Cardiac troponin I and creatine kinase-MB release after different cardiac surgeries

Exposure to Polypropylene Microplastics Causes Cardiomyocyte Apoptosis Through Oxidative Stress and Activation of the MAPK-Nrf2 Signaling Pathway

Microplastics are a growing concern as pollutants that impact both public health and the environment. However, the toxic effects of polypropylene microplastics (PP-MPs) are not well understood. This study aimed to investigate the effects of PP-MPs on cardiotoxicity and its underlying mechanisms. The cardiotoxicity of exposure to different amounts of PP-MPs were investigated in both ICR mice and H9C2 cells. Our results demonstrated that sub-chronic exposure to 5 and 50 mg/L PP-MPs led to myocardial structural damage, apoptosis, and fibrosis in mice cardiomyocytes. Flow cytometry analysis revealed that PP-MPs could decrease mitochondrial membrane potential and induce apoptosis in H9C2 cells. Western blotting revealed decreased expression of Bcl-2, poly(ADP-ribose) polymerase (PARP) and caspase 3 and increased expression of Bax, cleaved-PARP, and cleaved-caspase 3 in PP-MPs-treated cardiac tissue and H9C2 cells. These results confirmed the apoptotic effects induced by PP-MPs. Moreover, PP-MPs treatment triggered oxidative stress, as evidenced by the increased levels of malondialdehyde; reduction in glutathione peroxidase, superoxide dismutase, and catalase activities in mice cardiac tissues; and increased reactive oxygen species levels in H9C2 cells. Finally, western blotting demonstrated that exposure to PP-MPs significantly reduced the expression levels of Nrf2 and p-ERK proteins associated with MAPK-Nrf2 pathway in both cardiac tissue and H9C2 cells. Overall, our findings indicate that PP-MPs can induce cardiomyocyte apoptosis through MAPK-Nrf2 signaling pathway, which is triggered by oxidative stress. This study provides a foundation for determining the effects of PP-MPs on cardiotoxicity and their underlying mechanisms.

Myocardial Injury After Transcatheter Mitral Valve Replacement Versus Surgical Reoperation

This study aimed to evaluate the incidence and clinical implications of myocardial injury, as determined by cardiac biomarker increase, in patients who underwent mitral bioprosthesis dysfunction treatment with transcatheter mitral valve replacement (TMVR) versus surgical mitral valve replacement reoperation (SMVR-REDO). Between 2014 and 2023, 310 patients with mitral bioprosthesis failure were included (90 and 220 patients for TMVR and SMVR-REDO, respectively). Multivariable analysis and propensity score matching were performed to adjust for the intergroup differences in baseline characteristics. Creatinine kinase-MB (CK-MB) and cardiac troponin I (cTn) were collected at baseline and 6 to 12, 24, 48, and 72 hours after intervention. The cardiac biomarkers values were evaluated in relation to their reference values. The outcomes were determined according to the Mitral Valve Academic Research Consortium criteria. CK-MB and cTn increased above the reference level in almost all patients after SMVR-REDO and TMVR (100% vs 94%, respectively), with the peak occurring within 6 to 12 hours. SMVR-REDO was associated with a two- to threefold higher increase in cardiac biomarkers. After 30 days, the mortality rates were 13.3% in the TMVR and 16.8% in the SMVR-REDO groups. At a median follow-up of 19 months, the mortality rates were 21.1% in the TMVR and 17.7% in the SMVR-REDO groups. Left ventricular ejection fraction, estimated glomerular filtration rate, CK-MB, and cTn were predictors of mortality. In conclusion, some degree of myocardial injury occurred systematically after the treatment of mitral bioprosthetic degeneration, especially after SMVR, and higher CK-MB and cTn levels were associated with increased cumulative late mortality, regardless of the approach.

