Use of del Nido cardioplegia in acute coronary syndrome cases with decreased ejection fraction

BACKGROUND

There has been increasing interest in using del Nido cardioplegia in adult cardiac surgery. However, there is limited evidence for its efficacy in patients with acute coronary syndrome and reduced ejection fraction.

METHODS

This study examined patients with decreased ejection fraction (EF < 40%) who were hospitalized due to acute coronary syndrome and received either del Nido (DN) or cold blood cardioplegia (CB). The patients were matched based on age, gender, myocardial infarction at baseline, and number of conducted surgical procedures. An analysis was conducted on postoperative biomarker release (high-sensitivity troponin T and isoenzyme creatine kinase-MB (CK-MB)), changes in myocardial contractility and perioperative outcomes.

RESULTS

62 pairs of patients with similar baseline characteristics were selected. 51.6% of pairs underwent isolated coronary artery bypass grafting, while 48.4% underwent a complex procedure. Postoperative troponin values did not differ significantly at 12 h (median (IQR): 606.7 (381.4-974.8) pg/mL vs. 552 (231.8-1579.5) pg/mL; p = 0.913), nor did CK-MB (median (IQR): 24.3 (12.6-45.5) ng/mL vs. 23.7 (12.3-49.8) ng/mL; p = 0.972). The postoperative EF was similar between groups (median (IQR): 30% (30-35%) vs. 34% (30-38%); p = 0.323). No difference in perioperative mortality, myocardial infarction, stroke, or composite endpoint was noted. In a multivariate analysis, the cardioplegia protocol did not affect biomarker release or changes in ejection fraction. The first stage of acute kidney injury was more frequent in the CB group (28.5% vs. 9.7%, p = 0.033).

CONCLUSIONS

Both del Nido and cold blood cardioplegia provide adequate cardioprotection in patients with acute coronary syndrome with decreased ejection fraction.

The impact of the coronavirus pandemic on patients hospitalized due to acute coronary syndrome

The coronavirus disease 2019 (COVID-19) pandemic significantly increased mortality worldwide. However, only part of the excess mortality is related directly to the infection. Local healthcare accessibility, time to reach medical care and patients' reluctance to seek medical aid strongly affected the treatment results in many fields. The current report aims to analyze mortality and morbidity in patients who suffered from acute coronary syndrome (ACS) during the COVID-19 pandemic, as well as to investigate the factors that may have a significant impact on their baseline characteristics and outcome. Multiple reports were evaluated. Most of them point to reluctance and longer time to reach medical care, longer pre-hospital delay, lower overall number of ACS admissions, greater percentage of ST-elevation myocardial infarction patients and complications. Younger and less ill patients were more likely to suffer from ACS than in the pre-pandemic period. They presented with more prominent biomarker elevation. Further, the number of invasive procedures dropped significantly, which was most prominent in the field of surgical revascularization. Consequently, a higher number of adverse events and greater mortality during the COVID-19 pandemic were noted, which was valid for both patients with and without coronavirus infection. In summary, the pandemic had a great impact on overall populational mortality and morbidity, which was greatly pronounced in patients with cardiovascular disease, particularly in ACS cases. They differed in baseline characteristics, underwent different treatment and their outcome was worse as compared with the period prior to the pandemic.

Del Nido versus cold blood cardioplegia in adult patients with impaired ejection fraction undergoing valvular and complex heart surgery

BACKGROUND

There is sparse evidence on the efficacy of del Nido cardioplegia in high-risk patients with reduced ejection fraction undergoing valvular or complex heart surgery, and further investigation is required.

METHODS

An institutional registry was searched for patients who underwent valvular or complex heart surgery and had an ejection fraction <40%. Subjects who received del Nido cardioplegia (DNC) and cold blood cardioplegia (CBC) were selected. Propensity matching was performed with age, gender, and number of conducted procedures as matching criteria. A comparative analysis was performed on primary endpoints of the troponin rise and changes in ejection fraction (EF). A composite endpoint of a troponin rise of ≥20× baseline or fall of EF≥5% was assessed in a multivariate analysis. Other perioperative complications are reported.

RESULTS

One hundred patients from the DNC group were matched to the 100 patients in the CBC group. There were no differences between groups at baseline. Postoperatively, lower troponin values were observed in the DNC group at 12 hours (median; IQR: 523.2;349.1-740.4 pg/mL vs. 787.6;443.6-1689.0 pg/mL; P=0.016) and 36 hours (median; IQR: 426.1;337.2-492.1 pg/mL vs. 653.7;398.8-1737.5 pg/mL; P=0.044). Fewer patients in the DNC group had a fall in EF≥5% (7% vs. 16%; P=0.046). The multivariable analysis did not reveal a significant predictor of composite endpoint.

