and acute kidney injury (odds ratio, 1.25 [95% CI, 0.77 to 2.03]; P = 0.358).
Conclusions
In adults undergoing cardiac surgery with cardiopulmonary bypass, the class of volatile anesthetics was superior to propofol with regard to long-term mortality, as well as to many secondary outcomes indicating myocardial protection.
Editor’s Perspective
What We Already Know about This Topic
What This Article Tells Us That Is New
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Hausenloy DJ, Bøtker HE, Ferdinandy P, Heusch G, Ng GA, Redington A, Garcia-Dorado D. Cardiac innervation in acute myocardial ischaemia/reperfusion injury and cardioprotection. Cardiovasc Res 2020; 115:1167-1177. [PMID: 30796814 DOI: 10.1093/cvr/cvz053] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Revised: 12/21/2018] [Accepted: 02/21/2019] [Indexed: 12/13/2022] Open
Abstract
Acute myocardial infarction (AMI) and the heart failure (HF) that often complicates this condition, are among the leading causes of death and disability worldwide. To reduce myocardial infarct (MI) size and prevent heart failure, novel therapies are required to protect the heart against the detrimental effects of acute ischaemia/reperfusion injury (IRI). In this regard, targeting cardiac innervation may provide a novel therapeutic strategy for cardioprotection. A number of cardiac neural pathways mediate the beneficial effects of cardioprotective strategies such as ischaemic preconditioning and remote ischaemic conditioning, and nerve stimulation may therefore provide a novel therapeutic strategy for cardioprotection. In this article, we provide an overview of cardiac innervation and its impact on acute myocardial IRI, the role of extrinsic and intrinsic cardiac neural pathways in cardioprotection, and highlight peripheral and central nerve stimulation as a cardioprotective strategy with therapeutic potential for reducing MI size and preventing HF following AMI. This article is part of a Cardiovascular Research Spotlight Issue entitled 'Cardioprotection Beyond the Cardiomyocyte', and emerged as part of the discussions of the European Union (EU)-CARDIOPROTECTION Cooperation in Science and Technology (COST) Action, CA16225.
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Affiliation(s)
- Derek J Hausenloy
- Cardiovascular & Metabolic Disorders Program, Duke-National University of Singapore Medical School, Singapore.,National Heart Research Institute Singapore, National Heart Centre, Singapore.,Yong Loo Lin School of Medicine, National University Singapore, Singapore.,The Hatter Cardiovascular Institute, University College London, London, UK.,The National Institute of Health Research University College London Hospitals Biomedical Research Centre, Research & Development, London, UK.,Tecnologico de Monterrey, Centro de Biotecnologia-FEMSA, Nuevo Leon, Mexico
| | - Hans Erik Bøtker
- Department of Cardiology, Aarhus University Hospital, Aarhus N, Denmark
| | - Peter Ferdinandy
- Department of Pharmacology and Pharmacotherapy, Semmelweis University, Budapest, Hungary.,Pharmahungary Group, Szeged, Hungary
| | - Gerd Heusch
- Institute for Pathophysiology, West German Heart and Vascular Center, University of Essen Medical School, Essen, Germany
| | - G André Ng
- Department of Cardiovascular Sciences, University of Leicester, NIHR Leicester Biomedical Research Centre, Glenfield Hospital, UK
| | - Andrew Redington
- Cincinnati Children's Hospital Medical Center, Heart Institute, Cincinnati, OH, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - David Garcia-Dorado
- Department of Cardiology, Vascular Biology and Metabolism Area, Vall d'Hebron University Hospital and Research Institute (VHIR), Universitat Autónoma de Barcelona, Spain.,Instituto CIBER de Enfermedades Cardiovasculares (CIBERCV): Instituto de Salud Carlos III, Madrid, Spain
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Adamson C, Rocchiccioli P, Brogan R, Berry C, Ford TJ. Post-operative myocardial infarction following aortic root surgery with coronary reimplantation: a case series treated with percutaneous coronary intervention. EUROPEAN HEART JOURNAL-CASE REPORTS 2020; 3:1-6. [PMID: 32123801 PMCID: PMC7042144 DOI: 10.1093/ehjcr/ytz181] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 05/17/2019] [Accepted: 09/25/2019] [Indexed: 11/24/2022]
Abstract
Background Coronary ostial stenosis is an uncommon but potentially lethal complication following aortic root replacement with or without aortic valve replacement (including Bentall and David procedures). This manifests clinically as acute myocardial ischaemia in the early or late post-operative period. Traditionally, this might be managed with redo open-heart surgery. Case summary This case series describes two presentations where urgent percutaneous coronary intervention was used to manage myocardial infarction complicating aortic root surgery with coronary reimplantation. Discussion This series highlights the risk of acute myocardial infarction after cardiac surgery involving coronary reimplantation. Emergency percutaneous coronary intervention is feasible and illustrates the importance of shared post-operative care involving the cardiac surgeons and the cardiology team.
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Affiliation(s)
- Carly Adamson
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, G81 4DY, UK
| | - Paul Rocchiccioli
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, G81 4DY, UK.,British Heart Foundation, Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, G12 8TA, UK
| | - Richard Brogan
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, G81 4DY, UK
| | - Colin Berry
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, G81 4DY, UK.,British Heart Foundation, Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, G12 8TA, UK
| | - Thomas J Ford
- West of Scotland Heart and Lung Centre, Golden Jubilee National Hospital, Clydebank, G81 4DY, UK.,British Heart Foundation, Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, G12 8TA, UK.,Department of Cardiology, Gosford Hospital, NSW, Australia.,University of New South Wales, Sydney, Australia
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Billah M, Ridiandries A, Allahwala UK, Mudaliar H, Dona A, Hunyor S, Khachigian LM, Bhindi R. Remote Ischemic Preconditioning induces Cardioprotective Autophagy and Signals through the IL-6-Dependent JAK-STAT Pathway. Int J Mol Sci 2020; 21:ijms21051692. [PMID: 32121587 PMCID: PMC7084188 DOI: 10.3390/ijms21051692] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2020] [Revised: 02/19/2020] [Accepted: 02/27/2020] [Indexed: 02/08/2023] Open
Abstract
Autophagy is a cellular process by which mammalian cells degrade and assist in recycling damaged organelles and proteins. This study aimed to ascertain the role of autophagy in remote ischemic preconditioning (RIPC)-induced cardioprotection. Sprague Dawley rats were subjected to RIPC at the hindlimb followed by a 30-min transient blockade of the left coronary artery to simulate ischemia reperfusion (I/R) injury. Hindlimb muscle and the heart were excised 24 h post reperfusion. RIPC prior to I/R upregulated autophagy in the rat heart at 24 h post reperfusion. In vitro, autophagy inhibition or stimulation prior to RIPC, respectively, either ameliorated or stimulated the cardioprotective effect, measured as improved cell viability to mimic the preconditioning effect. Recombinant interleukin-6 (IL-6) treatment prior to I/R increased in vitro autophagy in a dose-dependent manner, activating the Janus kinase/signal transducers and activators of transcription (JAK-STAT) pathway without affecting the other kinase pathways, such as p38 mitogen-activated protein kinases (MAPK), and glycogen synthase kinase 3 Beta (GSK-3β) pathways. Prior to I/R, in vitro inhibition of the JAK-STAT pathway reduced autophagy upregulation despite recombinant IL-6 pre-treatment. Autophagy is an essential component of RIPC-induced cardioprotection that may upregulate autophagy through an IL-6/JAK-STAT-dependent mechanism, thus identifying a potentially new therapeutic option for the treatment of ischemic heart disease.
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Affiliation(s)
- Muntasir Billah
- Department of Cardiology, Kolling Institute of Medical Research, Northern Sydney Local Health District, St Leonards, NSW 2065, Australia; (A.R.); (U.K.A.); (H.M.); (A.D.); (S.H.); (R.B.)
- Sydney Medical School Northern, University of Sydney, Sydney, NSW 2006, Australia
- School of Life Sciences, Independent University Bangladesh, Dhaka 1229, Bangladesh
- Correspondence:
| | - Anisyah Ridiandries
- Department of Cardiology, Kolling Institute of Medical Research, Northern Sydney Local Health District, St Leonards, NSW 2065, Australia; (A.R.); (U.K.A.); (H.M.); (A.D.); (S.H.); (R.B.)
- Sydney Medical School Northern, University of Sydney, Sydney, NSW 2006, Australia
| | - Usaid K Allahwala
- Department of Cardiology, Kolling Institute of Medical Research, Northern Sydney Local Health District, St Leonards, NSW 2065, Australia; (A.R.); (U.K.A.); (H.M.); (A.D.); (S.H.); (R.B.)
- Sydney Medical School Northern, University of Sydney, Sydney, NSW 2006, Australia
| | - Harshini Mudaliar
- Department of Cardiology, Kolling Institute of Medical Research, Northern Sydney Local Health District, St Leonards, NSW 2065, Australia; (A.R.); (U.K.A.); (H.M.); (A.D.); (S.H.); (R.B.)
| | - Anthony Dona
- Department of Cardiology, Kolling Institute of Medical Research, Northern Sydney Local Health District, St Leonards, NSW 2065, Australia; (A.R.); (U.K.A.); (H.M.); (A.D.); (S.H.); (R.B.)
| | - Stephen Hunyor
- Department of Cardiology, Kolling Institute of Medical Research, Northern Sydney Local Health District, St Leonards, NSW 2065, Australia; (A.R.); (U.K.A.); (H.M.); (A.D.); (S.H.); (R.B.)
| | - Levon M. Khachigian
- Vascular Biology and Translational Research, School of Medical Sciences, University of New South Wales, Sydney, NSW 2052, Australia;
| | - Ravinay Bhindi
- Department of Cardiology, Kolling Institute of Medical Research, Northern Sydney Local Health District, St Leonards, NSW 2065, Australia; (A.R.); (U.K.A.); (H.M.); (A.D.); (S.H.); (R.B.)