European Association of Cardio-Thoracic Surgery (EACTS) expert consensus statement on perioperative myocardial infarction after cardiac surgery

Cardiac surgery may lead to myocardial damage and release of cardiac biomarkers through various mechanisms such as cardiac manipulation, systemic inflammation, myocardial hypoxia, cardioplegic arrest and ischaemia caused by coronary or graft occlusion. Defining perioperative myocardial infarction (PMI) after cardiac surgery presents challenges, and the association between the current PMI definitions and postoperative outcomes remains uncertain. To address these challenges, the European Association of Cardio-Thoracic Surgery (EACTS) facilitated collaboration among a multidisciplinary group to evaluate the existing evidence on the mechanisms, diagnosis and prognostic implications of PMI after cardiac surgery. The review found that the postoperative troponin value thresholds associated with an increased risk of mortality are markedly higher than those proposed by all the current definitions of PMI. Additionally, it was found that large postoperative increases in cardiac biomarkers are prognostically relevant even in absence of additional supportive signs of ischaemia. A new algorithm for PMI detection after cardiac surgery was also proposed, and a consensus was reached within the group that establishing a prognostically relevant definition of PMI is critically needed in the cardiovascular field and that PMI should be included in the primary composite outcome of coronary intervention trials.

Albumin and Cardioprotection in On-Pump Cardiac Surgery-A Post Hoc Analysis of a Randomized Trial

OBJECTIVES

To study the quantitative potency of plasma albumin on cardioprotection in terms of creatinine kinase-myocardial band mass (CK-MBm) in on-pump cardiac surgery.

DESIGN

Post hoc analysis of a double-blinded randomized clinical trial.

SETTING

Single-center study in the Helsinki University Hospital.

PARTICIPANTS

A total of 1,386 adult on-pump cardiac surgical patients.

INTERVENTION

Administration of 4% albumin (n = 693) or Ringers acetate (n = 693) for cardiopulmonary bypass priming and volume replacement intraoperatively and postoperatively during the first 24 hours.

MEASUREMENTS AND MAIN RESULTS

Albumin concentration was measured preoperatively and intraoperatively (after protamine administration), and CK-MBm on the first postoperative morning. Multivariate linear regression analyses were measured in the whole cohort and the Ringer group. Plasma albumin concentration did not differ between the groups preoperatively (Ringer v albumin: 38.3 ± 5.0 g/L v 38.6 ± 4.5 g/L; p = 0.171) but differed intraoperatively (29.5 ± 5.2 g/L v 41.5 ± 6.0 g/L; p < 0.001). Creatinine kinase-myocardial band mass was higher in the Ringer (32.0 ± 34.8 μg/L) than in the albumin group (24.3 ± 33.0 μg/L) (p < 0.001). Aortic cross-clamping time associated with CK-MBm in the whole cohort (standardized β = 0.376 [95% CI 0.315-0.437], p < 0.001) and the Ringer group (β = 0.363 [0.273-0.452]; p < 0.001). Albumin administration in the whole cohort (β = -0.156 [-0.201 to -0.111]; p < 0.001) and high intraoperative albumin concentration in the Ringer group (β = -0.07 [-0.140 to -0.003]; p = 0.04) associated with reduced CK-MBm. Compared with ischemia-induced increase in CK-MBm, albumin's potency to reduce CK-MBm was 41% in the whole cohort (β-value ratio of -0.156/0.376) and 19% in the Ringer group (β-value ratio of -0.07/0.363).

CONCLUSION

Both endogenous and exogenous albumin appear to be cardioprotective regarding CK-MBm release in on-pump cardiac surgery.

Effect of Dexmedetomidine on Cardiac Surgery Patients

ABSTRACT

Dexmedetomidine, an alpha-2 adrenoreceptor agonist that is widely used as a sedative medication, is becoming more and more attractive in clinical application on cardiac surgery patients. In this review, we aim to summarize and discuss both retrospective studies and clinical trials regarding the effect of dexmedetomidine on patients who underwent cardiac surgery (including coronary artery bypass grafting, valve surgery, aortic surgery, percutaneous coronary intervention, and so on), which illustrates that the clinical effects of dexmedetomidine could effectively reduce mortality, major complications, and the intensive care unit and hospital length of stay without comprising safety. In addition, inconsistent results from both retrospective studies and clinical trials have also been demonstrated. Although the effectiveness and safety of dexmedetomidine on cardiac surgery patients is suggested, high-quality clinical trials are needed for further verification.

