Methylprednisolone Does Not Enhance Paraoxonase 1 Activity During Cardiopulmonary Bypass Surgery-A Randomized, Controlled Clinical Trial

OBJECTIVES

Cardiopulmonary bypass (CPB) is linked to systemic inflammatory responses and oxidative stress. Paraoxonase 1 (PON1) is an antioxidant enzyme with a cardioprotective role whose activity is decreased in systemic inflammation and in patients with acute myocardial and global ischemia. Glucocorticoids counteract the effect of oxidative stress by upregulating PON1 gene expression. The authors aimed to determine the effect of methylprednisolone on PON1 activity during cardiac surgery on CPB.

DESIGN

Prospective, randomized, controlled clinical trial.

SETTING

The University Medical Center Ljubljana, Slovenia.

PARTICIPANTS

Forty adult patients who underwent complex cardiac surgery on CPB between February 2016 and December 2017 were randomized into methylprednisolone and control groups (n = 20 each).

INTERVENTIONS

Patients in the methylprednisolone group received 1 g of methylprednisolone in the CPB priming solution, whereas patients in the control group were not given methylprednisolone during CPB.

MEASUREMENTS AND MAIN RESULTS

The effect of methylprednisolone from the CPB priming solution was compared with standard care during CPB on PON1 activity until postoperative day 5. Correlations of PON1 activity with lipid status, mediators of inflammation, and hemodynamics were analyzed also. No significant differences were found between study groups for PON1 activity, high-density lipoprotein, and low-density lipoprotein in any of the measurement intervals (p > 0.016). The methylprednisolone group had significantly lower tumor necrosis factor alpha (p < 0.001) and interleukin-6 (p < 0.001), as well as C-reactive protein and procalcitonin (p < 0.016) after surgery. No significant difference was found between groups for hemodynamic parameters. A positive correlation existed between PON1 and lipid status, whereas a negative correlation was found between PON1 activity and tumor necrosis factor alpha, interleukin-6, and CPB duration.

CONCLUSIONS

Methylprednisolone does not influence PON1 activity during cardiac surgery on CPB.

Comparison of Procedural Sedation With Propofol and Dexmedetomidine During Transcatheter Aortic Valve Replacement Using the Transfemoral Approach

OBJECTIVES

Although procedural sedation is an established method of anesthesia for transcatheter aortic valve replacement (TAVR), reliable evidence to guide the choice of a suitable sedative agent remains scarce. Accordingly, this trial aimed to compare the effect of procedural sedation with dexmedetomidine versus propofol on postoperative neurocognitive and related clinical outcomes in patients undergoing TAVR.

DESIGN

Prospective, randomized, double-blind clinical trial.

SETTING

The study was conducted at the University Medical Centre Ljubljana, Slovenia.

PARTICIPANTS

The study enrolled 78 patients who underwent TAVR under procedural sedation between January 2019 and June 2021. Seventy-one patients randomized into the propofol group (n = 34) and dexmedetomidine group (n = 37) were included in the final analysis.

INTERVENTIONS

Patients in the propofol group received sedation with propofol (continuous intravenous infusion of 0.5-2.5 mg/kg/h), whereas patients in the dexmedetomidine group received sedation with dexmedetomidine (loading dose of 0.5 µg/kg over 10 minutes followed by continuous intravenous infusion of 0.2-1.0 µg/kg/h).

MEASUREMENTS AND MAIN RESULTS

Minimental state examination (MMSE) was performed before and 48 hours after TAVR. There was no statistically significant difference in MMSE scores between groups before TAVR (p = 0.253), but the MMSE after the procedure revealed a significantly lower incidence of delayed neurocognitive recovery (p = 0.005) and thus better cognitive outcomes in the dexmedetomidine group (p = 0.022).

CONCLUSIONS

Compared with propofol, procedural sedation with dexmedetomidine in TAVR was associated with a significantly lower incidence of delayed neurocognitive recovery.

Endothelial Dysfunction in Patients Undergoing Cardiac Surgery: A Narrative Review and Clinical Implications

Cardiac surgery is one of the highest-risk procedures, usually involving cardiopulmonary bypass and commonly inducing endothelial injury that contributes to the development of perioperative and postoperative organ dysfunction. Substantial scientific efforts are being made to unravel the complex interaction of biomolecules involved in endothelial dysfunction to find new therapeutic targets and biomarkers and to develop therapeutic strategies to protect and restore the endothelium. This review highlights the current state-of-the-art knowledge on the structure and function of the endothelial glycocalyx and mechanisms of endothelial glycocalyx shedding in cardiac surgery. Particular emphasis is placed on potential strategies to protect and restore the endothelial glycocalyx in cardiac surgery. In addition, we have summarized and elaborated the latest evidence on conventional and potential biomarkers of endothelial dysfunction to provide a comprehensive synthesis of crucial mechanisms of endothelial dysfunction in patients undergoing cardiac surgery, and to highlight their clinical implications.