- Sydney Medical School Northern, University of Sydney, Sydney, NSW 2006, Australia
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Abel F, Murke F, Gaida M, Garnier N, Ochsenfarth C, Theiss C, Thielmann M, Kleinbongard P, Giebel B, Peters J, Frey UH. Extracellular vesicles isolated from patients undergoing remote ischemic preconditioning decrease hypoxia-evoked apoptosis of cardiomyoblasts after isoflurane but not propofol exposure. PLoS One 2020; 15:e0228948. [PMID: 32059016 PMCID: PMC7021285 DOI: 10.1371/journal.pone.0228948] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Accepted: 01/26/2020] [Indexed: 12/27/2022] Open
Abstract
Remote ischemic preconditioning (RIPC) can evoke cardioprotection following ischemia/reperfusion and this may depend on the anesthetic used. We tested whether 1) extracellular vesicles (EVs) isolated from humans undergoing RIPC protect cardiomyoblasts against hypoxia-induced apoptosis and 2) this effect is altered by cardiomyoblast exposure to isoflurane or propofol. EVs were isolated before and 60 min after RIPC or Sham from ten patients undergoing coronary artery bypass graft surgery with isoflurane anesthesia and quantified by Nanoparticle Tracking Analysis. Following EV-treatment for 6 hours under exposure of isoflurane or propofol, rat H9c2 cardiomyoblasts were cultured for 18 hours in normoxic or hypoxic atmospheres. Apoptosis was detected by flow cytometry. Serum nanoparticle concentrations in patients had increased sixty minutes after RIPC compared to Sham (2.5x1011±4.9x1010 nanoparticles/ml; Sham: 1.2x1011±2.0x1010; p = 0.04). Hypoxia increased apoptosis of H9c2 cells (hypoxia: 8.4%±0.6; normoxia: 2.5%±0.1; p<0.0001). RIPC-EVs decreased H9c2 cell apoptosis compared to control (apoptotic ratio: 0.83; p = 0.0429) while Sham-EVs showed no protection (apoptotic ratio: 0.97). Prior isoflurane exposure in vitro even increased protection (RIPC-EVs/control, apoptotic ratio: 0.79; p = 0.0035; Sham-EVs/control, apoptotic ratio:1.04) while propofol (50μM) abrogated protection by RIPC-EVs (RIPC-EVs/control, Apoptotic ratio: 1.01; Sham-EVs/control, apoptotic ratio: 0.94; p = 0.602). Thus, EVs isolated from patients undergoing RIPC under isoflurane anesthesia protect H9c2 cardiomyoblasts against hypoxia-evoked apoptosis and this effect is abrogated by propofol. This supports a role of human RIPC-generated EVs in cardioprotection and underlines propofol as a possible confounder in RIPC-signaling mediated by EVs.
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Affiliation(s)
- Frederik Abel
- Klinik für Anästhesiologie und Intensivmedizin, Universität Duisburg-Essen & Universitätsklinikum Essen, Essen, Germany
| | - Florian Murke
- Institut für Transfusionsmedizin, Universität Duisburg-Essen & Universitätsklinikum Essen, Essen, Germany
| | - Morten Gaida
- Klinik für Anästhesiologie und Intensivmedizin, Universität Duisburg-Essen & Universitätsklinikum Essen, Essen, Germany
| | - Nicolas Garnier
- Klinik für Anästhesiologie und Intensivmedizin, Universität Duisburg-Essen & Universitätsklinikum Essen, Essen, Germany
| | - Crista Ochsenfarth
- Klinik für Anästhesiologie, Operative Intensivmedizin, Schmerz- und Palliativmedizin, Marien Hospital Herne, Universitätsklinikum der Ruhr-Universität Bochum, Bochum, Germany
| | - Carsten Theiss
- Institut für Anatomie, Abteilung für Cytologie, Ruhr-Universität-Bochum, Bochum, Germany
| | - Matthias Thielmann
- Klinik für Thorax- und Kardiovaskuläre Chirurgie, Universität Duisburg-Essen & Universitätsklinikum Essen, Essen, Germany
| | - Petra Kleinbongard
- Institut für Pathophysiologie, Universität Duisburg-Essen & Universitätsklinikum Essen, Essen, Germany
| | - Bernd Giebel
- Institut für Transfusionsmedizin, Universität Duisburg-Essen & Universitätsklinikum Essen, Essen, Germany
| | - Jürgen Peters
- Klinik für Anästhesiologie und Intensivmedizin, Universität Duisburg-Essen & Universitätsklinikum Essen, Essen, Germany
| | - Ulrich H. Frey
- Klinik für Anästhesiologie und Intensivmedizin, Universität Duisburg-Essen & Universitätsklinikum Essen, Essen, Germany
- Klinik für Anästhesiologie, Operative Intensivmedizin, Schmerz- und Palliativmedizin, Marien Hospital Herne, Universitätsklinikum der Ruhr-Universität Bochum, Bochum, Germany
- * E-mail:
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MySurgeryRisk: Development and Validation of a Machine-learning Risk Algorithm for Major Complications and Death After Surgery. Ann Surg 2020; 269:652-662. [PMID: 29489489 DOI: 10.1097/sla.0000000000002706] [Citation(s) in RCA: 163] [Impact Index Per Article: 40.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVE To accurately calculate the risk for postoperative complications and death after surgery in the preoperative period using machine-learning modeling of clinical data. BACKGROUND Postoperative complications cause a 2-fold increase in the 30-day mortality and cost, and are associated with long-term consequences. The ability to precisely forecast the risk for major complications before surgery is limited. METHODS In a single-center cohort of 51,457 surgical patients undergoing major inpatient surgery, we have developed and validated an automated analytics framework for a preoperative risk algorithm (MySurgeryRisk) that uses existing clinical data in electronic health records to forecast patient-level probabilistic risk scores for 8 major postoperative complications (acute kidney injury, sepsis, venous thromboembolism, intensive care unit admission >48 hours, mechanical ventilation >48 hours, wound, neurologic, and cardiovascular complications) and death up to 24 months after surgery. We used the area under the receiver characteristic curve (AUC) and predictiveness curves to evaluate model performance. RESULTS MySurgeryRisk calculates probabilistic risk scores for 8 postoperative complications with AUC values ranging between 0.82 and 0.94 [99% confidence intervals (CIs) 0.81-0.94]. The model predicts the risk for death at 1, 3, 6, 12, and 24 months with AUC values ranging between 0.77 and 0.83 (99% CI 0.76-0.85). CONCLUSIONS We constructed an automated predictive analytics framework for machine-learning algorithm with high discriminatory ability for assessing the risk of surgical complications and death using readily available preoperative electronic health records data. The feasibility of this novel algorithm implemented in real time clinical workflow requires further testing.
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Kleinbongard P, Bøtker HE, Ovize M, Hausenloy DJ, Heusch G. Co-morbidities and co-medications as confounders of cardioprotection-Does it matter in the clinical setting? Br J Pharmacol 2020; 177:5252-5269. [PMID: 31430831 PMCID: PMC7680006 DOI: 10.1111/bph.14839] [Citation(s) in RCA: 62] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Revised: 07/26/2019] [Accepted: 08/15/2019] [Indexed: 02/06/2023] Open
Abstract
The translation of cardioprotection from robust experimental evidence to beneficial clinical outcome for patients suffering acute myocardial infarction or undergoing cardiovascular surgery has been largely disappointing. The present review attempts to critically analyse the evidence for confounders of cardioprotection in patients with acute myocardial infarction and in patients undergoing cardiovascular surgery. One reason that has been proposed to be responsible for such lack of translation is the confounding of cardioprotection by co-morbidities and co-medications. Whereas there is solid experimental evidence for such confounding of cardioprotection by single co-morbidities and co-medications, the clinical evidence from retrospective analyses of the limited number of clinical data is less robust. The best evidence for interference of co-medications is that for platelet inhibitors to recruit cardioprotection per se and thus limit the potential for further protection from myocardial infarction and for propofol anaesthesia to negate the protection from remote ischaemic conditioning in cardiovascular surgery. LINKED ARTICLES: This article is part of a themed issue on Risk factors, comorbidities, and comedications in cardioprotection. To view the other articles in this section visit http://onlinelibrary.wiley.com/doi/10.1111/bph.v177.23/issuetoc.
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Affiliation(s)
- Petra Kleinbongard
- Institute for Pathophysiology, West German Heart and Vascular Center, University of Essen Medical School, Essen, Germany
| | - Hans Erik Bøtker
- Department of Cardiology, Aarhus University Hospital Skejby, Aarhus, Denmark
| | - Michel Ovize
- INSERM U1060, CarMeN Laboratory, Université de Lyon and Explorations Fonctionnelles Cardiovasculaires, Hôpital Louis Pradel, Hospices Civils de Lyon, Lyon, France
| | - Derek J Hausenloy
- Cardiovascular and Metabolic Disorders Program, Duke-National University of Singapore Medical School, Singapore.,National Heart Research Institute Singapore, National Heart Centre, Singapore.,Yong Loo Lin School of Medicine, National University Singapore, Singapore.,The Hatter Cardiovascular Institute, University College London, London, UK.,Research and Development, The National Institute of Health Research University College London Hospitals Biomedical Research Centre, London, UK.,Tecnologico de Monterrey, Centro de Biotecnologia-FEMSA, Monterrey, Nuevo Leon, Mexico
| | - Gerd Heusch
- Institute for Pathophysiology, West German Heart and Vascular Center, University of Essen Medical School, Essen, Germany
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Jiao XF, Lin XM, Ni XF, Li HL, Zhang C, Yang CS, Song HX, Yi QS, Zhang LL. Volatile anesthetics versus total intravenous anesthesia in patients undergoing coronary artery bypass grafting: An updated meta-analysis and trial sequential analysis of randomized controlled trials. PLoS One 2019; 14:e0224562. [PMID: 31661512 PMCID: PMC6818786 DOI: 10.1371/journal.pone.0224562] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Accepted: 10/16/2019] [Indexed: 12/29/2022] Open
Abstract
Background The benefits of volatile anesthetics in coronary artery bypass grafting (CABG) patients remain controversial. We aimed to conduct an updated meta-analysis to assess whether the use of volatile anesthetics during CABG could reduce mortality and other outcomes. Methods We searched eight databases from inception to June 2019 and included randomized controlled trials (RCTs) comparing the effects of volatile anesthetics versus total intravenous anesthesia (TIVA) in CABG patients. The primary outcomes were operative mortality and one-year mortality. The secondary outcomes included the length of stay in the intensive care unit (ICU) and hospital and postoperative safety outcomes (myocardial infarction, heart failure, arrhythmia, stroke, delirium, postoperative cognitive impairment, acute kidney injury, and the use of intra-aortic balloon pump (IABP) or other mechanical circulatory support). Trial sequential analysis (TSA) was performed to control for random errors. Results A total of 89 RCTs comprising 14,387 patients were included. There were no significant differences between the volatile anesthetics and TIVA groups in operative mortality (relative risk (RR) = 0.92, 95% confidence interval (CI): 0.68–1.24, p = 0.59, I2 = 0%), one-year mortality (RR = 0.64, 95% CI: 0.32–1.26, p = 0.19, I2 = 51%), or any of the postoperative safety outcomes. The lengths of stay in the ICU and hospital were shorter in the volatile anesthetics group than in the TIVA group. TSA revealed that the results for operative mortality, one-year mortality, length of stay in the ICU, heart failure, stroke, and the use of IABP were inconclusive. Conclusions Conventional meta-analysis suggests that the use of volatile anesthetics during CABG is not associated with reduced risk of mortality or other postoperative safety outcomes when compared with TIVA. TSA shows that the current evidence is insufficient and inconclusive. Thus, future large RCTs are required to clarify this issue.