Biomarker based biosensors: An opportunity for diagnosis of COVID-19

Early diagnosis and treatment of diseases are crucial research areas of human health. For early diagnosis, one method that has proven efficient is the detection of biomarkers which can provide real-time and accurate biological information. Most biomarker detection is currently carried out at localised dedicated laboratories using large and automated analysers, increasing waiting time and costs. Smaller, faster, and cheaper devices could potentially replace these time-consuming laboratory analyses and make analytical results available as point-of-care diagnostics. Innovative biosensor-based strategies could allow biomarkers to be tested reliably in a decentralised setting. Early diagnosis of COVID-19 patients has a key role in order to use quarantine and treatment strategies in a timely manner. Raised levels of several biomarkers in COVID-19 patients are associated with respiratory infections or dysfunction of various organs. Through clinical studies of COVID-19 patient biomarkers such as ferritin, Interleukins, albumin and …are found to reveals significant differences in their excretion ranges from healthy patients and patients with SARS-CoV-2, in addition to the development of biomarkers based biosensor such as stated biomarkers can be used and to investigate more specific biomarkers further proteomic analysis can be performed. This review presents several biomarker alterations in COVID-19 patients such as salivary, circulatory, coagulation, cardiovascular, renal, liver, C-reactive protein (CRP), immunological and inflammatory biomarkers. Also, biomarker sensors based on electrochemical, optical, and lateral flow characteristics which have potential applications for SARS-COV-2 in the recent COVID-19 pandemic, will be discussed.

Prognostic Value of Creatine Phosphate and Inflammatory Markers for Mitral Valve Replacement: A Systematic Review and Meta-Analysis

Purpose

The prognosis of mitral valve replacement is an important clinical issue and may produce unexpected mortality rates if not properly addressed. The postoperative examination results have important prognostic implications. This study was designed to determine the prognostic value of phosphocreatine and inflammatory markers after mitral valve replacement.

Method

Comparison and analysis of the data obtained using SPSS software. The computer retrieved PubMed, Science Citation Index (SCI), Embase, VIP, CNKI, CBM, and Wanfang database and manually retrieved randomized controlled trials (RCTs) published at home and abroad on the central muscle protection role of creatine phosphate in heart valve replacement, and the search period was established until February 2018. Two random literature reviewers independently screened the literature and extracted data, using Review Manager (RevMan) (Computer program), version 5.3 (The Nordic Cochrane Centre, The Cochrane Collaboration, Copenhagen, 2014). RevMan software version 5.0 assesses the risk of bias for inclusion in studies. The software performs a meta-analysis of the obtained data.

Results

Ten RCTs with a total of 464 participants were enrolled. The meta-analysis results showed that (1) elevated creatine kinase levels often predict a better prognosis after mitral valve replacement (RR = 1.36, 95% CI: 1.22 to 1.52, P < 0.00001), (2) the creatine kinase isoenzyme level in the venous blood of the phosphocreatine group after 24 h of aortic blocking was significantly lower than that in the control group (SMD = -2.90, 95% CI: -5.19 to -0.60, P = 0.01), and (3) Troponin I levels were significantly lower in the intravenous creatine group than in the control group 24 h after opening of the aortic block (SMD = -1.49, 95% CI: -2.02 to -0.97,P < 0.00001).

Conclusions

Creatine phosphate and inflammatory factor have good predictive value for the prognosis of mitral valve replacement.

Procedure-Specific Relationships Between Postoperative Troponin T and a Composite of Mortality and Low Cardiac Output Syndrome: A Retrospective Cohort Analysis

BACKGROUND

Myocardial injury after coronary artery bypass grafting (CABG) is defined as troponin concentrations >10 times 99th percentile upper reference limit (URL) according to the Fourth Universal Definition. However, troponin concentrations after non-CABG cardiac surgery which indicate greater-than-expected myocardial injury and increased risk for complications remain unclear. Our goal was to assess procedure-specific relationships between troponin T and a composite outcome of low cardiac output syndrome and in-hospital mortality in cardiac surgical patients.

