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Satdhabudha O, Songvasin M, Homvises B, Noppawinyoowong N, Chanawangsa P, Kaewbunjong J. Can heartbeat recovery be improved with terminal non-cardioplegic warm blood perfusion prior to aortic unclamping in single-clamp technique coronary artery bypass surgery? A randomized controlled trial. J Cardiothorac Surg 2024; 19:486. [PMID: 39169416 PMCID: PMC11340034 DOI: 10.1186/s13019-024-03006-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2024] [Accepted: 08/13/2024] [Indexed: 08/23/2024] Open
Abstract
BACKGROUND The objective of this study is to investigate whether the use of antegrade perfusion with terminal non-cardioplegic warm blood (TNWB) before aortic unclamping in single-clamp technique coronary artery bypass has a positive impact on intraoperative heartbeat recovery. METHODS Between December 2022 and May 2023, 40 consecutive patients undergoing coronary artery bypass using single-clamp technique were randomized into one of two groups: the TNWB group received an antegrade perfusion with TNWB before removing the aortic cross-clamp (n = 20), while the control group did not receive (n = 20). The time intervals between coronary perfusion and the onset of the first heartbeats and sinus rhythms, occurrences of spontaneous sinus rhythm, intraoperative defibrillation requirements, as well as postoperative CK-MB and troponin T levels were recorded and subjected to analysis. RESULTS In the TNWB group, the median onset of the first heartbeats after the initiation of coronary perfusion was 34 s (4-100), while in the control group, it was 90 s (15-340) (p < 0.001). The median onset of the sinus rhythms was 100 s (28-290) in the TNWB group and was 132 s (45-350) in the control group (p = 0.023). The occurrence of intraoperative arrhythmias was 15% in the TNWB group compared to 50% in the control group (p = 0.018), and the incidence for internal defibrillation was 5% in the TNWB group and was 30% in the control group (p = 0.037). The TNWB group showed the median CK-MB levels at 6 h postoperative was 14.10 ng/mL (9.78-19.26), compared to 18.31 ng/mL (13.98-23.80) in the control group (p = 0.045). CONCLUSIONS During single clamp coronary artery bypass, administration TNWB into the aortic root before aortic unclamping has the potential to enhance heartbeat recovery, as evidenced by the shortened time to the initial heartbeat and the establishment of sinus beats following coronary perfusion. TRIAL REGISTRATION Trial registration number (Study ID): TCTR20231002003.
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Affiliation(s)
- Opas Satdhabudha
- Division of Cardiothoracic Surgery, Department of Surgery, Faculty of Medicine, Thammasat University, 95 Phahonyothin Road, Khlong Nueng, Khlong Luang, Pathum Thani, 12120, Thailand.
| | - Manita Songvasin
- Division of Cardiothoracic Surgery, Department of Surgery, Faculty of Medicine, Thammasat University, 95 Phahonyothin Road, Khlong Nueng, Khlong Luang, Pathum Thani, 12120, Thailand
| | - Boonlawat Homvises
- Division of Cardiothoracic Surgery, Department of Surgery, Faculty of Medicine, Thammasat University, 95 Phahonyothin Road, Khlong Nueng, Khlong Luang, Pathum Thani, 12120, Thailand
| | - Narupa Noppawinyoowong
- Division of Cardiothoracic Surgery, Department of Surgery, Faculty of Medicine, Thammasat University, 95 Phahonyothin Road, Khlong Nueng, Khlong Luang, Pathum Thani, 12120, Thailand
| | - Pawana Chanawangsa
- Division of Cardiothoracic Surgery, Department of Surgery, Faculty of Medicine, Thammasat University, 95 Phahonyothin Road, Khlong Nueng, Khlong Luang, Pathum Thani, 12120, Thailand
| | - Jongrak Kaewbunjong
- Division of Cardiothoracic Surgery, Department of Surgery, Faculty of Medicine, Thammasat University, 95 Phahonyothin Road, Khlong Nueng, Khlong Luang, Pathum Thani, 12120, Thailand
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Dobson GP, Morris JL, Letson HL. ALM Resuscitation With Brain and Multiorgan Protection for Far-Forward Operations: Survival at Hypotensive Pressures. Mil Med 2024; 189:268-275. [PMID: 39160853 DOI: 10.1093/milmed/usae090] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Revised: 01/31/2024] [Accepted: 05/16/2024] [Indexed: 08/21/2024] Open
Abstract
INTRODUCTION Non-compressible torso hemorrhagic (NCTH) shock is the leading cause of potentially survivable trauma on the battlefield. New hypotensive drug therapies are urgently required to resuscitate and protect the heart and brain following NCTH. Our aim was to examine the strengths and limitations of permissive hypotension and discuss the development of small-volume adenosine, lidocaine, and Mg2+ (ALM) fluid resuscitation in rats and pigs. MATERIALS AND METHODS For review of permissive hypotension, a literature search was performed from inception up to November 2023 using PubMed, Cochrane, and Embase databases, with inclusion of animal studies, clinical trials and reviews with military and clinical relevance. For the preclinical study, adult female pigs underwent laparoscopic liver resection. After 30 minutes of bleeding, animals were resuscitated with 4 mL/kg 3% NaCl ± ALM bolus followed 60 minutes later with 4 h 3 mL/kg/h 0.9% NaCl ± ALM drip (n = 10 per group), then blood transfusion. Mean arterial pressure (MAP) and cardiac output (CO) were continuously measured via a left ventricular pressure catheter and pulmonary artery catheter, respectively. Systemic vascular resistance (SVR) was calculated using the formula: 80 × (MAP - CVP)/CI. Oxygen delivery was calculated as the product of CO and arterial oxygen content. RESULTS Targeting a MAP of ∼50 mmHg can be harmful or beneficial, depending on how CO and SVR are regulated. A theoretical example shows that for the same MAP of 50 mmHg, a higher CO and lower SVR can lead to a nearly 2-fold increase in O2 supply. We further show that in animal models of NCTH, 3% NaCl ALM bolus and 0.9% NaCl ALM drip induce a hypotensive, high flow, vasodilatory state with maintained tissue O2 supply and neuroprotection. ALM therapy increases survival by resuscitating the heart, reducing internal bleeding by correcting coagulopathy, and decreasing secondary injury. CONCLUSIONS In rat and pig models of NCTH, small-volume ALM therapy resuscitates at hypotensive pressures by increasing CO and reducing SVR. This strategy is associated with heart and brain protection and maintained tissue O2 delivery. Translational studies are required to determine reproducibility and optimal component dosing. ALM therapy may find wide utility in prehospital and far-forward military environments.
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Affiliation(s)
- Geoffrey P Dobson
- Heart and Trauma Research Laboratory, College of Medicine and Dentistry, James Cook University, Queensland, Queensland 4811, Australia
| | - Jodie L Morris
- Heart and Trauma Research Laboratory, College of Medicine and Dentistry, James Cook University, Queensland, Queensland 4811, Australia
| | - Hayley L Letson
- Heart and Trauma Research Laboratory, College of Medicine and Dentistry, James Cook University, Queensland, Queensland 4811, Australia
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Hu YN, Hsieh TH, Liang SF, Tsai MT, Chien CY, Kan CD, Roan JN. The Potential Neurological Impact of Intraoperative Hyponatremia Using Histidine-Tryptophan-Ketoglutarate Cardioplegia Infusion in Adult Cardiac Surgery. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:995. [PMID: 38929612 PMCID: PMC11205320 DOI: 10.3390/medicina60060995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/25/2024] [Revised: 05/31/2024] [Accepted: 06/12/2024] [Indexed: 06/28/2024]
Abstract
Background and Objectives: The relationship between histidine-tryptophan-ketoglutarate (HTK)-induced hyponatremia and brain injury in adult cardiac surgery patients is unclear. This study analyzed postoperative neurological outcomes after intraoperative HTK cardioplegia infusion. Materials and Methods: A prospective cohort study was conducted on 60 adult patients who underwent cardiac surgery with cardiopulmonary bypass. Of these patients, 13 and 47 received HTK infusion and conventional hyperkalemic cardioplegia, respectively. The patients' baseline characteristics, intraoperative data, brain injury markers, Mini-Mental State Examination (MMSE) scores, and quantitative electroencephalography (qEEG) data were collected. Electrolyte changes during cardiopulmonary bypass, the degree of hyponatremia, and any associated brain insults were evaluated. Results: The HTK group presented with acute hyponatremia during cardiopulmonary bypass, which was intraoperatively corrected through ultrafiltration and normal saline administration. Postoperative sodium levels were higher in the HTK group than in the conventional cardioplegia group. The change in neuron-specific enolase levels after cardiopulmonary bypass was significantly higher in the HTK group (p = 0.043). The changes showed no significant differences using case-control matching. qEEG analysis revealed a significant increase in relative delta power in the HTK group on postoperative day (POD) 7 (p = 0.018); however, no significant changes were noted on POD 60. The MMSE scores were not significantly different between the two groups on POD 7 and POD 60. Conclusions: HTK-induced acute hyponatremia and rapid correction with normal saline during adult cardiac surgeries were associated with a potential short-term but not long-term neurological impact. Further studies are required to determine the necessity of correction for HTK-induced hyponatremia.
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Affiliation(s)
- Yu-Ning Hu
- Division of Cardiovascular Surgery, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 701, Taiwan; (Y.-N.H.); (M.-T.T.); (C.-D.K.)
| | - Tsung-Hao Hsieh
- Department of Computer Science and Information Engineering, National Cheng Kung University, Tainan 701, Taiwan; (T.-H.H.); (S.-F.L.)
- Department of Psychology, National Cheng Kung University, Tainan 701, Taiwan
| | - Sheng-Fu Liang
- Department of Computer Science and Information Engineering, National Cheng Kung University, Tainan 701, Taiwan; (T.-H.H.); (S.-F.L.)
| | - Meng-Ta Tsai
- Division of Cardiovascular Surgery, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 701, Taiwan; (Y.-N.H.); (M.-T.T.); (C.-D.K.)
| | - Chung-Yao Chien
- Department of Neurology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 701, Taiwan;
| | - Chung-Dann Kan
- Division of Cardiovascular Surgery, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 701, Taiwan; (Y.-N.H.); (M.-T.T.); (C.-D.K.)
| | - Jun-Neng Roan
- Division of Cardiovascular Surgery, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 701, Taiwan; (Y.-N.H.); (M.-T.T.); (C.-D.K.)
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Abrasheva VO, Kovalenko SG, Slotvitsky M, Romanova SА, Aitova AA, Frolova S, Tsvelaya V, Syunyaev RA. Human sodium current voltage-dependence at physiological temperature measured by coupling a patch-clamp experiment to a mathematical model. J Physiol 2024; 602:633-661. [PMID: 38345560 DOI: 10.1113/jp285162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 01/02/2024] [Indexed: 02/20/2024] Open
Abstract
Voltage-gated Na+ channels are crucial to action potential propagation in excitable tissues. Because of the high amplitude and rapid activation of the Na+ current, voltage-clamp measurements are very challenging and are usually performed at room temperature. In this study, we measured Na+ current voltage-dependence in stem cell-derived cardiomyocytes at physiological temperature. While the apparent activation and inactivation curves, measured as the dependence of current amplitude on voltage, fall within the range reported in previous studies, we identified a systematic error in our measurements. This error is caused by the deviation of the membrane potential from the command potential of the amplifier. We demonstrate that it is possible to account for this artifact using computer simulation of the patch-clamp experiment. We obtained surprising results through patch-clamp model optimization: a half-activation of -11.5 mV and a half-inactivation of -87 mV. Although the half-activation deviates from previous research, we demonstrate that this estimate reproduces the conduction velocity dependence on extracellular potassium concentration. KEY POINTS: Voltage-gated Na+ currents play a crucial role in excitable tissues including neurons, cardiac and skeletal muscle. Measurement of Na+ current is challenging because of its high amplitude and rapid kinetics, especially at physiological temperature. We have used the patch-clamp technique to measure human Na+ current voltage-dependence in human induced pluripotent stem cell-derived cardiomyocytes. The patch-clamp data were processed by optimization of the model accounting for voltage-clamp experiment artifacts, revealing a large difference between apparent parameters of Na+ current and the results of the optimization. We conclude that actual Na+ current activation is extremely depolarized in comparison to previous studies. The new Na+ current model provides a better understanding of action potential propagation; we demonstrate that it explains propagation in hyperkalaemic conditions.