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Affiliation(s)
- Xue-feng Jiao
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Sichuan, China
- Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Sichuan, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Sichuan, China
- West China School of Medicine, Sichuan University, Sichuan, China
| | - Xue-mei Lin
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Sichuan, China
- Department of Anesthesiology, West China Second University Hospital, Sichuan University, Sichuan, China
| | - Xiao-feng Ni
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Sichuan, China
- Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Sichuan, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Sichuan, China
- West China School of Medicine, Sichuan University, Sichuan, China
| | - Hai-long Li
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Sichuan, China
- Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Sichuan, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Sichuan, China
| | - Chuan Zhang
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Sichuan, China
- Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Sichuan, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Sichuan, China
| | - Chun-song Yang
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Sichuan, China
- Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Sichuan, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Sichuan, China
| | - Hao-xin Song
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Sichuan, China
- Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Sichuan, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Sichuan, China
| | - Qiu-sha Yi
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Sichuan, China
- Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Sichuan, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Sichuan, China
- West China School of Medicine, Sichuan University, Sichuan, China
| | - Ling-li Zhang
- Department of Pharmacy, West China Second University Hospital, Sichuan University, Sichuan, China
- Evidence-Based Pharmacy Center, West China Second University Hospital, Sichuan University, Sichuan, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Sichuan, China
- * E-mail:
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Cho YJ, Kim WH. Perioperative Cardioprotection by Remote Ischemic Conditioning. Int J Mol Sci 2019; 20:ijms20194839. [PMID: 31569468 PMCID: PMC6801656 DOI: 10.3390/ijms20194839] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2019] [Revised: 09/11/2019] [Accepted: 09/27/2019] [Indexed: 12/24/2022] Open
Abstract
Remote ischemic conditioning has been investigated for cardioprotection to attenuate myocardial ischemia/reperfusion injury. In this review, we provide a comprehensive overview of the current knowledge of the signal transduction pathways of remote ischemic conditioning according to three stages: Remote stimulus from source organ; protective signal transfer through neuronal and humoral factors; and target organ response, including myocardial response and coronary vascular response. The neuronal and humoral factors interact on three levels, including stimulus, systemic, and target levels. Subsequently, we reviewed the clinical studies evaluating the cardioprotective effect of remote ischemic conditioning. While clinical studies of percutaneous coronary intervention showed relatively consistent protective effects, the majority of multicenter studies of cardiac surgery reported neutral results although there have been several promising initial trials. Failure to translate the protective effects of remote ischemic conditioning into cardiac surgery may be due to the multifactorial etiology of myocardial injury, potential confounding factors of patient age, comorbidities including diabetes, concomitant medications, and the coadministered cardioprotective general anesthetic agents. Given the complexity of signal transfer pathways and confounding factors, further studies should evaluate the multitarget strategies with optimal measures of composite outcomes.
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Affiliation(s)
- Youn Joung Cho
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul 03080, Korea.
| | - Won Ho Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul 03080, Korea.
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21
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Deferrari G, Bonanni A, Bruschi M, Alicino C, Signori A. Remote ischaemic preconditioning for renal and cardiac protection in adult patients undergoing cardiac surgery with cardiopulmonary bypass: systematic review and meta-analysis of randomized controlled trials. Nephrol Dial Transplant 2019; 33:813-824. [PMID: 28992285 DOI: 10.1093/ndt/gfx210] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Accepted: 04/28/2017] [Indexed: 12/20/2022] Open
Abstract
Background The main aim of this systematic review was to assess whether remote ischaemic preconditioning (RIPC) protects kidneys and the heart in cardiac surgery with cardiopulmonary bypass (CPB) and to investigate a possible role of anaesthetic agents. Methods Randomized clinical trials (RCTs) on the effects of RIPC through limb ischaemia in adult patients undergoing cardiac surgery with CPB were searched (1965-October 2016) in PubMed, Cochrane Library and article reference lists. A random effects model on standardized mean difference (SMD) for continuous outcomes and the Peto odds ratio (OR) for dichotomous outcomes were used to meta-analyse data. Subgroup analyses to evaluate the effects of different anaesthetic regimens were pre-planned. Results Thirty-three RCTs (5999 participants) were included. In the whole group, RIPC did not significantly reduce the incidence of acute kidney injury (AKI), acute myocardial infarction, atrial fibrillation, mortality or length of intensive care unit (ICU) and hospital stays. On the contrary, RIPC significantly reduced the area under the curve for myocardial injury biomarkers (MIBs) {SMD -0.37 [95% confidence interval (CI) -0.53 to - 0.21]} and the composite endpoint incidence [OR 0.85 (95% CI 0.74-0.97)]. In the volatile anaesthetic group, RIPC significantly reduced AKI incidence [OR 0.57 (95% CI 0.41-0.79)] and marginally reduced ICU stay. Conversely, except for MIBs, RIPC had fewer non-significant effects under propofol with or without volatile anaesthetics. Conclusions RIPC did not consistently reduce morbidity and mortality in adults undergoing cardiac surgery with CPB. In the subgroup on volatile anaesthetics only, RIPC markedly and significantly reduced the incidence of AKI and composite endpoint as well as myocardial injury.
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Affiliation(s)
- Giacomo Deferrari
- Department of Cardionephrology, Istituto Clinico Di Alta Specialità (ICLAS), Rapallo (GE), Italy.,Department of Internal Medicine (Di.MI), University of Genoa, Genoa, Italy
| | - Alice Bonanni
- Department of Cardionephrology, Istituto Clinico Di Alta Specialità (ICLAS), Rapallo (GE), Italy.,Division of Nephrology, Dialysis and Transplantation and Laboratory on Pathophysiology of Uremia, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Maurizio Bruschi
- Division of Nephrology, Dialysis and Transplantation and Laboratory on Pathophysiology of Uremia, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Cristiano Alicino
- Department of Health Science (Di.S.Sal), University of Genoa, Genoa, Italy
| | - Alessio Signori
- Department of Health Science (Di.S.Sal), University of Genoa, Genoa, Italy
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22
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Kleinbongard P, Peters J, Jakob H, Heusch G, Thielmann M. Persistent Survival Benefit From Remote Ischemic Pre-Conditioning in Patients Undergoing Coronary Artery Bypass Surgery. J Am Coll Cardiol 2019; 71:252-254. [PMID: 29325645 DOI: 10.1016/j.jacc.2017.10.083] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Revised: 10/19/2017] [Accepted: 10/29/2017] [Indexed: 10/18/2022]
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23
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Circulating mediators of remote ischemic preconditioning: search for the missing link between non-lethal ischemia and cardioprotection. Oncotarget 2019; 10:216-244. [PMID: 30719216 PMCID: PMC6349428 DOI: 10.18632/oncotarget.26537] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2018] [Accepted: 12/10/2018] [Indexed: 12/11/2022] Open
Abstract
Acute myocardial infarction (AMI) is one of the leading causes of mortality and morbidity worldwide. There has been an extensive search for cardioprotective therapies to reduce myocardial ischemia-reperfusion (I/R) injury. Remote ischemic preconditioning (RIPC) is a phenomenon that relies on the body's endogenous protective modalities against I/R injury. In RIPC, non-lethal brief I/R of one organ or tissue confers protection against subsequent lethal I/R injury in an organ remote to the briefly ischemic organ or tissue. Initially it was believed to be limited to direct myocardial protection, however it soon became apparent that RIPC applied to other organs such as kidney, liver, intestine, skeletal muscle can reduce myocardial infarct size. Intriguing discoveries have been made in extending the concept of RIPC to other organs than the heart. Over the years, the underlying mechanisms of RIPC have been widely sought and discussed. The involvement of blood-borne factors as mediators of RIPC has been suggested by a number of research groups. The main purpose of this review article is to summarize the possible circulating mediators of RIPC, and recent studies to establish the clinical efficacy of these mediators in cardioprotection from lethal I/R injury.
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24
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Spence J, Belley-Côté E, Ma HK, Donald S, Centofanti J, Hussain S, Gupta S, Devereaux PJ, Whitlock R. Efficacy and safety of inhaled anaesthetic for postoperative sedation during mechanical ventilation in adult cardiac surgery patients: a systematic review and meta-analysis. Br J Anaesth 2018; 118:658-669. [PMID: 28498903 DOI: 10.1093/bja/aex087] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
The aim was to evaluate the efficacy and safety of volatile anaesthetic for postoperative sedation in adult cardiac surgery patients through a systematic review and meta-analysis. We retrieved randomized controlled trials from MEDLINE, EMBASE, CENTRAL, Web of Science, clinical trials registries, conference proceedings, and reference lists of included articles. Independent reviewers extracted data, including patient characteristics, type of intraoperative anaesthesia, inhaled anaesthetic used, comparator sedation, and outcomes of interest, using pre-piloted forms. We assessed risk of bias using the Cochrane Tool and evaluated the strength of the evidence using the GRADE approach. Eight studies enrolling 610 patients were included. Seven had a high and one a low risk of bias. The times to extubation after intensive care unit (ICU) admission and sedation discontinuation were, respectively, 76 [95% confidence interval (CI) -150 to - 2, I2=79%] and 74 min (95% CI - 126 to - 23, I2=96%) less in patients who were sedated using volatile anaesthetic. There was no difference in ICU or hospital length of stay. Patients who received volatile anaesthetic sedation had troponin concentrations that were 0.71 ng ml-1 (95% CI 0.23-1.2) lower than control patients. Reporting on other outcomes was varied and not suitable for meta-analysis. Volatile anaesthetic sedation may be associated with a shorter time to extubation after cardiac surgery but no change in ICU or hospital length of stay. It is associated with a significantly lower postoperative troponin concentration, but the impact of this on adverse cardiovascular outcomes is uncertain. Blinded randomized trials using intention-to-treat analysis are required. PROSPERO registry number: 2016:CRD42016033874. Available from http://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42016033874.
