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Vedel AG, Holmgaard F, Danielsen ER, Langkilde A, Paulson OB, Ravn HB, Rasmussen LS, Nilsson JC. Blood pressure and brain injury in cardiac surgery: a secondary analysis of a randomized trial. Eur J Cardiothorac Surg 2021; 58:1035-1044. [PMID: 32840297 DOI: 10.1093/ejcts/ezaa216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Revised: 04/27/2020] [Accepted: 05/14/2020] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Brain dysfunction is a serious complication after cardiac surgery. In the Perfusion Pressure Cerebral Infarcts trial, we allocated cardiac surgery patients to a mean arterial pressure of either 70-80 or 40-50 mmHg during cardiopulmonary bypass (CPB). In this secondary analysis, we compared selected cerebral metabolites using magnetic resonance spectroscopy hypothesizing that a postoperative decrease in occipital grey matter (GM) N-acetylaspartate-to-total-creatine ratio, indicative of ischaemic injury, would be found in the high-target group. METHODS Of the 197 patients randomized in the Perfusion Pressure Cerebral Infarcts trial, 55 and 42 patients had complete and useful data from GM and white matter (WM), respectively. Spectroscopies were done preoperatively and on postoperative days 3-6. Cognitive function was assessed prior to surgery, at discharge and at 3 months. We predefined the statistical significance level to be 0.01. RESULTS A postoperative decrease was found in GM N-acetylaspartate-to-total-creatine ratio in the high-target group [mean difference -0.09 (95% confidence interval -0.14 to -0.04), P = 0.014]. No significant differences were found in other metabolite ratios investigated in GM or WM. No significant association was found between changes in metabolite ratios and new cerebral infarcts, WM lesion score or cognitive dysfunction. CONCLUSIONS A higher mean arterial pressure during CPB was associated with signs of impaired cerebral metabolism, though not at the predefined significance level of 0.01. No significant association was found between metabolite ratio changes and neuroradiological pathology or change in cognitive function. CLINICAL TRIAL REGISTRATION NUMBER Clinicaltrials.gov: NCT02185885.
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Affiliation(s)
- Anne G Vedel
- D epartment of Cardiothoracic Anaesthesiology, Heart Center, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.,D epartment of Anaesthesia, Center of Head and Orthopedics, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Frederik Holmgaard
- D epartment of Cardiothoracic Anaesthesiology, Heart Center, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Else R Danielsen
- D epartment of Radiology, Diagnostic Center, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Annika Langkilde
- D epartment of Radiology, Diagnostic Center, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Olaf B Paulson
- Neurobiology Research Unit, Neuroscience Center, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Hanne B Ravn
- D epartment of Cardiothoracic Anaesthesiology, Heart Center, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Lars S Rasmussen
- D epartment of Anaesthesia, Center of Head and Orthopedics, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Jens C Nilsson
- D epartment of Cardiothoracic Anaesthesiology, Heart Center, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
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Wiberg S, Holmgaard F, Blennow K, Nilsson JC, Kjaergaard J, Wanscher M, Langkilde AR, Hassager C, Rasmussen LS, Zetterberg H, Vedel AG. Associations between mean arterial pressure during cardiopulmonary bypass and biomarkers of cerebral injury in patients undergoing cardiac surgery: secondary results from a randomized controlled trial. Interact Cardiovasc Thorac Surg 2021; 32:229-235. [PMID: 33221914 PMCID: PMC8906782 DOI: 10.1093/icvts/ivaa264] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 09/15/2020] [Accepted: 10/04/2020] [Indexed: 08/26/2023] Open
Abstract
OBJECTIVES Cardiac surgery is associated with risk of cerebral injury and mean arterial pressure (MAP) during cardiopulmonary bypass (CPB) is suggested to be associated with cerebral injury. The 'Perfusion Pressure Cerebral Infarcts' (PPCI) trial randomized patients undergoing coronary artery bypass grafting (CABG) and/or aortic valve replacement to a MAP of 40-50 or 70-80 mmHg during CPB and found no difference in clinical or imaging outcomes between the groups. We here present PPCI trial predefined secondary end points, consisting of biomarkers of brain injury. METHODS Blood was collected from PPCI trial patients at baseline, 24 and 48 h after induction of anaesthesia and at discharge from the surgical ward. Blood was analysed for neuron-specific enolase, tau, neurofilament light and the glial marker glial fibrillary acidic protein. Linear mixed models were used to analyse differences in biomarker value changes from baseline between the 2 MAP allocation groups. RESULTS A total of 193 (98%) patients were included. We found no differences in biomarker levels over time from baseline to discharge between the 2 MAP allocation groups (PNSE = 0.14, PTau = 0.46, PNFL = 0.21, PGFAP = 0.13) and the result did not change after adjustment for age, sex and type of surgery. CONCLUSIONS We found no significant differences in levels of biomarkers of neurological injury in patients undergoing elective or subacute CABG and/or aortic valve replacement randomized to either a target MAP of 40-50 mmHg or a target MAP of 70-80 mmHg during CBP.
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Affiliation(s)
- Sebastian Wiberg
- Department of Cardiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Frederik Holmgaard
- Department of Cardiothoracic Anesthesia, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Kaj Blennow
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, The Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden
- Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Jens C Nilsson
- Department of Cardiothoracic Anesthesia, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Jesper Kjaergaard
- Department of Cardiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Michael Wanscher
- Department of Cardiothoracic Anesthesia, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Annika R Langkilde
- Department of Radiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Christian Hassager
- Department of Cardiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Lars S Rasmussen
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Anesthesia, Center of Head and Orthopedics, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Henrik Zetterberg
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, The Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden
- Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden
- Department of Neurodegenerative Disease, UCL Institute of Neurology, London, UK
- UK Dementia Research Institute at UCL, London, UK
| | - Anne Grønborg Vedel
- Department of Cardiothoracic Anesthesia, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
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Larsen MH, Draegert C, Vedel AG, Holmgaard F, Siersma V, Nilsson JC, Rasmussen LS. Long-term survival and cognitive function according to blood pressure management during cardiac surgery. A follow-up. Acta Anaesthesiol Scand 2020; 64:936-944. [PMID: 32270483 DOI: 10.1111/aas.13595] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Revised: 03/26/2020] [Accepted: 03/26/2020] [Indexed: 12/26/2022]
Abstract
BACKGROUND Cardiac surgery is associated with a risk of complications, including post-operative cognitive dysfunction (POCD). In the randomized Perfusion Pressure Cerebral Infarcts (PPCI) trial, we allocated cardiac surgery patients to either a low-target mean arterial pressure (40-50 mm Hg) or a high-target pressure (70-80 mm Hg). The study found no difference in the volume of new ischemic cerebral lesions nor POCD, but 30-day mortality tended to be higher in the high-target group. In the present study we did a long-term 3-year follow-up to assess survival and level of cognitive functioning. The primary hypothesis was that patients allocated to a high-target blood pressure had a higher long-term mortality at 3-year follow-up. METHODS We determined long-term mortality of patients included in the PPCI trial at 3-year follow-up using national registries and we assessed POCD using a cognitive test battery. Subjective level of functioning was assessed with questionnaires. POCD and subjective functioning at follow-up were evaluated in logistic regression models. RESULTS Among the 197 patients who participated in the original study, there was no significant difference in mortality over a median of 3.4 years according to blood pressure target during cardiopulmonary bypass (hazards ratio 1.23 [high vs low] 95% confidence interval: 0.50-3.02, P = .65). POCD was found in 18.9% and 14.0% in the high-target and low-target groups, respectively adjusted odds ratio 1.01 (CI 95% 0.33-3.12). No differences were found for subjective functioning between groups. CONCLUSIONS No difference in mortality nor in the level of cognitive functioning was found according to blood pressure target during cardiac surgery long-term at 3-year follow-up.