PROCALCITONIN GUIDED ANTIBIOTIC STEWARDSHIP: A BALKAN EXPERT CONSENSUS STATEMENT

Sepsis as a consequence of infection is a frequent cause of death among critically ill patients. The most common sites of infection are lover respiratory tract, abdominal, urinary tract and catheter-associated blood stream infections. Early empiric, broad-spectrum therapy in those with severe sepsis and/or shock with the aim of reducing mortality may lead to antibiotic overuse, resistance and increased costs. Among numerous serum biomarkers, procalcitonin (PCT) has proved to be one of the most reliable ones in the diagnosis of sepsis. An important means of limiting antibiotic resistance is the antibiotic stewardship program, especially in intensive care units with critically ill patients and prevalence of multiple drug-resistant pathogens. The PCT-guided antibiotic stewardship was first started in Western Europe and Asia-Pacific countries, as well as in the United States. Considering that this method has proven to be effective in reducing antibiotic consumption while improving clinical outcome, a group of experts from the Balkan region decided to make their own recommendations and PCT protocol. When creating this protocol for initiation and duration of antibiotic treatment, they especially reviewed the literature for lower respiratory tract infection and sepsis. In the protocol, they have included the severity of illness, clinical assessment, and PCT levels. Developing a consensus on the clinical algorithm by eminent experts/specialists in various fields of medicine should enable clinicians to use PCT for initiation of antibiotic therapy and monitoring PCT to stop antibiotics earlier. It is crucial that the PCT-guided algorithm becomes an integral part of institutional stewardship program.

PERIOPERATIVE PREPARATION OF CARDIAC PATIENTS IN REGIONAL ANESTHESIA

Preoperative cardiovascular management is an essential component of overall perioperative cardiovascular care. It involves preoperative detection and management of cardiovascular disease and prediction of both short-term and long-term cardiovascular risk. It affects anesthetic perioperative management and surgical decision making. This requires individualized management. Careful preoperative preparation at least a week before surgery, rational decisions regarding necessary tests and examinations, good cooperation with the cardiologist and surgeon and careful planning of early postoperative treatment are key for better outcome after surgery and reduction of postoperative complications.

Cerebral microemboli in mini-sternotomy compared to mini- thoracotomy for aortic valve replacement: a cross sectional cohort study

Background

Recently adopted mini-thoracotomy approach for surgical aortic valve replacement has shown benefits such as reduced pain and shorter recovery, compared to more conventional mini-sternotomy access. However, whether limited exposure of the heart and ascending aorta resulting from an incision in the second intercostal space may lead to increased intraoperative cerebral embolization and more prominent postoperative neurologic decline, remains inconclusive. The aim of our study was to assess potential neurological complications after two different minimal invasive surgical techniques for aortic valve replacement by measuring cerebral microembolic signal during surgery and by follow-up cognitive evaluation.

Methods

Trans-cranial Doppler was used for microembolic signal detection during aortic valve replacement performed via mini-sternotomy and mini-thoracotomy. Patients were evaluated using Addenbrooke’s Cognitive Examination Revised Test before and 30 days after surgical procedure.

Results

A total of 60 patients were recruited in the study. In 52 patients, transcranial Doppler was feasible. Of those, 25 underwent mini-sternotomy and 27 had mini-thoracotomy. There were no differences between groups with respect to sex, NYHA class distribution, Euroscore II or aortic valve area. Patients in mini-sternotomy group were younger (60.8 ± 14.4 vs.72 ± 5.84, p = 0.003), heavier (85.2 ± 12.4 vs.72.5 ± 12.9, p = 0.002) and had higher body surface area (1.98 ± 0.167 vs. 1.83 ± 0.178, p = 0.006). Surgery duration was longer in mini-sternotomy group compared to mini-thoracotomy (158 ± 24 vs. 134 ± 30 min, p < 0.001, respectively). There were no differences between groups in microembolic load, length of ICU or total hospital stay. Total microembolic signals count was correlated with cardiopulmonary bypass duration (5.64, 95%CI 0.677–10.60, p = 0.027). Addenbrooke’s Cognitive Examination Revised Test score decreased equivalently in both groups (p = 0.630) (MS: 85.2 ± 9.6 vs. 82.9 ± 11.4, p = 0.012; MT: 85.2 ± 9.6 vs. 81.3 ± 8.8, p = 0.001).

