New technique of local ischemic preconditioning induction without repetitive aortic cross-clamping in cardiac surgery

Journal of Cardiothoracic Surgery

Eugene V Shlyakhto¹  Michael M Galagudza³  Vladimir V Dorofeykov¹  Tatyana A Sheshurina¹  Vadim K Grebennik¹  Viktor O Kabanov¹  Dmitry I Kurapeev² 

[1] Institute of Heart and Vessels, Federal Almazov Medical Research Centre, Saint Petersburg, Russian Federation;Institute of Experimental Medicine, Federal Almazov Medical Research Centre, Saint Petersburg, Russian Federation;Department of Pathophysiology, First I.P. Pavlov Federal Medical University of St. Petersburg, Saint Petersburg, Russian Federation

关键词: Cardiac index;    Troponin I;    Cardiopulmonary bypass;    Cardioplegia;    Myocardial ischemia–reperfusion;    Local ischemic Preconditioning;   

Others  :  1135935
DOI  :  10.1186/s13019-015-0206-0

 received in 2014-09-01, accepted in 2015-01-07,  发布年份 2015

【 摘 要 】

Background

Several studies have demonstrated that local ischemic preconditioning can reduce myocardial ischemia–reperfusion injury in cardiac surgery patients; however, preconditioning has not become a standard cardioprotective intervention, primarily because of the increased risk of atheroembolism during repetitive aortic cross-clamping. In the present study, we aimed to describe and validate a novel technique of preconditioning induction.

Methods

Patients undergoing coronary artery bypass grafting (12 women and 78 men; mean age, 56 ± 11 years) were randomized into 3 groups: (1) Controls (n = 30), (2) Perfusion (n = 30), and (3) Preconditioning (n = 30). All patients were operated under cardiopulmonary bypass using normothermic blood cardioplegia. Preconditioning was induced by subjecting the hemodynamically unloaded heart to 2 cycles of 3 min of ischemia and 3 min of reperfusion with normokalemic blood prior to cardioplegia. In the Perfusion group, the heart perfusion remained unaffected for 12 min. Troponin I (TnI) levels were analyzed before surgery, and 12, 24, 48 h, and 7 days after surgery. The secondary endpoints included the cardiac index, plasma natriuretic peptide level, and postoperative use of inotropes.

Results

Preconditioning resulted in a significant reduction in the TnI level on the 7th postoperative day only (0.10 ± 0.05 and 0.33 ± 0.88 ng/ml in Preconditioning and Perfusion groups, respectively, P < 0.05). In addition, cardiac index was significantly higher in the Preconditioning group than in the Control and Perfusion groups just after weaning from cardiopulmonary bypass. The number of patients requiring inotropic support with ≥ 2 agents after surgery was significantly lower in the Preconditioning and Perfusion group than in the Control group (P < 0.05). No complications of the procedure were recorded in the Preconditioning group.

Conclusions

The preconditioning procedure described can be performed safely in cardiac surgery patients. The application of this technique of preconditioning was associated with certain benefits, including improved left ventricular function after weaning from cardiopulmonary bypass and a reduced need for inotropic support. However, the infarct-limiting effect of preconditioning in the early postoperative period was not evident. The procedure does not involve repetitive aortic cross-clamping, thus avoiding possible embolic complications.

