Remote ischemic preconditioning in aortic valve surgery: Results of a randomized controlled study

Pinaud, Frédéric; Corbeau, J.J.; Baufreton, Christophe; Binuani, Jean-Patrice; Brux, Jean-Louis De; Fouquet, Olivier; Angoulvant, Denis; Furber, Alain; Prunier, Fabrice

doi:10.1016/j.jjcc.2015.06.007

Cited by 44 publications

(40 citation statements)

References 52 publications

(35 reference statements)

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“…21 RCTs 17–37 with a total of 6302 patients met the inclusion criteria. 6 RCTs were conducted for isolated coronary artery bypass graft (CABG) 17, 22, 28–31 , 5 RCTs were done in isolated valve surgery 20, 21, 34, 35, 37 , and 10 RCTs included a combination of CABG and valve surgery 18, 19, 23–27, 32, 33, 36 . The ischemic protocol (cycles × I/R) was 3 × 5 min/5 min in 11 RCTs 17–19, 22, 26, 28, 29, 32, 35–37 , 4 × 5 min/5 min in 7 RCTs 24, 25, 27, 30, 31, 33, 34 , 3 × 10 min/10 min in 2 RCTs 20, 21 , and 2 × 5 min/5 min in 1 RCT 23 .…”

Section: Resultsmentioning

confidence: 99%

Age and Surgical Complexity impact on Renoprotection by Remote Ischemic Preconditioning during Adult Cardiac Surgery: A Meta analysis

Zhou

Bulluck

Fang

et al. 2017

Sci Rep

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We aimed to conduct an up-to-date meta-analysis to comprehensively assess the renoprotective effect of remote ischemic preconditioning (RIPC) in patients undergoing adult cardiac surgery. 21 randomized controlled trials (RCTs) with a total of 6302 patients were selected and identified. Compared with controls, RIPC significantly reduced the incidence of acute kidney injury (AKI) [odds ratio (OR) = 0.79; P = 0.02; I2 = 38%], and in particular, AKI stage I (OR = 0.65; P = 0.01; I2 = 55%). RIPC significantly shortened mechanical ventilation (MV) duration [weighted mean difference (WMD) = −0.79 hours; P = 0.002; I2 = 53%), and reduced intensive care unit (ICU) stay (WMD = −0.23 days; P = 0.07; I2 = 96%). Univariate meta-regression analyses showed that the major sources of heterogeneity for AKI stage I were age (coefficient = 0.06; P = 0.01; adjusted R2 = 0.86) and proportion of complex surgery (coefficient = 0.02; P = 0.03; adjusted R2 = 0.81). Subsequent multivariate regression and subgroup analyses also confirmed these results. The present meta-analysis suggests that RIPC reduces the incidence of AKI in adults undergoing cardiac surgery and this benefit was more pronounced in younger patients undergoing non-complex cardiac surgery. RIPC may also shorten MV duration and ICU stay. Future RCTs tailored for those most likely to benefit from RIPC warrants further investigation.

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Section: Resultsmentioning

confidence: 99%

Age and Surgical Complexity impact on Renoprotection by Remote Ischemic Preconditioning during Adult Cardiac Surgery: A Meta analysis

Zhou

Bulluck

Fang

et al. 2017

Sci Rep

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“…A randomized controlled study on patients undergoing aortic valve replacement surgery without CABG reported a lack of heart and kidney protection by RIC. This lack of protection could have been a consequence of the relatively short cross-clamp time of 55-59 min [37]. …”

Section: Discussionmentioning

confidence: 99%

Confounders of Cardioprotection by Remote Ischemic Preconditioning in Patients Undergoing Coronary Artery Bypass Grafting