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Affiliation(s)
- Mo H. Larsen
- Department of Anaesthesia Centre of Head and Orthopaedics, Rigshospitalet University of Copenhagen Copenhagen Denmark
| | - Christina Draegert
- Department of Anaesthesia Centre of Head and Orthopaedics, Rigshospitalet University of Copenhagen Copenhagen Denmark
| | - Anne G. Vedel
- Department of Anaesthesia Centre of Head and Orthopaedics, Rigshospitalet University of Copenhagen Copenhagen Denmark
- Department of Cardiothoracic Anaesthesia Heart Centre, Rigshospitalet University of Copenhagen Copenhagen Denmark
| | - Frederik Holmgaard
- Department of Cardiothoracic Anaesthesia Heart Centre, Rigshospitalet University of Copenhagen Copenhagen Denmark
| | - Volkert Siersma
- The Research Unit for General Practice and Section of General Practice Department of Public Health University of Copenhagen Copenhagen Denmark
| | - Jens C. Nilsson
- Department of Cardiothoracic Anaesthesia Heart Centre, Rigshospitalet University of Copenhagen Copenhagen Denmark
| | - Lars S. Rasmussen
- Department of Anaesthesia Centre of Head and Orthopaedics, Rigshospitalet University of Copenhagen Copenhagen Denmark
- Department of Clinical Medicine University of Copenhagen Copenhagen Denmark
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Holmgaard F, Vedel AG, Lange T, Nilsson JC, Ravn HB. In Response. Anesth Analg 2019; 129:e204-e205. [PMID: 31743212 DOI: 10.1213/ane.0000000000004462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Frederik Holmgaard
- Department of Cardiothoracic Anesthesiology, Heart Centre, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark, Section of Biostatistics, University of Copenhagen, Copenhagen, Denmark, Center for Statistical Science, Peking University, Beijing, China Department of Cardiothoracic Anesthesiology, Heart Centre, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
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Stensballe J, Ulrich AG, Nilsson JC, Henriksen HH, Olsen PS, Ostrowski SR, Johansson PI. Resuscitation of Endotheliopathy and Bleeding in Thoracic Aortic Dissections: The VIPER-OCTA Randomized Clinical Pilot Trial. Anesth Analg 2019; 127:920-927. [PMID: 29863610 PMCID: PMC6135474 DOI: 10.1213/ane.0000000000003545] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND: Thoracic aorta dissection is an acute critical condition associated with shock-induced endotheliopathy, coagulopathy, massive bleeding, and significant morbidity and mortality. Our aim was to compare the effect of coagulation support with solvent/detergent-treated pooled plasma (OctaplasLG) versus standard fresh frozen plasma (FFP) on glycocalyx and endothelial injury, bleeding, and transfusion requirements. METHODS: Investigator-initiated, single-center, blinded, randomized clinical pilot trial of adult patients undergoing emergency surgery for thoracic aorta dissection. Patients were randomized to receive OctaplasLG or standard FFP as coagulation factor replacement related to bleeding. The primary outcome was glycocalyx and endothelial injury. Other outcomes included bleeding, transfusions and prohemostatics at 24 hours, organ failure, length of stay in the intensive care unit and in the hospital, safety, and mortality at 30 and 90 days. RESULTS: Fifty-seven patients were included to obtain 44 evaluable on the primary outcome. The OctaplasLG group displayed significantly reduced damage to the endothelial glycocalyx (syndecan-1) and reduced endothelial tight junction injury (sVE-cadherin) compared to standard FFP. In the OctaplasLG group compared to the standard FFP, days on ventilator (1 day [interquartile range, 0–1] vs 2 days [1–3]; P = .013), bleeding during surgery (2150 [1600–3087] vs 2750 [2130–6875]; P = .046), 24-hour total transfusion and platelet transfusion volume (3975 mL [2640–6828 mL] vs 6220 mL [4210–10,245 mL]; P = .040, and 1400 mL [1050–2625 mL] vs 2450 mL [1400–3500 mL]; P = .027), and goal-directed use of prohemostatics (7/23 [30.4%] vs 13/21 [61.9%]; P = .036) were all significantly lower. Among the 57 patients randomized, 30-day mortality was 20.7% (6/29) in the OctaplasLG group and 25% (7/28) in the standard FFP group (P = .760). No safety concern was raised. CONCLUSIONS: In this randomized, clinical pilot trial of patients undergoing emergency surgery for thoracic aorta dissections, we found that OctaplasLG reduced glycocalyx and endothelial injury, reduced bleeding, transfusions, use of prohemostatics, and time on ventilator after surgery compared to standard FFP. An adequately powered multicenter trial is warranted to confirm the clinical importance of the findings.
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Affiliation(s)
- Jakob Stensballe
- From the Section for Transfusion Medicine, Capital Region Blood Bank, Copenhagen University Hospital, Rigshospitalet, Denmark.,Department of Anesthesia, Centre of Head and Orthopedics, Copenhagen University Hospital, Rigshospitalet, Denmark
| | | | | | - Hanne H Henriksen
- From the Section for Transfusion Medicine, Capital Region Blood Bank, Copenhagen University Hospital, Rigshospitalet, Denmark
| | - Peter S Olsen
- Cardiothoracic Surgery, Heart Centre, Copenhagen University Hospital, Rigshospitalet, Denmark
| | - Sisse R Ostrowski
- From the Section for Transfusion Medicine, Capital Region Blood Bank, Copenhagen University Hospital, Rigshospitalet, Denmark
| | - Pär I Johansson
- From the Section for Transfusion Medicine, Capital Region Blood Bank, Copenhagen University Hospital, Rigshospitalet, Denmark.,Department of Surgery, Division of Acute Care Surgery, Centre for Translational Injury Research (CeTIR), University of Texas Medical School at Houston, Houston, Texas.,Center for Systems Biology, the School of Engineering and Natural Sciences, University of Iceland, Reykjavik, Iceland
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Kandler K, Nilsson JC, Oturai P, Jensen ME, Møller CH, Clemmesen JO, Arendrup HC, Steinbrüchel DA. Higher arterial pressure during cardiopulmonary bypass may not reduce the risk of acute kidney injury. J Cardiothorac Surg 2019; 14:107. [PMID: 31196131 PMCID: PMC6567467 DOI: 10.1186/s13019-019-0929-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Accepted: 06/03/2019] [Indexed: 11/10/2022] Open
Abstract
Background Acute kidney injury after cardiac surgery is common and associated with increased mortality. It is unknown whether an intended higher arterial pressure during cardiopulmonary bypass reduces the incidence of acute and chronic kidney injury. Methods Patients were randomised either to a control group or a high pressure group (arterial pressure > 60 mmHg). The inclusion criteria were age > 70 years, combined cardiac surgery and serum creatinine < 200 μmol/L. Glomerular filtration rate using the Cr-EDTA clearance method was measured the day before surgery and 4 months postoperatively. The RIFLE criteria were used to define the presence of acute kidney injury. In addition, the ratio between urinary Neutrophil Gelatinase-Associated Lipocalin (NGAL) and creatinine was measured. Results Ninety patients were included. Mean age was 76 ± 4 years and 76% were male. Mean arterial pressure was 47 ± 5 mmHg in the control group and 61 ± 4 mmHg in the high pressure group (p < 0.0001). The change in glomerular filtration rate at follow-up was − 9 ± 12 ml/min in the control group and − 5 ± 16 ml/min in the high pressure group (p = 0.288, 95% CI − 13 to 4). According to the RIFLE criteria 38% in the control group and 46% in the high pressure group developed acute kidney injury (p = 0.447). The postoperative urinary NGAL/creatinine ratio was comparable between the groups. Conclusions An intended increase in arterial pressure during cardiopulmonary bypass to > 60 mmHg did not decrease the incidence of acute or chronic kidney injury after cardiac surgery. Trial registration Clinicaltrials.gov, identifier: NCT01408420. Registered 3rd of August 2011.