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Affiliation(s)
| | - Sandaara G Kovalenko
- Moscow Institute of Physics and Technology, Moscow, Russia
- M. F. Vladimirsky Moscow Regional Research Clinical Institute, Moscow, Russia
- ITMO University, St Petersburg, Russia
| | - Mihail Slotvitsky
- Moscow Institute of Physics and Technology, Moscow, Russia
- M. F. Vladimirsky Moscow Regional Research Clinical Institute, Moscow, Russia
- ITMO University, St Petersburg, Russia
| | - Serafima А Romanova
- Moscow Institute of Physics and Technology, Moscow, Russia
- M. F. Vladimirsky Moscow Regional Research Clinical Institute, Moscow, Russia
| | - Aleria A Aitova
- Moscow Institute of Physics and Technology, Moscow, Russia
- M. F. Vladimirsky Moscow Regional Research Clinical Institute, Moscow, Russia
- ITMO University, St Petersburg, Russia
| | - Sheida Frolova
- Moscow Institute of Physics and Technology, Moscow, Russia
- M. F. Vladimirsky Moscow Regional Research Clinical Institute, Moscow, Russia
| | - Valeria Tsvelaya
- Moscow Institute of Physics and Technology, Moscow, Russia
- M. F. Vladimirsky Moscow Regional Research Clinical Institute, Moscow, Russia
- ITMO University, St Petersburg, Russia
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5
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Osorio-Llanes E, Castellar-López J, Rosales W, Montoya Y, Bustamante J, Zalaquett R, Bravo-Sagua R, Riquelme JA, Sánchez G, Chiong M, Lavandero S, Mendoza-Torres E. Novel Strategies to Improve the Cardioprotective Effects of Cardioplegia. Curr Cardiol Rev 2024; 20:CCR-EPUB-137763. [PMID: 38275069 PMCID: PMC11071679 DOI: 10.2174/011573403x263956231129064455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 09/17/2023] [Accepted: 10/20/2023] [Indexed: 01/27/2024] Open
Abstract
The use of cardioprotective strategies as adjuvants of cardioplegic solutions has become an ideal alternative for the improvement of post-surgery heart recovery. The choice of the optimal cardioplegia, as well as its distribution mechanism, remains controversial in the field of cardiovascular surgery. There is still a need to search for new and better cardioprotective methods during cardioplegic procedures. New techniques for the management of cardiovascular complications during cardioplegia have evolved with new alternatives and additives, and each new strategy provides a tool to neutralize the damage after ischemia/reperfusion events. Researchers and clinicians have committed themselves to studying the effect of new strategies and adjuvant components with the potential to improve the cardioprotective effect of cardioplegic solutions in preventing myocardial ischemia/reperfusion-induced injury during cardiac surgery. The aim of this review is to explore the different types of cardioplegia, their protection mechanisms, and which strategies have been proposed to enhance the function of these solutions in hearts exposed to cardiovascular pathologies that require surgical alternatives for their corrective progression.
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Affiliation(s)
- Estefanie Osorio-Llanes
- Faculty of Exact and Natural Sciences, Grupo de Investigación Avanzada en Biomedicina, Universidad Libre Barranquilla, Atlantico, Colombia
| | - Jairo Castellar-López
- Faculty of Exact and Natural Sciences, Grupo de Investigación Avanzada en Biomedicina, Universidad Libre Barranquilla, Atlantico, Colombia
| | - Wendy Rosales
- Faculty of Exact and Natural Sciences, Grupo de Investigación Avanzada en Biomedicina, Universidad Libre Barranquilla, Atlantico, Colombia
| | - Yuliet Montoya
- Grupo de Dinámica Cardiovascular (GDC), Escuela de Ciencias de la Salud, Universidad Pontificia Bolivariana, Medellin, Colombia
| | - John Bustamante
- Grupo de Dinámica Cardiovascular (GDC), Escuela de Ciencias de la Salud, Universidad Pontificia Bolivariana, Medellin, Colombia
| | - Ricardo Zalaquett
- Department of Cardiovascular Diseases, Faculty of Medicine, Universidad Finis Terrae - Clínica Las Condes, Santiago, Chile
| | - Roberto Bravo-Sagua
- Advanced Center for Chronic Diseases (ACCDiS), Faculty of Chemical and Pharmaceutical Sciences & Faculty of Medicine, Universidad de Chile, Santiago, Chile
- Laboratorio OMEGA, INTA, University of Chile, Santiago, Chile
| | - Jaime A. Riquelme
- Advanced Center for Chronic Diseases (ACCDiS), Faculty of Chemical and Pharmaceutical Sciences & Faculty of Medicine, Universidad de Chile, Santiago, Chile
| | - Gina Sánchez
- Physiopathology Program, Institute of Biomedical Sciences (ICBM), Faculty of Medicine, University of Chile, Santiago, Chile
| | - Mario Chiong
- Advanced Center for Chronic Diseases (ACCDiS), Faculty of Chemical and Pharmaceutical Sciences & Faculty of Medicine, Universidad de Chile, Santiago, Chile
| | - Sergio Lavandero
- Advanced Center for Chronic Diseases (ACCDiS), Faculty of Chemical and Pharmaceutical Sciences & Faculty of Medicine, Universidad de Chile, Santiago, Chile
- Department of Internal Medicine (Cardiology Division), University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Evelyn Mendoza-Torres
- Advanced Center for Chronic Diseases (ACCDiS), Faculty of Chemical and Pharmaceutical Sciences & Faculty of Medicine, Universidad de Chile, Santiago, Chile
- Faculty of Health Sciences, Grupo de Investigación Avanzada en Biomedicina, Universidad Libre Seccional Barranquilla, Barranquilla, Colombia
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6
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Mukharyamov M, Schneider U, Kirov H, Caldonazo T, Doenst T. Myocardial protection in cardiac surgery-hindsight from the 2020s. Eur J Cardiothorac Surg 2023; 64:ezad424. [PMID: 38113432 DOI: 10.1093/ejcts/ezad424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 11/15/2023] [Accepted: 12/18/2023] [Indexed: 12/21/2023] Open
Abstract
Myocardial protection and specifically cardioplegia have been extensively investigated in the beginnings of cardiac surgery. After cardiopulmonary bypass had become routine, more and more cardiac operations were possible, requiring reliable and reproducible protection for times of blood flow interruptions to the most energy-demanding organ of the body. The concepts of hypothermia and cardioplegia evolved as tools to extend cardiac ischaemia tolerance to a degree considered safe for the required operation. A plethora of different solutions and delivery techniques were developed achieving remarkable outcomes with cross-clamp times of up to 120 min and more. With the beginning of the new millennium, interest in myocardial protection research declined and, as a consequence, conventional cardiac surgery is currently performed using myocardial protection strategies that have not changed in decades. However, the context, in which cardiac surgery is currently performed, has changed during this time. Patients are now older and suffer from more comorbidities and, thus, other organs move more and more into the centre of risk assessment. Yet, systemic effects of cardioplegic solutions have never been in the focus of attention. They say hindsight is always 20-20. We therefore review the biochemical principles of ischaemia, reperfusion and cardioplegic extension of ischaemia tolerance and address the concepts of myocardial protection with 'hindsight from the 2020s'. In light of rising patient risk profiles, minimizing surgical trauma and improving perioperative morbidity management becomes key today. For cardioplegia, this means accounting not only for cardiac, but also for systemic effects of cardioplegic solutions.
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Affiliation(s)
- Murat Mukharyamov
- Department of Cardiothoracic Surgery, Jena University Hospital, Friedrich Schiller University of Jena, Jena, Germany
| | - Ulrich Schneider
- Department of Cardiothoracic Surgery, Jena University Hospital, Friedrich Schiller University of Jena, Jena, Germany
| | - Hristo Kirov
- Department of Cardiothoracic Surgery, Jena University Hospital, Friedrich Schiller University of Jena, Jena, Germany
| | - Tulio Caldonazo
- Department of Cardiothoracic Surgery, Jena University Hospital, Friedrich Schiller University of Jena, Jena, Germany
| | - Torsten Doenst
- Department of Cardiothoracic Surgery, Jena University Hospital, Friedrich Schiller University of Jena, Jena, Germany
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7
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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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Hacker A, Maggs P, Treanor P, Lilly K, Birjiniuk V. Is cardioplegia system pressure the optimal measure of coronary perfusion during antegrade cardioplegia delivery? A critical review of pressure measurements for optimal antegrade delivery. Perfusion 2023:2676591231206016. [PMID: 37855099 DOI: 10.1177/02676591231206016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2023]
Abstract
Antegrade cardioplegia is routinely given during cardiac surgery. The delivery of antegrade cardioplegia from the cardiopulmonary bypass machine has many variables. Many perfusionists rely exclusively on cardioplegia system pressure to ensure safe antegrade delivery. Our group reviewed antegrade cardioplegia delivery in 50 patients undergoing coronary artery bypass graft. The data collected included the cardioplegia system pressure and the patient's direct aortic root pressure. The analysis of the data found weak correlation between the two pressures with a large mean difference and a wide standard deviation. The results suggest the direct measurement of aortic root pressure as guidance to antegrade cardioplegia instead of relying solely on cardioplegia system pressure.
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Affiliation(s)
- Allison Hacker
- Department of Cardiovascular Perfusion, Mount Auburn Hospital, Cambridge, MA, USA
| | - Peter Maggs
- Department of Cardiac Surgery, Mount Auburn Hospital, Cambridge, MA, USA
| | - Patrick Treanor
- Department of Cardiovascular Perfusion, Mount Auburn Hospital, Cambridge, MA, USA
| | - Kevin Lilly
- Department of Cardiovascular Perfusion, Mount Auburn Hospital, Cambridge, MA, USA
| | - Vladimir Birjiniuk
- Department of Cardiac Surgery, Mount Auburn Hospital, Cambridge, MA, USA
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9
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Dobson GP, Morris JL, Letson HL. Adenosine, lidocaine and Mg 2+ update: teaching old drugs new tricks. Front Med (Lausanne) 2023; 10:1231759. [PMID: 37828944 PMCID: PMC10565858 DOI: 10.3389/fmed.2023.1231759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 09/11/2023] [Indexed: 10/14/2023] Open
Abstract
If a trauma (or infection) exceeds the body's evolutionary design limits, a stress response is activated to quickly restore homeostasis. However, when the injury severity score is high, death is often imminent. The goal of this review is to provide an update on the effect of small-volume adenosine, lidocaine and Mg2+ (ALM) therapy on increasing survival and blunting secondary injury after non-compressible hemorrhagic shock and other trauma and infective/endotoxemic states. Two standout features of ALM therapy are: (1) resuscitation occurs at permissive hypotensive blood pressures (MAPs 50-60 mmHg), and (2) the drug confers neuroprotection at these low pressures. The therapy appears to reset the body's baroreflex to produce a high-flow, hypotensive, vasodilatory state with maintained tissue O2 delivery. Whole body ALM protection appears to be afforded by NO synthesis-dependent pathways and shifting central nervous system (CNS) control from sympathetic to parasympathetic dominance, resulting in improved cardiovascular function, reduced immune activation and inflammation, correction of coagulopathy, restoration of endothelial glycocalyx, and reduced energy demand and mitochondrial oxidative stress. Recently, independent studies have shown ALM may also be useful for stroke, muscle trauma, and as an adjunct to Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA). Ongoing studies have further shown ALM may have utility for burn polytrauma, damage control surgery and orthopedic surgery. Lastly, we discuss the clinical applications of ALM fluid therapy for prehospital and military far-forward use for non-compressible hemorrhage and traumatic brain injury (TBI).
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Affiliation(s)
- Geoffrey P. Dobson
- Heart and Trauma Research Laboratory, College of Medicine and Dentistry, James Cook University, Townsville, QLD, Australia
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Cardioplegia in Open Heart Surgery: Age Matters. J Clin Med 2023; 12:jcm12041698. [PMID: 36836232 PMCID: PMC9958799 DOI: 10.3390/jcm12041698] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 01/31/2023] [Accepted: 02/02/2023] [Indexed: 02/23/2023] Open
Abstract
INTRODUCTION Cardioplegia is a pharmacological approach essential for the protection of the heart from ischemia-reperfusion (I-R) injury. Over the years, numerous cardioplegic solutions have been developed, with each cardioplegic approach having its advantages and disadvantages. Cardioplegic solutions can be divided into crystalloid and blood cardioplegic solutions, and an experienced surgeon chooses the type of solution based on the individual needs of patients in order to provide optimal heart protection. Importantly, the pediatric immature myocardium is structurally, physiologically, and metabolically different from the adult heart, and consequently its needs to achieve cardioplegic arrest strongly differ. Therefore, the present review aimed to provide a summary of the cardioplegic solutions available to pediatric patients with a special focus on emphasizing differences in heart injury after various cardioplegic solutions, the dosing strategies, and regimens. MATERIAL AND METHODS The PubMed database was searched using the terms cardioplegia, I-R, and pediatric population, and studies that investigated the influence of cardioplegic strategies on markers of cardiac muscle damage were further analyzed in this review. CONCLUSIONS A large body of evidence suggested more prominent benefits achieved with blood compared to those with crystalloid cardioplegia in pediatric myocardium preservation. However, standardized and uniform protocols have not been established so far, and an experienced surgeon chooses the type of cardioplegia solution based on the individual needs of patients, while the severity of myocardial damage strongly depends on the type and duration of the surgical procedure, overall patient condition, and presence of comorbidities, etc.
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11
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Diao H, Gu H, Chen QM. Hyperkalemic or Low Potassium Cardioplegia Protects against Reduction of Energy Metabolism by Oxidative Stress. Antioxidants (Basel) 2023; 12:452. [PMID: 36830011 PMCID: PMC9952220 DOI: 10.3390/antiox12020452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 01/17/2023] [Accepted: 02/04/2023] [Indexed: 02/15/2023] Open
Abstract
Open-heart surgery is often an unavoidable option for the treatment of cardiovascular disease and prevention of cardiomyopathy. Cardiopulmonary bypass surgery requires manipulating cardiac contractile function via the perfusion of a cardioplegic solution. Procedure-associated ischemia and reperfusion (I/R) injury, a major source of oxidative stress, affects postoperative cardiac performance and long-term outcomes. Using large-scale liquid chromatography-tandem mass spectrometry (LC-MS/MS)-based metabolomics, we addressed whether cardioplegic solutions affect the baseline cellular metabolism and prevent metabolic reprogramming by oxidative stress. AC16 cardiomyocytes in culture were treated with commonly used cardioplegic solutions, High K+ (HK), Low K+ (LK), Del Nido (DN), histidine-tryptophan-ketoglutarate (HTK), or Celsior (CS). The overall metabolic profile shown by the principal component analysis (PCA) and heatmap revealed that HK or LK had a minimal impact on the baseline 78 metabolites, whereas HTK or CS significantly repressed the levels of multiple amino acids and sugars. H2O2-induced sublethal mild oxidative stress causes decreases in NAD, nicotinamide, or acetylcarnitine, but increases in glucose derivatives, including glucose 6-P, glucose 1-P, fructose, mannose, and mannose 6-P. Additional increases include metabolites of the pentose phosphate pathway, D-ribose-5-P, L-arabitol, adonitol, and xylitol. Pretreatment with HK or LK cardioplegic solution prevented most metabolic changes and increases of reactive oxygen species (ROS) elicited by H2O2. Our data indicate that HK and LK cardioplegic solutions preserve baseline metabolism and protect against metabolic reprogramming by oxidative stress.