METHODS

Patients having cardiac surgery between January 2010 and December 2017 were categorized into 4 groups by procedure: (1) CABG; (2) mitral valve repair; (3) aortic valve repair/replacement (AVR); (4) mitral valve replacement (MVR) or CABG + valve surgeries. Exclusion criteria were elevated preoperative troponin T, preoperative kidney failure, circulatory arrest, or preoperative/planned mechanical circulatory support. Logistic regression was used to assess the association between troponin T and composite outcome, both overall and by procedure, including assessment of the interaction between procedure and troponin T on outcome.

RESULTS

Among 10,253 patients, 37 (0.4%) died and 393 (3.8%) developed the primary outcome. Troponin T concentrations differed by procedure (P < .001). Compared to CABG, AVR had 0.53 (99.2% confidence interval [CI], 0.50-0.56; unadjusted P < .001) times lower troponin T concentrations, while MVR/CABG + valve were 1.54 (99.2% CI, 1.45-1.62, unadjusted P < .001) times higher. There were linear relationships between log2 troponin T concentration and log odds mortality/low cardiac output syndrome. The (unadjusted) relationships were parallel for various types of surgery (interaction P = .59), but at different levels of the outcome.

CONCLUSIONS

The relative increase in odds for mortality/low cardiac output syndrome per a similar increase in troponin T concentrations did not differ among cardiac surgical procedures, but the absolute troponin T concentrations did. Troponin concentrations should thus be interpreted in context of surgical procedure.

The impact of polystyrene microplastics on cardiomyocytes pyroptosis through NLRP3/Caspase-1 signaling pathway and oxidative stress in Wistar rats

The extensive existing of microplastics (MPs) in the ecosystem have increased considerable attention concerning their potential adverse effects, the toxicities and the underlying mechanism of MPs are still scarce. To explore the effect of MPs on cardiac tissue in Wistar rats and unravel the mechanism of pyroptosis and oxidative stress in the process of cardiomyocytes injury, 32 male Wister rats were divided into control group and three model groups, which were exposed to 0.5 mm PS MPs at 0.5, 5 and 50 mg/L for 90 days. Results revealed that MPs could damage cardiac structure and function with impaired mitochondria integrity, as well as increased levels of creatine kinase-MB and cardiac troponinI (cTnI). Moreover, MPs administration triggered oxidative stress as indicated by increased levels of malondialdehyde and decreased activity of superoxide dismutase, glutathione peroxidase and catalase. Treatment with MPs resulted in apoptosis and pyroptosis as evidenced by increasing expressions of interleukin (IL)-1β, IL-18. Additionally, MPs were shown to induce the NOD-like receptor protein 3 inflammasomes activation in cardiac tissue, enabling activation of Caspase-1-dependent signaling pathway induced by inflammatory stimuli resulting from oxidative stress. In summary, these results illustrated that pyroptosis played a vital role in polystyrene MPs-induced cardiotoxicity, which might be helpful to understand the mechanism of cardiac dysfunction and induced by MPs.

Two different troponin isoforms for detecting early myocardial injury after curative resection of oesophageal cancer

BACKGROUND

The objective of this study was to explore the consistency and correlation of two troponin (cTn) subtypes, troponin I (cTnI) and high-sensitivity troponin T (hs-cTnT), which can be used to judge early myocardial injury after curative resection of oesophageal cancer.