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Affiliation(s)
- Kristian Kandler
- Department of Cardiothoracic Surgery, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark.
| | - Jens C Nilsson
- Department of Cardiothoracic Anaesthesiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Peter Oturai
- Department of Clinical Physiology, Nuclear Medicine and PET, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Mathias E Jensen
- Department of Cardiothoracic Surgery, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Christian H Møller
- Department of Cardiothoracic Surgery, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Jens Otto Clemmesen
- Department of Hepatology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Henrik C Arendrup
- Department of Cardiothoracic Surgery, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Daniel A Steinbrüchel
- Department of Cardiothoracic Surgery, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
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Holmgaard F, Vedel AG, Lange T, Nilsson JC, Ravn HB. Impact of 2 Distinct Levels of Mean Arterial Pressure on Near-Infrared Spectroscopy During Cardiac Surgery: Secondary Outcome From a Randomized Clinical Trial. Anesth Analg 2019; 128:1081-1088. [PMID: 31094772 DOI: 10.1213/ane.0000000000003418] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Near-infrared spectroscopy (NIRS) is used worldwide to monitor regional cerebral oxygenation (rScO2) during cardiopulmonary bypass (CPB). Intervention protocols meant to mitigate cerebral desaturation advocate to increase mean arterial pressure (MAP) when cerebral desaturation occurs. However, the isolated effect of MAP on rScO2 is uncertain. The aim of the present study was in a randomized, blinded design to elucidate the effect of 2 distinct levels of MAP on rScO2 values during CPB.We hypothesized that a higher MAP would be reflected in higher rScO2 values, lower frequency of patients with desaturation, and a less pronounced cerebral desaturation load. METHODS This is a substudy of the Perfusion Pressure Cerebral Infarct trial, in which we investigated the impact of MAP levels during CPB on ischemic brain injury after cardiac surgery. Deviation in rScO2 was a predefined outcome in the Perfusion Pressure Cerebral Infarct trial. Patients were randomized to low MAP (LMAP; 40-50 mm Hg) or high MAP (HMAP; 70-80 mm Hg) during CPB. CPB pump flow was fixed at 2.4 L/min/m, and MAP levels were targeted using norepinephrine. Intraoperatively, NIRS monitoring was performed in a blinded fashion, with sensors placed on the left and right side of the patient's forehead. NIRS recordings were extracted for offline analysis as the mean value of left and right signal during prespecified periods. Mean rScO2 during CPB was defined as the primary outcome in the present study. RESULTS The average MAP level during CPB was 67 mm Hg ± SD 5.0 in the HMAP group (n = 88) and 45 mm Hg ± SD 4.4 in the LMAP group (n = 88). Mean rScO2 was significantly lower in the HMAP group during CPB (mean difference, 3.5; 95% confidence interval, 0.9-6.1; P = .010). There was no difference in rScO2 values at specified time points during the intraoperative period between the 2 groups. Significantly more patients experienced desaturation below 10% and 20% relative to rScO2 baseline in the HMAP group (P = .013 and P = .009, respectively), and the cerebral desaturation load below 10% relative to rScO2 baseline was more pronounced in the HMAP group (P = .042). CONCLUSIONS In a randomized blinded study, we observed that a higher MAP induced by vasopressors, with a fixed CPB pump flow, leads to lower mean rScO2 and more frequent and pronounced cerebral desaturation during CPB. The mechanism behind these observations is not clear. We cannot exclude extracranial contamination of the NIRS signal as a possible explanation. However, we cannot recommend increasing MAP by vasoconstrictors during cerebral desaturation because this is not supported by the findings of the present study.
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Affiliation(s)
- Frederik Holmgaard
- From the Department of Cardiothoracic Anesthesiology, Heart Centre, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Anne G Vedel
- From the Department of Cardiothoracic Anesthesiology, Heart Centre, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Theis Lange
- Section of Biostatistics, University of Copenhagen, Copenhagen, Denmark
- Center for Statistical Science, Peking University, Beijing, China
| | - Jens C Nilsson
- From the Department of Cardiothoracic Anesthesiology, Heart Centre, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Hanne B Ravn
- From the Department of Cardiothoracic Anesthesiology, Heart Centre, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
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Holmgaard F, Vedel AG, Rasmussen LS, Paulson OB, Nilsson JC, Ravn HB. The association between postoperative cognitive dysfunction and cerebral oximetry during cardiac surgery: a secondary analysis of a randomised trial. Br J Anaesth 2019; 123:196-205. [PMID: 31104758 DOI: 10.1016/j.bja.2019.03.045] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Revised: 03/11/2019] [Accepted: 03/15/2019] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Postoperative cognitive dysfunction (POCD) occurs commonly after cardiac surgery. Near-infrared spectroscopy (NIRS) has been used to monitor regional cerebral oxygen saturation (rScO2) in order to minimise the occurrence of POCD by applying dedicated interventions when rScO2 decreases. However, the association between rScO2 intraoperatively and POCD has not been clarified. METHODS This is a secondary analysis of a randomised trial with physician-blinded NIRS monitoring and cognitive testing at discharge from hospital and at 3 months after surgery. The association between intraoperative rScO2 values and POCD at discharge from hospital and at 3 months after surgery was investigated. The prespecified candidate predictive variable of interest was cumulative time during surgery with rScO2 ≥10% below its preoperative value. RESULTS One hundred and fifty-three patients had complete NIRS data and neurocognitive assessments at discharge, and 44 of these patients (29%) had POCD. At 3 months, 148 patients had complete data, and 12 (8%) of these patients had POCD. The median time with rScO2 >10% below preoperative values did not differ for patients with and without POCD at discharge (difference=0.0 min; Hodges-Lehmann 95% confidence interval, -3.11-1.47, P=0.88). Other rScO2 time thresholds that were assessed were also not significantly different between those with and without POCD at discharge. This applied both to absolute rScO2 values and relative changes from preoperative values. Similar results were found in relation to POCD at 3 months. CONCLUSIONS No significant association was found between intraoperative rScO2 values and POCD. These findings bring into question the rationale for attempting to avoid decreases in rScO2 if the goal is to prevent POCD. CLINICAL TRIAL REGISTRATION NCT02185885.