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Affiliation(s)
- Hongting Diao
- Department of Pharmacy Practice and Science, College of Pharmacy, The University of Arizona, Tucson, AZ 85721, USA
| | - Haiwei Gu
- College of Health Solutions, Arizona State University Phoenix, Phoenix, AZ 85004, USA
- Center for Translational Science, Florida International University, 11350 SW Village Parkway, Port St. Lucie, FL 34987, USA
| | - Qin M. Chen
- Department of Pharmacy Practice and Science, College of Pharmacy, The University of Arizona, Tucson, AZ 85721, USA
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12
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Mattila MS, Järvelä KM, Rinne TT, Nikus KC, Rantanen MJ, Siltanen JAA, Heleä JJ, Laurikka JO. High-dose adenosine versus saline-induced cardioplegic arrest in coronary artery bypass grafting: A randomized double-blind clinical feasibility trial. Scand J Surg 2022; 111:3-10. [PMID: 36000718 DOI: 10.1177/14574969221116943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND AND OBJECTIVE In this clinical trial, we evaluated if a short-acting nucleoside, adenosine, as a high-dose bolus injection with blood cardioplegia induces faster arrest and provides better myocardial performance in patients after bypass surgery for coronary artery disease. METHODS Forty-three patients scheduled for elective or urgent coronary artery bypass grafting were prospectively recruited in two-arm 1:1 randomized parallel groups to either receive 20 mg of adenosine (in 21 patients) or saline (in 22 patients) into the aortic root during the first potassium-enriched blood cardioplegia infusion. The main outcomes of the study were ventricular myocardial performance measured with cardiac index, right ventricular stroke work index, and left ventricular stroke work index at predefined time points and time to asystole after a single bolus injection of adenosine. Conventional myocardial biomarkers were compared between the two groups at predefined time points as secondary endpoints. Electrocardiographic data and other ad hoc clinical outcomes were compared between the groups. RESULTS Compared with saline, adenosine reduced the time to asystole (68 (95% confidence interval (95% CI) = 37-100) versus 150 (95% CI = 100-210) seconds, p = 0.005). With myocardial performance, the results were inconclusive, since right ventricular stroke work index recovered better in the adenosine group (p = 0.008), but there were no significant overall differences in cardiac index and left ventricular stroke work index between the groups. Only the post-cardiopulmonary bypass cardiac index was better in the adenosine group (2.3 (95% CI = 2.2-2.5) versus 2.1 (95% CI = 1.9-2.2) L/min/m2, p = 0.016). There were no significant differences between the groups in cardiac biomarker values. CONCLUSIONS A high dose adenosine bolus at the beginning of the first cardioplegia infusion resulted in significantly faster asystole in coronary artery bypass grafting patients but enhanced only partially the ventricular performance.EudraCT number: 2014-001382-26. https://www.clinicaltrialsregister.eu/ctr-search/trial/2014-001382-26/FI.
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Affiliation(s)
- Mikko S Mattila
- Heart Hospital Tampere University Hospital PL 2000 33521 Tampere Finland
| | - Kati M Järvelä
- Heart Hospital, Tampere University Hospital, Tampere, Finland
| | | | - Kjell C Nikus
- Heart Hospital, Tampere University Hospital, Tampere, Finland Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | | | - Juho A A Siltanen
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Jenna-Juulia Heleä
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Jari O Laurikka
- Heart Hospital, Tampere University Hospital, Tampere, Finland Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
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Abstract
Potassium homeostasis affects cardiac rhythm and contractility, along with vascular reactivity and vascular smooth muscle proliferation. This chapter will focus on potassium dynamics during and after cardiac surgery involving cardioplegic arrest and cardiopulmonary bypass (CPB). Hyperkalemic, hypothermic solutions are frequently used to induce cardioplegic arrest and protect the heart during cardiac surgery involving CPB. Common consequences of hyperkalemic cardioplegic arrest and reperfusion include microvascular dysfunction involving several organ systems and myocardial dysfunction. Immediately after CPB, blood potassium levels often drop precipitously due to a variety of factors, including CPB -induced electrolyte depletion and frequent, long-term administration of insulin during and after surgery. Meanwhile, some patients with pre-existing kidney dysfunction may experience postoperative hyperkalemia following cardioplegia. Any degree of postoperative hyper/hypokalemia significantly elevates the risk of cardiac arrythmias and subsequent myocardial failure. Therefore, proper management of blood potassium levels during and after cardioplegia/CPB is crucial for optimizing patient outcomes following cardiac surgery.
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Hypothermia Prevents Cardiac Dysfunction during Acute Ischemia Reperfusion by Maintaining Mitochondrial Bioenergetics and by Promoting Hexokinase II Binding to Mitochondria. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2022; 2022:4476448. [PMID: 35873800 PMCID: PMC9301761 DOI: 10.1155/2022/4476448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 03/04/2022] [Accepted: 06/14/2022] [Indexed: 11/18/2022]
Abstract
Background Hypothermia (H), cardioplegia (CP), and both combined (HCP) are known to be protective against myocardial ischemia reperfusion (IR) injury. Mitochondria have molecular signaling mechanisms that are associated with both cell survival and cell death. In this study, we investigated the dynamic changes in proapoptotic and prosurvival signaling pathways mediating H, CP, or HCP-induced protection of mitochondrial function after acute myocardial IR injury. Methods Rats were divided into five groups. Each group consists of 3 subgroups based on a specific reperfusion time (5, 20, or 60 min) after a 25-min global ischemia. The time control (TC) groups were not subjected to IR but were perfused with 37 °C Krebs-Ringer's (KR) buffer, containing 4.5 mM K+, in a specific perfusion protocol that corresponded with the duration of each IR protocol. The IR group (control) was perfused for 20 min with KR, followed by 25-min global ischemia, and then KR reperfusion for 5, 20, or 60 min. The treatment groups were exposed to 17 °C H, 37 °C CP (16 mM K+), or HCP (17 °C + CP) for 5 min before ischemia and for 2 min on reperfusion before switching to 37 °C KR perfusion for the remainder of each of the reperfusion times. Cardiac function and mitochondrial redox state (NADH/FAD) were monitored online in the ex vivo hearts before, during, and after ischemia. Mitochondria were isolated at the end of each specified reperfusion time, and changes in O2 consumption, membrane potential (ΔΨm), and Ca2+ retention capacity (CRC) were assessed using complex I and complex II substrates. In another set of hearts, mitochondrial and cytosolic fractions were isolated after a specified reperfusion time to conduct western blot assays to determine hexokinase II (HKII) and Bax binding/translocation to mitochondria, cytosolic pAkt levels, and cytochrome c (Cyto-c) release into the cytosol. Results H and HCP were more protective of mitochondrial integrity and, concomitantly, cardiac function than CP alone; H and HCP improved post-ischemic cardiac function by (1) maintaining mitochondrial bioenergetics, (2) maintaining HKII binding to mitochondria with an increase in pAkt levels, (3) increasing CRC, and (4) decreasing Cyto-c release during reperfusion. Bax translocation/binding to mitochondria was unaffected by any treatment, regardless of cardiac functional recovery. Conclusions Hypothermia preserved mitochondrial function and cardiac function, in part, by maintaining mitochondrial bioenergetics, by retaining HKII binding to mitochondria via upstream pAkt, and by reducing Cyto-c release independently of Bax binding to mitochondria.
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15
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Theoretical and Practical Aspects in the Use of Bretschneider Cardioplegia. J Cardiovasc Dev Dis 2022; 9:jcdd9060178. [PMID: 35735807 PMCID: PMC9225441 DOI: 10.3390/jcdd9060178] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Revised: 05/01/2022] [Accepted: 05/26/2022] [Indexed: 02/01/2023] Open
Abstract
The race for an ideal cardioplegic solution has remained enthusiastic since the beginning of the modern cardiac surgery era. The Bretschneider solution, belonging to the “intracellular cardioplegic” group, is safe and practical in myocardial protection during ischemic time. Over time, some particular concerns have arisen regarding the effects on cardiac metabolism and postoperative myocardial functioning. This paper reviews the most important standpoints in terms of theoretical and practical analyses.
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Protective effects of trehalose preconditioning on cardiac and coronary endothelial function through eNOS signaling pathway in a rat model of ischemia-reperfusion injury. Mol Cell Biochem 2022; 477:2403-2414. [PMID: 35578066 DOI: 10.1007/s11010-022-04451-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 04/25/2022] [Indexed: 01/18/2023]
Abstract
Coronary endothelial dysfunction is a major cause of ischemia-reperfusion (I/R) injury. Trehalose, a natural disaccharide, has been reported to ameliorate endothelial dysfunction during aging by activating endothelial nitric oxide synthase (eNOS); however, its role in I/R injury is unknown. This study evaluated the effects of trehalose preconditioning on cardiac and coronary endothelial function after I/R. Langendorff-perfused rat hearts underwent 30 min of global ischemia followed by 80 min of reperfusion with or without trehalose preconditioning. Rate pressure product (RPP) and coronary flow (CF) were measured during reperfusion. Perivascular edema was assessed by hematoxylin and eosin staining. Myocardial oxidative stress and apoptosis were evaluated by immunohistochemistry and TUNEL staining, respectively. eNOS dimerization was determined by western blotting. An eNOS inhibitor was used to examine the role of eNOS. Trehalose preconditioning showed a higher recovery rate after I/R as indicated by high RPP (control vs. trehalose, 28 ± 6% vs. 46 ± 9%; P = 0.017, Cohen's d = 2.3) and CF values (35 ± 10% vs. 55 ± 9%; P = 0.025, d = 1.7). Furthermore, trehalose preconditioning reduced perivascular edema, myocardial oxidative stress, and apoptosis. The eNOS dimerization ratio was increased by trehalose (1.2 ± 0.2 vs. 1.6 ± 0.2; P = 0.023, d = 2.1), which was associated with the recovery of RPP and CF. These effects of trehalose were abolished by the eNOS inhibitor. Trehalose preconditioning showed protective effects on cardiac and coronary endothelial function after I/R through the eNOS signaling pathway.
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Choi ES, Park GH, Kim DS, Shin HS, Park SY, Kim M, Hong JM. A novel global ischemia-reperfusion rat model with asymmetric brain damage simulating post-cardiac arrest brain injury. J Neurosci Methods 2022; 372:109554. [DOI: 10.1016/j.jneumeth.2022.109554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 02/21/2022] [Accepted: 02/28/2022] [Indexed: 11/29/2022]
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18
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An important cardiac surgery milestone: The first known stopped-heart operation. JTCVS Tech 2021; 10:460-463. [PMID: 34977785 PMCID: PMC8691650 DOI: 10.1016/j.xjtc.2021.08.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 08/16/2021] [Indexed: 11/27/2022] Open
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A Cardioplegic Solution with an Understanding of a Cardiochannelopathy. Antioxidants (Basel) 2021; 10:antiox10121878. [PMID: 34942981 PMCID: PMC8698488 DOI: 10.3390/antiox10121878] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 11/16/2021] [Accepted: 11/23/2021] [Indexed: 01/11/2023] Open
Abstract
Cardiac surgeries have been improved by accompanying developing cardioplegia solutions. However, the cardioplegia application presents an ongoing challenge with a view of a sufficiently restored cardiac function. In this review, we focus on the cardioplegia-induced mechanism and summarize the findings of studies undertaken to improve cardioprotective strategies. Currently, and somewhat surprisingly, relatively little is known about cardiac electrolyte regulation through channel physiology. We hope that an improved understanding of the electrolyte transport through ion channels/transporters and modulations of water channel aquaporins will provide an insight into cardiac channel physiology and a channel-based cardiac pathology of a cardiochannelopathy.
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20
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Francica A, Vaccarin A, Dobson GP, Rossetti C, Gardellini J, Faggian G, Onorati F. Short-term outcome of adenosine-lidocaine-magnesium polarizing cardioplegia in humans. Eur J Cardiothorac Surg 2021; 61:1125-1132. [PMID: 34751752 DOI: 10.1093/ejcts/ezab466] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 08/02/2021] [Accepted: 08/17/2021] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES Hyperkalaemic depolarized myocardial arrest is the cornerstone of myocardial protection, although some potassium-related cytotoxicity has been demonstrated. Polarized arrest has gained interest because of a reported better myocardial protection in preclinical studies. The goal of this study was to analyse the quality of myocardial protection and hospital outcome after normokalaemic adenosine-lidocaine-magnesium (ALM) blood polarizing cardioplegia, compared to hyperkalaemic blood Buckberg depolarizing cardioplegia, in elective routine adult cardiac surgery. METHODS One thousand consecutive elective adult cardiac patients [627 undergoing ALM-polarizing cardioplegia (ALM-POL) vs 373 Buckberg depolarized cardioplegia (BUCK-DEPOL)] who were operated on were analysed. Perioperative leakage of high-sensitivity troponin I (Hs-TnI), peripheral lactate, inotropic and vasoactive daily requirement [maximal vasoactive inotropic score (VISMAX)], hospital mortality and morbidity were collected and compared in the overall population and in the propensity score (PS) matched population (206 pairs). RESULTS A significantly lower leakage of Hs-TnI during hospitalization was detected in patients receiving ALM-POL versus those receiving BUCK-DEPOL (group time P < 0.001 for overall population and PS matched pairs). The maximum value of postoperative Hs-TnI was also lower after ALM-POL (P < 0.001 in both cohorts), and spontaneous recovery of sinus rhythm at aortic declamping was higher (P < 0.001 in favour of ALM-POL). Maximal VISMAX during hospitalization was significantly higher after BUCK-DEPOL in both cohorts (P = 0.019 for overall population; P = 0.031 for PS matched population), with significantly higher VISMAX on the day of surgery in BUCK-DEPOL PS matched patients (P = 0.042). No other significant differences in hospital morbidity and mortality were found. CONCLUSIONS Despite comparable short-term clinical outcomes, ALM-POL cardioplegia proved superior in terms of quality of myocardial protection compared to BUCK-DEPOL cardioplegia in elective routine adult cardiac surgery.