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Affiliation(s)
- J Spence
- Department of Anaesthesia and Critical Care.,Department of Clinical Epidemiology and Biostatistics.,Population Health Research Institute, Hamilton, ON, Canada
| | - E Belley-Côté
- Department of Anaesthesia and Critical Care.,Department of Medicine (Cardiology), McMaster University, Population Health Research Institute, Hamilton, ON, Canada.,Population Health Research Institute, Hamilton, ON, Canada
| | - H K Ma
- Department of Anaesthesia and Critical Care
| | - S Donald
- Department of Anaesthesia and Critical Care
| | | | - S Hussain
- Department of Surgery, Division of Cardiac Surgery, McGill University, Montreal, PQ, Canada.,Population Health Research Institute, Hamilton, ON, Canada
| | - S Gupta
- Department of Surgery, Division of Cardiac Surgery
| | - P J Devereaux
- Department of Clinical Epidemiology and Biostatistics.,Department of Medicine (Division of Cardiology) Population Health Research Institute, Hamilton, ON, Canada.,Population Health Research Institute, Hamilton, ON, Canada
| | - R Whitlock
- Department of Clinical Epidemiology and Biostatistics.,Department of Surgery, Division of Cardiac Surgery.,Population Health Research Institute, Hamilton, ON, Canada
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25
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Monaco F, Di Prima AL, De Luca M, Barucco G, Zangrillo A. Periprocedural and perioperatory management of patients with tricuspid valve disease. Minerva Cardioangiol 2018; 66:691-699. [DOI: 10.23736/s0026-4725.18.04699-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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26
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Benstoem C, Goetzenich A, Autschbach R, Marx G, Stoppe C, Breuer T. Volatile anesthetics versus propofol in the cardiac surgical setting of remote ischemic preconditioning: a secondary analysis of a Cochrane Systematic Review. Minerva Anestesiol 2018; 84:1298-1306. [PMID: 29945432 DOI: 10.23736/s0375-9393.18.12465-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
INTRODUCTION So far, the concept of remote ischemic preconditioning (RIPC) failed its translation from experimental to clinical studies. In addition to our Cochrane Systematic Review, we systematically assessed the use of the intravenous anesthetic propofol, as a potential confounding factor. EVIDENCE ACQUISITION We searched CENTRAL, MEDLINE, Embase and Web of Science. We included randomized controlled trials comparing RIPC with no RIPC in adult patients scheduled for coronary artery bypass graft surgery (with or without valve surgery) receiving either exclusively propofol or exclusively volatile anesthetics. Two authors independently assessed methodological quality and extracted data. We report odds ratios (ORs) with 95% confidence intervals as our summary statistics are based on random-effects models. EVIDENCE SYNTHESIS We included 14 studies involving 4060 participants. We found no difference in treatment effect between the propofol and volatile anesthetic groups when RIPC or no RIPC is applied on a composite endpoint (all-cause mortality, non-fatal myocardial infarction and/or any new stroke), all-cause mortality, non-fatal myocardial infarction, stroke, or length of stay on ICU. On cardiac markers, RIPC did show a treatment effect on cardiac troponin T measured as AUC 72 hours (SMD -0.80, CI -1.34, -0.25) in the propofol group. However, these findings have to be interpreted with great caution, to date only a very limited number of patients received volatile anesthetics in RIPC trials (minimum N.=15, maximum N.=232). CONCLUSIONS Present data do not permit a final assessment regarding the role of volatile or intravenous anesthetics as a possible confounding factor in RIPC trials.
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Affiliation(s)
- Carina Benstoem
- Department of Intensive Care Medicine and Intermediate Care, Medical Faculty, RWTH Aachen University, Aachen, Germany -
| | - Andreas Goetzenich
- Department of Thoracic and Cardiovascular Surgery, Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Rüdiger Autschbach
- Department of Thoracic and Cardiovascular Surgery, Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Gernot Marx
- Department of Intensive Care Medicine and Intermediate Care, Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Christian Stoppe
- Department of Intensive Care Medicine and Intermediate Care, Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Thomas Breuer
- Department of Intensive Care Medicine and Intermediate Care, Medical Faculty, RWTH Aachen University, Aachen, Germany
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27
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Bøtker HE, Hausenloy D, Andreadou I, Antonucci S, Boengler K, Davidson SM, Deshwal S, Devaux Y, Di Lisa F, Di Sante M, Efentakis P, Femminò S, García-Dorado D, Giricz Z, Ibanez B, Iliodromitis E, Kaludercic N, Kleinbongard P, Neuhäuser M, Ovize M, Pagliaro P, Rahbek-Schmidt M, Ruiz-Meana M, Schlüter KD, Schulz R, Skyschally A, Wilder C, Yellon DM, Ferdinandy P, Heusch G. Practical guidelines for rigor and reproducibility in preclinical and clinical studies on cardioprotection. Basic Res Cardiol 2018; 113:39. [PMID: 30120595 PMCID: PMC6105267 DOI: 10.1007/s00395-018-0696-8] [Citation(s) in RCA: 304] [Impact Index Per Article: 50.7] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Revised: 07/18/2018] [Accepted: 08/03/2018] [Indexed: 02/07/2023]
Affiliation(s)
- Hans Erik Bøtker
- Department of Cardiology, Aarhus University Hospital, Palle-Juul Jensens Boulevard 99, 8200, Aarhus N, Denmark.
| | - Derek Hausenloy
- The Hatter Cardiovascular Institute, University College London, 67 Chenies Mews, London, WC1E 6HX, UK
- The National Institute of Health Research, University College London Hospitals Biomedial Research Centre, Research and Development, London, UK
- National Heart Research Institute Singapore, National Heart Centre, Singapore, Singapore
- Yon Loo Lin School of Medicine, National University Singapore, Singapore, Singapore
- Cardiovascular and Metabolic Disorders Program, Duke-National University of Singapore, 8 College Road, Singapore, 169857, Singapore
| | - Ioanna Andreadou
- Laboratory of Pharmacology, Faculty of Pharmacy, National and Kapodistrian University of Athens, Athens, Greece
| | - Salvatore Antonucci
- Department of Biomedical Sciences, CNR Institute of Neuroscience, University of Padova, Via Ugo Bassi 58/B, 35121, Padua, Italy
| | - Kerstin Boengler
- Institute for Physiology, Justus-Liebig University Giessen, Giessen, Germany
| | - Sean M Davidson
- The Hatter Cardiovascular Institute, University College London, 67 Chenies Mews, London, WC1E 6HX, UK
| | - Soni Deshwal
- Department of Biomedical Sciences, CNR Institute of Neuroscience, University of Padova, Via Ugo Bassi 58/B, 35121, Padua, Italy
| | - Yvan Devaux
- Cardiovascular Research Unit, Luxembourg Institute of Health, Strassen, Luxembourg
| | - Fabio Di Lisa
- Department of Biomedical Sciences, CNR Institute of Neuroscience, University of Padova, Via Ugo Bassi 58/B, 35121, Padua, Italy
| | - Moises Di Sante
- Department of Biomedical Sciences, CNR Institute of Neuroscience, University of Padova, Via Ugo Bassi 58/B, 35121, Padua, Italy
| | - Panagiotis Efentakis
- Laboratory of Pharmacology, Faculty of Pharmacy, National and Kapodistrian University of Athens, Athens, Greece
| | - Saveria Femminò
- Department of Clinical and Biological Sciences, University of Torino, Turin, Italy
| | - David García-Dorado
- Experimental Cardiology, Vall d'Hebron Institut de Recerca (VHIR), Hospital Universitari Vall d'Hebron, Pg. Vall d'Hebron 119-129, 08035, Barcelona, Spain
| | - Zoltán Giricz
- Department of Pharmacology and Pharmacotherapy, Semmelweis University, Budapest, Hungary
- Pharmahungary Group, Szeged, Hungary
| | - Borja Ibanez
- Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), IIS-Fundación Jiménez Díaz, CIBERCV, Madrid, Spain
| | - Efstathios Iliodromitis
- Second Department of Cardiology, Faculty of Medicine, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Nina Kaludercic
- Department of Biomedical Sciences, CNR Institute of Neuroscience, University of Padova, Via Ugo Bassi 58/B, 35121, Padua, Italy
| | - Petra Kleinbongard
- Institute for Pathophysiology, West German Heart and Vascular Center, University of Essen Medical School, Essen, Germany
| | - Markus Neuhäuser
- Department of Mathematics and Technology, Koblenz University of Applied Science, Remagen, Germany
- Institute for Medical Informatics, Biometry, and Epidemiology, University Hospital Essen, Essen, Germany
| | - Michel Ovize
- Explorations Fonctionnelles Cardiovasculaires, Hôpital Louis Pradel, Lyon, France
- UMR, 1060 (CarMeN), Université Claude Bernard, Lyon1, Villeurbanne, France
| | - Pasquale Pagliaro
- Department of Clinical and Biological Sciences, University of Torino, Turin, Italy
| | - Michael Rahbek-Schmidt
- Department of Cardiology, Aarhus University Hospital, Palle-Juul Jensens Boulevard 99, 8200, Aarhus N, Denmark
| | - Marisol Ruiz-Meana
- Experimental Cardiology, Vall d'Hebron Institut de Recerca (VHIR), Hospital Universitari Vall d'Hebron, Pg. Vall d'Hebron 119-129, 08035, Barcelona, Spain
| | | | - Rainer Schulz
- Institute for Physiology, Justus-Liebig University Giessen, Giessen, Germany
| | - Andreas Skyschally
- Institute for Pathophysiology, West German Heart and Vascular Center, University of Essen Medical School, Essen, Germany
| | - Catherine Wilder
- The Hatter Cardiovascular Institute, University College London, 67 Chenies Mews, London, WC1E 6HX, UK
| | - Derek M Yellon
- The Hatter Cardiovascular Institute, University College London, 67 Chenies Mews, London, WC1E 6HX, UK
| | - Peter Ferdinandy
- Department of Pharmacology and Pharmacotherapy, Semmelweis University, Budapest, Hungary
- Pharmahungary Group, Szeged, Hungary
| | - Gerd Heusch
- Institute for Pathophysiology, West German Heart and Vascular Center, University of Essen Medical School, Essen, Germany.