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Affiliation(s)
- Frederik Holmgaard
- Department of Cardiothoracic Anesthesia, Heart Centre, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.
| | - Anne G Vedel
- Department of Cardiothoracic Anesthesia, Heart Centre, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark; Department of Anesthesia, Centre of Head and Orthopaedics, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Lars S Rasmussen
- Department of Anesthesia, Centre of Head and Orthopaedics, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Olaf B Paulson
- Neurobiological Research Unit, The Neuro Centre, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Jens C Nilsson
- Department of Cardiothoracic Anesthesia, Heart Centre, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Hanne B Ravn
- Department of Cardiothoracic Anesthesia, Heart Centre, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
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Hansen KL, Juul K, Møller-Sørensen H, Nilsson JC, Jensen JA, Nielsen MB. Pediatric Transthoracic Cardiac Vector Flow Imaging - A Preliminary Pictorial Study. Ultrasound Int Open 2019; 5:E20-E26. [PMID: 30599042 PMCID: PMC6303157 DOI: 10.1055/a-0656-5430] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Revised: 05/15/2018] [Accepted: 07/01/2018] [Indexed: 01/06/2023] Open
Abstract
Purpose
Conventional pediatric echocardiography is crucial for diagnosing congenital heart disease (CHD), but the technique is impaired by angle dependency. Vector flow imaging (VFI) is an angle-independent noninvasive ultrasound alternative for blood flow assessment and can assess complex flow patterns not visible on conventional Doppler ultrasound.
Materials and Methods
12 healthy newborns and 3 infants with CHD were examined with transthoracic cardiac VFI using a conventional ultrasound scanner and a linear array.
Results
VFI examinations revealed common cardiac flow patterns among the healthy newborns, and flow changes among the infants with CHD not previously reported with conventional echocardiography.
Conclusion
For assessment of cardiac flow in the normal and diseased pediatric heart, VFI may provide additional information compared to conventional echocardiography and become a useful diagnostic tool.
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Affiliation(s)
| | - Klaus Juul
- Department of Pediatric Cardiology, Copenhagen University Hospital, Copenhagen, Denmark
| | - Hasse Møller-Sørensen
- Department of Cardiothoracic Anesthesiology, Copenhagen University Hospital, Copenhagen, Denmark
| | - Jens C Nilsson
- Department of Cardiothoracic Anesthesiology, Copenhagen University Hospital, Copenhagen, Denmark
| | - Jørgen Arendt Jensen
- Center for Fast Ultrasound Imaging, Technical University of Denmark, DTU Elektro, Lyngby, Denmark
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Holmgaard F, Vedel AG, Ravn HB, Nilsson JC, Rasmussen LS. Impact of mean arterial pressure on sublingual microcirculation during cardiopulmonary bypass-Secondary outcome from a randomized clinical trial. Microcirculation 2018; 25:e12459. [DOI: 10.1111/micc.12459] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Accepted: 05/03/2018] [Indexed: 11/30/2022]
Affiliation(s)
- Frederik Holmgaard
- Department of Cardiothoracic Anesthesia; Heart Centre; Rigshospitalet; University of Copenhagen; Copenhagen Denmark
| | - Anne G. Vedel
- Department of Cardiothoracic Anesthesia; Heart Centre; Rigshospitalet; University of Copenhagen; Copenhagen Denmark
| | - Hanne Berg Ravn
- Department of Cardiothoracic Anesthesia; Heart Centre; Rigshospitalet; University of Copenhagen; Copenhagen Denmark
| | - Jens C. Nilsson
- Department of Cardiothoracic Anesthesia; Heart Centre; Rigshospitalet; University of Copenhagen; Copenhagen Denmark
| | - Lars S. Rasmussen
- Department of Anesthesia; Centre of Head and Orthopedics; Rigshospitalet; University of Copenhagen; Copenhagen Denmark
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Vedel AG, Holmgaard F, Rasmussen L, Langkilde A, Paulson OB, Olsen PS, Lange T, Ravn HB, Nilsson JC. The influence of mean arterial pressure during cardiopulmonary bypass on cerebral complications. J Cardiothorac Vasc Anesth 2017. [DOI: 10.1053/j.jvca.2017.02.077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Fenger AS, Vedel AG, Rasmussen SR, Nilsson JC, Ravn HB. Effects of mean arterial pressure on haematocrit during cardiopulmonary bypass - a substudy of the PPCI-trial. J Cardiothorac Vasc Anesth 2017. [DOI: 10.1053/j.jvca.2017.02.074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Holmgaard F, Vedel AG, Rasmussen LS, Langkilde A, Nilsson JC, Ravn HB. Near infrared spectroscopy at two levels of mean arterial pressure during cardiopulmonary bypass. J Cardiothorac Vasc Anesth 2017. [DOI: 10.1053/j.jvca.2017.02.061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Jakobsen C, Kandler K, Nielsen R, Knudsen N, Nilsson JC, Ravn HB. Oxygen delivery and acute kidney injury after cardiac surgery. J Cardiothorac Vasc Anesth 2017. [DOI: 10.1053/j.jvca.2017.02.101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Grønlykke L, Ravn HB, Gustafsson F, Hassager C, Kjaergaard J, Nilsson JC. Right ventricular dysfunction after cardiac surgery – diagnostic options. SCAND CARDIOVASC J 2016; 51:114-121. [DOI: 10.1080/14017431.2016.1264621] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Lars Grønlykke
- Department of Cardiothoracic Anaesthesiology, The Heart Centre, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Hanne Berg Ravn
- Department of Cardiothoracic Anaesthesiology, The Heart Centre, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Finn Gustafsson
- Department of Cardiology, The Heart Centre, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Christian Hassager
- Department of Cardiology, The Heart Centre, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Jesper Kjaergaard
- Department of Cardiology, The Heart Centre, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Jens C. Nilsson
- Department of Cardiothoracic Anaesthesiology, The Heart Centre, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
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Holmgaard F, Vedel AG, Langkilde A, Nilsson JC, Ravn HB. Does depth of the frontal sinus affect near-infrared spectroscopy measurement? Perfusion 2016; 31:659-661. [PMID: 27235422 DOI: 10.1177/0267659116649425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Near-infrared spectroscopy (NIRS) is a non-invasive method that reflects real-time cerebral oxygenation (rSO2) by the use of two adhesive optodes placed on the forehead of the patient. Frontal sinuses vary anatomically and a large frontal sinus might compromise the NIRS signal since the NIRS optodes are placed at the skin surface superficial to the underlying frontal sinus. The aim of this case-series was to elucidate whether there is a difference in the obligate changes in rSO2 during cardiac surgery between patients with a small as opposed to a large anterior-posterior distance of the frontal sinus based on magnetic resonance imaging. Two matched groups with small (n = 5) vs. large (n = 5) frontal sinus (3.2 vs. 18.1 millimeters) in this case-series showed no difference in obligate changes of rSO2 (p = 0.54).