【 授权许可】

   
2015 Kurapeev et al.; licensee BioMed Central.

【 参考文献 】

• [1]Johnson WM, Smith JM, Woods SE, Hendy MP, Hiratzka LF: Cardiac surgery in octogenarians: does age alone influence outcomes? Arch Surg 2005, 140:1089-93.
• [2]Salazar E, Torres J, Barragan R, Lopez M, Lasses LA: Aortic valve replacement in patients 70 years and older. Clin Cardiol 2004, 27:565-70.
• [3]Hakala T, Pitkanen O, Halonen P, Mustonen J, Turpeinen A, Hippelainen M: Early and late outcome after coronary artery bypass surgery in diabetic patients. Scand Cardiovasc J 2005, 39:177-81.
• [4]Sommerhaug RG, Wolfe SF, Reid DA, Lindsey DE, Prato SJ, Frounfelkner LE, et al.: Comparative use of cold blood potassium cardioplegia in coronary bypass patients necessitating long (2.5-6 h) versus short (less than 1.5 h) aortic cross-clamp times. Clin Cardiol 1988, 11:690-5.
• [5]Mariani J, Ou R, Bailey M, Rowland M, Nagley P, Rosenfeldt F, et al.: Tolerance to ischemia and hypoxia is reduced in aged human myocardium. J Thorac Cardiovasc Surg 2000, 120:660-7.
• [6]Alegria JR, Miller TD, Gibbons RJ, Yi QL, Yusuf S: Collaborative Organization of RheothRx Evaluation (CORE) Trial Investigators: Infarct size, ejection fraction, and mortality in diabetic patients with acute myocardial infarction treated with thrombolytic therapy. Am Heart J 2007, 154:743-50.
• [7]Murry CE, Jennings RB, Reimer KA: Preconditioning with ischemia: a delay of lethal cell injury in ischemic myocardium. Circulation 1986, 74:1124-36.
• [8]Yellon DM, Downey JM: Preconditioning the myocardium: from cellular physiology to clinical cardiology. Physiol Rev 2003, 83:1113-51.
• [9]Galagudza MM, Blokhin IO, Shmonin AA, Mischenko KA: Reduction of myocardial ischemia-reperfusion injury with pre- and postconditioning: molecular mechanisms and therapeutic targets. Cardiovasc Hematol Disord Drug Targets 2008, 8:47-65.
• [10]Jenkins DP, Pugsley WB, Alkhulaifi AM, Kemp M, Hooper J, Yellon DM: Ischaemic preconditioning reduces troponin T release in patients undergoing coronary artery bypass surgery. Heart 1997, 77:314-8.
• [11]Wu ZK, Tarkka M, Pehkonen E, Kaukinen L, Honkonen EL, Kaukinen S: Ischaemic preconditioning has beneficial effects on left ventricular haemodynamic function after a coronary artery bypass grafting operation. Scand Cardiovasc J 2000, 34:247-53.
• [12]Wu ZK, Tarkka M, Pehkonen E, Kaukinen L, Honkonen EL, Kaukinen S: Beneficial effects of ischemic preconditioning on right ventricular function after coronary artery bypass grafting. Ann Thorac Surg 2000, 70:1551-7.
• [13]Wu ZK, Iivainen T, Pehkonen E, Laurikka J, Tarkka MR: Antiarrhythmic effect of ischemic preconditioning in recent unstable angina patients undergoing coronary artery bypass grafting. World J Surg 2004, 28:74-9.
• [14]Illes RW, Swoyer KD: Prospective, randomized clinical study of ischemic preconditioning as an adjunct to intermittent cold blood cardioplegia. Ann Thorac Surg 1998, 65:748-52.
• [15]Li G, Chen S, Lu E, Li Y: Ischemic preconditioning improves preservation with cold blood cardioplegia in valve replacement patients. Eur J Cardiothorac Surg 1999, 15:653-7.
• [16]Luo WJ: Ischemic preconditioning in children undergoing open heart operation. Ann Thorac Surg 1998, 66:2163-4.
• [17]Valen G, Vaage J: Pre- and postconditioning during cardiac surgery. Basic Res Cardiol 2005, 100:179-86.
• [18]Maruyama Y, Chambers DJ: Myocardial protection: efficacy of a novel magnesium-based cardioplegia (RS-C) compared to St Thomas’ Hospital cardioplegic solution. Interact Cardiovasc Thorac Surg 2008, 7:745-9.
• [19]Minasian SM, Galagudza MM, Dmitriev YV, Kurapeev DI, Vlasov TD: Myocardial protection against global ischemia with Krebs-Henseleit buffer-based cardioplegic solution. J Cardiothorac Surg 2013, 8:60. BioMed Central Full Text
• [20]Dahlin LG, Olin C, Svedjeholm R: Perioperative myocardial infarction in cardiac surgery–risk factors and consequences: a case control study. Scand Cardiovasc J 2000, 34:522-7.
• [21]Masse L, Antonacci M: Low cardiac output syndrome: identification and management. Crit Care Nurs Clin North Am 2005, 17:375-83.
• [22]Westaby S, Balacumaraswami L, Sayeed R: Maximizing survival potential in very high risk cardiac surgery. Heart Fail Clin 2007, 3:159-80.
• [23]Yellon DM, Alkhulaifi AM, Pugsley WB: Preconditioning the human myocardium. Lancet 1993, 342:276-7.
• [24]Teoh LK, Grant R, Hulf JA, Pugsley WB, Yellon DM: A comparison between ischemic preconditioning, intermittent cross-clamp fibrillation and cold crystalloid cardioplegia for myocardial protection during coronary artery bypass graft surgery. Cardiovasc Surg 2002, 10:251-5.