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Affiliation(s)
- Alessandra Francica
- Department of Surgery, Dentistry, Paediatrics, and Gynaecology, Division of Cardiac Surgery, University of Verona Medical School, Verona, Italy
| | - Arianna Vaccarin
- Department of Surgery, Dentistry, Paediatrics, and Gynaecology, Division of Cardiac Surgery, University of Verona Medical School, Verona, Italy
| | - Geoffrey Phillip Dobson
- Heart, Trauma & Sepsis Research Laboratory, College of Medicine and Dentistry, James Cook University, Townsville, Australia
| | - Cecilia Rossetti
- Department of Surgery, Dentistry, Paediatrics, and Gynaecology, Division of Cardiac Surgery, University of Verona Medical School, Verona, Italy
| | - Jacopo Gardellini
- Department of Surgery, Dentistry, Paediatrics, and Gynaecology, Division of Cardiac Surgery, University of Verona Medical School, Verona, Italy
| | - Giuseppe Faggian
- Department of Surgery, Dentistry, Paediatrics, and Gynaecology, Division of Cardiac Surgery, University of Verona Medical School, Verona, Italy
| | - Francesco Onorati
- Department of Surgery, Dentistry, Paediatrics, and Gynaecology, Division of Cardiac Surgery, University of Verona Medical School, Verona, Italy
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21
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Tveita T, Sieck GC. Physiological Impact of Hypothermia: The Good, the Bad and the Ugly. Physiology (Bethesda) 2021; 37:69-87. [PMID: 34632808 DOI: 10.1152/physiol.00025.2021] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Hypothermia is defined as a core body temperature of < 35°C, and as body temperature is reduced the impact on physiological processes can be beneficial or detrimental. The beneficial effect of hypothermia enables circulation of cooled experimental animals to be interrupted for 1-2 h without creating harmful effects, while tolerance of circulation arrest in normothermia is between 4 and 5 min. This striking difference has attracted so many investigators, experimental as well as clinical, to this field, and this discovery was fundamental for introducing therapeutic hypothermia in modern clinical medicine in the 1950's. Together with the introduction of cardiopulmonary bypass, therapeutic hypothermia has been the cornerstone in the development of modern cardiac surgery. Therapeutic hypothermia also has an undisputed role as a protective agent in organ transplantation and as a therapeutic adjuvant for cerebral protection in neonatal encephalopathy. However, the introduction of therapeutic hypothermia for organ protection during neurosurgical procedures or as a scavenger after brain and spinal trauma has been less successful. In general, the best neuroprotection seems to be obtained by avoiding hyperthermia in injured patients. Accidental hypothermia occurs when endogenous temperature control mechanisms are incapable of maintaining core body temperature within physiologic limits and core temperature becomes dependent on ambient temperature. During hypothermia spontaneous circulation is considerably reduced and with deep and/or prolonged cooling, circulatory failure may occur, which may limit safe survival of the cooled patient. Challenges that limit safe rewarming of accidental hypothermia patients include cardiac arrhythmias, uncontrolled bleeding, and "rewarming shock".
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Affiliation(s)
- Torkjel Tveita
- Anesthesia and Critical Care Research Group, Department of Clinical Medicine, UiT The Arctic University of Norway, Tromsø, Norway.,Division of Surgical Medicine and Intensive Care, University Hospital of North Norway, Tromsø, Norway
| | - Gary C Sieck
- Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, Minnesota, United States
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Francica A, Tonelli F, Rossetti C, Tropea I, Luciani GB, Faggian G, Dobson GP, Onorati F. Cardioplegia between Evolution and Revolution: From Depolarized to Polarized Cardiac Arrest in Adult Cardiac Surgery. J Clin Med 2021; 10:jcm10194485. [PMID: 34640503 PMCID: PMC8509840 DOI: 10.3390/jcm10194485] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Accepted: 09/28/2021] [Indexed: 12/12/2022] Open
Abstract
Despite current advances in perioperative care, intraoperative myocardial protection during cardiac surgery has not kept the same pace. High potassium cardioplegic solutions were introduced in the 1950s, and in the early 1960s they were soon recognized as harmful. Since that time, surgeons have minimized many of the adverse effects by lowering the temperature of the heart, lowering K+ concentration, reducing contact K+ time, changing the vehicle from a crystalloid solution to whole-blood, adding many pharmacological protectants and modifying reperfusion conditions. Despite these attempts, high potassium remains a suboptimalway to arrest the heart. We briefly review the historical advances and failures of finding alternatives to high potassium, the drawbacks of a prolonged depolarized membrane, altered Ca2+ intracellular circuits and heterogeneity in atrial-ventricular K+ repolarization during reanimation. Many of these untoward effects may be alleviated by a polarized membrane, and we will discuss the basic science and clinical experience from a number of institutions trialling different alternatives, and our institution with a non-depolarizing adenosine, lidocaine and magnesium (ALM) cardioplegia. The future of polarized arrest is an exciting one and may play an important role in treating the next generation of patients who are older, and sicker with multiple comorbidities and require more complex operations with prolonged cross-clamping times.
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Affiliation(s)
- Alessandra Francica
- Division of Cardiac Surgery, University of Verona Medical School, 37126 Verona, Italy; (F.T.); (C.R.); (I.T.); (G.B.L.); (G.F.); (F.O.)
- Correspondence: ; Tel.: +39-3356213738
| | - Filippo Tonelli
- Division of Cardiac Surgery, University of Verona Medical School, 37126 Verona, Italy; (F.T.); (C.R.); (I.T.); (G.B.L.); (G.F.); (F.O.)
| | - Cecilia Rossetti
- Division of Cardiac Surgery, University of Verona Medical School, 37126 Verona, Italy; (F.T.); (C.R.); (I.T.); (G.B.L.); (G.F.); (F.O.)
| | - Ilaria Tropea
- Division of Cardiac Surgery, University of Verona Medical School, 37126 Verona, Italy; (F.T.); (C.R.); (I.T.); (G.B.L.); (G.F.); (F.O.)
| | - Giovanni Battista Luciani
- Division of Cardiac Surgery, University of Verona Medical School, 37126 Verona, Italy; (F.T.); (C.R.); (I.T.); (G.B.L.); (G.F.); (F.O.)
| | - Giuseppe Faggian
- Division of Cardiac Surgery, University of Verona Medical School, 37126 Verona, Italy; (F.T.); (C.R.); (I.T.); (G.B.L.); (G.F.); (F.O.)
| | - Geoffrey Phillip Dobson
- Heart and Trauma Research Laboratory, College of Medicine and Dentistry, James Cook University, Townsville 4811, Australia;
| | - Francesco Onorati
- Division of Cardiac Surgery, University of Verona Medical School, 37126 Verona, Italy; (F.T.); (C.R.); (I.T.); (G.B.L.); (G.F.); (F.O.)
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Patel S, Dexter F. Narrative review of neuraxial potassium chloride administration errors: clinical features, human factors, and prevention measures. Reg Anesth Pain Med 2021; 46:904-908. [PMID: 34380745 DOI: 10.1136/rapm-2021-102933] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 07/29/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND Administration of the wrong drug via the epidural or intrathecal route can cause devastating consequences. Because of the commonality of potassium replacement therapy coupled to its potential neurotoxic profile, we suspected that injuries related to this drug error would be present in the literature. OBJECTIVES We aimed to identify clinical characteristics associated with the inadvertent administration of potassium chloride (KCl) during neuraxial anesthesia. Our secondary objective was to identify human factors that may have been associated. EVIDENCE REVIEW Published reports of neuraxial administration of KCl in humans were searched using Medline and Google Scholar. Error reports in any language were included. FINDINGS 25 case reports/series reported administration of KCl via epidural (25 patients) or intrathecal routes (three patients). There were six cases during interventional pain procedures, five cases in operating rooms and 17 in wards or intensive care units. Neuraxial KCl caused paraplegia in 22 patients. Mechanical ventilation was instituted in 11 of 28 patients. Three patients died. Epidural (eight patients) and spinal (two patients) lavage were performed to minimize consequences. A correctly prepared KCl infusion was connected to the epidural catheter for nine patients on wards (32%; 95% upper confidence limit: 48%) due to epidural-intravenous line confusion. Among the other 19 errors, KCl was confused with normal saline for 13 patients or local anesthetic in three patients. A wide range of concentrations and doses of KCl were administered. Variable use of intravenous steroid (13 patients) and epidural saline (eight patients) was found among patients who received epidural KCl. Human factors identified included incorrect visual perception, inadequate monitoring of infusions and substandard practice related to neuraxial anesthesia or analgesia. CONCLUSIONS KCl administration via epidural or intrathecal route has been reported to cause catastrophic consequences.
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Affiliation(s)
- Santosh Patel
- Department of Anaesthesia, Tawam Hospital, Al Ain, UAE
| | - Franklin Dexter
- Department of Anesthesia, University of Iowa, Iowa City, Iowa, USA
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Validation of using cardioplegic solutions for preserving cardiac function in isolated rabbit heart assays. J Pharmacol Toxicol Methods 2021; 111:107082. [PMID: 34082139 DOI: 10.1016/j.vascn.2021.107082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 04/29/2021] [Accepted: 05/23/2021] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Cardioplegic solutions were first developed to preserve heart function during cardiac surgeries and heart transplants but have application in the nonclinical setting. Due to lack of lab space in the vivarium, cardioplegic solution was used to conserve cardiac function for ex-vivo studies performed in a separate building. All studies in this report were conducted with isolated female rabbit hearts (IRHs) via retrograde perfusion using the Langendorff apparatus to investigate if cardioplegia usage affects cardiac function. METHODS Cardioplegia was achieved with a hyperkalemia (27 mM KCL) solution kept at 4 °C. Cardiac function was assessed by measuring ECG parameters, left ventricular contractility, and coronary flow under constant perfusion pressure. IRHs were cannulated with Krebs Henseleit buffer (KH) either fresh or after cardioplegic solution storage (C-IRH). Three comparisons were performed with and without cardioplegia; (i) direct side-by side studies of cardiac function; (ii) pharmacological responses to typical ion channels blockers, dofetilide, flecainide, and diltiazem; (iii) retrospective evaluation of cardiac functions in a large sample of hearts. RESULTS In the side-by-side comparisons, cardioplegia-stored IRHs (C-IRH; storage time 90 min) had similar electrocardiographic (ECG) and hemodynamic parameters to fresh-cannulated hearts with KH buffer (KH-IRH). In addition, responses to dofetilide, flecainide, and diltiazem, were similar for C-IRH and KH-IRH hearts. Over the years (2006-2011), baseline data was collected from 79 hearts without cardioplegia and 100 hearts with cardioplegia (C-IRH; storage time 15 min), which showed no meaningful differences in a retrospective analysis. DISCUSSION Cardiac function was preserved after cardioplegic treatment, however, coronary flow rates were decreased (-19.3%) in C-IRH hearts which indicated an altered coronary vascular tone. In conclusion, storage in cardioplegic solution preserves rabbit cardiac function, a practice that enables heart tissues to be collected at one site (e.g., vivarium) and transported to a laboratory in a separate location.
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Dobson GP, Biros E, Letson HL, Morris JL. Living in a Hostile World: Inflammation, New Drug Development, and Coronavirus. Front Immunol 2021; 11:610131. [PMID: 33552070 PMCID: PMC7862725 DOI: 10.3389/fimmu.2020.610131] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 11/25/2020] [Indexed: 12/14/2022] Open
Abstract
We present a brief history of the immune response and show that Metchnikoff's theory of inflammation and phagocytotic defense was largely ignored in the 20th century. For decades, the immune response was believed to be triggered centrally, until Lafferty and Cunningham proposed the initiating signal came from the tissues. This shift opened the way for Janeway's pattern recognition receptor theory, and Matzinger's danger model. All models failed to appreciate that without inflammation, there can be no immune response. The situation changed in the 1990s when cytokine biology was rapidly advancing, and the immune system's role expanded from host defense, to the maintenance of host health. An inflammatory environment, produced by immune cells themselves, was now recognized as mandatory for their attack, removal and repair functions after an infection or injury. We explore the cellular programs of the immune response, and the role played by cytokines and other mediators to tailor the right response, at the right time. Normally, the immune response is robust, self-limiting and restorative. However, when the antigen load or trauma exceeds the body's internal tolerances, as witnessed in some COVID-19 patients, excessive inflammation can lead to increased sympathetic outflows, cardiac dysfunction, coagulopathy, endothelial and metabolic dysfunction, multiple organ failure and death. Currently, there are few drug therapies to reduce excessive inflammation and immune dysfunction. We have been developing an intravenous (IV) fluid therapy comprising adenosine, lidocaine and Mg2+ (ALM) that confers a survival advantage by preventing excessive inflammation initiated by sepsis, endotoxemia and sterile trauma. The multi-pronged protection appears to be unique and may provide a tool to examine the intersection points in the immune response to infection or injury, and possible ways to prevent secondary tissue damage, such as that reported in patients with COVID-19.
