Evaluation of high-dose atorvastatin pretreatment influence in patients preconditioning of post coronary artery bypass graft surgery: A prospective triple blind randomized clinical trial.

Context: Atorvastatin is considered as lipid reductive drugs with anti-inflammatory and pleotherapic effects in coronary artery bypass graph (CABG). Aim: This study is conducted to evaluate the effects of atorvastatin in CABG. Setting and Design: Patients with a coronary bypass graph procedure in Nemazee hospital in Shiraz were divided into two 50-groups receiving high-dose (80 mg) and low-dose (20 mg) atorvastatin. Materials and Methods: Troponin I, creatinine kinase-MB (CK-MB), atrial fibrillation (AF) after CABG, duration of mechanical ventilation, inotrope duration of consumption, blood sugar profile, liver and renal function, death during 30 days of CABG, MACE (major advance cardiac events) during admission in ICU, and 1 month follow up were surveyed. Statistical Analysis: Collected data were analyzed by independent and paired t-test and Chi square. Results: AST was increased, ALT, ALK-P after CABG were decreased, and urine volume in the second day of admission in ICU was increased in the high-dose group. There was an increase and following decrease in blood sugar of patients in the high-dose after CABG. An inflammatory marker after CABG was raised in both groups, ck-mb had an increase, and then followed by a reduction. Troporin had no significant differences between groups. Patients with high-dose atorvastatin had better glomerular filtration rate and renal performance. Along with decreasing AF in the case group, hemodynamics' disorder reduced and there was less bleeding. Conclusion: According to the above, it seems that a short-time prescription of high dose of atorvastatin in CABG can lead to better renal function, decreasing of arrhythmia and AF.

The Effect of Melatonin on the Serum Level of Interleukin 6 and Interleukin 9 in Coronary Artery Bypass Grafting Surgery.

OBJECTIVE: Cardiopulmonary bypass has been recognized as one of the main causes of systemic inflammatory response syndrome, leading to post-operative complications. The aim of this study was to investigate the effect of melatonin on the serum levels of interleukin 6 (IL-6) and IL-9 in patients undergoing coronary artery bypass grafting surgery. METHODS: Forty-four patients undergoing elective coronary artery bypass surgery were randomly allocated into two study groups of melatonin (n = 23) and placebo (n = 21). Patients in the melatonin group received two melatonin tablet, 5 mg daily for 3 days before surgery, 10 mg tablet (two doses of 5 mg) 1 h before induction of anesthesia and finally, 10 mg melatonin tablet in the intensive care unit, placebo group patients received placebo at the same time periods. Serum levels of IL-9 and IL-6 were measured as baseline (T1), before induction of anesthesia (T2), 6 and 24 h after off pump (T3, T4). Data were analyzed using SPSS 23 software (IBM Corp., Armonk, NY, USA). RESULTS: The mean serum level of IL-6 was significantly lower in the melatonin group at T3 and T4 (p ＜ 0.05). Also, in both groups, serum levels of IL-6 in T3 showed a significant increase compared to T1. Serum levels of IL-9 had no significant difference between the two groups at T1, T2, T3, and T4. CONCLUSION: The results of this study showed that pre-operative melatonin administration could modify inflammatory cytokines secretion such as IL-6 while it has no significant effect on the serum levels of IL- 9. Neither of the changes was clinically significant.

The Effect of Remote Ischemic Preconditioning on the Incidence of Acute Kidney Injury in Patients Undergoing Coronary Artery Bypass Graft Surgery: A Randomized Controlled Trial.