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28
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Chong J, Bulluck H, Yap EP, Ho AFW, Boisvert WA, Hausenloy DJ. Remote ischemic conditioning in ST-segment elevation myocardial infarction - an update. CONDITIONING MEDICINE 2018; 1:13-22. [PMID: 30338313 PMCID: PMC6191186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Acute myocardial infarction (AMI) and the heart failure (HF) that often results are among the leading causes of death and disability in the world. As such, novel strategies are required to protect the heart against the detrimental effects of acute ischemia/reperfusion injury (IRI), in order to reduce myocardial infarct (MI) size and prevent the onset of HF. The endogenous cardioprotective strategy of remote ischemic conditioning (RIC), in which cycles of brief ischemia and reperfusion are applied to a tissue or organ away from the heart, has been reported in experimental studies to reduce MI size in animal models of acute IRI. In the clinical setting, RIC can be induced by simply inflating and deflating a cuff placed on the upper arm or thigh to induce brief cycles of ischemia and reperfusion, a strategy which has been shown to reduce MI size in ST-segment elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (PPCI). The results of the ongoing CONDI2/ERIC-PPCI trial are eagerly awaited, and will provide definitive answers with regards to the cardioprotective effect and clinical outcome benefits of RIC in STEMI.
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Affiliation(s)
- Jun Chong
- Barts Heart Centre, St Bartholomew’s Hospital, London, United Kingdom
| | - Heerajnarain Bulluck
- Hatter Cardiovascular Institute, London, United Kingdom
- Norfolk and Norwich University Hospital, Norwich, UK
| | - En Ping Yap
- National Heart Research Institute Singapore, National Heart Centre Singapore, Singapore
| | - Andrew FW Ho
- Department of Emergency Medicine, Singapore General Hospital
- Cardiovascular and Metabolic Disorders Program, Duke-National University of Singapore, Singapore
| | - William A. Boisvert
- Center for Cardiovascular Research, John A. Burns School of Medicine, University of Hawaii, USA
| | - Derek J Hausenloy
- Barts Heart Centre, St Bartholomew’s Hospital, London, United Kingdom
- Hatter Cardiovascular Institute, London, United Kingdom
- National Heart Research Institute Singapore, National Heart Centre Singapore, Singapore
- Cardiovascular and Metabolic Disorders Program, Duke-National University of Singapore, Singapore
- The National Institute of Health Research University College London Hospitals Biomedical Research Centre, London, United Kingdom
- Yong Loo Lin School of Medicine, National University Singapore, Singapore
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29
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De Simone F, Cassarà L, Sardo S, Scarparo E, Saleh O, Nigro Neto C, Zangrillo A, Landoni G. An innovative technique to improve safety of volatile anesthetics suction from the cardiopulmonary bypass circuit. Ann Card Anaesth 2018; 20:399-402. [PMID: 28994673 PMCID: PMC5661307 DOI: 10.4103/aca.aca_50_17] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Context: Myocardial injury during cardiac surgery on cardiopulmonary bypass (CPB) is a major determinant of morbidity and mortality. Preclinical and clinical evidence of dose- and time-related cardioprotective effects of volatile anesthetic drugs exist and their use during the whole surgery duration could improve perioperative cardiac protection. Even if administering volatile agents during CPB are relatively easy, technical problems, such as waste gas scavenging, may prevent safe and manageable administration of halogenated vapors during CPB. Aims: The aim of this study is to improve the safe administration of volatile anesthesia during CPB. Settings and Design: Tertiary teaching hospital. Subjects and Methods: We describe an original device that collects and disposes of any volatile anesthetic vapors present in the exit stream of the oxygenator, hence preventing its dispersal into the operating theatre environment and adaptively regulates pressure of oxygenator chamber in the CPB circuit. Results: We have so far applied a prototype of this device in more than 1300 adult cardiac surgery patients who received volatile anesthetics during the CPB phase. Conclusions: Widespread implementation of scavenging system like the one we designed may facilitate the perfusionist and the anesthesiologist in delivering these cardioprotective drugs with beneficial impact on patients’ outcome without compromising on safety.
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Affiliation(s)
- Francesco De Simone
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Luigi Cassarà
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Salvatore Sardo
- Department of Biomedical Sciences, University of Cagliari, Cagliari, Italy
| | - Elena Scarparo
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Omar Saleh
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | | | - Alberto Zangrillo
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute; University Vita-Salute San Raffaele, Milan, Italy
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute; Anesthesia and Intensive Care, Vita-Salute San Raffaele University, Milan, Italy
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30
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Pagel PS, Crystal GJ. The Discovery of Myocardial Preconditioning Using Volatile Anesthetics: A History and Contemporary Clinical Perspective. J Cardiothorac Vasc Anesth 2018; 32:1112-1134. [DOI: 10.1053/j.jvca.2017.12.029] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Indexed: 12/24/2022]
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31
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Basalay MV, Davidson SM, Gourine AV, Yellon DM. Neural mechanisms in remote ischaemic conditioning in the heart and brain: mechanistic and translational aspects. Basic Res Cardiol 2018; 113:25. [PMID: 29858664 PMCID: PMC5984640 DOI: 10.1007/s00395-018-0684-z] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Revised: 05/02/2018] [Accepted: 05/23/2018] [Indexed: 12/13/2022]
Abstract
Remote ischaemic conditioning (RIC) is a promising method of cardioprotection, with numerous clinical studies having demonstrated its ability to reduce myocardial infarct size and improve prognosis. On the other hand, there are several clinical trials, in particular those conducted in the setting of elective cardiac surgery, that have failed to show any benefit of RIC. These contradictory data indicate that there is insufficient understanding of the mechanisms underlying RIC. RIC is now known to signal indiscriminately, protecting not only the heart, but also other organs. In particular, experimental studies have demonstrated that it is able to reduce infarct size in an acute ischaemic stroke model. However, the mechanisms underlying RIC-induced neuroprotection are even less well understood than for cardioprotection. The existence of bidirectional feedback interactions between the heart and the brain suggests that the mechanisms of RIC-induced neuroprotection and cardioprotection should be studied as a whole. This review, therefore, addresses the topic of the neural component of the RIC mechanism.
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Affiliation(s)
- Marina V Basalay
- The Hatter Cardiovascular Institute, University College London, 67 Chenies Mews, London, WC1E 6HX, UK
| | - Sean M Davidson
- The Hatter Cardiovascular Institute, University College London, 67 Chenies Mews, London, WC1E 6HX, UK
| | - Andrey V Gourine
- Department of Cardiology, Karolinska University Hospital, 171 76, Stockholm, Sweden
| | - Derek M Yellon
- The Hatter Cardiovascular Institute, University College London, 67 Chenies Mews, London, WC1E 6HX, UK.
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32
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Perez-Protto S, Nazemian R, Matta M, Patel P, Wagner KJ, Latifi SQ, Lebovitz DJ, Reynolds JD. The effect of inhalational anaesthesia during deceased donor organ procurement on post-transplantation graft survival. Anaesth Intensive Care 2018. [PMID: 29519220 DOI: 10.1177/0310057x1804600206] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Many deceased by neurologic criteria donors are administered inhalational agents during organ recovery surgery-a process that is characterised by warm and cold ischaemia followed by warm reperfusion. In certain settings, volatile anaesthetics (VA) are known to precondition organs to protect them from subsequent ischaemia-reperfusion injury. As such, we hypothesised that exposure to VA during organ procurement would improve post-graft survival. Lifebanc (organ procurement organisation [OPO] for NE Ohio) provided the investigators with a list of death by neurologic criteria organ donors cared for at three large tertiary hospitals in Cleveland between 2006 and 2016-details about the surgical recovery phase were extracted from the organ donors' medical records. De-identified data on graft survival were obtained from the United Network for Organ Sharing (UNOS). The collated data underwent comparative analysis based on whether or not VA were administered during procurement surgery. Records from 213 donors were obtained for analysis with 138 exposed and 75 not exposed. Demographics, medical histories, and organ procurement rates were similar between the two cohorts. For the primary endpoint, there were no significant differences observed in either early (30-day) or late (five-year) graft survival rates for kidney, liver, lung, or heart transplants. Our findings from this retrospective review of a relatively small cohort do not support the hypothesis that the use of VA during the surgical procurement phase improves graft survival. Reviews of larger datasets and/or a prospective study may be required to provide a definitive answer.
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Affiliation(s)
- S Perez-Protto
- Assistant Professor, Department of Critical Care, Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - R Nazemian
- MD, Institute for Transformative Molecular Medicine, Case Western Reserve University; Physician Resident, Department of Anesthesiology & Perioperative Medicine, University Hospitals Cleveland Medical Center; Cleveland, Ohio, USA
| | - M Matta
- Assistant Professor, Department of Pulmonary, Critical Care and Sleep Medicine, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - P Patel
- Clinical Fellow, Department of Anesthesiology & Perioperative Medicine, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - K J Wagner
- Assistant Professor, Department of Anesthesiology, Metro Health Medical Center, Cleveland, Ohio, USA
| | - S Q Latifi
- Attending Physician, Department of Pediatric Critical Care, Cleveland Clinic Children's Hospital; Co-Medical Director Lifebanc, Cleveland, Ohio, USA
| | - D J Lebovitz
- Attending Physician, Department of Critical Care, Akron Children's Hospital, Akron; Medical Director, Lifebanc, Cleveland; Ohio, USA
| | - J D Reynolds
- Institute for Transformative Molecular Medicine, Case Western Reserve University; Associate Professor, Department of Anesthesiology & Perioperative Medicine, University Hospitals Cleveland Medical Center; Cleveland, Ohio, USA
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Remote Ischemic Preconditioning Does Not Affect the Release of Humoral Factors in Propofol-Anesthetized Cardiac Surgery Patients: A Secondary Analysis of the RIPHeart Study. Int J Mol Sci 2018; 19:ijms19041094. [PMID: 29621201 PMCID: PMC5979505 DOI: 10.3390/ijms19041094] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Revised: 03/29/2018] [Accepted: 03/30/2018] [Indexed: 12/15/2022] Open
Abstract
In contrast to several smaller studies, which demonstrate that remote ischemic preconditioning (RIPC) reduces myocardial injury in patients that undergo cardiovascular surgery, the RIPHeart study failed to demonstrate beneficial effects of troponin release and clinical outcome in propofol-anesthetized cardiac surgery patients. Therefore, we addressed the potential biochemical mechanisms triggered by RIPC. This is a predefined prospective sub-analysis of the randomized and controlled RIPHeart study in cardiac surgery patients (n = 40) that was recently published. Blood samples were drawn from patients prior to surgery, after RIPC of four cycles of 5 min arm ischemia/5 min reperfusion (n = 19) and the sham (n = 21) procedure, after connection to cardiopulmonary bypass (CPB), at the end of surgery, 24 h postoperatively, and 48 h postoperatively for the measurement of troponin T, macrophage migration inhibitory factor (MIF), stromal cell-derived factor 1 (CXCL12), IL-6, CXCL8, and IL-10. After RIPC, right atrial tissue samples were taken for the measurement of extracellular-signal regulated kinase (ERK1/2), protein kinase B (AKT), Glycogen synthase kinase 3 (GSK-3β), protein kinase C (PKCε), and MIF content. RIPC did not significantly reduce the troponin release when compared with the sham procedure. MIF serum levels intraoperatively increased, peaking at intensive care unit (ICU) admission (with an increase of 48.04%, p = 0.164 in RIPC; and 69.64%, p = 0.023 over the baseline in the sham procedure), and decreased back to the baseline 24 h after surgery, with no differences between the groups. In the right atrial tissue, MIF content decreased after RIPC (1.040 ± 1.032 Arbitrary units [au] in RIPC vs. 2.028 ± 1.631 [au] in the sham procedure, p < 0.05). CXCL12 serum levels increased significantly over the baseline at the end of surgery, with no differences between the groups. ERK1/2, AKT, GSK-3β, and PKCɛ phosphorylation in the right atrial samples were no different between the groups. No difference was found in IL-6, CXCL8, and IL10 serum levels between the groups. In this cohort of cardiac surgery patients that received propofol anesthesia, we could not show a release of potential mediators of signaling, nor an effect on the inflammatory response, nor an activation of well-established protein kinases after RIPC. Based on these data, we cannot exclude that confounding factors, such as propofol, may have interfered with RIPC.