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Affiliation(s)
- Geoffrey P. Dobson
- Heart, Trauma and Sepsis Research Laboratory, College of Medicine and Dentistry, James Cook University, Townsville, QLD, Australia
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Onorati F, Francica A, Dobson GP, Faggian G. Myocardial protection: the forgotten 'polarized' modality. Eur J Cardiothorac Surg 2021; 59:284. [PMID: 32728693 DOI: 10.1093/ejcts/ezaa218] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Accepted: 05/23/2020] [Indexed: 11/13/2022] Open
Affiliation(s)
- Francesco Onorati
- Division of Cardiac Surgery, University of Verona, Verona, Italy.,Heart, Trauma and Sepsis Research Laboratory, James Cook University, Townsville, QLD, Australia
| | - Alessandra Francica
- Division of Cardiac Surgery, University of Verona, Verona, Italy.,Heart, Trauma and Sepsis Research Laboratory, James Cook University, Townsville, QLD, Australia
| | - Geoffrey P Dobson
- Division of Cardiac Surgery, University of Verona, Verona, Italy.,Heart, Trauma and Sepsis Research Laboratory, James Cook University, Townsville, QLD, Australia
| | - Giuseppe Faggian
- Division of Cardiac Surgery, University of Verona, Verona, Italy.,Heart, Trauma and Sepsis Research Laboratory, James Cook University, Townsville, QLD, Australia
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Sanaiha Y, Juo YY, Rudasill SE, Jaman R, Sareh S, de Virgilio C, Benharash P. Percutaneous cholecystostomy for grade III acute cholecystitis is associated with worse outcomes. Am J Surg 2020; 220:197-202. [DOI: 10.1016/j.amjsurg.2019.11.025] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2019] [Revised: 11/17/2019] [Accepted: 11/18/2019] [Indexed: 12/07/2022]
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Niederberger P, Farine E, Raillard M, Dornbierer M, Freed DH, Large SR, Chew HC, MacDonald PS, Messer SJ, White CW, Carrel TP, Tevaearai Stahel HT, Longnus SL. Heart Transplantation With Donation After Circulatory Death. Circ Heart Fail 2020; 12:e005517. [PMID: 30998395 DOI: 10.1161/circheartfailure.118.005517] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Heart transplantation remains the preferred option for improving quality of life and survival for patients suffering from end-stage heart failure. Unfortunately, insufficient supply of cardiac grafts has become an obstacle. Increasing organ availability with donation after circulatory death (DCD) may be a promising option to overcome the organ shortage. Unlike conventional donation after brain death, DCD organs undergo a period of warm, global ischemia between circulatory arrest and graft procurement, which raises concerns for graft quality. Nonetheless, the potential of DCD heart transplantation is being reconsidered, after reports of more than 70 cases in Australia and the United Kingdom over the past 3 years. Ensuring optimal patient outcomes and generalized adoption of DCD in heart transplantation, however, requires further development of clinical protocols, which in turn require a better understanding of cardiac ischemia-reperfusion injury and the various possibilities to limit its adverse effects. Thus, we aim to provide an overview of the knowledge obtained with preclinical studies in animal models of DCD heart transplantation, to facilitate and promote the most effective and efficient advancement in preclinical research. A literature search of the PubMed database was performed to identify all relevant preclinical studies in DCD heart transplantation. Specific aspects relevant for DCD heart transplantation were analyzed, including animal models, graft procurement and storage conditions, cardioprotective approaches, and graft evaluation strategies. Several potential therapeutic strategies for optimizing graft quality are identified, and recommendations for further preclinical research are provided.
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Affiliation(s)
- Petra Niederberger
- Department of Cardiovascular Surgery, Inselspital, Bern University Hospital and Department for BioMedical Research, University of Bern, Switzerland (P.N., E.F., M.D., T.P.C., H.T.T.S., S.L.L.)
| | - Emilie Farine
- Department of Cardiovascular Surgery, Inselspital, Bern University Hospital and Department for BioMedical Research, University of Bern, Switzerland (P.N., E.F., M.D., T.P.C., H.T.T.S., S.L.L.)
| | - Mathieu Raillard
- Experimental Surgery Unit (ESI), Experimental Surgery Unit, Department for BioMedical Research and Vetsuisse Faculty, Department of Clinical Veterinary Medicine, Institute of Anaesthesiology and Pain Therapy, University of Bern, Switzerland (M.R.)
| | - Monika Dornbierer
- Department of Cardiovascular Surgery, Inselspital, Bern University Hospital and Department for BioMedical Research, University of Bern, Switzerland (P.N., E.F., M.D., T.P.C., H.T.T.S., S.L.L.)
| | - Darren H Freed
- Cardiac Surgery, University of Alberta, Edmonton, Canada (D.H.F., C.W.W.)
| | - Stephen R Large
- Department of Transplantation, Royal Papworth Hospital, Papworth Everard, Cambridge, United Kingdom (S.R.L., S.J.M.)
| | - Hong C Chew
- St Vincent's Hospital, University of New South Wales, Victor Chang Cardiac Research Institute, Sydney, Australia (H.C.C., P.S.M.)
| | - Peter S MacDonald
- St Vincent's Hospital, University of New South Wales, Victor Chang Cardiac Research Institute, Sydney, Australia (H.C.C., P.S.M.)
| | - Simon J Messer
- Department of Transplantation, Royal Papworth Hospital, Papworth Everard, Cambridge, United Kingdom (S.R.L., S.J.M.)
| | | | - Thierry P Carrel
- Department of Cardiovascular Surgery, Inselspital, Bern University Hospital and Department for BioMedical Research, University of Bern, Switzerland (P.N., E.F., M.D., T.P.C., H.T.T.S., S.L.L.)
| | - Hendrik T Tevaearai Stahel
- Department of Cardiovascular Surgery, Inselspital, Bern University Hospital and Department for BioMedical Research, University of Bern, Switzerland (P.N., E.F., M.D., T.P.C., H.T.T.S., S.L.L.)
| | - Sarah L Longnus
- Department of Cardiovascular Surgery, Inselspital, Bern University Hospital and Department for BioMedical Research, University of Bern, Switzerland (P.N., E.F., M.D., T.P.C., H.T.T.S., S.L.L.)
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de Haan M, van Straten A, Overdevest E, de Jong M, Soliman-Hamad M. Safety of Custodiol cardioplegia: a cohort study in patients undergoing cardiac surgery with elongated aortic cross-clamp time. Perfusion 2020; 35:591-597. [PMID: 31948381 DOI: 10.1177/0267659119897239] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND/OBJECTIVES The increasing complexity of patients undergoing cardiac surgery requires extended myocardial ischaemic periods. Cardiac surgeons demand a cardioplegic solution with prolonged myocardial protection. Therefore, we introduced Custodiol in our centre in 2011. The aim of this study was to investigate the safety and efficacy of Custodiol compared with the standard method of cardioplegia. METHODS Between 2011 and 2016, 188 adult patients who underwent mitral valve surgery combined with coronary artery bypass grafting were included in this retrospective study. In 113 patients, Custodiol cardioplegia was used to achieve cardiac arrest, while St. Thomas Hospital solution was used in 75 patients. The primary endpoint of the study was the degree myocardial damage which was estimated by the measurement of creatine kinase-myocardial band on the first postoperative day. A linear regression analysis was performed to compare the aortic cross-clamp time with the postoperative myocardial damage in both groups. RESULTS The extracorporeal circulation time and aortic cross-clamp were significantly longer in the Custodiol group than in the St. Thomas group: 125.6 ± 32.5 minutes versus 93.1 ± 27.7 minutes (p < 0.001), respectively. However, there was no significant difference between the two groups regarding the postoperative levels of creatine kinase-myocardial band (96 (70-140) U/L vs. 86 (69-120) U/L, respectively; p = 0.321). There was no significant differences between the two groups regarding the 30-day mortality (6.1% vs. 5.5%, respectively; p = 1.000) or 120-day mortality (9.6% vs. 11.0%, respectively; p = 0.806). CONCLUSION Our findings demonstrate that Custodiol is a safe method of myocardial protection for patients who underwent mitral valve surgery with coronary artery bypass grafting in our hospital. Further investigations extended to more cardiac surgery populations are needed to confirm clinical benefits of Custodiol cardioplegia.
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Affiliation(s)
- Maarten de Haan
- Department of Cardiothoracic Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | - Albert van Straten
- Department of Cardiothoracic Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | - Ed Overdevest
- Department of Cardiothoracic Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | - Michel de Jong
- Department of Cardiothoracic Surgery, UMC Utrecht, Utrecht, The Netherlands
| | - Mohamed Soliman-Hamad
- Department of Cardiothoracic Surgery, Catharina Hospital, Eindhoven, The Netherlands
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Abstract
Mitochondria are key to the cellular response to energetic demand, but are also vital to reactive oxygen species signaling, calcium hemostasis, and regulation of cell death. Cardiac surgical patients with diabetes, heart failure, advanced age, or cardiomyopathies may have underlying mitochondrial dysfunction or be more sensitive to perioperative mitochondrial injury. Mitochondrial dysfunction, due to ischemia/reperfusion injury and an increased systemic inflammatory response due to exposure to cardiopulmonary bypass and surgical tissue trauma, impacts myocardial contractility and predisposes to arrhythmias. Strategies for perioperative mitochondrial protection and recovery include both well-established cardioprotective protocols and targeted therapies that remain under investigation.
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Enhanced Activity by NKCC1 and Slc26a6 Mediates Acidic pH and Cl - Movement after Cardioplegia-Induced Arrest of db/db Diabetic Heart. Mediators Inflamm 2019; 2019:7583760. [PMID: 31582903 PMCID: PMC6754936 DOI: 10.1155/2019/7583760] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 07/26/2019] [Accepted: 08/13/2019] [Indexed: 01/22/2023] Open
Abstract
Diabetic heart dysfunctions during cardiac surgeries have revealed several clinical problems associated with ion imbalance. However, the mechanism of ion imbalance mediated by cardioplegia and a diabetic heart is largely unclear. We hypothesized that ion transporters might be regulated differently in the diabetic heart and that the differentially regulated ion transporters may involve in ion imbalance of the diabetic heart after cardioplegic arrest. In this study, we modified the Langendorff-free cardioplegia method and identified the involved ion transporters after cardioplegia-induced arrest between wild type and db/db heart. Enhanced expression of Na+-K+-2Cl− cotransporter 1 (NKCC1) was observed in the db/db heart compared to the wild type heart. Enhanced NKCC1 activity was observed in the left ventricle of db/db mice compared to that of wild type after cardioplegia-induced arrest. The expression and activity of Slc26a6, a dominant Cl−/HCO3− exchanger in cardiac tissues, were enhanced in left ventricle strips of db/db mice compared to that of wild type. The Cl− transporting activity in left ventricle strips of db/db mice was dramatically increased as compared to that of wild type. Interestingly, expression of Slc26a6, as well as carbonic anhydrase IV as a supportive enzyme of Slc26a6, was increased in db/db cardiac strips compared to wild type cardiac strips. Thus, the enhanced Cl− transporting activity and expression by NKCC1 and Slc26a6 in db/db cardiac tissues after cardioplegia-induced arrest provide greater insight into enhanced acidosis and Cl− movement-mediated db/db heart dysfunction. Thus, we suggested that enhanced Cl− influx and HCO3− efflux through NKCC1 and Slc26a6 offer more acidic circumstances in the diabetic heart after cardioplegic arrest. These transporters should be considered as potential therapeutic targets to develop the next generation of cardioplegia solution for protection against ischemia-reperfusion injury in diabetic hearts.
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Huang PC, Shibu MA, Kuo CH, Han CK, Chen YS, Lo FY, Li H, Viswanadha VP, Lai CH, Li X, Huang CY. Pheretima aspergillum extract attenuates high-KCl-induced mitochondrial injury and pro-fibrotic events in cardiomyoblast cells. ENVIRONMENTAL TOXICOLOGY 2019; 34:921-927. [PMID: 31066208 DOI: 10.1002/tox.22763] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Revised: 04/17/2019] [Accepted: 04/24/2019] [Indexed: 06/09/2023]
Abstract
Hyperkalemia is often associated with cardiac dysfunction. In this study an earthworm extract (dilong) was prepared from dried Pheretima aspergillum powder and its effect against high-KCl challenge was determined in H9c2 cardiomyoblast cells. H9c2 cells pre-treated with dilong (31.25, 62.5, 125, and 250 mg/mL) for 24 hours, where challenged with different doses of KCl treatment for 3 hours to determine the protective mechanisms of dilong against cardiac fibrosis. High-KCl administration induced mitochondrial injury and elevated the levels of pro-apoptotic proteins. The mediators of fibrosis such as ERK, uPA, SP1, and CTGF were also found to be upregulated in high-KCl condition. However, dilong treatment enhanced IGF1R/PI3k/Akt activation which is associated with cell survival. In addition, dilong also reversed high-KCl induced cardiac fibrosis related events in H9c2 cells and displayed a strong cardio-protective effect. Therefore, dilong is a potential agent to overcome cardiac events associated with high-KCl toxicity.