BACKGROUND: Remote ischemic preconditioning (RIPC) protects other organs from subsequent lethal ischemic injury, but uncertainty remains. We investigated if RIPC could prevent acute kidney injury (AKI) in patients undergoing coronary artery bypass graft (CABG) surgery. METHODS: This parallel-group, double-blind, randomized, controlled trial was done on adults undergoing elective or urgent on-pump CABG surgery from 2013 to 2017 in Shiraz, Iran. Patients were allocated to RIPC or control groups through permuted blocking. The patients in the RIPC group received three cycles of 5 min ischemia and 5 min reperfusion in the upper arm after induction of anesthesia. We placed an uninflated cuff on the arm for 30 min in the control group. The study primary endpoint was an incidence of AKI. Secondary endpoints included short-term clinical outcomes. We compared categorical and continuous variables using Pearson χ2 and unpaired t tests, respectively. P<0.05 was considered significant. RESULTS: of the 180 patients randomized to RIPC (n=90) and control (n=90) groups, 87 patients in the RIPC and 90 patients in the control group were included in the analysis. There was no significant difference in the incidence of AKI between the groups (38 patients [43.7%] in the RIPC group and 41 patients [45.6%] in the control group; relative risk, 0.96; 95% confidence interval, 0.69 to 1.33; P=0.80). No significant differences were seen regarding secondary endpoints such as postoperative liver function, atrial fibrillation, and inpatient mortality. CONCLUSION: RIPC did not reduce the incidence of AKI, neither did it improve short-term clinical outcomes in patients undergoing on-pump CABG surgery. Trial Registration Number: IRCT2017110537254N1.

Diagnosing Myocardial Contusion after Blunt Chest Trauma.

A myocardial contusion refers to a bruise of the cardiac muscle, the severity of which can vary depending on the severity of the injury and when the injury occurs. It is a major cause of rapid death which happens after blunt chest trauma and should be suspected at triage in the emergency department. We demonstrated that suspected myocardial contusion patients who have normal electrocardiograms (ECGs) and biomarker tests can be safely discharged. However, if the test results are abnormal, the next steps should be echocardiography and more advanced measures. Diagnosing myocardial contusion is very difficult because of its nonspecific symptoms. If a myocardial contusion happens, cardiogenic shock or arrhythmia must be anticipated, and the patient must be carefully monitored.

Ultrasound for Localization of Central Venous Catheter: A Good Alternative to Chest X-Ray?

BACKGROUND: Chest radiography after central venous catheter (CVC) insertion is the main method of verifying the catheter location. Despite the widespread use of radiography for detecting catheter position, x-ray may not always be readily available, especially in the operating room. OBJECTIVES: We aimed to compare contrast-enhanced ultrasonography (CEUS) and chest radiography for detecting the correct location of CVCs. METHODS: One hundred sixteen consecutive patients with indications for CVC before cardiac surgery were enrolled in this observational study. After catheter insertion, CEUS was performed. Portable radiography was obtained postoperatively in the intensive care unit. Sensitivity, specificity, and predictive values were determined by comparing the ultrasonography results with radiographic findings as a reference standard. RESULTS: Chest radiography revealed 16 CVC misplacements: two cases of intravascular and 14 cases of right atrium (RA) misplacement. CEUS detected 11 true catheter malpositionings in the RA, while it could not recognize seven catheter placements correctly. CEUS showed two false RA misplacements and five falsely correct CVC positions. A sensitivity of 98% and specificity of 69% were achieved for CEUS in detecting CVC misplacements. Positive and negative predictive values were 95% and 85%, respectively. The interrater agreement (kappa) between CEUS and radiography was 0.72 (P < 0.001). CONCLUSIONS: Despite close concordance between ultrasonography and chest radiography, CEUS is not a suitable alternative for standard chest radiography in detecting CVC location; however, considering its high sensitivity and acceptable specificity in our study, its usefulness as a triage method for detecting CVC location on a real-time basis in the operating room cannot be ignored.

Cardioprotective Effect of Extended Remote Ischemic Preconditioning in Patients Coronary Artery Bypass Grafting Undergoing: A Randomized Clinical Trial.

BACKGROUND: The cardioprotective effect of ischemic preconditioning has been known for many years. Since the temporary ischemia in the heart may cause lethal cardiac effects, the idea of creating ischemia in organs far from the heart such as limbs was raised as remote ischemic preconditioning (RIPC). We hypothesized that the extension of RIPC has more cardioprotective effect in patients undergoing coronary artery bypass graft (CABG) surgeries. METHODS: In this triple-blind randomized clinical trial study, 96 patients were randomly divided into 3 groups and two blood pressure cuffs were placed on both upper and lower extremities. In group A, only upper extremity cuff and in group B upper limb and lower limb cuff was inflated intermittently and group C was the control group. RIPC was induced with three 5-min cycles of cuff inflation about 100 mmHg over the initial systolic blood pressure before starting cardiopulmonary bypass. The primary endpoints were troponin I and creatine phosphokinase-myoglobin isoenzyme (CK-MB). RESULTS: Six hours after the termination of CPB, there was a peak release of the troponin I level in all groups (group A=4.90 ng/ml, group B=4.40 ng/ml, and group C=4.50 ng/ml). There was a rise in plasma CK-MB in all groups postoperatively and there were not any significant differences in troponin I and CK-MB release between the three groups. CONCLUSION: RIPC induced by upper and lower limb ischemia does not reduce postoperative myocardial enzyme elevation in adult patients undergoing CABG. TRIAL REGISTRATION NUMBER: IRCT2012071710311N1.

