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A Randomised Controlled Double-Blind Study of Remote Ischaemic Preconditioning in High-Risk Cardiac Surgery
474
Heart, Lung and Circulation 2013;22:455–489
2012 ANZSCTS Annual Scientific Meeting
ABSTRACTS
2012 Poster Presentation/Panel 17
2012 Poster Presentation/Panel 18
A Randomised Controlled Double-Blind Study of Remote Ischaemic Preconditioning in High-Risk Cardiac Surgery
Experience of Endobronchial Valve Management of Chronic Airflow Limitation
Paul Young 1,2 , Barry Mahon 1,∗ , Paul Dalley 1 , Alexander Garden 1,3 , Christopher Horrocks 1 , Anne La Flamme 3 , John Miller 3 , Janine Pilcher 2 , Mark Weatherall 2 , Jenni Williams 3 , William Young 3 , Richard Beasley 1,2,4
Matthew Bayfield, Louise Rushworth, Mavis Duncanson, Mohammad Ali Malik, James Nadel
1 Wellington
Introduction: After extensive experience with both thoracoscopic and open lung-volume-reductionsurgery (LVRS) before endobronchial valves (EBV) became available, we moved to EBV in hopes of reducing patient morbidity. The aim of the valve is to create atelectasis in hyper-inflated emphysematous segments of the lung, simulating the effects of LVRS. With this study we assessed one of the worlds largest case series in this field. We evaluated patients’ functional outcomes and in-patient morbidity of this procedure. Methods: Hospital records of 69 patients that underwent bronchoscopic implantation of endobronchial valves were analysed. A total of 112 procedures were recorded, among which 98 (88%) were EBV implantations and 14 (13%) were EBV removals. Data for FVC, FEV1, 6-minute walk distance (6MWD) and St. George Questionnaire (SGQ) was evaluated for changes before and after the procedure. FVC and FEV1 data for 69 (70.4%) procedures was retrieved, 6MWD data for 43 (43.9%) procedures was retrieved and SGQ data for 33 (33.7%) procedures was retrieved. Patients’ hospital stay time of 90 (80.35%) procedures was also noted. All post-operative complications were documented. Results: Improvement in FVC and FVC% predicted was 0.13 L (5.5%) (p = 0.05) and 3.53% (5.83%) (p = 0.04) respectively. Improvement in FEV1 and FEV1% predicted was 0.05 L (5.75%) (p = 0.02) and 1.96% (5.99%) (p = 0.02) respectively. Increase in 6MWD was 18.72 m (5.09%) (p = 0.05) and change in SGQ was −8.57 (p = 0.01). The average hospital stay per procedure was 2.00 days, (8.88% = <1 day, 54.44% = 1 day, 17.77% = 2 days, 7.77% = 3–5 days, 7.77% = >5 days). The most common postoperative complications were RTI’s (16 (23%) patients), expectoration of valves (six (8.69%) patients) and pneumothorax (six (8.695%) patients). Among the six patients that developed pneumothorax, five patients were treated with underwater seal chest tube drainage and one had the valves removed. Discussion: Management of emphysema with EBV implantation shows mild improvement in pulmonary function, exercise tolerance and quality of life. These outcomes may be comparable to results achieved with conventional LVRS. Bronchoscopic implantation is less invasive than LVRS and reduces patient morbidity by reducing hospital stay and decreasing postoperative complications. The data analysed also includes patients that have a reduction in pulmonary function after implantation (non-responders). As this treatment method is still under development, better understanding of nonresponders will lead to improved outcomes of this procedure.