Conclusion

There is no difference in microembolic load between the groups. Total intraoperative microembolic signals count was associated with cardiopulmonary bypass duration. Age, but not micorembolic signals load, was associated with postoperative neurologic decline.

Trial registry number

clinicaltrials.gov, NCT02697786 14.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13019-021-01509-8.

Cardiac Melanoma Metastasis with ERBB2 Gene Amplification: A Potential for Future Targeted Therapy

Cardiac tumors are rare, and their treatment differs interindividually regarding the histopathological proprieties and the stage of disease. Authors present a case of symptomatic cardiac melanoma metastasis that expressed an ERBB2 (HER2) gene amplification in a course of the disease that has not yet been reported. The frail patient with a history of pulmonary and renal carcinoma, was admitted to the hospital due to a symptomatic left atrial tumor mass. The patient underwent a tumor-resecting cardiac surgery. At first mistaken for myxoma on echocardiography, the histopathological examination of the tumor revealed a melanoma of acral or mucosal origin. The melanoma metastasis was negative for common genetic mutations in BRAF, NRAS or KIT genes, and for the presence of NTRK genes fusions, but carried ERBB2 (HER2) gene amplification. The absence of standard gene mutations rendered it unresponsive to treatment with BRAF and MEK inhibitors. This molecular finding is rare in melanomas and represented a therapeutic target for off-label systemic treatment with drugs, primarily aimed at ERBB2 positive breast, gastric, and gastroesophageal junction cancers. A rare finding like this justifies molecular genetic analysis of unusual tumor specimen and guarantees optimal treatment for uncommon types of cardiac metastatic tumors.

Effectiveness of wound infusion of 0.2% ropivacaine by patient control analgesia pump after minithoracotomy aortic valve replacement: a randomized, double-blind, placebo-controlled trial

BACKGROUND

Local anesthetic wound infusion has become an invaluable technique in multimodal analgesia. The effectiveness of wound infusion of 0.2% ropivacaine delivered by patient controlled analgesia (PCA) pump has not been evaluated in minimally invasive cardiac surgery. We tested the hypothesis that 0.2% ropivacaine wound infusion by PCA pump reduces the cumulative dose of opioid needed in the first 48 h after minithoracothomy aortic valve replacement (AVR).

METHODS

In this prospective, randomized, double-blind, placebo-controlled study, 70 adult patients (31 female and 39 male) were analyzed. Patients were randomized to receive 0.2% ropivacaine or 0.9% saline wound infusion by PCA pump for 48 h postoperatively. PCA pump was programmed at 5 ml h^- 1 continuously and 5 ml of bolus with 60 min lockout. Pain levels were assessed and recorded hourly by Numeric Rating Scale (NRS). If NRS score was higher than three the patient was administered 3 mg of opioid piritramide repeated and titrated as needed until pain relief was achieved. The primary outcome was the cumulative dose of the opioid piritramide in the first 48 h after surgery. Secondary outcomes were frequency of NRS scores higher than three, patient's satisfaction with pain relief, hospital length of stay, side effects related to the local anesthetic and complications related to the wound catheter.

RESULTS

The cumulative dose of the opioid piritramide in the first 48 h after minithoracotomy AVR was significantly lower (p < 0.001) in the ropivacaine (R) group median 3 mg (IQR 6 mg) vs. 9 mg (IQR 9 mg). The number of episodes of pain where NRS score was greater than three median 2 (IQR 2), vs 3 (IQR 3), (p = 0.002) in the first 48 h after surgery were significantly lower in the ropivacaine group, compared to control. Patient satisfaction with pain relief in our study was high. There were no wound infections and no side-effects from the local anesthetic.

CONCLUSIONS

Wound infusion of local anesthetic by PCA pump significantly reduced opioid dose needed and improves pain control postoperatively. We have also shown that it is a feasible method of analgesia and it should be considered in the multimodal pain control strategy following minimally invasive cardiac surgery.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03079830 , date of registration: March 15, 2017. Retrospecitvely registered.