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Affiliation(s)
- Frederik Holmgaard
- 1 Department of Cardiothoracic Anesthesiology, Heart Centre, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Anne G Vedel
- 1 Department of Cardiothoracic Anesthesiology, Heart Centre, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Annika Langkilde
- 2 Department of Radiology, Diagnostic Centre, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Jens C Nilsson
- 1 Department of Cardiothoracic Anesthesiology, Heart Centre, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Hanne Berg Ravn
- 1 Department of Cardiothoracic Anesthesiology, Heart Centre, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
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Vedel AG, Holmgaard F, Rasmussen LS, Paulson OB, Thomsen C, Danielsen ER, Langkilde A, Goetze JP, Lange T, Ravn HB, Nilsson JC. Perfusion Pressure Cerebral Infarct (PPCI) trial - the importance of mean arterial pressure during cardiopulmonary bypass to prevent cerebral complications after cardiac surgery: study protocol for a randomised controlled trial. Trials 2016; 17:247. [PMID: 27189028 PMCID: PMC4869311 DOI: 10.1186/s13063-016-1373-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2015] [Accepted: 04/29/2016] [Indexed: 11/30/2022] Open
Abstract
Background Debilitating brain injury occurs in 1.6–5 % of patients undergoing cardiac surgery with cardiopulmonary bypass. Diffusion-weighted magnetic resonance imaging studies have reported stroke-like lesions in up to 51 % of patients after cardiac surgery. The majority of the lesions seem to be caused by emboli, but inadequate blood flow caused by other mechanisms may increase ischaemia in the penumbra or cause watershed infarcts. During cardiopulmonary bypass, blood pressure can be below the lower limit of cerebral autoregulation. Although much debated, the constant blood flow provided by the cardiopulmonary bypass system is still considered by many as appropriate to avoid cerebral ischaemia despite the low blood pressure. Methods/design The Perfusion Pressure Cerebral Infarct trial is a single-centre superiority trial with a blinded outcome assessment. The trial is randomising 210 patients with coronary vessel and/or valve disease and who are undergoing cardiac surgery with the use of cardiopulmonary bypass. Patients are stratified by age and surgical procedure and are randomised 1:1 to either an increased mean arterial pressure (70–80 mmHg) or ‘usual practice’ (40–50 mmHg) during cardiopulmonary bypass. The cardiopulmonary bypass pump flow is fixed and set at 2.4 L/minute/m2 body surface area plus 10–20 % in both groups. The primary outcome measure is the volume of the new ischaemic cerebral lesions (in mL), expressed as the difference between a baseline, diffusion-weighted, magnetic resonance imaging scan and an equal scan conducted 3–6 days postoperatively. Secondary endpoints are the total number of new ischaemic cerebral lesions, postoperative cognitive dysfunction at discharge and 3 months postoperatively, diffuse cerebral injury evaluated by magnetic resonance spectroscopy and selected biochemical markers of cerebral injury. The sample size will enable us to detect a 50 % reduction in the primary outcome measure in the intervention compared to the control group at a significance level of 0.05 and with a power of 0.80. Discussion This is the first clinical randomised study to evaluate whether the mean arterial pressure level during cardiopulmonary bypass influences the development of brain injuries that are detected by diffusion-weighted magnetic resonance imaging. Trial registration ClinicalTrials.gov, NCT02185885. Registered on 7 July 2014. Electronic supplementary material The online version of this article (doi:10.1186/s13063-016-1373-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Anne G Vedel
- Department of Cardiothoracic Anaesthesiology, Heart Centre, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, DK-2100, Copenhagen, Denmark.
| | - Frederik Holmgaard
- Department of Cardiothoracic Anaesthesiology, Heart Centre, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, DK-2100, Copenhagen, Denmark
| | - Lars Simon Rasmussen
- Department of Anaesthesia, Centre of Head and Orthopaedics, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, DK-2100, Copenhagen, Denmark
| | - Olaf B Paulson
- Neurobiology Research Unit, Neuroscience Centre, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, DK-2100, Copenhagen, Denmark
| | - Carsten Thomsen
- Department of Radiology, Diagnostic Centre, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, DK-2100, Copenhagen, Denmark
| | - Else Rubæk Danielsen
- Department of Radiology, Diagnostic Centre, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, DK-2100, Copenhagen, Denmark
| | - Annika Langkilde
- Department of Radiology, Diagnostic Centre, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, DK-2100, Copenhagen, Denmark
| | - Jens P Goetze
- Department of Clinical Biochemistry, Diagnostic Centre, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, DK-2100, Copenhagen, Denmark
| | - Theis Lange
- Department of Biostatistics, University of Copenhagen, Øster Farimagsgade 5, DK-2100, Copenhagen, Denmark
| | - Hanne Berg Ravn
- Department of Cardiothoracic Anaesthesiology, Heart Centre, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, DK-2100, Copenhagen, Denmark
| | - Jens C Nilsson
- Department of Cardiothoracic Anaesthesiology, Heart Centre, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, DK-2100, Copenhagen, Denmark
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Vedel AG, Holmgaard F, Ravn HB, Nilsson JC. Perfusion pressure cerebral infarction (PPCI trial - a protocol for a randomised clinical trial. J Cardiothorac Vasc Anesth 2016. [DOI: 10.1053/j.jvca.2016.03.112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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19
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Grønlykke L, Ihlemann N, Nilsson JC, Kjaergaard J, Korshin A, Gustafsson F, Thyregod HG, Søndergaard L, Ravn HB. Echocardiographic changes in right ventricular function after transcatheter versus surgical aortic valve replacement for severe aortic valve stenosis. J Cardiothorac Vasc Anesth 2016. [DOI: 10.1053/j.jvca.2016.03.085] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Kandler K, Jensen ME, Nilsson JC, Møller CH, Steinbrüchel DA. Acute kidney injury is independently associated with higher mortality after cardiac surgery. J Cardiothorac Vasc Anesth 2014; 28:1448-52. [PMID: 25440657 DOI: 10.1053/j.jvca.2014.04.019] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2014] [Indexed: 11/11/2022]
Abstract
OBJECTIVES To investigate the incidence of acute kidney injury after cardiac surgery and its association with mortality in a patient population receiving ibuprofen and gentamicin perioperatively. DESIGN Retrospective study with Cox regression analysis to control for possible preoperative, intraoperative and postoperative confounders. SETTING University hospital-based single-center study. PARTICIPANTS All patients who underwent coronary artery bypass grafting ± valve surgery during 2012. INTERVENTIONS None. MEASUREMENT AND MAIN RESULTS Acute surgery within 24 hours of coronary angiography, previous nephrectomy, preoperative sCr >2.26 mg/dL and selective cerebral perfusion during cardiopulmonary bypass were used as exclusion criteria. Acute kidney injury was defined, using the Acute Kidney Injury Network (AKIN) criteria. Six hundred eight patients were included in the study. Mean age was 68.2 ± 9.7 years, and 81% were males. Acute kidney injury was seen in 28.1% of the patients. Overall mortality at one year was 7% and 3% in the no-AKI group. At one year, mortality was 15% in patients with AKIN stage 1 and AKIN stage 2 compared to 70% in AKIN stage 3. A hazard ratio of 2.34 (95% CI: 1.21-4.51, p = 0.011) and 5.62 (95% CI: 2.42-13.06), p<0.0001) were found for AKIN stage 1 and 2/3 combined, respectively. CONCLUSIONS More than 28% of the patients undergoing elective or subacute cardiac surgery developed AKI in this contemporary cohort. Furthermore, acute kidney injury was an independent predictor of increased mortality irrespective of the perioperative risk factors.