2 Medical
Hospital, Wellington, New Zealand Research Institute of New Zealand, Wellington, New
Zealand 3 Victoria 4 Otago
University, Wellington, New Zealand University, Wellington, New Zealand
Introduction: Remote ischaemic preconditioning (RIPC) describes the phenomenon by which brief periods of ischaemia in one organ can condition other organs to subsequent prolonged ischaemia. There is interest in the potential utility of this technique in protecting the heart from ischaemic injury induced by cardiopulmonary bypass; however, its efficacy in high risk cardiac surgery is unknown. Methods: Ninety-six adult participants undergoing double valve surgery, triple valve surgery, mitral valve surgery, CABG plus valve(s), CABG with documented preoperative ejection fraction of less than 50%, or any ‘redo’ operation were recruited at Wellington Hospital between 18 May 2010 and 23 June 2011. Phase 2b randomised, double blind, controlled trial comparing RIPC (three cycles of 5 min of upper limb ischaemia induced by inflating a blood pressure cuff to 200 mmHg with 5 min of reperfusion) with control. Main endpoints: plasma high sensitivity troponin T (hsTNT) levels at six and 12 h, worst post-operative acute kidney injury (AKI) by RIFLE criteria, and noradrenaline duration. Results: hsTNT levels were log-normally distributed and higher with RIPC than control at six hours (810 ng/ml [IQR 527–1724] vs. 634 ng/ml [429–1012]; ratio of means 1.41 [95% CI 1.03–1.93]; P = 0.04) and 12 h (742 ng/ml [IQR 427–1700] vs. 514 ng/ml [IQR 356–833]; ratio of means 1.56 [95% CI 1.10–2.23]; P = 0.01). In the RIPC group, 35/48 (72.9%) had no AKI, 5/48 (10.4%) had AKI risk, and 8/48 (16.7%) had either renal injury or failure vs. controls where 34/48 (70.8%) had no AKI, 7/48 (14.6%) had AKI risk, and 7/48 (14.6%) had renal injury or failure (Chi-squared 0.41; two degrees of freedom; P = 0.82). RIPC increased postoperative noradrenaline support duration (21 h [IQR 7–45] vs. 9 h [IQR 3–19]; ratio of means 1.70 [95% CI 1.03–2.08]; P = 0.04). Conclusion: RIPC does not reduce hsTNT, AKI, or ICUsupport requirements in high risk cardiac surgery and may worsen outcomes. http://dx.doi.org/10.1016/j.hlc.2013.03.043
Sydney, Australia
http://dx.doi.org/10.1016/j.hlc.2013.03.044
Heart, Lung and Circulation 2013;22:455–489
2012 ANZSCTS Annual Scientific Meeting
ABSTRACTS
2012 Poster Presentation/Panel 17
2012 Poster Presentation/Panel 18
A Randomised Controlled Double-Blind Study of Remote Ischaemic Preconditioning in High-Risk Cardiac Surgery
Experience of Endobronchial Valve Management of Chronic Airflow Limitation
Paul Young 1,2 , Barry Mahon 1,∗ , Paul Dalley 1 , Alexander Garden 1,3 , Christopher Horrocks 1 , Anne La Flamme 3 , John Miller 3 , Janine Pilcher 2 , Mark Weatherall 2 , Jenni Williams 3 , William Young 3 , Richard Beasley 1,2,4
Matthew Bayfield, Louise Rushworth, Mavis Duncanson, Mohammad Ali Malik, James Nadel
1 Wellington
Introduction: After extensive experience with both thoracoscopic and open lung-volume-reductionsurgery (LVRS) before endobronchial valves (EBV) became available, we moved to EBV in hopes of reducing patient morbidity. The aim of the valve is to create atelectasis in hyper-inflated emphysematous segments of the lung, simulating the effects of LVRS. With this study we assessed one of the worlds largest case series in this field. We evaluated patients’ functional outcomes and in-patient morbidity of this procedure. Methods: Hospital records of 69 patients that underwent bronchoscopic implantation of endobronchial valves were analysed. A total of 112 procedures were recorded, among which 98 (88%) were EBV implantations and 14 (13%) were EBV removals. Data for FVC, FEV1, 6-minute walk distance (6MWD) and St. George Questionnaire (SGQ) was evaluated for changes before and after the procedure. FVC and FEV1 data for 69 (70.4%) procedures was retrieved, 6MWD