METHODS

This study is a secondary analysis of data obtained from a previous randomized controlled trial on postoperative myocardial injury in 70 patients undergoing elective curative resection of oesophageal cancer who were randomly assigned to undergo aggressive body temperature management (nasopharyngeal temperature 36.61 ± 0.18 °C) or standard body temperature management (35.80 ± 0.18 °C, n = 35 in each arm). The serum cTnI and hs-cTnT levels were measured in each patient at the 4 time points: before the operation and 6 h ~ 12 h, 24 h and 48 h after the operation. The diagnostic criteria of myocardial injury followed the third edition ESC/ACCF definition of myocardial infarction. The primary outcomes included the following: (1) the incidence of myocardial injury and the relationship between hs-cTnT and cTn and (2) the consistency and correlation of the two cTn subtypes.

RESULTS

A total of 280 pairs of cTn samples were tested. The incidence of postoperative day 2 myocardial injury was 8.6% (3/35) among patients receiving aggressive body temperature management and 31.4% (11/35) among patients receiving standard body temperature management (P < 0.05). Among 3 patients who experienced myocardial injury in the aggressive body temperature management group, 2 met the diagnostic criteria for cTnI and hs-cTnT and only 1 met the diagnostic criteria for hs-cTnT. Among the 11 patients who experienced myocardial injury in the standard body temperature management group, 7 met the diagnostic criteria for cTnI and hs-cTnT and only 3 met the diagnostic criteria for hs-cTnT; only 1 met the diagnostic criteria for cTnI. The bias of cTnI and hs-cTnT was - 8.82 ± 31.91 ng/L. The consistency limit was - 71.37 ~ 53.73 ng/L. The proportion within the scope of the consistency of its corresponding boundary was 98.57%. The correlation coefficient of cTnI and hs-cTnT was 0.845 (P < 0.05).

CONCLUSIONS

In the evaluation of postoperative myocardial injury in patients undergoing curative resection of oesophageal cancer, cTnI and hs-cTnT exhibit high consistency and a good correlation. The combination of cTnI and hs-cTnT can improve the detection rate of myocardial injury, thus providing a better reference than a single measure alone for reducing the risk of perioperative myocardial injury in patients.

TRIAL REGISTRATION

ChiCTR-INR-17011621 . Registered June 10, 2017.

Plasma exosomes characterization reveals a perioperative protein signature in older patients undergoing different types of on-pump cardiac surgery

Although exosomes are extracellular nanovesicles mainly involved in cardioprotection, it is not known whether plasma exosomes of older patients undergoing different types of on-pump cardiac surgery protect cardiomyocytes from apoptosis. Since different exosomal proteins confer pro-survival effects, we have analyzed the protein cargo of exosomes circulating early after aortic unclamping. Plasma exosomes and serum cardiac troponin I levels were measured in older cardiac surgery patients (NYHA II-III) who underwent first-time on-pump coronary artery bypass graft (CABG; n = 15) or minimally invasive heart valve surgery (mitral valve repair, n = 15; aortic valve replacement, n = 15) at induction of anesthesia (T0, baseline), 3 h (T1) and 72 h (T2) after aortic unclamping. Anti-apoptotic role of exosomes was assessed in HL-1 cardiomyocytes exposed to hypoxia/re-oxygenation (H/R) by TUNEL assay. Protein exosomal cargo was characterized by mass spectrometry approach. Exosome levels increased at T1 (P < 0.01) in accord with troponin values in all groups. In CABG group, plasma exosomes further increased at T2 (P < 0.01) whereas troponin levels decreased. In vitro, all T1-exosomes prevented H/R-induced apoptosis. A total of 340 exosomal proteins were identified in all groups, yet 10% of those proteins were unique for each surgery type. In particular, 22 and 12 pro-survival proteins were detected in T1-exosomes of heart valve surgery and CABG patients, respectively. Our results suggest that endogenous intraoperative cardioprotection in older cardiac surgery patients is early mediated by distinct exosomal proteins regardless of surgery type.

