ABSTRACT
Myocardial ischemia/reperfusion injury is a major problem in cardiac surgery, characterized by an enhanced inflammatory response postoperatively. Sevoflurane has anti-inflammatory effects and may attenuate this injury. This study describes a novel approach to using sevoflurane as a local anti-inflammatory drug and not as an anesthetic. Therefore, a pediatric oxygenator with a sevoflurane vaporizer was integrated into the blood cardioplegia system of an adult bypass system. In addition, a gas blender was implemented to regulate pO2 and pCO2 concentrations in the cardioplegia. This proof-of-principle study was tested in vivo and shows that it is feasible to deliver sevoflurane locally while regulating O2 and CO2 concentrations. Moreover, this set-up enables one to use only the specific cardioprotective features of sevoflurane. Inflammatory responses were attenuated, both locally (i.e. the heart) as well as systemically through intramyocardial delivery of sevoflurane.
Subject(s)
Anesthetics/administration & dosage , Cardioplegic Solutions/administration & dosage , Heart Arrest, Induced/methods , Methyl Ethers/administration & dosage , Myocardial Reperfusion Injury/prevention & control , Aged , Female , Heart Arrest, Induced/adverse effects , Humans , Male , Middle Aged , Sevoflurane , Volatile Organic Compounds/administration & dosageABSTRACT
BACKGROUND: Inflammation is considered a key mediator of complications after cardiac surgery. Sevoflurane has been shown to quench inflammation and to provide cardioprotection in preclinical studies. Clinical studies using sevoflurane confirm this effect on inflammation but do not consistently show clinical benefits. This paradox may indicate that the contribution of inflammation to postoperative sequalae is less than commonly thought or that systemic doses are too low in their local concentration. To test the latter, we evaluated the effects of intramyocardial sevoflurane delivery. METHODS: Selective myocardial sevoflurane delivery was performed during aortic cross-clamping in patients undergoing valve surgery (n=11). Results were compared with a control group not receiving sevoflurane (n=10). A reference group (n=5) was added to evaluate the effects of systemic sevoflurane delivery. Paired arterial and myocardial venous blood samples were collected at various time points post-reperfusion. Inflammatory mediators and myocardial cell damage were studied. RESULTS: Intramyocardial delivery was superior to systemic delivery in attenuation of interleukin-6 and interleukin-8 (-44% and -25%, respectively; both P=0.001). Myocardial and systemic sevoflurane delivery effectively suppressed surgery-related inflammatory responses including postoperative C-reactive protein levels when compared with controls [63 (47-99) (P=0.01) and 58 (56-81) (P=0.04) compared with 107 (79-144) mg litre(-1)]. Sevoflurane treatment did not reduce postoperative troponin T, creatine kinase, and creatine kinase-MB values. CONCLUSIONS: This proof-of-concept study suggests that intramyocardial delivery compared with the systemic delivery of sevoflurane more strongly attenuates the systemic inflammatory response after cardiopulmonary bypass without reducing postoperative markers of myocardial cell damage. CLINICAL TRIAL REGISTRATION: Nederlands Trial Register NTR2089.
Subject(s)
Cardiotonic Agents/therapeutic use , Methyl Ethers/therapeutic use , Mitral Valve/surgery , Myocarditis/blood , Myocarditis/drug therapy , Postoperative Complications/blood , Postoperative Complications/drug therapy , Adult , Aged , Aged, 80 and over , Anesthetics, Inhalation/administration & dosage , Anesthetics, Inhalation/blood , Anesthetics, Inhalation/therapeutic use , Biomarkers/blood , C-Reactive Protein/drug effects , Cardiac Surgical Procedures/methods , Cardiopulmonary Bypass/methods , Cardiotonic Agents/administration & dosage , Cardiotonic Agents/blood , Female , Humans , Interleukin-6/blood , Interleukin-8/blood , Interleukin-8/drug effects , Male , Methyl Ethers/blood , Middle Aged , Prospective Studies , Sevoflurane , Single-Blind MethodABSTRACT
BACKGROUND: Heart failure is characterised as a strong risk factor for systemic failure after cardiac surgery. However, the impact has never been substantiated. METHODS: Patients with heart failure (n = 48) - scheduled for elective ventricular reconstruction or external constraint device-were compared with a one-to-one matched control group of patients without heart failure undergoing cardiac surgery between 2006 and 2009. RESULTS: As expected, patients with heart failure more frequently experienced complications definitely related to pump failure (p = 0.01). However, complications not related to their pump failure were also more often observed, such as prolonged mechanical ventilation, sepsis and vasoplegia (p = 0.01). Overall, organ dysfunction-circulatory, renal, and pulmonary failure-was often observed in heart failure patients, contributing to a prolonged stay in the intensive care unit (p < 0.001) as well as in hospital (p = 0.01). CONCLUSION: The adverse postoperative course in patients with heart failure is not only directly related to circulatory failure, but merely reflects a systemic dysregulation. Our findings suggest that heart failure impacts outcome and should therefore be included in prevailing risk classification systems. Offensive perioperative treatment strategies, focused on the main complications in patients with heart failure, will lead to improved results after cardiac surgery.