data for 43 (43.9%) procedures was retrieved and SGQ data for 33 (33.7%) procedures was retrieved. Patients’ hospital stay time of 90 (80.35%) procedures was also noted. All post-operative complications were documented. Results: Improvement in FVC and FVC% predicted was 0.13 L (5.5%) (p = 0.05) and 3.53% (5.83%) (p = 0.04) respectively. Improvement in FEV1 and FEV1% predicted was 0.05 L (5.75%) (p = 0.02) and 1.96% (5.99%) (p = 0.02) respectively. Increase in 6MWD was 18.72 m (5.09%) (p = 0.05) and change in SGQ was −8.57 (p = 0.01). The average hospital stay per procedure was 2.00 days, (8.88% = <1 day, 54.44% = 1 day, 17.77% = 2 days, 7.77% = 3–5 days, 7.77% = >5 days). The most common postoperative complications were RTI’s (16 (23%) patients), expectoration of valves (six (8.69%) patients) and pneumothorax (six (8.695%) patients). Among the six patients that developed pneumothorax, five patients were treated with underwater seal chest tube drainage and one had the valves removed. Discussion: Management of emphysema with EBV implantation shows mild improvement in pulmonary function, exercise tolerance and quality of life. These outcomes may be comparable to results achieved with conventional LVRS. Bronchoscopic implantation is less invasive than LVRS and reduces patient morbidity by reducing hospital stay and decreasing postoperative complications. The data analysed also includes patients that have a reduction in pulmonary function after implantation (non-responders). As this treatment method is still under development, better understanding of nonresponders will lead to improved outcomes of this procedure.
2 Medical
Hospital, Wellington, New Zealand Research Institute of New Zealand, Wellington, New
Zealand 3 Victoria 4 Otago
University, Wellington, New Zealand University, Wellington, New Zealand
Introduction: Remote ischaemic preconditioning (RIPC) describes the phenomenon by which brief periods of ischaemia in one organ can condition other organs to subsequent prolonged ischaemia. There is interest in the potential utility of this technique in protecting the heart from ischaemic injury induced by cardiopulmonary bypass; however, its efficacy in high risk cardiac surgery is unknown. Methods: Ninety-six adult participants undergoing double valve surgery, triple valve surgery, mitral valve surgery, CABG plus valve(s), CABG with documented preoperative ejection fraction of less than 50%, or any ‘redo’ operation were recruited at Wellington Hospital between 18 May 2010 and 23 June 2011. Phase 2b randomised, double blind, controlled trial comparing RIPC (three cycles of 5 min of upper limb ischaemia induced by inflating a blood pressure cuff to 200 mmHg with 5 min of reperfusion) with control. Main endpoints: plasma high sensitivity troponin T (hsTNT) levels at six and 12 h, worst post-operative acute kidney injury (AKI) by RIFLE criteria, and noradrenaline duration. Results: hsTNT levels were log-normally distributed and higher with RIPC than control at six hours (810 ng/ml [IQR 527–1724] vs. 634 ng/ml [429–1012]; ratio of means 1.41 [95% CI 1.03–1.93]; P = 0.04) and 12 h (742 ng/ml [IQR 427–1700] vs. 514 ng/ml [IQR 356–833]; ratio of means 1.56 [95% CI 1.10–2.23]; P = 0.01). In the RIPC group, 35/48 (72.9%) had no AKI, 5/48 (10.4%) had AKI risk, and 8/48 (16.7%) had either renal injury or failure vs. controls where 34/48 (70.8%) had no AKI, 7/48 (14.6%) had AKI risk, and 7/48 (14.6%) had renal injury or failure (Chi-squared 0.41; two degrees of freedom; P = 0.82). RIPC increased postoperative noradrenaline support duration (21 h [IQR 7–45] vs. 9 h [IQR 3–19]; ratio of means 1.70 [95% CI 1.03–2.08]; P = 0.04). Conclusion: RIPC does not reduce hsTNT, AKI, or ICUsupport requirements in high risk cardiac surgery and may worsen outcomes. http://dx.doi.org/10.1016/j.hlc.2013.03.043
Sydney, Australia
http://dx.doi.org/10.1016/j.hlc.2013.03.044