Prognostic Value of Cardiovascular Biomarkers in COVID-19: A Review

In early December 2019, the coronavirus disease (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) first emerged in Wuhan, China. As of May 10th, 2020, a total of over 4 million COVID-19 cases and 280,000 deaths have been reported globally, reflecting the raised infectivity and severity of this virus. Amongst hospitalised COVID-19 patients, there is a high prevalence of established cardiovascular disease (CVD). There is evidence showing that COVID-19 may exacerbate cardiovascular risk factors and preexisting CVD or may lead to cardiovascular complications. With intensive care units operating at maximum capacity and such staggering mortality rates reported, it is imperative during this time-sensitive COVID-19 outbreak to identify patients with an increased risk of adverse outcomes and/or myocardial injury. Preliminary findings from COVID-19 studies have shown the association of biomarkers of acute cardiac injury and coagulation with worse prognosis. While these biomarkers are recognised for CVD, there is emerging prospect that they may aid prognosis in COVID-19, especially in patients with cardiovascular comorbidities or risk factors that predispose to worse outcomes. Consequently, the aim of this review is to identify cardiovascular prognostic factors associated with morbidity and mortality in COVID-19 and to highlight considerations for incorporating laboratory testing of biomarkers of cardiovascular performance in COVID-19 to optimise outcomes.

Deficiency of Interleukin-36 Receptor Protected Cardiomyocytes from Ischemia-Reperfusion Injury in Cardiopulmonary Bypass

Background

Interleukin-36 has been demonstrated to be involved in inflammatory responses. Inflammatory responses due to ischemia-reperfusion injury following cardiopulmonary bypass (CPB) can cause heart dysfunction or damage.

Material/Methods

The CPB models were constructed in IL-36R−/−, IL-36RN−/−, and wild-type SD rats. Ultrasonic cardiography and ELISA were used to evaluate the cardiac function and measuring myocardial biomarker levels in different groups. TUNEL assay was used to evaluate apoptosis. Western blot assays and RT-PCR were performed to measure the expression of chemokines and secondary inflammatory cytokines in the heart. Oxidative stress in tissue and cultured cells was assessed using a DCFH-DA fluorescence probe and quantification of superoxide dismutase activity.

Results

Improved systolic function and decreased serum levels of myocardial damage biomarkers were found in IL-36R−/− rats compared to WT rats, while worse cardiac function and cardiomyocyte IR injury were observed in IL-36RN−/− rats compared to WT rats. TUNEL staining and Western blot analyses found that cardiomyocyte apoptosis and inflammation were significantly lower in the hearts of IL-36R−/− rats compared with that of WT rats. Oxidative stress was significantly lower in IL-36R−/− rats compared to WT rats. iNOS expression was significantly reduced, while eNOS expression was increased in the hearts of IL-36R−/− rats. Silencing of IL-36R expression in vitro activated SIRT1/FOXO1/p53 signaling in cardiomyocytes.

Conclusions

IL-36R deficiency in cardiomyocytes repressed infiltration of bone marrow-derived inflammatory cells and oxidative stress dependent on SIRT1-FOXO1 signaling, thus protecting cardiomyocytes and improving cardiac function in CPB model rats.

Definitions of post-coronary artery bypass grafting myocardial infarction: variations in incidence and prognostic significance

OBJECTIVES

Using data from the CORONARY trial (n = 4752), we evaluated the incidence and prognostic significance of myocardial infarction (MI) applying different definitions based on peak postoperative creatine kinase-MB isoenzyme and cardiac troponin levels. We then aimed to identify the peak cardiac troponin during the first 3 postoperative days that was independently associated with a 2-fold increase in 30-day mortality.

METHODS

To combine different assays, we analysed cardiac troponins in multiples of their respective upper limit of normal (ULN). We identified the lowest threshold with a hazard ratio (HR) >2 for 30-day mortality independent of EuroSCORE and on- versus off-pump surgery.

RESULTS

Depending on the definition used based on creatine kinase-MB, the incidence of MI after coronary artery bypass grafting (CABG) ranged from 0.6% to 19% and the associated HRs for 30-day mortality ranged from 2.7 to 6.9. Using cardiac troponin (1528 patients), the incidence of MI ranged from 1.7% to 13% depending on the definition used with HRs for 30-day mortality ranging from 5.1 to 7.2. The first cardiac troponin threshold we evaluated, 180xULN, was associated with an adjusted HR for 30-day mortality of 7.6 [95% confidence interval (CI) 3.4-17.1] when compared to <130xULN. The next independent threshold was 130xULN with an adjusted HR for 30-day mortality of 7.8 (95% CI 2.3-26.1). The next cardiac troponin tested threshold (70xULN) did not meet criteria for significance.