• [25]Lu EX, Chen SX, Yuan MD, Hu TH, Zhou HC, Luo WJ, et al.: Preconditioning improves myocardial preservation in patients undergoing open heart operations. Ann Thorac Surg 1997, 64:1320-4.
• [26]Buyukates M, Kalaycioglu S, Oz E, Soncul H: Effects of ischemic preconditioning in human heart. J Card Surg 2005, 20:241-5.
• [27]Szmagala P, Morawski W, Krejca M, Gburek T, Bochenek A: Evaluation of perioperative myocardial tissue damage in ischemically preconditioned human heart during aorto coronary bypass surgery. J Cardiovasc Surg (Torino) 1998, 39:791-5.
• [28]Ji B, Liu M, Liu J, Wang G, Feng W, Lu F, et al.: Evaluation by cardiac troponin I: the effect of ischemic preconditioning as an adjunct to intermittent blood cardioplegia on coronary artery bypass grafting. Card Surg 2007, 22:394-400.
• [29]Wu ZK, Iivainen T, Pehkonen E, Laurikka J, Tarkka MR: Ischemic preconditioning suppresses ventricular tachyarrhythmias after myocardial revascularization. Circulation 2002, 106:3091-6.
• [30]Heusch G: Cardioprotection: chances and challenges of its translation to the clinic. Lancet 2013, 381:166-75.
• [31]Perrault LP, Menasche P, Bel A, De Chaumaray T, Peynet J, Mondry A, et al.: Ischemic preconditioning in cardiac surgery: a word of caution. J Thorac Cardiovasc Surg 1996, 112:1378-86.
• [32]Kaukoranta PK, Lepojarvi MV, Kiviluoma KT, Ylitalo KV, Peuhkurinen KJ: Myocardial protection during antegrade versus retrograde cardioplegia. Ann Thorac Surg 1998, 66:755-61.
• [33]Cremer J, Steinhoff G, Karck M, Ahnsell T, Brandt M, Teebken OE, et al.: Ischemic preconditioning prior to myocardial protection with cold blood cardioplegia in coronary surgery. Eur J Cardiothorac Surg 1997, 12:753-8.
• [34]Wu ZK, Tarkka MR, Eloranta J, Pehkonen E, Kaukinen L, Honkonen EL, et al.: Effect of ischemic preconditioning on myocardial protection in coronary artery bypass graft patients: can the free radicals act as a trigger for ischemic preconditioning? Chest 2001, 119:1061-8.
• [35]Hausenloy DJ, Baxter G, Bell R, Botker HE, Davidson SM, Downey J, et al.: Translating novel strategies for cardioprotection: the Hatter Workshop Recommendations. Basic Res Cardiol 2010, 105:677-86.
• [36]Liu Y, Downey JM: Ischemic preconditioning protects against infarction in rat heart. Am J Physiol 1992, 263:H1107-12.
• [37]Ghosh S, Galinanes M: Protection of the human heart with ischemic preconditioning during cardiac surgery: role of cardiopulmonary bypass. J Thorac Cardiovasc Surg 2003, 126:133-42.
• [38]BhaskerRao B, VanHimbergen D, Edmonds HL Jr, Jaber S, Ali AT, Pagni S, et al.: Evidence for improved cerebral function after minimally invasive bypass surgery. J Card Surg 1998, 13:27-31.
• [39]Reichenspurner H, Navia JA, Berry G, Robbins RC, Barbut D, Gold JP, et al.: Particulate emboli capture by an intra-aortic filter device during cardiac surgery. J Thorac Cardiovasc Surg 2000, 119:233-41.
• [40]Walsh SR, Tang TY, Kullar P, Jenkins DP, Dutka DP, Gaunt ME: Ischaemic preconditioning during cardiac surgery: systematic review and meta-analysis of perioperative outcomes in randomised clinical trials. Eur J Cardiothorac Surg 2008, 34:985-94.
• [41]Jebeli M, Esmaili HR, Mandegar MH, Rasouli MR, Eghtesadi-Araghi P, Mohammadzadeh R, et al.: Evaluation of the effects of ischemic preconditioning with a short reperfusion phase on patients undergoing a coronary artery bypass graft. Ann Thorac Cardiovasc Surg 2010, 16:248-52.
• [42]Burns PG, Krukenkamp IB, Calderone CA, Gaudette GR, Bukhari EA, Levitsky S: Does cardiopulmonary bypass alone elicit myoprotective preconditioning? Circulation 1995, 92:II447-51.
• [43]Laurikka J, Wu ZK, Iisalo P, Kaukinen L, Honkonen EL, Kaukinen S, et al.: Regional ischemic preconditioning enhances myocardial performance in off-pump coronary artery bypass grafting. Chest 2002, 121:1183-99.
• [44]Wu ZK, Iivainen T, Pehkonen E, Laurikka J, Tarkka MR: Arrhythmias in off-pump coronary artery bypass grafting and the antiarrhythmic effect of regional ischemic preconditioning. J Cardiothorac Vasc Anesth 2003, 17:459-64.
• [45]Talha S, Charloux A, Enache I, Piquard F, Geny B: Mechanisms involved in increased plasma brain natriuretic peptide after heart transplantation. Cardiovasc Res 2011, 89:273-81.
• [46]Provenchère S, Berroeta C, Reynaud C, Baron G, Poirier I, Desmonts JM, et al.: Plasma brain natriuretic peptide and cardiac troponin I concentrations after adult cardiac surgery: association with postoperative cardiac dysfunction and 1-year mortality. Crit Care Med 2006, 34:995-1000.