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Hausenloy DJ, Garcia-Dorado D, Bøtker HE, Davidson SM, Downey J, Engel FB, Jennings R, Lecour S, Leor J, Madonna R, Ovize M, Perrino C, Prunier F, Schulz R, Sluijter JPG, Van Laake LW, Vinten-Johansen J, Yellon DM, Ytrehus K, Heusch G, Ferdinandy P. Novel targets and future strategies for acute cardioprotection: Position Paper of the European Society of Cardiology Working Group on Cellular Biology of the Heart. Cardiovasc Res 2018; 113:564-585. [PMID: 28453734 DOI: 10.1093/cvr/cvx049] [Citation(s) in RCA: 243] [Impact Index Per Article: 40.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2016] [Accepted: 03/15/2017] [Indexed: 02/06/2023] Open
Abstract
Ischaemic heart disease and the heart failure that often results, remain the leading causes of death and disability in Europe and worldwide. As such, in order to prevent heart failure and improve clinical outcomes in patients presenting with an acute ST-segment elevation myocardial infarction and patients undergoing coronary artery bypass graft surgery, novel therapies are required to protect the heart against the detrimental effects of acute ischaemia/reperfusion injury (IRI). During the last three decades, a wide variety of ischaemic conditioning strategies and pharmacological treatments have been tested in the clinic-however, their translation from experimental to clinical studies for improving patient outcomes has been both challenging and disappointing. Therefore, in this Position Paper of the European Society of Cardiology Working Group on Cellular Biology of the Heart, we critically analyse the current state of ischaemic conditioning in both the experimental and clinical settings, provide recommendations for improving its translation into the clinical setting, and highlight novel therapeutic targets and new treatment strategies for reducing acute myocardial IRI.
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Affiliation(s)
- Derek J Hausenloy
- The Hatter Cardiovascular Institute, University College London, 67 Chenies Mews, London WC1E 6HX, UK; The National Institute of Health Research University College London Hospitals Biomedical Research Centre, 149 Tottenham Court Road London, W1T 7DN, UK; Cardiovascular and Metabolic Disorders Program, Duke-National University of Singapore, 8 College Road, Singapore 169857; National Heart Research Institute Singapore, National Heart Centre Singapore, 5 Hospital Dr, Singapore 169609, Singapore; Yong Loo Lin School of Medicine, National University Singapore, Singapore; Barts Heart Centre, St Bartholomew's Hospital, London, UK
| | - David Garcia-Dorado
- Department of Cardiology, Vall d Hebron University Hospital and Research Institute. Universitat Autònoma, Passeig de la Vall d'Hebron, 119-129, 08035 Barcelona, Spain
| | - Hans Erik Bøtker
- Department of Cardiology, Aarhus University Hospital Skejby, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark
| | - Sean M Davidson
- The Hatter Cardiovascular Institute, University College London, 67 Chenies Mews, London WC1E 6HX, UK
| | - James Downey
- Department of Physiology and Cell Biology, College of Medicine, University of South Alabama, 5851 USA Dr. N., MSB 3074, Mobile, AL 36688, USA
| | - Felix B Engel
- Experimental Renal and Cardiovascular Research, Department of Nephropathology, Institute of Pathology, Friedrich-Alexander-Universität Erlangen-Nßrnberg, Schloßplatz 4, 91054 Erlangen, Germany
| | - Robert Jennings
- Department of Cardiology, Duke University, Durham, NC 27708, USA
| | - Sandrine Lecour
- Department of Medicine, Hatter Institute for Cardiovascular Research in Africa and South African Medical Research Council Inter-University Cape Heart Group, Faculty of Health Sciences, University of Cape Town, Chris Barnard Building, Anzio Road, Observatory, 7925, Cape Town, Western Cape, South Africa
| | - Jonathan Leor
- Tamman Cardiovascular Research Institute, Sheba Medical Center, Tel Hashomer, Israel; Neufeld Cardiac Research Institute, Tel-Aviv University, Sheba Medical Center, Tel Hashomer, 5265601, Israel; Sheba Center for Regenerative Medicine, Stem Cell, and Tissue Engineering, Tel Hashomer, 5265601, Israel
| | - Rosalinda Madonna
- Center of Aging Sciences and Translational Medicine - CESI-MeT, "G. d'Annunzio" University, Chieti, Italy; Institute of Cardiology, Department of Neurosciences, Imaging, and Clinical Sciences, "G. d'Annunzio University, Chieti, Italy; Texas Heart Institute and University of Texas Medical School in Houston, Department of Internal Medicine, 6770 Bertner Avenue, Houston, Texas 77030 USA
| | - Michel Ovize
- Explorations Fonctionnelles Cardiovasculaires, Hôpital Louis Pradel, 28 Avenue du Doyen Jean Lépine, 69500 Bron, France; UMR 1060 (CarMeN), Université Claude Bernard Lyon, 43 Boulevard du 11 Novembre 1918, 69100 Villeurbanne, France
| | - Cinzia Perrino
- Department of Advanced Biomedical Sciences, Division of Cardiology, Federico II University Corso Umberto I, 40, 80138 Napoli, Italy
| | - Fabrice Prunier
- Department of Cardiology, University of Angers, University Hospital of Angers, 4 Rue Larrey, 49100 Angers, France
| | - Rainer Schulz
- Institute of Physiology, Justus-Liebig, University of Giessen, Ludwigstraße 23, 35390 Gießen, Germany
| | - Joost P G Sluijter
- Cardiology and UMC Utrecht Regenerative Medicine Center, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, Netherlands
| | - Linda W Van Laake
- Division Heart and Lungs, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, Netherlands
| | - Jakob Vinten-Johansen
- Division of Cardiothoracic Surgery, Department of Surgery, Emory University, 201 Dowman Dr, Atlanta, GA 30322, USA
| | - Derek M Yellon
- The Hatter Cardiovascular Institute, University College London, 67 Chenies Mews, London WC1E 6HX, UK; The National Institute of Health Research University College London Hospitals Biomedical Research Centre, 149 Tottenham Court Road London, W1T 7DN, UK
| | - Kirsti Ytrehus
- Cardiovascular Research Group, Department of Medical Biology, UiT The Arctic University of Norway, Hansine Hansens veg 18, 9019 Tromsø, Norway
| | - Gerd Heusch
- Institute for Pathophysiology, West-German Heart and Vascular Center, University Hospital Essen, Hufelandstrasse 55, 45147 Essen, Germany
| | - Péter Ferdinandy
- Department of Pharmacology and Pharmacotherapy, Semmelweis University, Budapest, Nagyvárad tér 4, 1089 Hungary; Pharmahungary Group, Graphisoft Park, 7 Záhony street, Budapest, H-1031, Hungary
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Silachev DN, Usatikova EA, Pevzner IB, Zorova LD, Babenko VA, Gulyaev MV, Pirogov YA, Plotnikov EY, Zorov DB. Effect of Anesthetics on Efficiency of Remote Ischemic Preconditioning. BIOCHEMISTRY (MOSCOW) 2017; 82:1006-1016. [PMID: 28988529 DOI: 10.1134/s0006297917090036] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Remote ischemic preconditioning of hind limbs (RIPC) is an effective method for preventing brain injury resulting from ischemia. However, in numerous studies RIPC has been used on the background of administered anesthetics, which also could exhibit neuroprotective properties. Therefore, investigation of the signaling pathways triggered by RIPC and the effect of anesthetics is important. In this study, we explored the effect of anesthetics (chloral hydrate and Zoletil) on the ability of RIPC to protect the brain from injury caused by ischemia and reperfusion. We found that RIPC without anesthesia resulted in statistically significant decrease in neurological deficit 24 h after ischemia, but did not affect the volume of brain injury. Administration of chloral hydrate or Zoletil one day prior to brain ischemia produced a preconditioning effect by their own, decreasing the degree of neurological deficit and lowering the volume of infarct with the use of Zoletil. The protective effects observed after RIPC with chloral hydrate or Zoletil were similar to those observed when only the respective anesthetic was used. RIPC was accompanied by significant increase in the level of brain proteins associated with the induction of ischemic tolerance such as pGSK-3β, BDNF, and HSP70. However, Zoletil did not affect the level of these proteins 24 h after injection, and chloral hydrate caused increase of only pGSK-3β. We conclude that RIPC, chloral hydrate, and Zoletil produce a significant neuroprotective effect, but the simultaneous use of anesthetics with RIPC does not enhance the degree of neuroprotection.
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Affiliation(s)
- D N Silachev
- Belozersky Institute of Physico-Chemical Biology, Lomonosov Moscow State University, Moscow, 119992, Russia.
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Abstract
The translation from numerous successful animal experiments on cardioprotection beyond that by reperfusion to clinical practice has to date been disappointing. Animal experiments often use reductionist approaches and are mostly performed in young and healthy animals which lack the risk factors, comorbidities, and comedications which are characteristics of patients suffering an acute myocardial infarction or undergoing cardiovascular surgery. Conceptually, it is still unclear by how much the time window for successful reperfusion is extended by preconditioning, and how long the duration of ischemia can be so that adjunct cardioprotection by postconditioning at reperfusion still protects. Experimental studies addressing long-term effects of adjunct cardioprotection beyond infarct size reduction, that is, on repair, remodeling, and mortality, are lacking. Technically, reproducibility and robustness of experimental studies are often limited. Grave faults in design and conduct of clinical trials have also substantially contributed to the failure of translation of cardioprotection to clinical practice. Cardiovascular surgery with ischemic cardioplegic arrest is only a surrogate of acute myocardial infarction and confounded by the choice of anesthesia, hypothermia, cardioplegia, and traumatic myocardial injury. Trials in patients with acute myocardial infarction have been performed on agents/interventions with no or inconsistent previous animal data and in patients who had either some reperfusion already at admission or were reperfused too late to expect any myocardial salvage. Of greatest concern is the lack of adequate phase II dosing and timing studies when rushing from promising proof-of-concept trials with surrogate end points such as infarct size to larger clinical outcome trials. Future trials must focus on interventions/agents with robust preclinical evidence, have solid phase II dosing and timing data, and recruit patients who have truly a chance to benefit from adjunct cardioprotection.