CONCLUSIONS

Our results illustrate that the incidence and prognosis of a post-CABG MI varies based on the definition used. Validated post-CABG MI diagnostic criteria formulated from their independent association with important clinical outcomes are needed.

Comparison of prognostic ability of perioperative myocardial biomarkers in acute type A aortic dissection

Stanford type A aortic dissection (AD) is a lethal disease requiring surgery. Evidence regarding the prognostic ability of perioperative myocardiac markers on long-term outcome is limited.In this cohort study, we measured perioperative myocardiac markers level in 583 surgical patients with type A AD in our hospital between 2015 and 2017. All patients were followed up after surgery for a median period of 864 days to determine short- and long-term mortality.About one-fifth of patients has a positive preoperative myocardial markers, which was increased significantly after operation. Increase log10 post-creatine kinase MB isoenzyme (CK-MB) (hazard ratio [HR], 4.64; 95% confidence interval [CI] 1.89-11.43; P = .0008), log10 post-TnI (HR, 3.11; 95% CI 1.56-6.21; P = .0013), log10 post-Mb (HR, 3.00; 95% CI 1.40-6.43; P = .0048), log10 pre-CK-MB (HR,1.82; 95% CI 1.03-3.21; P = .0377), and upper tertile of post-CK-MB (HR,1.52; 95% CI 1.05-2.20; P = .0261) were the independent risk factor for 30 days mortality adjusted for potential confounders. None of cardiac markers was significantly associated with long-term outcome independent of other factors.Perioperative myocardiac predicts early outcome in type A AD patients undergoing surgery. Increasing perioperative myocardial markers do not appear to be a predictor for long-term all-cause mortality.

Efficacy and safety of inhaled anaesthetic for postoperative sedation during mechanical ventilation in adult cardiac surgery patients: a systematic review and meta-analysis

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.

Protective effects of fentanyl preconditioning on cardiomyocyte apoptosis induced by ischemia-reperfusion in rats

We aimed to study the effect of fentanyl (Fen) preconditioning on cardiomyocyte apoptosis induced by ischemia-reperfusion (I/R) in rats. A total of 120 Sprague Dawley male rats (age: 3 months) were randomly divided into: sham operation group (S group), I/R group, normal saline I/R group (NS group), and fentanyl low, middle, and high dose groups (Fen1: 2 μg/kg; Fen2: 4 μg/kg; Fen3: 6 μg/kg). Heart rate (HR), mean arterial pressure (MAP), left ventricular developed pressure (LVDP), ±dp/dtmax, malondialdehyde (MDA), superoxide dismutase (SOD) activity, creatine phosphokinase-MB (CK-MB), and cardiac troponin-I (cTnI) were measured. Myocardial ischemic (MI) area, total apoptotic myocardial cells, and protein and mRNA expressions of B-cell lymphoma 2 (Bcl-2) and Bax were detected. HR and MAP were higher, while LVDP and ±dp/dtmax were close to the base value in the Fen groups compared to those in the I/R group. Decreased MDA concentration and CK-MB value and increased SOD activity were found in the Fen groups compared to the I/R group, while cTnI concentration was significantly lower in the Fen1 and Fen2 groups (all P<0.05). Myocardial damage was less in the Fen groups compared to the I/R group and the MI areas and apoptotic indexes were significantly lower in the Fen1 and Fen2 groups (all P<0.05). Furthermore, significantly increased protein and mRNA expressions of Bcl-2, and decreased protein and mRNA expressions of Bax were found in the Fen groups compared to the I/R group (all P<0.05). Fentanyl preconditioning may suppress cardiomyocyte apoptosis induced by I/R in rats by regulating Bcl-2 and Bax.