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Affiliation(s)
| | | | - Jens C Nilsson
- Cardiothoracic Anesthesiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
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Wang Y, Tägil K, Ripa RS, Nilsson JC, Carstensen S, Jørgensen E, Søndergaard L, Hesse B, Johnsen HE, Kastrup J. Effect of mobilization of bone marrow stem cells by granulocyte colony stimulating factor on clinical symptoms, left ventricular perfusion and function in patients with severe chronic ischemic heart disease. Int J Cardiol 2005; 100:477-83. [PMID: 15837093 DOI: 10.1016/j.ijcard.2004.12.006] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2004] [Accepted: 12/31/2004] [Indexed: 12/23/2022]
Abstract
OBJECTIVES A phase I safety and efficacy study with granulocyte colony stimulating factor (G-CSF) mobilization of bone marrow stem cells to induce vasculogenesis in patients with severe ischemic heart disease (IHD) was conducted. DESIGN, PATIENTS AND RESULTS 29 patients with IHD participated in the study. Thirteen patients were treated with G-CSF for 6 days and 16 patients served as controls. G-CSF treatment was without any serious adverse events. Four patients were "poor mobilizers" with a maximal increase in CD34+ cells to 5,000+/-700/mL blood (mean+/-S.D.) compared to 28,900+/-5,100/mL blood in "mobilizers". At the follow-up, G-CSF treated had improved in CCS classification, NTG consumption and angina attacks, but the controls only in CCS classification. No difference was seen between the two groups. The decline in NTG consumption tended to be significant in "mobilizers" compared to controls. Myocardial perfusion was unchanged at adenosine stress single photon emission computerized tomography (SPECT) or magnetic resonance images (MRI). Left ventricular ejection fraction decreased from 57% to 52% (p<0.01, MRI) and from 48% to 44% (p=0.07, SPECT) in G-CSF treated, but was unchanged measured with echocardiography. CONCLUSIONS Treatment by G-CSF improved symptoms but not signs of myocardial ischemia in patients with severe IHD. The effects seemed related to mobilization of stem cells. An adverse effect on ejection fraction could not be excluded.
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Affiliation(s)
- Yongzhong Wang
- Cardiac Catheterization Laboratory, The Heart Centre, Rigshospitalet, Copenhagen, Denmark
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Ostergaard M, Nilsson LB, Nilsson JC, Rasmussen JP, Berthelsen PG. Precision of bolus thermodilution cardiac output measurements in patients with atrial fibrillation. Acta Anaesthesiol Scand 2005; 49:366-72. [PMID: 15752403 DOI: 10.1111/j.1399-6576.2005.00613.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND The precision of bolus thermodilution cardiac output measurements in patients with atrial fibrillation (AF) has not previously been determined. A priori we suspected that the precision would be lower in patients with AF than in patients with sinus rhythm (SR). Consequently, we also determined if the precision could be improved by injecting the thermal indicator into the right ventricle instead of the right atrium. METHODS Cardiac output was determined as the average result of four injections of 10 ml of iced saline. Replicate measurements were performed with thermal indicator injections into the right atrium and ventricle. The coefficients of variation and the precisions were calculated. RESULTS In the 25 patients with AF, mean cardiac output was 3.96 l min(-1) (range 2.4-7.4), the coefficient of variation 0.073 (95% CI +/- 0.011), and the precision 0.38 l min(-1) (95% CI +/- 0.14) with injection into the right atrium. In the 25 patients with SR, mean cardiac output was 4.73 l min(-1) (range 2.4-7.3), the coefficient of variation 0.047(95% CI +/- 0.006), and the precision 0.38 l min(-1) (95% CI +/- 0.14). In both groups, an agreement analysis demonstrated that the injection of indicator into the right ventricle resulted in a significantly higher cardiac output [AF+0.25 (95% CI +/- 0.15) l min(-1), SR+0.29 ( +/- 0.20) l min(-1)]. CONCLUSION The coefficient of variation for cardiac output determinations is 55% higher in patients with AF. Two measurements, separated by time or intervention, must differ by 15% in AF patients and 9% in SR patients before one can be 95% confident that a real change has taken place.
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Affiliation(s)
- M Ostergaard
- Department of Anesthesiology, Gentofte Hospital, University of Copenhagen, Denmark
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Abstract
BACKGROUND Bolus thermodilution cardiac output measurements have been a mainstay in clinical monitoring of critically ill patients for more than 30 years. Usually the results of an arbitrarily chosen number (1-6) of thermal indicator injections are averaged to increase the reliability of the measurement. The number of injections needed to achieve a given level of precision has, however, not previously been systematically investigated. METHODS AND RESULTS In 80 hemodynamically stable patients cardiac output was determined as the average of eight injections of 10 ml of iced saline. From the 638 measurements we examined the relationship between the number of thermal indicator injections and the precision of the resulting cardiac output estimate. Furthermore, the association between the number of injections and the least detectable difference among two sets of measurements was established. CONCLUSION The current study shows that one needs to average the results of four injections to be 95% confident that the result is within 5% of the 'true' cardiac output and that two series of four measurements have to differ by at least 7% before one can be sure (95%) that a change in cardiac function has taken place.
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Affiliation(s)
- L B Nilsson
- Department of Anesthesiology, Gentofte Hospital, Denmark
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Groenning BA, Raymond I, Hildebrandt PR, Nilsson JC, Baumann M, Pedersen F. Diagnostic and prognostic evaluation of left ventricular systolic heart failure by plasma N-terminal pro-brain natriuretic peptide concentrations in a large sample of the general population. Heart 2004; 90:297-303. [PMID: 14966052 PMCID: PMC1768111 DOI: 10.1136/hrt.2003.026021] [Citation(s) in RCA: 143] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVE To evaluate N-terminal pro-brain natriuretic peptide (NT-proBNP) as a diagnostic and prognostic marker for systolic heart failure in the general population. DESIGN Study participants, randomly selected to be representative of the background population, filled in a heart failure questionnaire and underwent pulse and blood pressure measurements, electrocardiography, echocardiography, and blood sampling and were followed up for a median (range) period of 805 (60-1171) days. SETTING Participants were recruited from four randomly selected general practitioners and were examined in a Copenhagen university hospital. PATIENTS 382 women and 290 men in four age groups (50-59 (n = 174); 60-69 (n = 204); 70-79 (n = 174); > or = 80 years (n = 120)). MAIN OUTCOME MEASURES Value of NT-proBNP in evaluating patients with symptoms of heart failure and impaired left ventricular (LV) systolic function; prognostic value of NT-proBNP for mortality and hospital admissions. RESULTS In 38 (5.6%) participants LV ejection fraction (LVEF) was < or = 40%. NT-proBNP identified patients with symptoms of heart failure and LVEF < or = 40% with a sensitivity of 0.92, a specificity of 0.86, positive and negative predictive values of 0.11 and 1.00, and area under the curve of 0.94. NT-proBNP was the strongest independent predictor of mortality (hazard ratio (HR) = 5.70, p < 0.0001), hospital admissions for heart failure (HR = 13.83, p < 0.0001), and other cardiac admissions (HR = 3.69, p < 0.0001). Mortality (26 v 6, p = 0.0003), heart failure admissions (18 v 2, p = 0.0002), and admissions for other cardiac causes (44 v 13, p < 0.0001) were significantly higher in patients with NT-proBNP above the study median (32.5 pmol/l). CONCLUSIONS Measurement of NT-proBNP may be useful as a screening tool for systolic heart failure in the general population.
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Affiliation(s)
- B A Groenning
- Department of Cardiology and Endocrinology, Copenhagen University Hospital Frederiksberg, 57 Nordre Fasanvej, DK-2000 Frederiksberg, Denmark.