et al. 2015

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Objectives: Remote ischemic conditioning (RIC) by repetitive blood pressure cuff inflation/deflation around a limb provides cardioprotection in patients undergoing coronary artery bypass grafting (CABG). Cardioprotection is confounded by risk factors, comorbidities and comedications. We aimed to identify confounders that possibly attenuate the protection provided by RIC. Methods: In a retrospective analysis of our single-center, randomized, double-blind trial of patients undergoing elective CABG with/without RIC prior to ischemic cardioplegic arrest, we analyzed demographics, medications and intraoperative variables. The primary end point was myocardial injury, as reflected by the area under the curve for serum troponin I (TnI) from baseline to 72 h after surgery. Results: In models with 2 independent variables and in the multivariate analysis, age and aortic cross-clamp time impacted on TnI release. Subgroup analyses confirmed RIC-induced protection in all age tertiles. There was no protection with an aortic cross-clamp time ≤56 min (RIC/control = 1.026 not significant), but there was protection with 57-75 min (RIC/control = 0.757; p = 0.0348) and ≥76 min (RIC/control = 0.735; p = 0.0277). Gender, β-blockers, statins, angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) and intraoperative nitroglycerine did not impact on TnI release. Conclusion: Age, gender, β-blockers, statins, ACE inhibitors, ARBs and intraoperative nitroglycerine have no significant impact on RIC-induced cardioprotection during CABG. However, greater myocardial ischemia/reperfusion injury at longer cross-clamp time facilitates the detection of protection by RIC.

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“…148 However, one study with increased infarct size also found increased need for postoperative inotropic support and increased ventilation time 128 (Table 3). Also, in adult cardiac valve surgery [150][151][152][153][154][155] and in pediatric cardiac surgery, 103,[156][157][158][159][160][161] most studies found reduced infarct size, as reflected by reduced biomarker release ( Figure 3). The need for inotropic support was reduced in some studies.…”

Section: Remote Ischemic Conditioningmentioning

confidence: 99%

“…Propofol is known to abrogate protection by remote ischemic conditioning, which is seen with volatile anesthesia, 153,[162][163][164] and volatile anesthesia is the recommended anesthesia for patients at cardiac risk. 233,234 As seen from Figure 3, the only study with a significant increase of infarct size 128 and all neutral studies where information on the anesthetic regime is available 36,38,[130][131][132][133][135][136][137][138]150,155 had used propofol anesthesia, which, therefore, appears as the major denominator of all neutral/negative studies on remote ischemic conditioning in cardiovascular surgery.…”

Section: Current State Of Translation For Remote Ischemic Conditioningmentioning

confidence: 99%

Time to Give Up on Cardioprotection?

Heusch

Rassaf

2016

Circulation Research

174

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Abstract:The mortality from acute myocardial infarction (AMI) remains significant, and the prevalence of postmyocardial infarction heart failure is increasing. Therefore, cardioprotection beyond timely reperfusion is needed. Conditioning procedures are the most powerful cardioprotective interventions in animal experiments. However, ischemic preconditioning cannot be used to reduce infarct size in patients with AMI because its occurrence is not predictable; several studies in patients undergoing surgical coronary revascularization report reduced release of creatine kinase and troponin. Ischemic postconditioning reduces infarct size in most, but not all, studies in patients undergoing interventional reperfusion of AMI, but may require direct stenting and exclusion of patients with >6 hours of symptom onset to protect. Remote ischemic conditioning reduces infarct size in patients undergoing interventional reperfusion of AMI, elective percutaneous or surgical coronary revascularization, and other cardiovascular surgery in many, but not in all, studies. Adequate dose-finding phase II studies do not exist. There are only 2 phase III trials, both on remote ischemic conditioning in patients undergoing cardiovascular surgery, both with neutral results in terms of infarct size and clinical outcome, but also both with major problems in trial design. We discuss the difficulties in translation of cardioprotection from animal experiments and proof-ofconcept trials to clinical practice. Given that most studies on ischemic postconditioning and all studies on remote ischemic preconditioning in patients with AMI reported reduced infarct size, it would be premature to give up on cardioprotection. (Circ Res. 2016;119:676-695.

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Remote ischemic preconditioning in aortic valve surgery: Results of a randomized controlled study

Abstract: RIPC did not exhibit significant cardiac or kidney protective effects in patients undergoing aortic valve replacement surgery without CABG.

Cited by 44 publications

References 52 publications

Age and Surgical Complexity impact on Renoprotection by Remote Ischemic Preconditioning during Adult Cardiac Surgery: A Meta analysis

Age and Surgical Complexity impact on Renoprotection by Remote Ischemic Preconditioning during Adult Cardiac Surgery: A Meta analysis

Confounders of Cardioprotection by Remote Ischemic Preconditioning in Patients Undergoing Coronary Artery Bypass Grafting

Time to Give Up on Cardioprotection?

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