Remote Ischemic Conditioning in Percutaneous Coronary Intervention and Coronary Artery Bypass Grafting

Yetgin, Tuncay; Manintveld, Olivier C.; Boersma, Eric; Kappetein, Arie Pieter; Geuns, Robert‐Jan van; Zijlstra, Felix; Duncker, Dirk J.; Giessen, Wim J. van der

doi:10.1253/circj.cj-12-0518

Cited by 34 publications

(32 citation statements)

References 39 publications

(29 reference statements)

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“…Although it is the largest study to date to simultaneously document cardioprotection and prognostic benefit, the trial is in fact not sufficiently sized for comparing clinical outcomes. The difference in MACCE and mortality between groups seems real, but the early clinical effects have not been observed in other trials 4,14 and require confirmation in large-scale trials. As in the study by Hong et al, 7 an important detail in the present study is the anesthetic regimens used.…”

Section: Schmidt Et Al Remote Ischemic Preconditioning 1279mentioning

confidence: 83%

“…Although several trials have investigated the effect of RIPC in the context of CABG [3][4][5] and a recent meta-analysis of these trials indicates that RIPC reduces troponin release in these patients, 6 there is continued skepticism regarding the clinical efficacy of RIPC. In contrast to earlier studies, Thielmann et al 2 conducted a detailed follow-up analysis on clinical end points, albeit these were secondary outcomes in the trial design.…”

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confidence: 99%

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Remote Ischemic Preconditioning

Schmidt

Kristiansen

Bøtker

2013

Circulation Research

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During the past 3 decades, several experimental studies have shown that ischemic conditioning reduces myocardial damage by modifying ischemia-reperfusion injury. A recent study in the Lancet indicates that remote ischemic preconditioning translates into clinical benefit in patients undergoing coronary artery bypass surgery. The implications of the study extend to patients undergoing elective and acute coronary angioplasty and beyond.Adjunctive therapies to reduce myocardial ischemiareperfusion injury related to cardiac surgery and percutaneous coronary interventions have yet to find their way into clinical practice, mainly because no pharmacological or mechanical cardioprotective strategy has convincingly shown clinically relevant benefit to the patient.1 That may be about to change. In a recent study by Thielmann et al, 2 329 low-risk patients undergoing elective isolated on-pump first-time coronary artery bypass grafting (CABG) were randomized to either standard CABG or CABG preceded by remote ischemic preconditioning (RIPC), achieved by 3 cycles of 5-minute upper limb ischemia through inflation of a blood pressure cuff followed by 5-minute deflation. The results indicate that RIPC confers a prognostic benefit to the patient.The study was conducted as a single-center, double-blind, randomized, controlled trial. The primary end point was perioperative myocardial injury assessed by troponin I release measured at 6, 12, 24, 48, and 72 hours after surgery. The secondary end points comprised all-cause mortality, major adverse cardiac and cerebrovascular events (MACCE), and repeat revascularization at 30 days, 1 year, and at completion of follow-up, ranging from 1 to >4 years with a mean of 1.54 years. The group demographics were well-matched, and there were no significant differences in baseline risk factors.The authors demonstrated acutely reduced myocardial injury (assessed by troponin I release), as also shown previously by others 3 but, in addition, they also found a reduction in allcause and cardiac mortality, as well as MACCE in the intervention group during the follow-up period. During the follow-up period, MACCE occurred 23 times in the control group versus 8 times in the RIPC group (P=0.011). The authors observed 11 deaths in the control group and only 3 deaths in the RIPC group (P=0.046). The combined end point (death, MACCE, and repeat revascularization) exhibited a hazard ratio of 0.38 (0.21-0.70) in favor of RIPC. There was no difference between groups regarding the need for revascularization.The present study is noteworthy because it is the first to show that the reduction in surrogate end points in patients treated with RIPC before CABG translates into clinical benefit. Although several trials have investigated the effect of RIPC in the context of CABG 3-5 and a recent meta-analysis of these trials indicates that RIPC reduces troponin release in these patients, 6 there is continued skepticism regarding the clinical efficacy of RIPC. In contrast to earlier studies, Thielmann et al 2 conducted a detail...