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Raymond I, Groenning BA, Hildebrandt PR, Nilsson JC, Baumann M, Trawinski J, Pedersen F. The influence of age, sex and other variables on the plasma level of N-terminal pro brain natriuretic peptide in a large sample of the general population. Heart 2003; 89:745-51. [PMID: 12807847 PMCID: PMC1767734 DOI: 10.1136/heart.89.7.745] [Citation(s) in RCA: 247] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To identify potentially confounding variables for the interpretation of plasma N-terminal pro brain natriuretic peptide (NT-proBNP). DESIGN Randomly selected subjects filled in a heart failure questionnaire and underwent pulse and blood pressure measurements, ECG, echocardiography, and blood sampling. SETTING Subjects were recruited from four Copenhagen general practices located in the same urban area and were examined in a Copenhagen University Hospital. PATIENTS 382 women and 290 men in four age groups: 50-59 years (n = 174); 60-69 years (n = 204); 70-79 years (n = 174); and > 80 years (n = 120). MAIN OUTCOME MEASURES Associations between the plasma concentration of NT-proBNP and a range of clinical variables. RESULTS In the undivided study sample, female sex (p < 0.0001), greater age (p < 0.0001), increasing dyspnoea (p = 0.0001), diabetes mellitus (p = 0.01), valvar heart disease (p = 0.002), low heart rate (p < 0.0001), left ventricular ejection fraction < or = 45% (p < 0.0001), abnormal ECG (p < 0.0001), high log10[plasma creatinine] (p = 0.0009), low log10[plasma glycosylated haemoglobin A1c] (p = 0.0004), and high log10[urine albumin] (p < 0.0001) were independently associated with a high plasma log10[plasma NT-proBNP] by multiple linear regression analysis. CONCLUSIONS A single reference interval for the normal value of NT-proBNP is unlikely to suffice. There are several confounders for the interpretation of a given NT-proBNP concentration and at the very least adjustment should be made for the independent effects of age and sex.
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Affiliation(s)
- I Raymond
- Department of Cardiology and Endocrinology, Copenhagen University Hospital Frederiksberg, Frederiksberg, Denmark
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Groenning BA, Nilsson JC, Hildebrandt PR, Kjaer A, Fritz-Hansen T, Larsson HBW, Sondergaard L. Neurohumoral prediction of left-ventricular morphologic response to beta-blockade with metoprolol in chronic left-ventricular systolic heart failure. Eur J Heart Fail 2002; 4:635-46. [PMID: 12413508 DOI: 10.1016/s1388-9842(02)00038-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND In order to tailor therapy in heart failure, a solution might be to develop sensitive and reliable markers that can predict response in individual patients or monitor effectiveness of therapy. AIMS To evaluate neurohumoral factors as markers for left-ventricular (LV) antiremodelling from metoprolol treatment in patients with chronic LV systolic heart failure. METHODS Forty-one subjects randomised to placebo or metoprolol were studied with magnetic resonance imaging and blood samples to measure LV dimensions and ejection fraction, epinephrine, norepinephrine, plasma renin activity, aldosterone, atrial (ANP) and brain natriuretic peptides, arginine-vasopressin and endothelin-1 at baseline, 5 weeks and 6 months after randomisation. RESULTS Baseline ANP was identified as sole independent marker for changes in LV end-diastolic (deltaLVEDVI: r=-0.70, P=0.002), and end-systolic (deltaLVESVI: r=-0.53, P=0.03) volumes during metoprolol treatment. Change in ANP during the study was an independent marker for deltaLVEDVI: r=0.66, P=0.004, and deltaLVESVI: r=0.69, P=0.002 in the entire metoprolol group, but at the individual patient level, results were less clear. CONCLUSION The pre-treatment plasma level of ANP may be a predictor of LV antiremodelling from treatment with metoprolol in patients with chronic heart failure. However, the potential for individual neurohumoral monitoring of the effects on LV dimensions during beta-blockade appears limited.
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Affiliation(s)
- Bjoern A Groenning
- Department of Cardiology and Endocrinology, Copenhagen University Hospital Frederiksberg, Frederiksberg, Denmark.
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Groenning BA, Nilsson JC, Sondergaard L, Pedersen F, Trawinski J, Baumann M, Larsson HBW, Hildebrandt PR. Detection of left ventricular enlargement and impaired systolic function with plasma N-terminal pro brain natriuretic peptide concentrations. Am Heart J 2002; 143:923-9. [PMID: 12040359 DOI: 10.1067/mhj.2002.122168] [Citation(s) in RCA: 73] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND Brain- and N-terminal pro brain natriuretic peptide (NT-proBNP) have been identified as promising markers for heart failure. However, previous studies have revealed that they may hold insufficient diagnostic power for implementation into clinical practice because of a significant overlap in the range of plasma levels between healthy subjects and subjects with heart failure. We hypothesized that imprecision of the reference method (ie, the echocardiographic evaluation of left ventricular [LV] function) may have affected results from those earlier studies. We therefore wanted to investigate the diagnostic potential of NT-proBNP with magnetic resonance imaging as the reference method for the cardiac measurements. METHODS Forty-eight patients with stable symptomatic heart failure in New York Heart Association functional classifications II to IV were examined once with blood samples and magnetic resonance imaging along with 20 age-matched and gender-matched healthy control subjects. RESULTS NT-proBNP was associated with LV end-diastolic (r = 0.69; P <.0001) and end-systolic (r = 0.73; P <.0001) volume indices, LV mass index (r = 0.69; P <.0001), and LV ejection fraction (r = -0.75; P <.0001). Receiver operating characteristic curves were calculated for the ability of NT-proBNP to detect LV end-diastolic volume index (>105 mL. m(-2)[cut-off]; sensitivity/specificity, 82%/87%), LV end-systolic volume index (>35 mL. m(-2); sensitivity/specificity, 86%/86%), LV mass index (>152 g. m(-2); sensitivity/specificity, 85%/86%), and LV ejection fraction (<58%; sensitivity/specificity, 84%/85%) deviating more than 2 standard deviations from control values. CONCLUSION NT-proBNP is a powerful marker for LV dimensions and systolic function in patients with heart failure and discriminates well between healthy subjects and subjects with impaired LV systolic function or increased LV dimensions.
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Affiliation(s)
- Bjoern A Groenning
- Department of Cardiology and Endocrinology, Copenhagen University Hospital Frederiksberg.
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Nilsson JC, Groenning BA, Nielsen G, Fritz-Hansen T, Trawinski J, Hildebrandt PR, Jensen GB, Larsson HBW, Sondergaard L. Left ventricular remodeling in the first year after acute myocardial infarction and the predictive value of N-terminal pro brain natriuretic peptide. Am Heart J 2002; 143:696-702. [PMID: 11923808 DOI: 10.1067/mhj.2002.120293] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND Left ventricular (LV) remodeling after myocardial infarction (MI) has received much attention because of its severe impact on morbidity and mortality rates. However, the incidence and extent of LV remodeling in a modern infarct population who were offered antiremodeling treatment in compliance with daily clinical practice is unknown. The purpose of this study was to clarify this issue and to evaluate the predictive value of N-terminal pro brain natriuretic peptide (NT-proBNP). METHODS Forty-two patients with a first transmural MI were examined after 1 week, 1 month, 3 months, 6 months, and 1 year with blood samples and magnetic resonance imaging. RESULTS In 12 patients (29%), LV end-diastolic volume index (LVEDVI) and LV end-systolic volume index (LVESVI) increased by 24% and 22% (P <.0001; P =.01). In 12 patients (29%), LVEDVI and LVESVI decreased by 19% and 23% (P <.0001; P =.0005), whereas the remaining 18 patients (43%) had stable conditions regarding these LV measures. LV ejection fraction at baseline was significantly reduced in all patient categories but was unchanged over time. Elevated NT-proBNP level at baseline was identified as an independent predictor of increase in LVEDVI during follow-up examination (P =.007). A baseline level of NT-proBNP >115 pmol/L identified patients who later had LV dilatation develop with a sensitivity and specificity of 89% and 68% (area under curve = 0.77). CONCLUSION In this 1-year follow-up study of patients with a first transmural MI, approximately 30% had significant increments develop in LVEDVI and LVESVI, and LV ejection fraction remained unchanged. Patients in whom LV dilatation developed could be identified early after the MI with elevated plasma levels of NT-proBNP.