Effects of a New Metabolic Conditioning Supplement on Perioperative Metabolic Stress and Clinical Outcomes: A Randomized, Placebo-Controlled Trial.

BACKGROUND: Insulin resistance is a measure of metabolic stress in the perioperative period. Before now, no clinical trial has determined the summative effects of glutamine, L-carnitine, and antioxidants as metabolic conditioning supplements in the perioperative period. OBJECTIVES: The purpose of this study was to determine the effects of a new conditioning supplement on perioperative metabolic stress and clinical outcomes in non-diabetic patients. PATIENTS AND METHODS: In this randomized controlled trial, 89 non-diabetic patients scheduled for coronary artery bypass grafting, with ejection fractions above 30%, were selected. Using the balanced block randomization method, the patients were allocated to one of four study arms: 1) SP (supplement/placebo): supplement seven days before and placebo 30 days after the surgery; 2) PS: placebo before and supplement after the surgery; 3) SS: supplement before and after the surgery; and 4) PP: placebo before and after the surgery. The supplement was composed of glutamine, L-carnitine, vitamin C, vitamin E, and selenium, which was manufactured for the first time by this research team. Five blood samples were drawn: seven days preoperatively, at the entrance to the operating room, while leaving the operating room, seven days postoperatively, and 30 days postoperatively. Levels of glucose, insulin, and HbA1c were measured in blood samples. Insulin resistance and sensitivity were calculated using a formula. Surgical complications were assessed 30 days postoperatively. Data analysis was done using one-way ANOVA, the Chi-square test, and a general linear model repeated-measures analysis with Bonferroni adjustment. RESULTS: Blood glucose levels were increased postoperatively in the four groups (< 0.001), but a significantly higher increase occurred in the PP group compared to the SP (0.027), PS (0.026), and SS (0.004) groups. The superficial wound infection rate was significantly different between the four groups (0.021): 26.08% in PP, 9.09% in SP, 4.54% in PS, and 0% in SS. CONCLUSIONS: Our new metabolic conditioning supplement, whether given pre- or postoperatively, led to better perioperative glycemic control and decreased postsurgical wound infections in non-diabetic patients.

Incidence and outcome of documented fungal endocarditis.

BACKGROUND: Fungal endocarditis, the most severe form of infective endocarditis, is characterized by excessive mortality and morbidity. OBJECTIVES: The present study aimed to analyze the characteristics of fungal endocarditis to improve the management of these patients. MATERIALS AND METHODS: In this cross-sectional study, vegetations on the mitral or tricuspid valves and embolic material surgically removed from the patients with suspected infective endocarditis between December 2009 and November 2011 were examined for fungal infection by direct smear and culture, and the susceptibility patterns of the isolated species were determined. Then, blood samples were cultured on BACTEC media and real-time PCR was done with blood and tissue samples. RESULTS: Of the 31 patients with suspected infective endocarditis who did not respond to antibacterial therapy, 11 had confirmed fungal endocarditis. The most frequent predisposing risk factors were previous surgery and drug abuse. The organisms isolated were Aspergillus spp. and Candida albicans. Resistance to amphotericin B and itraconazole was observed in Aspergillus species, and to fluconazole in Candida albicans. Positive PCR results were obtained in blood and tissue samples. CONCLUSIONS: Fungal endocarditis should be considered in the patients not responsive to antimicrobials. Moreover, management of these patients can be improved with molecular diagnostic methods and by determining the susceptibility patterns of the etiologic agents.

Serum Lactate Is not Correlated with Mixed or Central Venous Oxygen Saturation for Detecting Tissue Hypo Perfusion During Coronary Artery Bypass Graft Surgery: A Prospective Observational Study.