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Affiliation(s)
- Pei-Chen Huang
- Graduate Institute of Clinical Medical Science, China Medical University, Taichung, Taiwan
- Department of Obstetrics and Gynecology, China Medical University Hospital, China Medical University, Taichung, Taiwan
| | - Marthandam Asokan Shibu
- Department of Medical Research, China Medical University Hospital, China Medical University, Taichung, Taiwan
| | - Chia-Hua Kuo
- Department of Sports Sciences, University of Taipei, Taipei, Taiwan
| | - Chien-Kuo Han
- Department of Biotechnology, Asia University, Taichung, Taiwan
| | - Yueh-Sheng Chen
- Graduate Institute of Clinical Medical Science, China Medical University, Taichung, Taiwan
| | - Feng-Yueh Lo
- Department of Medical Research, China Medical University Hospital, China Medical University, Taichung, Taiwan
| | - Heng Li
- Department of Anesthesiology, The Sixth Affiliated Hospital of Guangzhou Medical University, Qingyuan People's Hospital, Qingyuan, Guangdong, China
| | | | - Chao-Hung Lai
- Division of Cardiology, Department of Internal Medicine, Taichung Armed Force General Hospital, Taichung, Taiwan
| | - Xudong Li
- Division of Cardiac Surgery, The Sixth Affiliated Hospital of Guangzhou Medical University, Qingyuan People's Hospital, Qingyuan, Guangdong, China
| | - Chih-Yang Huang
- Department of Medical Research, China Medical University Hospital, China Medical University, Taichung, Taiwan
- Department of Biotechnology, Asia University, Taichung, Taiwan
- College of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Tzu Chi University, Hualien, Taiwan
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Pretreatment with glucose-insulin-potassium improves ventricular performances after coronary artery bypass surgery: a randomized controlled trial. J Clin Monit Comput 2019; 34:29-40. [PMID: 30788810 PMCID: PMC7223403 DOI: 10.1007/s10877-019-00280-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2018] [Accepted: 02/12/2019] [Indexed: 12/19/2022]
Abstract
Heart failure is the main cause of poor outcome following open heart surgery and experimental studies have demonstrated that glucose–insulin–potassium (GIK) infusion exerts cardioprotective effects by reducing myocardial ischemia–reperfusion injuries. This randomized controlled trial was designed to assess the effects of GIK on left ventricular function in moderate-to-high risk patients undergoing on-pump isolated coronary artery bypass surgery (CABGS), or combined with aortic valve replacement. The primary outcomes were the effects of GIK on two- and three-dimensional left ventricular ejection fraction (2D and 3D-LVEF), and on transmitral flow propagation velocity (Vp), that occurred between the pre- and post-CPB periods. GIK administration was associated with favorable interaction effects (p < 0.001) on 2D-LVEF, 3D-LVEF and Vp changes over the study periods. In GIK pretreated patients (N = 54), 2-D and 3D-LVEF and Vp increased slightly during surgery (mean difference [MD] + 3.5%, 95% confidence interval [95% CI] − 0.2 to 7.1%, MD + 4.0%, 95% CI 0.6–7.4%, and MD + 22.2%, 95% CI 16.0–28.4%, respectively). In contrast, in the Placebo group (N = 46), 2D-and 3D-LVEF, as well as Vp all decreased after CPB (MD − 7.5% [− 11.6 to − 3.4%], MD − 12.0% [− 15.2 to − 8.8%] and MD − 21.3% [− 25.7 to − 16.9%], respectively). In conclusion, the administration of GIK resulted in better preservation of systolic and diastolic ventricular function in the early period following weaning from CPB.
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Lee CC, Hsieh YJ, Chen SW, Fu SH, Hsu CW, Wu CC, Han W, Li Y, Huan T, Chang YS, Yu JS, Li L, Chang CH, Chen YT. Bretschneider solution-induced alterations in the urine metabolome in cardiac surgery patients. Sci Rep 2018; 8:17774. [PMID: 30538262 PMCID: PMC6290005 DOI: 10.1038/s41598-018-35631-w] [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] [Received: 08/16/2018] [Accepted: 11/01/2018] [Indexed: 01/01/2023] Open
Abstract
The development of Bretschneider’s histidine-tryptophan-ketoglutarate (HTK) cardioplegia solution represented a major advancement in cardiac surgery, offering significant myocardial protection. However, metabolic changes induced by this additive in the whole body have not been systematically investigated. Using an untargeted mass spectrometry-based method to deeply explore the urine metabolome, we sought to provide a holistic and systematic view of metabolic perturbations occurred in patients receiving HTK. Prospective urine samples were collected from 100 patients who had undergone cardiac surgery, and metabolomic changes were profiled using a high-performance chemical isotope labeling liquid chromatography-mass spectrometry (LC-MS) method. A total of 14,642 peak pairs or metabolites were quantified using differential 13C-/12C-dansyl labeling LC-MS, which targets the amine/phenol submetabolome from urine specimens. We identified 223 metabolites that showed significant concentration change (fold change > 5) and assembled several potential metabolic pathway maps derived from these dysregulated metabolites. Our data indicated upregulated histidine metabolism with subsequently increased glutamine/glutamate metabolism, altered purine and pyrimidine metabolism, and enhanced vitamin B6 metabolism in patients receiving HTK. Our findings provide solid evidence that HTK solution causes significant perturbations in several metabolic pathways and establish a basis for further study of key mechanisms underlying its organ-protective or potential harmful effects.
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Affiliation(s)
- Cheng-Chia Lee
- Kidney Research Center, Department of Nephrology, Chang Gung Memorial Hospital, Linkou branch, College of Medicine, Chang Gung University, Guishan, Taoyuan, Taiwan.,Graduate Institute of Clinical Medical Sciences, College of medicine, Chang Gung University, Guishan, Taoyuan, Taiwan
| | - Ya-Ju Hsieh
- Molecular and Medicine Research Center, Chang Gung University, Guishan, Taoyuan, Taiwan
| | - Shao-Wei Chen
- Graduate Institute of Clinical Medical Sciences, College of medicine, Chang Gung University, Guishan, Taoyuan, Taiwan.,Department of cardiothoracic and vascular surgery, Chang Gung Memorial Hospital, Linkou branch, College of Medicine, Chang Gung University, Guishan, Taoyuan, Taiwan
| | - Shu-Hsuan Fu
- Molecular and Medicine Research Center, Chang Gung University, Guishan, Taoyuan, Taiwan
| | - Chia-Wei Hsu
- Molecular and Medicine Research Center, Chang Gung University, Guishan, Taoyuan, Taiwan
| | - Chih-Ching Wu
- Molecular and Medicine Research Center, Chang Gung University, Guishan, Taoyuan, Taiwan.,Department of Medical Biotechnology and Laboratory Science, Chang Gung University, Guishan, Taoyuan, 33302, Taiwan.,Department of Otolaryngology-Head & Neck Surgery, Chang Gung Memorial Hospital at Linkou, Guishan, Taoyuan, 33305, Taiwan
| | - Wei Han
- Department of Chemistry, University of Alberta, Edmonton, AB, T6G2G2, Canada
| | - Yunong Li
- Department of Chemistry, University of Alberta, Edmonton, AB, T6G2G2, Canada
| | - Tao Huan
- Department of Chemistry, University of Alberta, Edmonton, AB, T6G2G2, Canada
| | - Yu-Sun Chang
- Molecular and Medicine Research Center, Chang Gung University, Guishan, Taoyuan, Taiwan.,Department of Otolaryngology-Head & Neck Surgery, Chang Gung Memorial Hospital at Linkou, Guishan, Taoyuan, 33305, Taiwan.,Graduate Institute of Biomedical Sciences, Chang Gung University, Guishan, Taoyuan, 33302, Taiwan
| | - Jau-Song Yu
- Molecular and Medicine Research Center, Chang Gung University, Guishan, Taoyuan, Taiwan.,Liver Research Center, Chang Gung Memorial Hospital at Linkou, Guishan, Taoyuan, 33305, Taiwan.,Department of Cell and Molecular Biology, Chang Gung University, Guishan, Taoyuan, 33302, Taiwan
| | - Liang Li
- Department of Chemistry, University of Alberta, Edmonton, AB, T6G2G2, Canada.
| | - Chih-Hsiang Chang
- Kidney Research Center, Department of Nephrology, Chang Gung Memorial Hospital, Linkou branch, College of Medicine, Chang Gung University, Guishan, Taoyuan, Taiwan. .,Graduate Institute of Clinical Medical Sciences, College of medicine, Chang Gung University, Guishan, Taoyuan, Taiwan.
| | - Yi-Ting Chen
- Kidney Research Center, Department of Nephrology, Chang Gung Memorial Hospital, Linkou branch, College of Medicine, Chang Gung University, Guishan, Taoyuan, Taiwan. .,Molecular and Medicine Research Center, Chang Gung University, Guishan, Taoyuan, Taiwan. .,Department of Biomedical Sciences, College of Medicine, Chang Gung University, Guishan, Taoyuan, Taiwan. .,Graduate Institute of Biomedical Sciences, College of Medicine, Chang Gung University, Guishan, Taoyuan, Taiwan.
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Khan MS, Biederman R. Dynamic cardiac anatomy: the "cypress tree" papillary muscle root. J Cardiovasc Thorac Res 2018; 10:138-143. [PMID: 30386533 PMCID: PMC6203870 DOI: 10.15171/jcvtr.2018.22] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2018] [Accepted: 09/05/2018] [Indexed: 11/09/2022] Open
Abstract
Introduction: The understanding of gross cardiac anatomy has been relatively stable over the last
80 years, reliant on well-established autopsy findings. The advent of dynamic imaging by cardiac
MRI and CT provides a window to view anatomic features in vivo, providing insights typically
masked at autopsy due to death.
Hypothesis: We hypothesize that cardiac magnetic resonance (CMR) with its high spatial and
temporal resolution allows detection of anatomic features not previously appreciated at autopsy.
Methods: Two hundred fifty-five sequential, CMR examinations were retrospectively examined
to describe the anatomic features of the LV (left ventricular) PM (papillary muscles). Specifically,
the origin of the base of the PM was delineated. The insertion of the PM was seen in 255/255
patients.
Results: In 249 out of 255 patients (97.6%), the appearance of the PM was not a uniform muscle
arising from the inner face of the LV myocardium, but was a finger-like series of long, slender
trabeculae carneae traversing >1 cm before inserting into the main body of PM challenging our
previous understanding of PM anatomy.
Conclusion: The capabilities of dynamic CMR to view cardiac features in vivo non-invasively
provides a useful tool to study cardiac anatomy. Unlike the widely accepted representation of
papillary muscles, uniformly arising from the floor of the LV, the base resolves into a ‘cypress-tree’
root-like structure with multiple thin projections before coalescing into a thick muscle head. Such
observations have far reaching clinical implications in areas such as mitral regurgitation, post-MI
remodeling and electrical transmission of the His-Purkinje system, and further work is indicated
to delineate the role of non-invasive imaging in these areas.
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Affiliation(s)
| | - Robert Biederman
- Department of Cardiac MRI, Allegheny General Hospital, Pittsburgh, USA
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Abdelwahab AA, Sabry M, Elshora HA, Arafat AA. Effect of Fast Cardioplegic Arrest Induced by Adenosine on Cardiac Troponin Levels After Heart Valve Surgery. Heart Lung Circ 2018; 28:1714-1719. [PMID: 30253969 DOI: 10.1016/j.hlc.2018.08.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2017] [Revised: 07/16/2018] [Accepted: 08/28/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Cellular injury is not avoidable with current cardioplegic solutions. The effect of adenosine on reducing cardiac injury post-surgery is controversial. The objective of the current study is to evaluate the effect of fast cardioplegic arrest induced by adenosine on high sensitive cardiac troponin I after heart valve surgery. METHODS Forty-five (45) patients with rheumatic heart diseases underwent heart valve surgery using conventional approach through median sternotomy. They were classified into two groups, group I (n=21) patients received 0.25mg/kg adenosine into the aortic root just after aortic cross-clamping and before infusion of the cold hyperkalaemic crystalloid cardioplegia via antegrade route and group II (n=24) who received cold crystalloid hyperkalaemic cardioplegia without adenosine. Cardiac troponin I was measured preoperatively and on postoperative days 0, 3 and 7. RESULTS There was no significant difference between both groups in the demographic, preoperative and operative data. Adenosine significantly reduced arrest time. Postoperative high sensitive cardiac troponin I increased significantly in both groups compared to the preoperative levels and the rise continued till postoperative day 3. Troponin levels were significantly lower in the adenosine group compared to the control at all measurements. The clinical outcomes were non-significant different between groups. CONCLUSIONS Using adenosine in inducing fast cardioplegic arrest in heart valve surgery after aortic cross clamp and prior to infusion of the cold cardioplegia had significantly decreased postoperative cardiac troponin levels which was used as a proxy for cellular injury compared to the control group.
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Affiliation(s)
| | - Mohab Sabry
- Cardiothoracic Surgery Department, Tanta University, Egypt
| | - Hatem A Elshora
- Anesthesia and Surgical ICU Department, Tanta University, Egypt
| | - Amr A Arafat
- Cardiothoracic Surgery Department, Tanta University, Egypt.
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Aass T, Stangeland L, Moen CA, Solholm A, Dahle GO, Chambers DJ, Urban M, Nesheim K, Haaverstad R, Matre K, Grong K. Left ventricular dysfunction after two hours of polarizing or depolarizing cardioplegic arrest in a porcine model. Perfusion 2018; 34:67-75. [PMID: 30058944 PMCID: PMC6304685 DOI: 10.1177/0267659118791357] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
INTRODUCTION This experimental study compares myocardial function after prolonged arrest by St. Thomas' Hospital polarizing cardioplegic solution (esmolol, adenosine, Mg2+) with depolarizing (hyperkalaemic) St. Thomas' Hospital No 2, both administered as cold oxygenated blood cardioplegia. METHODS Twenty anaesthetized pigs on tepid (34°C) cardiopulmonary bypass (CPB) were randomised to cardioplegic arrest for 120 min with antegrade, repeated, cold, oxygenated, polarizing (STH-POL) or depolarizing (STH-2) blood cardioplegia every 20 min. Cardiac function was evaluated at Baseline and 60, 150 and 240 min after weaning from CPB, using a pressure-conductance catheter and epicardial echocardiography. Regional tissue blood flow, cleaved caspase-3 activity and levels of malondialdehyde were evaluated in myocardial tissue samples. RESULTS Preload recruitable stroke work (PRSW) was increased after polarizing compared to depolarizing cardioplegia 150 min after declamping (73.0±3.2 vs. 64.3±2.4 mmHg, p=0.047). Myocardial tissue blood flow rate was high in both groups compared to the Baseline levels and decreased significantly in the STH-POL group only, from 60 min to 150 min after declamping (p<0.005). Blood flow was significantly reduced in the STH-POL compared to the STH-2 group 240 min after declamping (p<0.05). Left ventricular mechanical efficiency, the ratio between total pressure-volume area and blood flow rate, gradually decreased after STH-2 cardioplegia and was significantly reduced compared to STH-POL cardioplegia after 150 and 240 min (p<0.05 for both). CONCLUSION Myocardial protection for two hours of polarizing cardioplegic arrest with STH-POL in oxygenated blood is non-inferior compared to STH-2 blood cardioplegia. STH-POL cardioplegia alleviates the mismatch between myocardial function and perfusion after weaning from CPB.