CONCLUSIONS

In patients with impaired contractility undergoing valvular and complex procedures, the use of del Nido cardioplegia as an alternative to cold blood cardioplegia is associated with lower troponin release and improved preservation of ejection fraction.

Incidence and course of acute coronary syndrome cases after the first wave of the COVID-19 pandemic

BACKGROUND

The collateral damage caused by the COVID-19 pandemic affected cardiovascular disease patients, mainly acute coronary syndrome (ACS) cases. Additionally, lockdown caused treatment-related concerns and reluctance to seek medical help, factors that can delay treatment.

AIM

We aimed to analyze the incidence and course of ACS after the first COVID-19 wave.

METHODS

The report is based on a multi-institutional registry of 10 interventional cardiology departments. ACS patient data were gathered from June to October 2020, i.e. in the period following the first lockdown in Poland (March 30-May 31, 2020) and compared with the corresponding 2019 timeframe.

RESULTS

Patients (2801 and 2620) hospitalized for ACS in 2019 and 2020 (June-October) represented 52.8% and 57.9% of coronary artery disease admissions, respectively. In 2020 vs. 2019, more cases of arterial hypertension (80.2% vs. 71.5%; P <0.001), diabetes (32.7% vs. 28.2%; P <0.001) hyperlipidemia (53.2% vs. 49.8%; P = 0.01), and smoking history (29.5% vs. 25.8%; P = 0.003) were detected. Median troponin and cholesterol values, as well as glycemia, were higher in 2020. Patients were more likely to undergo percutaneous treatment (91.2% vs. 87.5%; P <0.001) and were less often referred for surgery (3.7% vs. 4.9%; P = 0.03). No differences in deaths from repeat myocardial infarction, stroke, and/or composite endpoint (major adverse cardiac and cerebrovascular events [MACCE]) were noted. However, suffering from ACS in 2020 (June-October) was a risk factor for mortality based on multivariable analysis.

CONCLUSIONS

The COVID-19 pandemic affected ACS patient profile, course of treatment, and increased risk for mortality.

The impact of first wave of the SARS-CoV-2 2019 pandemic in Poland on characteristics and outcomes of patients hospitalized due to stable coronary artery disease

BACKGROUND

An investigation of baseline characteristics, treatment, and outcomes in patients with stable coronary disease after the first wave of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic may provide valuable data and is beneficial for public health strategy in upcoming years.

METHODS

A multi-institutional registry, including 10 cardiology departments, was searched for patients admitted from June 2020 to October 2020. The baseline characteristics (age, gender, symptoms, comorbidities), treatment (non-invasive, invasive, surgical), and hospitalization outcome (mortality, myocardial infarction, stroke, composite endpoint - major adverse cardiac and cerebrovascular events [MACCE]) were evaluated. The comparison was made to parameters presented by patients from the same timeframe in 2019 (June-October). Multivariable analysis was performed.

RESULTS

Number of hospitalized stable patients following lockdown was lower (2498 vs. 1903; p < 0.0001). They were younger (68.0 vs. 69.0; p < 0.019), more likely to present with hypertension (88.5% vs. 77.5%; p < 0.0001), diabetes (35.7% vs. 31.5%; p = 0.003), hyperlipidemia (67.9% vs. 55.4%; p < 0.0001), obesity (35.8% vs. 31.3%; p = 0.002), and more pronounced symptoms (Canadian Cardiovascular Society [CCS] III and CCS class IV angina: 30.4% vs. 26.5%; p = 0.005). They underwent percutaneous treatment more often (35.0% vs. 25.9%; p < 0.0001) and were less likely to be referred for surgery (3.7% vs. 4.9%; p = 0.0001). There were no significant differences in hospitalization outcome. New York Heart Association (NYHA) class IV for heart failure was a risk factor for both mortality and MACCE in multivariate analysis.

CONCLUSIONS

The SARS-CoV-2 2019 pandemic affected the characteristics and hospitalization course of stable angina patients hospitalized following the first wave. The hospitalization outcome was similar in the analyzed time intervals. The higher prevalence of comorbidities raises concern regarding upcoming years.