Association of cardiac biomarkers with acute kidney injury after cardiac surgery: A multicenter cohort study

OBJECTIVE

Acute kidney injury is common after cardiac surgery and associated with postoperative mortality. Perioperative cardiac biomarkers may predict acute kidney injury and mortality. We evaluated whether cardiac biomarkers were associated with severe acute kidney injury, defined as a doubling in serum creatinine or requiring renal replacement therapy during hospital stay after surgery, and mortality.

METHODS

In a prospective multicenter cohort of adults undergoing cardiac surgery, we measured the following biomarkers in preoperative and postoperative banked plasma: high-sensitivity troponin T, cardiac troponin I, creatine kinase-MB, and N-terminal prohormone of brain natriuretic peptide.

RESULTS

In the patients who were discharged alive, severe acute kidney injury occurred in 37 of 960 (3.9%), and 43 of 960 (4.5%) died within 1 year of follow-up. N-terminal prohormone of brain natriuretic peptide was the only preoperative biomarker that was independently associated with severe acute kidney injury (with log transformation, adjusted odds ratio, 1.4; 95% confidence interval, 1.0-1.9). Biomarkers measured within 6 hours of surgery (day 1) were all associated with severe acute kidney injury. Preoperative N-terminal prohormone of brain natriuretic peptide was also independently associated with 1-year mortality (with log transformation, adjusted odds ratio, 1.7; 95% confidence interval, 1.2-2.2). Patients in the highest tertile for N-terminal prohormone of brain natriuretic peptide preoperatively (>1006.4 ng/L) had marked increases in their risk for 1-year mortality (adjusted odds ratio, 27.2; 95% confidence interval, 3.5-213.5). Day 1 N-terminal prohormone of brain natriuretic peptide was associated with mortality independently of change in serum creatinine from preoperative baseline.

CONCLUSIONS

Of the studied biomarkers, N-terminal prohormone of brain natriuretic peptide was the only preoperative biomarker independently associated with severe acute kidney injury and mortality. Early increases in postoperative cardiac biomarkers were associated with severe acute kidney injury after cardiac surgery. Future research should focus on whether interventions that lower N-terminal prohormone of brain natriuretic peptide can affect postoperative outcomes.

The Use of Lidocaine Containing Cardioplegia in Surgery for Adult Acquired Heart Disease

BACKGROUND

Del Nido cardioplegia, a crystalloid-based solution with lidocaine as a key element, is given as a single dose and has been used successfully in congenital cardiac surgery.

HYPOTHESIS

We retrospectively compared a lidocaine containing "modified del Nido" solution with our standard whole blood cardioplegia to investigate its safety and efficacy in adult cardiac surgery.

METHODS

From June 1, 2013 to December 30, 2013, we used a single dose of lidocaine containing cardioplegia (LC group) in 92 consecutive operations. Propensity matching analysis was undertaken to compare the outcomes of such patients with those who underwent their surgery by the same surgeon using standard whole blood cardioplegia (WB group), n = 396. Propensity score matching yielded 79 pairs of patients.

RESULTS

After propensity matching, LC and WB groups were similar in baseline operative characteristics including cross-clamp time (LC: 65 minutes [range 54 to 89] vs. WB: 70 minutes [54 to 86], p = 0.993). Postoperative outcomes were similar including inotropic requirements (30.4% [24/72] vs. 25.3% [20/72], p < 0.60), median ventilation time (4.7 hours vs. 5.3, p < 0.74) and median length of stay was seven days for both groups (p < 0.82). Despite higher median postoperative, 24-hour CK-MB levels LC group (LC:22.3 ng/ml, range [15.6 to 40.3] vs. WB:18.4 ng/ml [13.9 to 28.2], p = 0.040), operative and one-year mortality were comparable among study groups (both p > 0.798).

CONCLUSIONS

Lidocaine containing cardioplegia appears to be safe in adults undergoing cardiac procedure when administered for the first 60 minutes of aortic cross clamping. Higher CK-MB levels did not translate into adverse clinical outcomes.