OBJECTIVES: Effective assessment of tissue perfusion is highly important during Coronary Artery Bypass Graft (CABG). Mixed venous O2 saturation (Svo2) is one of the best and routinely used markers of tissue perfusion. However, this method is costly and leads to considerable complications. Thus, the present study aimed to determine whether the Svo2 can be substituted with central venous saturation (Scvo2) and if there is any correlation between lactate level and Svo2. METHODS: This prospective observational study was conducted on 62 patients scheduled for CABG. After induction and maintenance of anesthesia, blood samples drawn from central venous, pulmonary artery, and radial artery were used to measure Scvo2, Svo2 and serum lactate level respectively before and after Cardio Pulmonary Bypass (CPB). Pearson's correlation test was used to determine the correlation between Svo2 and Scvo2 as well as between Svo2 and serum lactate level. Besides, P < 0.05 was considered as statistically significant. RESULTS: Overall, 62 Patients, 33 males (53.2%) and 29 females (46.8%) were enrolled into the present study. The most common coexisting illness was hypertension detected in 33 patients (53.2%) followed by hypercholesterolemia in 28 ones (44.4%). In this study, Svo2 was positively correlated with Scvo2 (r = 0.63, P < 0.001). However, no correlation was found between Svo2 and lactate (r = 0.124, P = 0.348). CONCLUSIONS: In summary, Scvo2 is considered as the best substitute of Svo2 for detecting tissue hypo perfusion during CPB. Although the lactate level had been considered as an appropriate marker of tissue perfusion and ischemia, it was not correlated to Svo2 during CABG.

Ability of amiodarone and propranolol alone or in combination to prevent post-coronary bypass atrial fibrillation.

Atrial fibrillation (AF) is the most common arrhythmia in coronary artery bypass grafting (CABG) patients. The purpose of this study was to determine the best prophylaxis for AF prior to CABG. In this double-blind randomized study, 240 consecutive patients underwent elective CABG. They were then divided randomly into three groups to receive propranolol (n = 80), amiodarone (n = 80), or both drugs (n = 80). All groups received their medications from preoperative day 7 to post-CABG day 5. The patients were well matched for age, sex, risk factors, comorbidities, ejection fraction, and cardioplegic technique. Post-CABG AF developed in 22 patients (9.2%) of whom 13 (16.3%) had received propranolol, 5 (6.3%) had received amiodarone, and 4 (5%) had received both drugs. The difference between the propranolol group and the other two groups was statistically significant (P= 0.02), but that between the amiodarone and amiodarone + propranolol group was not significant. Age was a significant predictor of post-CABG AF (P= 0.034). Other factors such as diabetes, sex, hyperlipidemia, smoking, hypertension, family history, cerebrovascular accidents, left atrial size, and ejection fraction were not significant predictors of post-CABG AF. Preoperative amiodarone or amiodarone with propranolol were more effective than propranolol in reducing the frequency of AF. There was a strong relationship between age and the development of AF. (Clinicaltrial.gov registration NCT00654290.).

Comparison of the effects of levosimendan and papaverine on human internal mammary artery and saphenous vein.

PURPOSE: Internal mammary artery (IMA) and saphenous vein (SV) are two most common vessels used in coronary artery bypass grafting (CABG). In the present study, the effect of levosimendan (a novel inotropic/vasodilator compound) and papaverine are compared, using IMA and SV obtained from CABG patients. METHODS: Unused segments of IMA and SV of each patient were cut into two rings of 3 mm length. Four rings (two from IMA, two from SV) were suspended in an organ bath, contracted with norepinephrine and then the responses to the cumulative concentrations of levosimendan and papaverine were recorded. RESULTS: Levosimendan relaxed IMA but failed to relax SV completely. In addition, its IC50 value (concentration which reduced 50% of initial contraction) to relax SV was about 300 times higher than the IC50 value for IMA. Its arteriodilating concentration was in the range of its clinically effective inotropic concentration. Papaverine relaxed both vascular preparations completely. Its IC50 value was about 2.4 times higher toward SV in comparison to that of IMA. CONCLUSIONS: It is concluded that levosimendan is much more potent to relax norepinephrine-induced contraction of human IMA in comparison to its effect on human SV. It may have the potential to be used as a mixed inotropic/arteriodilator compound in several clinical settings including CABG in which it can increase cardiac contractility and prevent IMA vasospasm.