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Affiliation(s)
- Terje Aass
- 1 Section of Cardiothoracic Surgery, Department of Heart Disease, Haukeland University Hospital, Bergen, Norway.,2 Department of Clinical Science, Faculty of Medicine, University of Bergen, Bergen, Norway
| | - Lodve Stangeland
- 2 Department of Clinical Science, Faculty of Medicine, University of Bergen, Bergen, Norway
| | - Christian Arvei Moen
- 1 Section of Cardiothoracic Surgery, Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
| | - Atle Solholm
- 1 Section of Cardiothoracic Surgery, Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
| | - Geir Olav Dahle
- 2 Department of Clinical Science, Faculty of Medicine, University of Bergen, Bergen, Norway
| | - David J Chambers
- 3 Cardiac Surgical Research, The Rayne Institute (King's College London), Guy's and St Thomas' NHS Foundation Trust, St Thomas' Hospital, London, United Kingdom
| | - Malte Urban
- 1 Section of Cardiothoracic Surgery, Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
| | - Knut Nesheim
- 1 Section of Cardiothoracic Surgery, Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
| | - Rune Haaverstad
- 1 Section of Cardiothoracic Surgery, Department of Heart Disease, Haukeland University Hospital, Bergen, Norway.,2 Department of Clinical Science, Faculty of Medicine, University of Bergen, Bergen, Norway
| | - Knut Matre
- 2 Department of Clinical Science, Faculty of Medicine, University of Bergen, Bergen, Norway
| | - Ketil Grong
- 2 Department of Clinical Science, Faculty of Medicine, University of Bergen, Bergen, Norway
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Arsyad A, Sokoya E, Dobson GP. Adenosine and lidocaine (AL) combination dilates intimally damaged rat thoracic aortic rings and guinea pig mesenteric arteries: possible significance to cardiac surgery. Am J Transl Res 2018; 10:1841-1851. [PMID: 30018724 PMCID: PMC6038079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2017] [Accepted: 05/05/2017] [Indexed: 06/08/2023]
Abstract
New pharmacotherapies are required to improve vessel graft protection and prevent vasoconstriction and spasm in CABG surgery. Previously we have studied adenosine (A) and lidocaine (L) relaxation in rat aortic rings, and reported a possible crosstalk between L relaxation and adenosine A2a receptor inhibition. The aim of the present study was to examine the effect of AL combination compared to A and L alone on relaxation in intact and denuded rat aortic rings and in guinea-pig pressurized mesenteric arterial segments. Aortic rings were harvested from Sprague-Dawley rats and equilibrated in an organ bath containing modified Krebs-Henseleit (KH) solution, pH 7.4, 37°C. Rings were pre-contracted sub-maximally with 0.3 µM norepinephrine, and the effects of increasing AL, A or L (up to 1.0 mM) were examined in intact and denuded rings. Mesenteric artery segments were isolated from guinea-pigs and mounted in an arteriograph containing KH solution and pressurised to 60 mmHg. Arteries were preconstricted with 10-8 M vasopressin and AL, A, or L was administered luminally or abluminally. Diameters were measured using video-microscopy. We report in intact rat aortic rings, AL increased relaxation from 21 to 100% (0.1-1.0 mM) and relaxation was endothelium-independent. Adenosine alone was also a potent relaxant of aortic rings but, unlike AL relaxation, it was partially endothelium-dependent. In intact mesenteric artery segments, increasing luminal AL produced a potent endothelium-independent dilation (up to 90%). Adenosine dilation was endothelium-independent but not lidocaine, which produced 33% dilation only after endothelial removal. Extra-luminal AL and A led to 76% and 80% dilationin intact segments respectively, whereas L resulted in constriction (10-17%). In conclusion, we show that AL can dilate aortic rings and mesenteric artery segments by up to 90% regardless of whether the endothelium is intact. We discuss the potential translational significance of AL to improve conduit protection in cardiac surgery, and other major surgeries.
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Affiliation(s)
- Aryadi Arsyad
- Department of Physiology, Medical Faculty, Hasanuddin UniversityJl. Perintis Kemerdekaan, Km. 10, Tamalanrea Makassar 90213, Indonesia
| | - Elke Sokoya
- Department of Human Physiology, School of Medicine, Flinders UniversityGPO Box 2100, Adelaide, SA 5001, Australia
| | - Geoffrey P Dobson
- Heart, Trauma and Sepsis Research Laboratory, Australian Institute of Tropical Health and Medicine, College of Medicine and Dentistry, 1 James Cook Drive, James Cook UniversityQueensland 4811, Australia
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Comentale G, Giordano R, Palma G. Comparison of the different cardioplegic strategies in cardiac valves surgery: who wins the "arm-wrestling"? J Thorac Dis 2018; 10:714-717. [PMID: 29607140 DOI: 10.21037/jtd.2018.01.133] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Giuseppe Comentale
- Adult and Pediatric Cardiac Surgery, Department of Advanced Biomedical Sciences, University of Naples "Federico II", Naples, Italy
| | - Raffaele Giordano
- Adult and Pediatric Cardiac Surgery, Department of Advanced Biomedical Sciences, University of Naples "Federico II", Naples, Italy
| | - Gaetano Palma
- Adult and Pediatric Cardiac Surgery, Department of Advanced Biomedical Sciences, University of Naples "Federico II", Naples, Italy
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Adenosine, lidocaine and Mg2+ (ALM) fluid therapy attenuates systemic inflammation, platelet dysfunction and coagulopathy after non-compressible truncal hemorrhage. PLoS One 2017; 12:e0188144. [PMID: 29145467 PMCID: PMC5690633 DOI: 10.1371/journal.pone.0188144] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Accepted: 11/01/2017] [Indexed: 11/19/2022] Open
Abstract
Background Systemic inflammation and coagulopathy are major drivers of injury progression following hemorrhagic trauma. Our aim was to examine the effect of small-volume 3% NaCl adenosine, lidocaine and Mg2+ (ALM) bolus and 0.9% NaCl/ALM ‘drip’ on inflammation and coagulation in a rat model of hemorrhagic shock. Methods Sprague-Dawley rats (429±4 g) were randomly assigned to: 1) shams, 2) no-treatment, 3) saline-controls, 4) ALM-therapy, and 5) Hextend®. Hemorrhage was induced in anesthetized-ventilated animals by liver resection (60% left lateral lobe and 50% medial lobe). After 15 min, a bolus of 3% NaCl ± ALM (0.7 ml/kg) was administered intravenously (Phase 1) followed 60 min later by 4 hour infusion of 0.9% NaCl ± ALM (0.5 ml/kg/hour) with 1-hour monitoring (Phase 2). Plasma cytokines were measured on Magpix® and coagulation using Stago/Rotational Thromboelastometry. Results After Phase 1, saline-controls, no-treatment and Hextend® groups showed significant falls in white and red cells, hemoglobin and hematocrit (up to 30%), whereas ALM animals had similar values to shams (9–15% losses). After Phase 2, these deficits in non-ALM groups were accompanied by profound systemic inflammation. In contrast, after Phase 1 ALM-treated animals had undetectable plasma levels of IL-1α and IL-1β, and IL-2, IL-6 and TNF-α were below baseline, and after Phase 2 they were less or similar to shams. Non-ALM groups (except shams) also lost their ability to aggregate platelets, had lower plasma fibrinogen levels, and were hypocoagulable. ALM-treated animals had 50-fold higher ADP-induced platelet aggregation, and 9.3-times higher collagen-induced aggregation compared to saline-controls, and had little or no coagulopathy with significantly higher fibrinogen shifting towards baseline. Hextend® had poor outcomes. Conclusions Small-volume ALM bolus/drip mounted a frontline defense against non-compressible traumatic hemorrhage by defending immune cell numbers, suppressing systemic inflammation, improving platelet aggregation and correcting coagulopathy. Saline-controls were equivalent to no-treatment. Possible mechanisms of ALM's immune-bolstering effect are discussed.
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3% NaCl adenosine, lidocaine, Mg2+ (ALM) bolus and 4 hours "drip" infusion reduces noncompressible hemorrhage by 60% in a rat model. J Trauma Acute Care Surg 2017; 82:1063-1072. [PMID: 28520687 DOI: 10.1097/ta.0000000000001454] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Noncompressible torso hemorrhage is the leading cause of potentially survivable trauma in far-forward combat environments. Our aim was to examine the effect of small-volume 3% NaCl adenosine, lidocaine, and Mg (ALM) bolus and 0.9% NaCl/ALM "drip" on survivability and cardiac/gut/kidney function in a rat model of hepatic hemorrhage and shock. METHODS Male Sprague-Dawley rats (428 ± 4 g) were anesthetized and randomly assigned to one of five groups (n = 16): (1) Sham, (2) No treatment, (3) Saline controls, (4) ALM therapy, and (5) Hextend. Animals were ventilated, instrumented with single or double laparotomy for tissue probe insertion, and hemorrhage induced by liver resection. After 15 minutes, a single 3% NaCl ± ALM bolus (0.7 ml/kg) was injected IV (phase 1) and after 60 minutes, 4 hours 0.9% NaCl ± ALM stabilization "drip" (0.5 ml/kg/h) was administered (phase 2), with 1-hour monitoring. RESULTS Mortality for Shams (no resection) was 0% (25%); No treatment, 87.5% (100%); Saline controls, 37.5% (75%); ALM therapy, 0% (25%), and Hextend, 87.5% (100%) (double laparotomy in parentheses). Hextend-treated animals died during the first 20 minutes of phase 2. A single ALM bolus during phase 1 led to a 2.4-fold higher cardiac output and improved hemodynamics. 3% NaCl ALM bolus increased tissue pO2 and flow in gut and kidney during phase 1 and, during ALM "drip" in phase 2, tissue pO2 decreased but flow continued to rise, indicating increased tissue O2 extraction and delivery. During phase 2, CO, ejection fraction, and fractional shortening decreased and were erratic in all groups except ALM treatment. ALM therapy led to up to 60% less bleeding over 6 hours compared to Saline controls and 75% less bleeding than Hextend. CONCLUSIONS Small-volume ALM therapy significantly reduced mortality and internal bleeding compared to Saline controls or Hextend-treated rats. Hextend increased mortality, severe bleeding, and microvascular-organ injury.
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Ramani J, Malhotra A, Wadhwa V, Sharma P, Garg P, Tarsaria M, Pandya H. Single-Dose Lignocaine-Based Blood Cardioplegia in Single Valve Replacement Patients. Braz J Cardiovasc Surg 2017; 32:90-95. [PMID: 28492789 PMCID: PMC5409253 DOI: 10.21470/1678-9741-2016-0025] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Accepted: 11/24/2016] [Indexed: 11/21/2022] Open
Abstract
Objective Myocardial protection is the most important in cardiac surgery. We compared
our modified single-dose long-acting lignocaine-based blood cardioplegia
with short-acting St Thomas 1 blood cardioplegia in patients undergoing
single valve replacement. Methods A total of 110 patients who underwent single (aortic or mitral) valve
replacement surgery were enrolled. Patients were divided in two groups based
on the cardioplegia solution used. In group 1 (56 patients), long-acting
lignocaine based-blood cardioplegia solution was administered as a single
dose while in group 2 (54 patients), standard St Thomas IB (short-acting
blood-based cardioplegia solution) was administered and repeated every 20
minutes. All the patients were compared for preoperative baseline
parameters, intraoperative and all the postoperative parameters. Results We did not find any statistically significant difference in preoperative
baseline parameters. Cardiopulmonary bypass time were 73.8±16.5 and
76.4±16.9 minutes (P=0.43) and cross clamp time were
58.9±10.3 and 66.3±11.2 minutes (P=0.23) in
group 1 and group 2, respectively. Mean of maximum inotrope score was
6.3±2.52 and 6.1±2.13 (P=0.65) in group 1 and
group 2, respectively. We also did not find any statistically significant
difference in creatine-phosphokinase-MB (CPK-MB), Troponin-I levels, lactate
level and cardiac functions postoperatively. Conclusion This study proves the safety and efficacy of long-acting lignocaine-based
single-dose blood cardioplegia compared to the standard short-acting
multi-dose blood cardioplegia in patients requiring the single valve
replacement. Further studies need to be undertaken to establish this
non-inferiority in situations of complex cardiac procedures especially in
compromised patients.