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Affiliation(s)
- Jens C Nilsson
- Danish Research Center of Magnetic Resonance, Copenhagen University Hospital, Hvidovre, Denmark.
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Groenning BA, Nilsson JC, Sondergaard L, Kjaer A, Larsson HB, Hildebrandt PR. Evaluation of impaired left ventricular ejection fraction and increased dimensions by multiple neurohumoral plasma concentrations. Eur J Heart Fail 2001; 3:699-708. [PMID: 11738222 DOI: 10.1016/s1388-9842(01)00181-7] [Citation(s) in RCA: 59] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND A range of neurohumoral substances have been suggested as diagnostic markers in heart failure. It is, however, undetermined which marker has the greatest diagnostic potential, and whether additional information is gained by a comprehensive neurohumoral evaluation. AIMS The purpose of the study was to compare the value of epinephrine, norepinephrine, renin activity, aldosterone (ALDO), atrial (ANP) and brain (BNP) natriuretic peptides, arginine-vasopressin and endothelin (ENDO) as markers for left ventricular (LV) dimensions and ejection fraction (LVEF) in patients with systolic heart failure. METHODS Forty-eight patients with symptomatic heart failure were examined with blood samples and magnetic resonance imaging along with 20 age and gender-matched normal controls. RESULTS In multiple regression analyses, BNP was the strongest independent marker for LV end-diastolic (r=0.71, P<0.0001), and end-systolic (r=0.75, P<0.0001) volumes, myocardial mass (r=0.69, P<0.0001), and LVEF (r=-0.78, P<0.0001). ANP was a supplementary independent marker for LV end-diastolic (r=0.76, P<0.0001) and end-systolic (r=0.78, P<0.0001) (ANP and BNP combined) volumes, ENDO for myocardial mass [r=0.71, P<0.0001 (ENDO/BNP)], and ALDO for LVEF [r=-0.81, P<0.0001 (ALDO/BNP)]. CONCLUSION BNP is the strongest marker for LV dimensions and LVEF in patients with systolic heart failure. However, a comprehensive neurohumoral evaluation may add some information to the diagnosis.
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Affiliation(s)
- B A Groenning
- Danish Research Centre of Magnetic Resonance, Section 340, H:S Hvidovre Hospital, University of Copenhagen, Kettegaard Allé 30, DK-2650, Hvidovre, Denmark.
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Nilsson JC, Nielsen G, Groenning BA, Fritz-Hansen T, Sondergaard L, Jensen GB, Larsson HB. Sustained postinfarction myocardial oedema in humans visualised by magnetic resonance imaging. Heart 2001; 85:639-42. [PMID: 11359743 PMCID: PMC1729755 DOI: 10.1136/heart.85.6.639] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
OBJECTIVE To demonstrate postinfarction myocardial oedema in humans with particular reference to the longitudinal course, using magnetic resonance imaging (MRI). DESIGN Prospective observational study. Subjects were studied one week, one month, three months, six months, and one year after presenting with a myocardial infarct. SETTING Cardiology and magnetic resonance departments in a Danish university hospital. PATIENTS 10 patients (three women, seven men), mean (SEM) age 58.2 (3.20) years, with a first transmural myocardial infarct. MAIN OUTCOME MEASURES Location and duration of postinfarction myocardial oedema. RESULTS All patients had signs of postinfarction myocardial oedema. The magnetic resonance images were evaluated by two blinded procedures, employing two MRI and two ECG observers: (1) MRI determined oedema location was compared with the ECG determined site of infarction and almost complete agreement was found; (2) the time course of postinfarction myocardial oedema was explored semiquantitatively, using an image ranking procedure. Myocardial oedema was greatest at the initial examination one week after the infarction, with a gradual decline during the following months (Spearman's rank correlation analysis: rho(observer 1) = 0.94 (p < 0.0001) and rho(observer 2) = 0.97 (p < 0.0001)). The median duration of oedema was six months. CONCLUSIONS Postinfarction myocardial oedema seems surprisingly long lasting. This observation is of potential clinical interest because the oedema may have prognostic significance.
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Affiliation(s)
- J C Nilsson
- Danish Research Centre of Magnetic Resonance, H:S Hvidovre Hospital, University of Copenhagen, Kettegaard Allé 30, DK-2650 Hvidovre, Denmark.
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Grønning B, Nilsson JC. Multiple regression: a primer. Paul D. Allison, Sage, London, 1999. No. of pages: 220. Price: £ 11.99. ISBN 0-7619-8533-6. Stat Med 2001. [DOI: 10.1002/sim.895] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Nilsson JC, Grønning BA. Multivariable Analysis. A Practical Guide for Clinicians. Mitchell H. Katz, Cambridge University Press, Cambridge, 1999. No. of. pages: xv+192. Price:£17.95. ISBN 0-521-59693-9. Stat Med 2001. [DOI: 10.1002/sim.833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Groenning BA, Nilsson JC, Sondergaard L, Fritz-Hansen T, Larsson HB, Hildebrandt PR. Antiremodeling effects on the left ventricle during beta-blockade with metoprolol in the treatment of chronic heart failure. J Am Coll Cardiol 2000; 36:2072-80. [PMID: 11127443 DOI: 10.1016/s0735-1097(00)01006-8] [Citation(s) in RCA: 195] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
OBJECTIVES The purpose of the study was to investigate the effects of beta1-blockade on left ventricular (LV) size and function for patients with chronic heart failure. BACKGROUND Large-scale trials have shown that a marked decrease in mortality can be obtained by treatment of chronic heart failure with beta-adrenergic blocking agents. Possible mechanisms behind this effect remain yet to be fully elucidated, and previous studies have presented insignificant results regarding suspected LV antiremodeling effects. METHODS In this randomized, placebo-controlled and double-blind substudy to the Metoprolol CR/XL Randomized Intervention Trial in Heart Failure (MERIT-HF), 41 patients were examined with magnetic resonance imaging three times in a six-month period, assessing LV dimensions and function. RESULTS Decreases in both LV end-diastolic volume index (150 ml/m2 at baseline to 126 ml/m2 after six months, p = 0.007) and LV end-systolic volume index (107 ml/m2 to 81 ml/m2, p = 0.001) were found, whereas LV ejection fraction increased in the metoprolol CR/XL group (29% to 37%, p = 0.005). No significant changes were seen in the placebo group regarding these variables. Left ventricular stroke volume index remained unchanged, whereas LV mass index decreased in both groups (175 g/m2 to 160 g/m2 in the placebo group [p = 0.005] and 179 g/m2 to 164 g/m2 in the metoprolol CR/XL group [p = 0.011). CONCLUSIONS This study is the first randomized study to demonstrate that the beta1-blocker metoprolol CR/XL has antiremodeling effects on the LV in patients with chronic heart failure and consequently provides an explanation for the highly significant decrease in mortality from worsening heart failure found in the MERIT-HF trial.
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Affiliation(s)
- B A Groenning
- Danish Research Center of Magnetic Resonance, Department of Magnetic Resonance, H:S Hvidovre Hospital, University of Copenhagen, Denmark.
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