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Affiliation(s)
- Gerd Heusch
- From the Institute for Pathophysiology, West German Heart and Vascular Center, University of Essen Medical School, Germany.
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Abstract
Perioperative myocardial ischemia and infarction are the leading causes of morbidity and mortality following anesthesia and surgery. The discovery of endogenous cardioprotective mechanisms has led to testing of new methods to protect the human heart. These approaches have included ischemic pre-conditioning, per-conditioning, post-conditioning, and remote conditioning of the myocardium. Pre-conditioning and per-conditioning include brief and repetitive periods of sub-lethal ischemia before and during prolonged ischemia, respectively; and post-conditioning is applied at the onset of reperfusion. Remote ischemic conditioning involves transient, repetitive, non-lethal ischemia and reperfusion in one organ or tissue (remote from the heart) that renders myocardium more resistant to lethal ischemia/reperfusion injury. In healthy, young hearts, many conditioning maneuvers can significantly increase the resistance of the heart against ischemia/reperfusion injury. The large multicenter clinical trials with ischemic remote conditioning have not been proven successful in cardiac surgery thus far. The lack of clinical success is due to underlying risk factors that interfere with remote ischemic conditioning and the use of cardioprotective agents that have activated the endogenous cardioprotective mechanisms prior to remote ischemic conditioning. Future preclinical research using remote ischemic conditioning will need to be conducted using comorbid models.
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Affiliation(s)
- Zeljko J Bosnjak
- Department of Anesthesiology, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI, 53226, USA.,Department of Physiology, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI, 53226, USA
| | - Zhi-Dong Ge
- Department of Anesthesiology, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI, 53226, USA
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Bignami E, Guarnieri M, Pieri M, De Simone F, Rodriguez A, Cassarà L, Lembo R, Landoni G, Zangrillo A. Volatile anaesthetics added to cardiopulmonary bypass are associated with reduced cardiac troponin. Perfusion 2017; 32:547-553. [DOI: 10.1177/0267659117701562] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Background: Every year, over 1 million cardiac surgical procedures are performed all over the world. Reducing myocardial necrosis could have strong implications in postoperative clinical outcomes. Volatile anaesthetics have cardiac protective properties in the perioperative period of cardiac surgery. However, little data exists on the administration of volatile agents during cardiopulmonary bypass. The aim of this study was to assess if volatile anaesthetics administration during cardiopulmonary bypass reduces cardiac troponin release after cardiac surgery. Materials and methods: We retrospectively analysed data from 942 patients who underwent cardiac surgery in a teaching hospital. The only difference between the groups was the management of anaesthesia during CPB. The volatile group received sevoflurane or desflurane while the control group received a combination of propofol infusion and fentanyl boluses. Patients who received volatile anaesthetics during cardiopulmonary bypass (n=314) were propensity-matched 1:2 with patients who did not receive volatile anaesthetics during CPB (n=628). Results: We found a reduction in peak postoperative troponin I, from 7.8 ng/ml (4.8-13.1) in the non-volatile group to 6.8 ng/ml (3.7-11.8) in the volatile group (p=0.013), with no differences in mortality [2 (0.6%) in the volatile group and 2 (0.3%) in the non-volatile group (p=0.6)]. Conclusions: Adding volatile anaesthetics during cardiopulmonary bypass was associated with reduced peak postoperative troponin levels. Larger studies are required to confirm our data and to assess the effect of volatile agents on survival.
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Affiliation(s)
- Elena Bignami
- Anaesthesia and Intensive Care Department, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Marcello Guarnieri
- Anaesthesia and Intensive Care Department, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Marina Pieri
- Anaesthesia and Intensive Care Department, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Francesco De Simone
- Cardiothoracic Surgery Department, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Alcira Rodriguez
- Cardiothoracic Surgery Department, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Luigi Cassarà
- Anaesthesia and Intensive Care Department, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Rosalba Lembo
- Anaesthesia and Intensive Care Department, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Giovanni Landoni
- Anaesthesia and Intensive Care Department, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
| | - Alberto Zangrillo
- Anaesthesia and Intensive Care Department, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
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Pieri M, Belletti A, Oriani A, Landoni G, Latib A, Mangieri A, Colombo A, Zangrillo A, Monaco F. Anesthetic Management of Cardioband Implantation: Data From a Preliminary Experience and New Insights. J Cardiothorac Vasc Anesth 2017; 31:482-488. [DOI: 10.1053/j.jvca.2016.08.028] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Indexed: 11/11/2022]
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Cho YJ, Lee EH, Lee K, Kim TK, Hong DM, Chin JH, Choi DK, Bahk JH, Sim JY, Choi IC, Jeon Y. Long-term clinical outcomes of Remote Ischemic Preconditioning and Postconditioning Outcome (RISPO) trial in patients undergoing cardiac surgery. Int J Cardiol 2017; 231:84-89. [DOI: 10.1016/j.ijcard.2016.12.146] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Revised: 12/19/2016] [Accepted: 12/20/2016] [Indexed: 01/20/2023]
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Abstract
The existing clinical studies on remote ischemic preconditioning in patients undergoing cardiovascular surgery are critically reviewed, with a focus on infarct size reduction and clinical outcome as end points. Confounders, notably the use of propofol anesthesia are identified. The need for better designed trials with a more targeted approach is emphasized.
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Affiliation(s)
- Gerd Heusch
- 1 Institute for Pathophysiology, West German Heart and Vascular Center, University of Essen Medical School, Essen, Germany
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43
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Cardioprotection by remote ischemic conditioning and its signal transduction. Pflugers Arch 2016; 469:159-181. [DOI: 10.1007/s00424-016-1922-6] [Citation(s) in RCA: 107] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2016] [Accepted: 11/28/2016] [Indexed: 12/23/2022]
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Cassisi C, Tsoutsouras T, Chiarenza F, Santonocito C, Sanfilippo F. Reply: The Role of Intraoperative Management on Postoperative Hemodynamic and Metabolic Profile After Coronary Artery Bypass Grafting. J Cardiothorac Vasc Anesth 2016; 31:e9-e10. [PMID: 27919722 DOI: 10.1053/j.jvca.2016.09.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2016] [Indexed: 11/11/2022]
Affiliation(s)
- Cesare Cassisi
- Cardiothoracic Intensive Care Unit, Oxford Heart Centre, John Radcliffe Hospital-Oxford University Hospitals, Oxford, United Kingdom; School of Anaesthesia and Intensive Care, University of Catania, Catania, Italy
| | - Theodoros Tsoutsouras
- Cardiothoracic Intensive Care Unit, Oxford Heart Centre, John Radcliffe Hospital-Oxford University Hospitals, Oxford, United Kingdom
| | - Federica Chiarenza
- Cardiothoracic Intensive Care Unit, Oxford Heart Centre, John Radcliffe Hospital-Oxford University Hospitals, Oxford, United Kingdom; School of Anaesthesia and Intensive Care, University of Catania, Catania, Italy
| | - Cristina Santonocito
- Cardiothoracic Intensive Care Unit, Oxford Heart Centre, John Radcliffe Hospital-Oxford University Hospitals, Oxford, United Kingdom; School of Anaesthesia and Intensive Care, University of Catania, Catania, Italy; IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), Palermo, Italy
| | - Filippo Sanfilippo
- Cardiothoracic Intensive Care Unit, Oxford Heart Centre, John Radcliffe Hospital-Oxford University Hospitals, Oxford, United Kingdom; School of Anaesthesia and Intensive Care, University of Catania, Catania, Italy; IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), Palermo, Italy
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Kahlert P, Hildebrandt HA, Patsalis PC, Al-Rashid F, Jánosi RA, Nensa F, Schlosser TW, Schlamann M, Wendt D, Thielmann M, Kottenberg E, Frey U, Neuhäuser M, Forsting M, Jakob HG, Rassaf T, Peters J, Heusch G, Kleinbongard P. No protection of heart, kidneys and brain by remote ischemic preconditioning before transfemoral transcatheter aortic valve implantation: Interim-analysis of a randomized single-blinded, placebo-controlled, single-center trial. Int J Cardiol 2016; 231:248-254. [PMID: 27940009 DOI: 10.1016/j.ijcard.2016.12.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Revised: 11/28/2016] [Accepted: 12/02/2016] [Indexed: 12/26/2022]
Abstract
BACKGROUND Remote ischemic preconditioning (RIPC) reduces myocardial injury and improves clinical outcome in patients undergoing coronary revascularization, but only in the absence of propofol-anesthesia. We investigated whether RIPC provides protection of heart, kidneys and brain and improves outcome in patients undergoing transfemoral transcatheter aortic valve implantation (TF-TAVI). METHODS Patients undergoing TF-TAVI were randomized to receive RIPC (3cycles of 5min left upper arm ischemia and 5min reperfusion) or placebo. The primary endpoint was myocardial injury, reflected by the area under the curve for serum troponin I concentrations (AUC-TnI) over the first 72h. Secondary endpoints included the incidences of periprocedural myocardial infarction, delayed gadolinium enhancement on postprocedural cardiac MRI, acute kidney injury, periprocedural stroke, and the incidence and volume of new lesions on postprocedural cerebral MRI. All-cause and cardiovascular mortality and major adverse cardiac and cerebrovascular events (MACCE) were assessed over 1-year follow-up. A prespecified interim-analysis was performed after the last patient had completed 1-year follow-up (NCT02080299). RESULTS 100 consecutive patients were enrolled between September 2013 and June 2015. There were no significant between-group differences in the primary endpoint of peri-interventional myocardial injury (ratio RIPC/placebo AUC-TnI: 0.87, 95% CI: 0.57-1.34, p=0.53) or the secondary endpoints of cardiac, renal and cerebral impairment. There was no significant treatment effect in subgroup-analyses of patients undergoing cardiac or cerebral MRI. Mortality and MACCE did not differ. No RIPC-related adverse events were observed. CONCLUSIONS RIPC did neither protect heart, kidneys and brain nor improve clinical outcome in patients undergoing TF-TAVI.