Dopamine Autoxidation Is Controlled by Acidic pH

We studied the reaction mechanism of dopamine autoxidation using quantum chemical methods. Unlike other biogenic amines important in the central nervous system, dopamine and noradrenaline are capable of undergoing a non-enzymatic autoxidative reaction giving rise to a superoxide anion that further decomposes to reactive oxygen species. The reaction in question, which takes place in an aqueous solution, is as such not limited to the mitochondrial membrane where scavenging enzymes such as catalase and superoxide dismutase are located. With the experimental rate constant of 0.147 s⁻¹, the dopamine autoxidation reaction is comparably as fast as the monoamine oxidase B catalyzed dopamine decomposition with a rate constant of 1 s⁻¹. By using quantum chemical calculations, we demonstrated that the rate-limiting step is the formation of a hydroxide ion from a water molecule, which attacks the amino group that enters intramolecular Michael addition, giving rise to a pharmacologically inert aminochrome. We have shown that for dopamine stability on a time scale of days, it is essential that the pH value of the synaptic vesicle interior is acidic. The pathophysiologic correlates of the results are discussed in the context of Parkinson's disease as well as the pathology caused by long-term amphetamine and cocaine administration.

The response of aminopeptidases of Phaseolus vulgaris to drought depends on the developmental stage of the leaves

Aminopeptidases, together with other proteases, execute and regulate the total and specifically limited protein breakdown involved in plant physiology, raising the possibility of their involvement in response to drought. We have identified, in leaves of Phaseolus vulgaris L., five aminopeptidases (E.C.3.4.11) whose levels of activity changed when three week old plants were subjected to drought. First, second and third trifoliate leaves were investigated separately. The aminopeptidases were first identified then isolated using ion exchange chromatography of leaf extracts. Three, named PvAP1, PvAP2 and PvAP4, are metallo aminopeptidases with broad substrate specificity, active against substrates conjugated to alanine and lysine. Two others, PvAP3 and PvAP5, are apparently serine aminopeptidases, the former active against substrates conjugated to phenylalanine and leucine, and the latter characterised by narrow specificity against substrates conjugated to phenylalanine. Their apparent molecular weights range from ∼37 kDa to ∼80 kDa. Levels of activity of individual aminopeptidases in both watered and drought stressed plants are shown to depend on the age of leaves. In watered plants they were generally highest in young, and very low in older, trifoliate leaves, the latter with the exception of PvAP5. Drought initiated an almost general increase of their activities, although to different extents, with the exception of PvAP4 and PvAP5 in young trifoliate leaves. Thus, in such studies it is necessary to investigate the effects of drought separately in leaves of different ages in order to elucidate the different complex and probably specific roles of aminopeptidases in the response of common bean to drought.

The Role of Levosimendan in Patients with Decreased Left Ventricular Function Undergoing Cardiac Surgery

The postoperative low cardiac output is one of the most important complications following cardiac surgery and is associated with increased morbidity and mortality. The condition requires inotropic support to achieve adequate hemodynamic status and tissue perfusion. While catecholamines are utilised as a standard therapy in cardiac surgery, their use is limited due to increased oxygen consumption. Levosimendan is calcium sensitising inodilatator expressing positive inotropic effect by binding with cardiac troponin C without increasing oxygen demand. Furthermore, the drug opens potassium ATP (KATP) channels in cardiac mitochondria and in the vascular muscle cells, showing cardioprotective and vasodilator properties, respectively. In the past decade, levosimendan demonstrated promising results in treating patients with reduced left ventricular function when administered in peri- or post- operative settings. In addition, pre-operative use of levosimendan in patients with severely reduced left ventricular ejection fraction may reduce the requirements for postoperative inotropic support, mechanical support, duration of intensive care unit stay as well as hospital stay and a decrease in post-operative mortality. However, larger studies are needed to clarify clinical advantages of levosimendan versus conventional inotropes.

USE OF RECOMBINANT ACTIVATED FACTOR VIIa IN A-SIX-MONTH-OLD CHILD DUE TO MASSIVE HEMORRHAGE DURING ELECTIVE SURGERY FOR CHOROID PLEXUS CARCINOMA: CASE REPORT

We present the use of recombinant activated factor VIIa (rFVIIa) in a 6-month-old infant that suffered massive bleeding and subsequent coagulation disturbances during elective surgery for choroid plexus carcinoma in the lateral ventricle. The administration of rFVIIa resulted in good hemostasis. No intra- or postoperative thromboembolic complications were observed.