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Section: Schmidt Et Al Remote Ischemic Preconditioning 1279mentioning

confidence: 83%

mentioning

confidence: 99%

Remote Ischemic Preconditioning

Schmidt

Kristiansen

Bøtker

2013

Circulation Research

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“…Cellular mechanisms that promote reperfusion injury are incompletely understood [16,17]. Ischemia-reperfusion injury induces several histopathological changes and a cascade leading to tissue injury.…”

Section: Discussionmentioning

confidence: 99%

“…Their report was according to experiments on canine hearts following coronary ligation in which reperfusion accelerated the development of necrosis [16]. Several pathophysiologic processes contribute to myocardial I-R injury during perioperative cardiac dysfunction and related morbidity.…”

Section: Discussionmentioning

confidence: 99%

Comparison of Serum Myocardial Biomarkers Following Two Different Methods of Venoaortic Connection in Coronary Artery Bypass Grafting: A Randomized Clinical Trial

Jelodar

Zarrabi

Nazifi

et al. 2017

Zahedan J Res Med Sci

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Background: Myocardium will expose to excessive ischemia and reperfusion during post-cardiac surgery, hence the aim of this study was to investigate the cardioprotective effect of sequential partial aortic side biting technique for proximal veno-aortic anastomosis constructions in patients undergoing coronary artery bypass grafting (CABG). Methods: In this randomized clinical trial study, 60 consecutive patients who were diagnosed to suffering from triple vessel coronary artery diseases were selected. CABG patients were assigned randomly into two groups; the first group received sooner and gradual myocardial reperfusion one-by-one top end venous anastomosis to the aorta (sequential aortic side biting technique) (n = 30) and the second group undergo proximal anastomoses constructed during a single period of aortic side biting (single aortic side biting technique) (n = 30). The serum levels of myocardial damage biomarkers including creatine phosphokinase-MB (CPK-MB), Troponin I, glutathione peroxidase (GPX), superoxide dismutase (SOD), malondialdehyde (MDA) and catalase (CAT) were measured preoperatively, postoperatively and 24 h after operation. Independent t-tests was used to compare results between groups. Results: The level of all myocardial biomarkers increased after the operation. Those in study group had significantly lower levels of troponin I (P < 0.001), CPK-MB (P = 0.001), GPX (P = 0.007), SOD (P = 0.005), and CAT (P = 0.015), 24h after the operation when compared to control group. Only the serum level of CPK-MB was significantly lower in study group after the operation (P = 0.029) while the other markers were comparable. Conclusions: Sequential partial occluding aortic side biting technique associated with less myocardial damage and ischemiareperfusion injury compared to conventional single method in patients undergoing elective coronary grafting.

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“…Many more trials have since been conducted, along with several meta-analyses specifically analyzing CABG results. Yetgin et al included 891 CABG patients (13 trials) in their review and demonstrated RIC to have an overall beneficial effect on myocardial injury biomarkers in this subgroup [11]. Their findings revealed anesthetic agents (cardioprotection induced by volatile agents) and the timing of RIC protocol to be confounding factors.…”

Section: Ric In Cabg Surgerymentioning

confidence: 99%

Remote ischemic conditioning: Current clinical perspectives

Page

Prunier

2015

Journal of Cardiology

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Remote ischemic conditioning (RIC) constitutes a promising method in which a tissue or organ is exposed to intermittent ischemia/reperfusion periods enabling it to provide protection to a distant target organ. RIC has been tested in various clinical settings through its simple application by means of intermittent inflation of a blood pressure cuff placed on a limb, primarily evaluating its potential abilities to decrease myocardial injury biomarkers. Its use on other organs, such as the kidneys or brain, has recently been a topic of research. To date, no study has yet been powerful enough to reach a conclusion on the potential benefit of RIC on clinical outcomes. The future role of RIC in the clinical arena could be clarified by the large phase III trials currently underway targeting major outcomes as primary endpoints.

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Remote Ischemic Conditioning in Percutaneous Coronary Intervention and Coronary Artery Bypass Grafting

Cited by 34 publications

References 39 publications

Remote Ischemic Preconditioning

Remote Ischemic Preconditioning

Comparison of Serum Myocardial Biomarkers Following Two Different Methods of Venoaortic Connection in Coronary Artery Bypass Grafting: A Randomized Clinical Trial

Remote ischemic conditioning: Current clinical perspectives

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