Effect of triiodothyronine (T3) excess on fatty acid metabolism in the soleus muscle from endurance-trained rats

We studied whether short-term administration of triiodothyronine (T3) for the last 3 days of endurance training would influence the rate of uptake of palmitic acid (PA) as well as metabolism in rat soleus muscle, in vitro. Training per se did not affect the rate of PA uptake by the soleus; however, an excess of T3increased the rate of this process at 1.5 mmol/L PA, as well as the rate that at which PA was incorporated into intramuscular triacylglycerols (TG). The rate of TG synthesis in trained euthyroid rats was reduced after exercise (1.5 mmol/L PA). The rate of PA oxidation in all of the trained rats immediately after exercise was enhanced by comparison with the sedentary values. Hyperthyroidism additionally increased the rate of this process at 1.5 mmol/L PA. After a recovery period, the rate of PA oxidation returned to the control values in both the euthyroid and the hyperthyroid groups. Examination of the high-energy phosphate levels indicated that elevated PA oxidation after exercise-training in euthyroid rats was associated with stable ATP levels and increased ADP and AMP levels, thus reducing energy cellular potential (ECP). In the hyperthyroid rats, levels of ADP and AMP were increased in the sedentary as well as the exercise-trained rats. ECP levels were high as a result of high levels of ATP and decreased levels of ADP and AMP in hyperthyroid rats after the recovery period. In conclusion, short-term hyperthyroidism accelerates PA utilization in well-trained soleus muscle.

Palmitic acid incorporation into intramuscular acylglycerols depends on both total and unbound to albumin palmitic acid concentration

Palmitic acid incorporation into the intramuscular acylglycerols in rat skeletal muscles of different fiber types was investigated at various total and unbound to albumin concentrations by means of the hind-limb perfusion technique. It was found that at simultaneously increasing total and unbound to albumin palmitic acid concentrations in the perfusion medium the incorporation of palmitic acid into acylglycerols increased. However, when the concentration of palmitic acid not bound to albumin was kept constant and the total palmitic acid concentration was increased, the incorporation also increased although markedly less than under former conditions. The increase was most apparent in the muscles composed of slow-twitch oxidative and fast-twitch oxidative-glycolytic fibers where fatty acid uptake is the greatest. These findings suggest that fatty acid incorporation into intramuscular acylglycerols depends not only on the unbound to albumin fatty acid concentration but also, to some extent, on the total fatty acid concentration.

Palmitic acid uptake by the rat soleus muscle in vitro

Abstract: The rate of fatty acid uptake, oxidation, and deposition in skeletal muscles in relation to total and unbound to albumin fatty acids concentration in the medium were investigated in the incubated rat soleus muscle. An immunohistochemical technique was applied to demonstrate whether the albumin-bound fatty acid complex from the medium penetrates well within all areas of the muscle strips. It was found that the percentage of incorporation of palmitic acid into intramuscular lipids was fairly constant, independently of the fatty acid concentration in the medium, and amounted to 63-72% for triacylglycerols, 7-12% for diacylglycerols-monoacylglycerols, and 19-26% for phospholipids. Both palmitic acid incorporation into the muscle triacylglycerol stores and its oxidation to CO2 closely correlated with an increase in both total and unbound to albumin fatty acid concentrations in the incubation medium. Under conditions of increased total but constant unbound to albumin palmitic acid concentrations, the incorporation of palmitic acid into triacylglycerols and its oxidation to CO2 were also increased, but to a lower extent. This supports the hypothesis that the cellular fatty acid metabolism depends not only on the availability of fatty acids unbound to albumin, but also on the availability of fatty acids complexed to albumin.

Palmitic acid uptake by the rat soleus muscle in vitro

The rate of fatty acid uptake, oxidation, and deposition in skeletal muscles in relation to total and unbound to albumin fatty acids concentration in the medium were investigated in the incubated rat soleus muscle. An immunohistochemical technique was applied to demonstrate whether the albumin-bound fatty acid complex from the medium penetrates well within all areas of the muscle strips. It was found that the percentage of incorporation of palmitic acid into intramuscular lipids was fairly constant, independently of the fatty acid concentration in the medium, and amounted to 63–72% for triacylglycerols, 7–12% for diacylglycerols-monoacylglycerols, and 19–26% for phospholipids. Both palmitic acid incorporation into the muscle triacylglycerol stores and its oxidation to CO2closely correlated with an increase in both total and unbound to albumin fatty acid concentrations in the incubation medium. Under conditions of increased total but constant unbound to albumin palmitic acid concentrations, the incorporation of palmitic acid into triacylglycerols and its oxidation to CO2were also increased, but to a lower extent. This supports the hypothesis that the cellular fatty acid metabolism depends not only on the availability of fatty acids unbound to albumin, but also on the availability of fatty acids complexed to albumin.Key words: skeletal muscle, fatty acids, triacylglycerols, phospholipids.

[Mechanisms for tissue transport of fatty acids]

Fatty acids (FA) play an important role in energy metabolism. They are not only used as substrates for energy production but are also involved in many other metabolic pathways. However, the exact mechanisms by which FA are taken up by the cells are not yet fully understood. Fatty acids circulating in blood cross the cell membranes partly via a mechanism facilitated by plasma membrane proteins and partly via a passive diffusion mechanism, the former mechanism being of major importance.