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Affiliation(s)
- Philipp Kahlert
- Department of Cardiology and Vascular Medicine, West-German Heart and Vascular Center Essen, Universitätsklinikum Essen, Universität Duisburg-Essen, Germany.
| | - Heike Annelie Hildebrandt
- Department of Cardiology and Vascular Medicine, West-German Heart and Vascular Center Essen, Universitätsklinikum Essen, Universität Duisburg-Essen, Germany.
| | - Polykarpos Christos Patsalis
- Department of Cardiology and Vascular Medicine, West-German Heart and Vascular Center Essen, Universitätsklinikum Essen, Universität Duisburg-Essen, Germany.
| | - Fadi Al-Rashid
- Department of Cardiology and Vascular Medicine, West-German Heart and Vascular Center Essen, Universitätsklinikum Essen, Universität Duisburg-Essen, Germany.
| | - Rolf Alexander Jánosi
- Department of Cardiology and Vascular Medicine, West-German Heart and Vascular Center Essen, Universitätsklinikum Essen, Universität Duisburg-Essen, Germany.
| | - Felix Nensa
- Institute for Diagnostic and Interventional Radiology and Neuroradiology, Universitätsklinikum Essen, Universität Duisburg-Essen, Germany.
| | - Thomas Wilfried Schlosser
- Institute for Diagnostic and Interventional Radiology and Neuroradiology, Universitätsklinikum Essen, Universität Duisburg-Essen, Germany.
| | - Marc Schlamann
- Institute for Diagnostic and Interventional Radiology and Neuroradiology, Universitätsklinikum Essen, Universität Duisburg-Essen, Germany; Department of Neuroradiology, University Hospital Gießen, Gießen, Germany.
| | - Daniel Wendt
- Department of Thoracic and Cardiovascular Surgery, West-German Heart and Vascular Center Essen, Universitätsklinikum Essen, Universität Duisburg-Essen, Germany.
| | - Matthias Thielmann
- Department of Thoracic and Cardiovascular Surgery, West-German Heart and Vascular Center Essen, Universitätsklinikum Essen, Universität Duisburg-Essen, Germany.
| | - Eva Kottenberg
- Klinik für Anästhesiologie und Intensivmedizin, Universitätsklinikum Essen, Universität Duisburg-Essen, Germany; Klinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Evangelisches Krankenhaus Mülheim, Germany.
| | - Ulrich Frey
- Klinik für Anästhesiologie und Intensivmedizin, Universitätsklinikum Essen, Universität Duisburg-Essen, Germany.
| | - Markus Neuhäuser
- Institute for Medical Informatics, Biometry, and Epidemiology, Universitätsklinikum Essen, Universität Duisburg-Essen, Germany; Department of Mathematics and Technology, Koblenz, University of Applied Science, Remagen, Germany.
| | - Michael Forsting
- Institute for Diagnostic and Interventional Radiology and Neuroradiology, Universitätsklinikum Essen, Universität Duisburg-Essen, Germany.
| | - Heinz Günther Jakob
- Department of Thoracic and Cardiovascular Surgery, West-German Heart and Vascular Center Essen, Universitätsklinikum Essen, Universität Duisburg-Essen, Germany.
| | - Tienush Rassaf
- Department of Cardiology and Vascular Medicine, West-German Heart and Vascular Center Essen, Universitätsklinikum Essen, Universität Duisburg-Essen, Germany.
| | - Jürgen Peters
- Klinik für Anästhesiologie und Intensivmedizin, Universitätsklinikum Essen, Universität Duisburg-Essen, Germany.
| | - Gerd Heusch
- Institute for Pathophysiology, West-German Heart and Vascular Center Essen, Universitätsklinikum Essen, Universität Duisburg-Essen, Germany.
| | - Petra Kleinbongard
- Institute for Pathophysiology, West-German Heart and Vascular Center Essen, Universitätsklinikum Essen, Universität Duisburg-Essen, Germany.
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Meybohm P, Stoppe C, Zacharowski K. Dubious effects by the choice of anesthetics in remote ischemic preconditioning. J Thorac Dis 2016; 8:E1549-E1550. [PMID: 28066658 DOI: 10.21037/jtd.2016.11.47] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Patrick Meybohm
- Department of Anesthesiology, Intensive Care Medicine, and Pain Therapy, University Hospital Frankfurt, Frankfurt, Germany
| | - Christian Stoppe
- Department of Intensive Care Medicine, University Hospital RWTH Aachen, Aachen, Germany
| | - Kai Zacharowski
- Department of Anesthesiology, Intensive Care Medicine, and Pain Therapy, University Hospital Frankfurt, Frankfurt, Germany
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Likhvantsev VV, Landoni G, Levikov DI, Grebenchikov OA, Skripkin YV, Cherpakov RA. Sevoflurane Versus Total Intravenous Anesthesia for Isolated Coronary Artery Bypass Surgery With Cardiopulmonary Bypass: A Randomized Trial. J Cardiothorac Vasc Anesth 2016; 30:1221-7. [DOI: 10.1053/j.jvca.2016.02.030] [Citation(s) in RCA: 67] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2015] [Indexed: 12/22/2022]
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Abstract
The mortality from acute myocardial infarction (AMI) remains significant, and the prevalence of post-myocardial infarction heart failure is increasing. Therefore, cardioprotection beyond timely reperfusion is needed. Conditioning procedures are the most powerful cardioprotective interventions in animal experiments. However, ischemic preconditioning cannot be used to reduce infarct size in patients with AMI because its occurrence is not predictable; several studies in patients undergoing surgical coronary revascularization report reduced release of creatine kinase and troponin. Ischemic postconditioning reduces infarct size in most, but not all, studies in patients undergoing interventional reperfusion of AMI, but may require direct stenting and exclusion of patients with >6 hours of symptom onset to protect. Remote ischemic conditioning reduces infarct size in patients undergoing interventional reperfusion of AMI, elective percutaneous or surgical coronary revascularization, and other cardiovascular surgery in many, but not in all, studies. Adequate dose-finding phase II studies do not exist. There are only 2 phase III trials, both on remote ischemic conditioning in patients undergoing cardiovascular surgery, both with neutral results in terms of infarct size and clinical outcome, but also both with major problems in trial design. We discuss the difficulties in translation of cardioprotection from animal experiments and proof-of-concept trials to clinical practice. Given that most studies on ischemic postconditioning and all studies on remote ischemic preconditioning in patients with AMI reported reduced infarct size, it would be premature to give up on cardioprotection.
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Affiliation(s)
- Gerd Heusch
- From the Institute for Pathophysiology (G.H.) and Clinic for Cardiology (T.R.), West German Heart and Vascular Center, University School of Medicine Essen, Essen, Germany
| | - Tienush Rassaf
- From the Institute for Pathophysiology (G.H.) and Clinic for Cardiology (T.R.), West German Heart and Vascular Center, University School of Medicine Essen, Essen, Germany
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Sardar P, Chatterjee S, Kundu A, Samady H, Owan T, Giri J, Nairooz R, Selzman CH, Heusch G, Gersh BJ, Abbott JD, Mukherjee D, Fang JC. Remote ischemic preconditioning in patients undergoing cardiovascular surgery: Evidence from a meta-analysis of randomized controlled trials. Int J Cardiol 2016; 221:34-41. [PMID: 27400294 DOI: 10.1016/j.ijcard.2016.06.325] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Revised: 06/27/2016] [Accepted: 06/29/2016] [Indexed: 12/22/2022]
Abstract
BACKGROUND Remote ischemic preconditioning (RIPC) has been associated with reduced risk of myocardial injury in patients undergoing cardiovascular surgery, but uncertainty about clinical outcomes remains, particularly in the light of 2 recent large randomized clinical trials (RCTs) which were neutral. We performed a meta-analysis to evaluate the efficacy of RIPC on clinically relevant outcomes in patients undergoing cardiovascular surgery. METHODS We searched PubMed, Cochrane CENTRAL, EMBASE, EBSCO, Web of Science and CINAHL databases from inception through November 30, 2015. RCTs that compared the effects of RIPC vs. control in patients undergoing cardiac and/or vascular surgery were selected. We calculated summary random-effect odds ratios (ORs) and 95% confidence intervals (CI). RESULTS The analysis included 5652 patients from 27 RCTs. RIPC reduced the risk of myocardial infarction (MI) (OR 0.72, 95% CI, 0.52 to 1.00; p=0.05; number needed to treat (NNT)=42), acute renal failure (OR 0.73, 95% CI, 0.53 to 1.00; p=0.05; NNT=44) as well as the composite of all cause mortality, MI, stroke or acute renal failure (OR 0.60, 95% CI, 0.39 to 0.90; p=0.01; NNT=25). No significant difference between RIPC and the control groups was observed for the outcome of all-cause mortality (OR 1.10, 95% CI, 0.81 to 1.51). Randomization to RIPC group was also associated with significantly shorter hospital stay (weighted mean difference -0.15days; 95% CI -0.27 to -0.03days). CONCLUSIONS RIPC did not decrease overall mortality, but was associated with less MI and acute renal failure and shorter hospitalizations in patients undergoing cardiac or vascular surgery.
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Affiliation(s)
- Partha Sardar
- Division of Cardiovascular Medicine, University of Utah, Salt Lake City, UT, United States.
| | - Saurav Chatterjee
- St Luke's-Roosevelt Hospital of the Mount Sinai Health System, New York, NY, United States
| | - Amartya Kundu
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA, United States
| | - Habib Samady
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA, United States
| | - Theophilus Owan
- Division of Cardiovascular Medicine, University of Utah, Salt Lake City, UT, United States
| | - Jay Giri
- Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, PA, United States
| | - Ramez Nairooz
- University of Arkansas for Medical Sciences, Little Rock, AR, United States
| | - Craig H Selzman
- Division of Cardiothoracic Surgery, Department of Surgery, University of Utah, Salt Lake City, UT,United States
| | - Gerd Heusch
- Institute for Pathophysiology, West German Heart and Vascular Center, University of Essen Medical School, Hufelandstr. 55, 45122 Essen, Germany
| | - Bernard J Gersh
- Division of Cardiovascular Diseases, Mayo Clinic and Mayo Clinic College of Medicine, Rochester, MN, United States
| | - J Dawn Abbott
- Division of Cardiology, Brown Medical School, Rhode Island Hospital, Providence, RI, United States
| | | | - James C Fang
- Division of Cardiovascular Medicine, University of Utah, Salt Lake City, UT, United States
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