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Affiliation(s)
- Jaydip Ramani
- Department of Cardiovascular and Thoracic Surgery of U.N. Mehta Institute of Cardiology and Research Center (Affiliated to B.J. Medical College), Civil hospital Campus, Asarwa, Ahmedabad, India
| | - Amber Malhotra
- Department of Cardiovascular and Thoracic Surgery of U.N. Mehta Institute of Cardiology and Research Center (Affiliated to B.J. Medical College), Civil hospital Campus, Asarwa, Ahmedabad, India
| | - Vivek Wadhwa
- Department of Cardiovascular and Thoracic Surgery of U.N. Mehta Institute of Cardiology and Research Center (Affiliated to B.J. Medical College), Civil hospital Campus, Asarwa, Ahmedabad, India
| | - Pranav Sharma
- Department of Cardiovascular and Thoracic Surgery of U.N. Mehta Institute of Cardiology and Research Center (Affiliated to B.J. Medical College), Civil hospital Campus, Asarwa, Ahmedabad, India
| | - Pankaj Garg
- Department of Cardiovascular and Thoracic Surgery of U.N. Mehta Institute of Cardiology and Research Center (Affiliated to B.J. Medical College), Civil hospital Campus, Asarwa, Ahmedabad, India
| | - Malkesh Tarsaria
- Department of Cardiovascular and Thoracic Surgery of U.N. Mehta Institute of Cardiology and Research Center (Affiliated to B.J. Medical College), Civil hospital Campus, Asarwa, Ahmedabad, India
| | - Himani Pandya
- Department of Cardiovascular and Thoracic Surgery of U.N. Mehta Institute of Cardiology and Research Center (Affiliated to B.J. Medical College), Civil hospital Campus, Asarwa, Ahmedabad, India
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Choi YH, Stamm C. More complex than expected? Eur J Cardiothorac Surg 2017; 51:608. [PMID: 27694245 DOI: 10.1093/ejcts/ezw331] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Accepted: 08/29/2016] [Indexed: 11/14/2022] Open
Affiliation(s)
- Yeong-Hoon Choi
- Heart Center of the University, Cardiothoracic Surgery, University of Cologne, Cologne, Germany
| | - Christof Stamm
- Deutsches Herzzentrum Berlin, Cardiothoracic Surgery, Berlin, Germany
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Vognsen M, Fabian-Jessing BK, Secher N, Løfgren B, Dezfulian C, Andersen LW, Granfeldt A. Contemporary animal models of cardiac arrest: A systematic review. Resuscitation 2017; 113:115-123. [PMID: 28214538 DOI: 10.1016/j.resuscitation.2017.01.024] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Revised: 01/21/2017] [Accepted: 01/25/2017] [Indexed: 01/01/2023]
Abstract
AIM OF THE STUDY Animal models are widely used in cardiac arrest research. This systematic review aimed to provide an overview of contemporary animal models of cardiac arrest. METHODS Using a comprehensive research strategy, we searched PubMed and EMBASE from March 8, 2011 to March 8, 2016 for cardiac arrest animal models. Two investigators reviewed titles and abstracts for full text inclusion from which data were extracted according to pre-defined definitions. RESULTS Search criteria yielded 1741 unique titles and abstracts of which 490 full articles were included. The most common animals used were pigs (52%) followed by rats (35%) and mice (6%). Studies favored males (52%) over females (16%); 17% of studies included both sexes, while 14% omitted to report on sex. The most common methods for induction of cardiac arrest were either electrically-induced ventricular fibrillation (54%), asphyxia (25%), or potassium (8%). The median no-flow time was 8min (quartiles: 5, 8, range: 0-37min). The majority of studies used adrenaline during resuscitation (64%), while bicarbonate (17%), vasopressin (8%) and other drugs were used less prevalently. In 53% of the studies, the post-cardiac arrest observation time was ≥24h. Neurological function was an outcome in 48% of studies while 43% included assessment of a cardiac outcome. CONCLUSIONS Multiple animal models of cardiac arrest exist. The great heterogeneity of these models along with great variability in definitions and reporting make comparisons between studies difficult. There is a need for standardization of animal cardiac arrest research and reporting.
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Affiliation(s)
- Mikael Vognsen
- Research Center for Emergency Medicine, Aarhus University Hospital, Aarhus, Denmark
| | | | - Niels Secher
- Department of Anaesthesiology and Intensive Care Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Bo Løfgren
- Research Center for Emergency Medicine, Aarhus University Hospital, Aarhus, Denmark; Institute of Clinical Medicine, Aarhus University, Aarhus, Denmark; Department of Internal Medicine, Regional Hospital of Randers, Randers, Denmark
| | - Cameron Dezfulian
- Safar Center for Resuscitation Research, Vascular Medicine Institute and Critical Care Medicine Department, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Lars W Andersen
- Research Center for Emergency Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Asger Granfeldt
- Department of Anaesthesiology and Intensive Care Medicine, Aarhus University Hospital, Aarhus, Denmark; Institute of Clinical Medicine, Aarhus University, Aarhus, Denmark.
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Hamaoui K, Aftab A, Gowers S, Boutelle M, Cook T, Rudd D, Dobson GP, Papalois V. An ex vivo comparison of adenosine and lidocaine solution and University of Wisconsin solution for hypothermic machine perfusion of porcine kidneys: potential for development. J Surg Res 2016; 208:219-229. [PMID: 27993213 DOI: 10.1016/j.jss.2016.08.068] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2016] [Revised: 07/29/2016] [Accepted: 08/18/2016] [Indexed: 01/13/2023]
Abstract
BACKGROUND The optimal hypothermic machine perfusion (HMP) solution has not yet been developed. An adenosine and lidocaine (AL) solution has been shown to be protective in cardiac preservation. The aim of the present study was to examine a modified AL solution with low Ca2+, 16 mM Mg2+, and 4% albumin on kidney preservation compared with University Wisconsin solution (UW). METHODS Twenty donation of organs after cardiac death porcine kidneys underwent HMP for 10 h (AL, n = 10; UW, n = 10) and then 2 h of normothermic reperfusion. Perfusion dynamics, functional parameters, histology, and real-time microdialysis were used to assess kidney responses and viability. RESULTS During HMP, modified AL-perfused kidneys maintained higher flow rates (21.5 versus 17.9 mL/min/100 g, P = 0.01), with perfusion flow index during the first 3 h 25% greater than with UW (AL = 0.50 ± 0.2, UW = 0.40 ± 0.17 mL/min/100 g/mmHg; P = 0.03), followed by an increase in UW kidneys which was not significantly different to AL over the remaining 7 h (0.54 versus 0.55 mL/min/100 g/mmHg, respectively). During warm reperfusion, there were no significant differences between the two HMP groups in creatinine clearance, oxygen, and glucose consumption between groups. Modified AL kidneys had significantly lower perfusate lactates (3.1 versus 4.1 mmol/L, P = 0.04) during reperfusion and lower cortical lactate levels (AL = 0.66 ± 0.31, UW = 0.89 ± 0.53 mM, P = 0.33). Histology showed similar degrees of reperfusion injury. CONCLUSIONS We conclude that HMP with modified AL solution showed improved perfusion compared with UW and lower perfusate lactate levels during warm reperfusion. Further modification of the AL composition is warranted and may lead to more rapid kidney stabilization and improved graft viability assessment, potentially expanding donor pools.
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Affiliation(s)
- Karim Hamaoui
- Department of Surgery, Imperial College London, London, United Kingdom.
| | - Adeel Aftab
- Department of Surgery, Imperial College London, London, United Kingdom
| | - Sally Gowers
- Department of Bioengineering, Imperial College London, London, United Kingdom
| | - Martyn Boutelle
- Department of Bioengineering, Imperial College London, London, United Kingdom
| | - Terry Cook
- Imperial College Renal and Transplant Centre, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Donna Rudd
- College of Public Health, Medical and Vet Sciences, James Cook University, Townsville, Queensland, Australia
| | - Geoffrey P Dobson
- Heart, Trauma and Sepsis Research Laboratory, College of Medicine and Dentistry, AITHM, James Cook University, Townsville, Queensland, Australia
| | - Vassilios Papalois
- Department of Surgery, Imperial College London, London, United Kingdom; Imperial College Renal and Transplant Centre, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
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Vinten-Johansen J. Whole Blood Cardioplegia: Do We Still Need to Dilute? THE JOURNAL OF EXTRA-CORPOREAL TECHNOLOGY 2016; 48:P9-P14. [PMID: 27578906 PMCID: PMC5001534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Affiliation(s)
- Jakob Vinten-Johansen
- Division of Cardiothoracic Surgery, Department of Surgery, Emory University, Atlanta, Georgia
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Arsyad A, Dobson GP. Adenosine relaxation in isolated rat aortic rings and possible roles of smooth muscle Kv channels, KATP channels and A2a receptors. BMC Pharmacol Toxicol 2016; 17:23. [PMID: 27211886 PMCID: PMC4876563 DOI: 10.1186/s40360-016-0067-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Accepted: 04/29/2016] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND An area of ongoing controversy is the role adenosine to regulate vascular tone in conduit vessels that regulate compliance, and the role of nitric oxide (NO), potassium channels and receptor subtypes involved. The aim of our study was to investigate adenosine relaxation in rat thoracic aortic rings, and the effect of inhibitors of NO, prostanoids, Kv, KATP channels, and A2a and A2b receptors. METHODS Aortic rings were freshly harvested from adult male Sprague Dawley rats and equilibrated in an organ bath containing oxygenated, modified Krebs-Henseleit solution, 11 mM glucose, pH 7.4, 37 °C. Isolated rings were pre-contracted sub-maximally with 0.3 μM norepinephrine (NE), and the effect of increasing concentrations of adenosine (1 to 1000 μM) were examined. The drugs L-NAME, indomethacin, 4-aminopyridine (4-AP), glibenclamide, 5-hydroxydecanoate, ouabain, 8-(3-chlorostyryl) caffeine and PSB-0788 were examined in intact and denuded rings. Rings were tested for viability after each experiment. RESULTS Adenosine induced a dose-dependent, triphasic relaxation response, and the mechanical removal of the endothelium significantly deceased adenosine relaxation above 10 μM. Interestingly, endothelial removal significantly decreased the responsiveness (defined as % relaxation per μM adenosine) by two-thirds between 10 and 100 μM, but not in the lower (1-10 μM) or higher (>100 μM) ranges. In intact rings, L-NAME significantly reduced relaxation, but not indomethacin. Antagonists of voltage-dependent Kv (4-AP), sarcolemma KATP (glibenclamide) and mitochondrial KATP channels (5-HD) led to significant reductions in relaxation in both intact and denuded rings, with ouabain having little or no effect. Adenosine-induced relaxation appeared to involve the A2a receptor, but not the A2b subtype. CONCLUSIONS It was concluded that adenosine relaxation in NE-precontracted rat aortic rings was triphasic and endothelium-dependent above 10 μM, and relaxation involved endothelial nitric oxide (not prostanoids) and a complex interplay between smooth muscle A2a subtype and voltage-dependent Kv, SarcKATP and MitoKATP channels. The possible in vivo significance of the regulation of arterial compliance to left ventricular function coupling is discussed.
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Affiliation(s)
- Aryadi Arsyad
- Physiology Department, Medical Faculty, Hasanuddin University, Jl. Perintis Kemerdekaan, Km. 10, Tamalanrea, Makassar, 90213, Indonesia
| | - Geoffrey P Dobson
- Heart, Trauma and Sepsis Research Laboratory, Australian Institute of Tropical Health and Medicine, College of Medicine and Dentistry, James Cook University, 1 James Cook Drive, Queensland, 4811, Australia.
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Onorati F, Dobson GP, San Biagio L, Abbasciano R, Fanti D, Covajes C, Menon T, Gottin L, Biancari F, Mazzucco A, Faggian G. Superior Myocardial Protection Using “Polarizing” Adenosine, Lidocaine, and Mg 2+ Cardioplegia in Humans. J Am Coll Cardiol 2016; 67:1751-3. [DOI: 10.1016/j.jacc.2015.12.071] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Revised: 12/10/2015] [Accepted: 12/22/2015] [Indexed: 10/22/2022]
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Janssen C, Kellermann S, Münch F, Purbojo A, Cesnjevar RA, Rüffer A. Myocardial Protection During Aortic Arch Repair in a Piglet Model: Beating Heart Technique Compared With Crystalloid Cardioplegia. Ann Thorac Surg 2015; 100:1758-66. [DOI: 10.1016/j.athoracsur.2015.06.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2015] [Revised: 05/19/2015] [Accepted: 06/01/2015] [Indexed: 11/26/2022]
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Dobson GP. Addressing the Global Burden of Trauma in Major Surgery. Front Surg 2015; 2:43. [PMID: 26389122 PMCID: PMC4558465 DOI: 10.3389/fsurg.2015.00043] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2015] [Accepted: 08/17/2015] [Indexed: 12/18/2022] Open
Abstract
Despite a technically perfect procedure, surgical stress can determine the success or failure of an operation. Surgical trauma is often referred to as the "neglected step-child" of global health in terms of patient numbers, mortality, morbidity, and costs. A staggering 234 million major surgeries are performed every year, and depending upon country and institution, up to 4% of patients will die before leaving hospital, up to 15% will have serious post-operative morbidity, and 5-15% will be readmitted within 30 days. These percentages equate to around 1000 deaths and 4000 major complications every hour, and it has been estimated that 50% may be preventable. New frontline drugs are urgently required to make major surgery safer for the patient and more predictable for the surgeon. We review the basic physiology of the stress response from neuroendocrine to genomic systems, and discuss the paucity of clinical data supporting the use of statins, beta-adrenergic blockers and calcium-channel blockers. Since cardiac-related complications are the most common, particularly in the elderly, a key strategy would be to improve ventricular-arterial coupling to safeguard the endothelium and maintain tissue oxygenation. Reduced O2 supply is associated with glycocalyx shedding, decreased endothelial barrier function, fluid leakage, inflammation, and coagulopathy. A healthy endothelium may prevent these "secondary hit" complications, including possibly immunosuppression. Thus, the four pillars of whole body resynchronization during surgical trauma, and targets for new therapies, are: (1) the CNS, (2) the heart, (3) arterial supply and venous return functions, and (4) the endothelium. This is termed the Central-Cardio-Vascular-Endothelium (CCVE) coupling hypothesis. Since similar sterile injury cascades exist in critical illness, accidental trauma, hemorrhage, cardiac arrest, infection and burns, new drugs that improve CCVE coupling may find wide utility in civilian and military medicine.
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Affiliation(s)
- Geoffrey P Dobson
- Heart, Trauma and Sepsis Research Laboratory, Australian Institute of Tropical Health and Medicine, College of Medicine and Dentistry, James Cook University , Townsville, QLD , Australia
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