BackgroundRemote ischemic preconditioning (RIPC) is reported to reduce biomarkers of ischemic and reperfusion injury in patients undergoing cardiac surgery, but uncertainty about clinical outcomes remains. MethodsWe conducted a prospective, double-blind, multicenter, randomized, controlled trial involving adults who were scheduled for elective cardiac surgery requiring cardiopulmonary bypass under total anesthesia with intravenous propofol. The trial compared upper-limb RIPC with a sham intervention. The primary end point was a composite of death, myocardial infarction, stroke, or acute renal failure up to the time of hospital discharge. Secondary end points included the occurrence of any individual component of the primary end point by day 90. ResultsA total of 1403 patients underwent randomization. The full analysis set comprised 1385 patients (692 in the RIPC group and 693 in the sham-RIPC group). There was no significant between-group difference in the rate of the composite primary end point (99 patie...

https://www.nejm.org/doi/pdf/10.1056/NEJMoa1413579

A Multicenter Trial of Remote Ischemic Preconditioning for Heart Surgery

Remote Ischemic Conditioning

Pre-, post-, and remote conditioning of the myocardium are well described adaptive responses that markedly enhance the ability of the heart to withstand a prolonged ischemia/reperfusion insult and provide therapeutic paradigms for cardioprotection. Nevertheless, more than 25 years after the discovery of ischemic preconditioning, we still do not have established cardioprotective drugs on the market. Most experimental studies on cardioprotection are still undertaken in animal models, in which ischemia/reperfusion is imposed in the absence of cardiovascular risk factors. However, ischemic heart disease in humans is a complex disorder caused by, or associated with, cardiovascular risk factors and comorbidities, including hypertension, hyperlipidemia, diabetes, insulin resistance, heart failure, altered coronary circulation, and aging. These risk factors induce fundamental alterations in cellular signaling cascades that affect the development of ischemia/reperfusion injury per se and responses to cardioprotective interventions. Moreover, some of the medications used to treat these risk factors, including statins, nitrates, and antidiabetic drugs, may impact cardioprotection by modifying cellular signaling. The aim of this article is to review the recent evidence that cardiovascular risk factors and their medication may modify the response to cardioprotective interventions. We emphasize the critical need to take into account the presence of cardiovascular risk factors and concomitant medications when designing preclinical studies for the identification and validation of cardioprotective drug targets and clinical studies. This will hopefully maximize the success rate of developing rational approaches to effective cardioprotective therapies for the majority of patients with multiple risk factors.

/pdf/interaction-of-risk-factors-comorbidities-and-comedications-4148oj0qud.pdf

Interaction of Risk Factors, Comorbidities, and Comedications with Ischemia/Reperfusion Injury and Cardioprotection by Preconditioning, Postconditioning, and Remote Conditioning

The 30-year anniversary of the discovery of 'ischaemic preconditioning' is in 2016. This endogenous phenomenon can paradoxically protect the heart from acute myocardial infarction by subjecting it to one or more brief cycles of ischaemia and reperfusion. Apart from complete reperfusion, this method is the most powerful intervention known for reducing infarct size. The concept of ischaemic preconditioning has evolved into 'ischaemic conditioning', a term that encompasses a number of related endogenous cardioprotective strategies, applied either directly to the heart (ischaemic preconditioning or postconditioning) or from afar, for example a limb (remote ischaemic preconditioning, perconditioning, or postconditioning). Investigations of signalling pathways underlying ischaemic conditioning have identified a number of therapeutic targets for pharmacological manipulation. Over the past 3 decades, a number of ischaemic and pharmacological cardioprotection strategies, discovered in experimental studies, have been examined in the clinical setting of acute myocardial infarction and CABG surgery. The results from many of the studies have been disappointing, and no effective cardioprotective therapy is currently used in clinical practice. Several large, multicentre, randomized, controlled clinical trials on cardioprotection have highlighted the challenges of translating ischaemic conditioning and pharmacological cardioprotection strategies into patient benefit. However, a number of cardioprotective therapies have shown promising results in reducing infarct size and improving clinical outcomes in patients with ischaemic heart disease.

/pdf/ischaemic-conditioning-and-reperfusion-injury-54igg9n97b.pdf

Ischaemic conditioning and reperfusion injury

https://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(13)61450-6.pdf

Cardioprotective and prognostic effects of remote ischaemic preconditioning in patients undergoing coronary artery bypass surgery: a single-centre randomised, double-blind, controlled trial

Introduction: The use of cardiopulmonary bypass during coronary artery bypass grafting (CABG) surgery has been associated with substantial morbidity. Off-pump coronary bypass (OPCAB) surgery has become a widely used technique during recent years. EuroSCORE risk scale is the most rigorously evaluated scoring system in cardiac surgery to preoperatively quantify the risk of death and other serious postoperative complications. The aim of this prospective observational study was to compare the mortality and morbidity between OPCAB and conventional CABG in three major preoperative groups as assessed by EuroSCORE. Material and Method: All consecutive patients undergoing isolated coronary artery bypass surgery between January 2003 and December 2004 at Wellington Hospital were included. In this period, 347 patients had conventional CABG and 254 patients had OPCAB. Data were prospectively collected according to Australasian Society of Cardiothoracic Surgeons’ cardiac surgery data set. The preoperative additive EuroSCORE was computed in each patient and the patients were divided into three risk groups. Results of OPCAB and conventional CABG were compared on basis of EuroSCORE group. Results: OPCAB surgery is preferably performed in patients with low-risk. OPCAB group had lesser number of grafts per patient. When adjusted with risk score, there was no statistically significant difference in mortality in any of the three groups. No significant difference was found for stroke, renal dysfunction, atrial fibrillation, re-exploration for bleeding, deep sternal wound infection, or pulmonary complications in either of three groups. However, inotropic requirement and requirements of blood products were less in OPCAB group. Conclusion: OPCAB does not offer any significant advantage in terms of mortality and morbidity over conventional CABG. (J Card Surg 2010;25:495-500)

A Prospective Observational Study to Compare Conventional Coronary Artery Bypass Grafting Surgery with Off-Pump Coronary Artery Bypass Grafting on Basis of EuroSCORE

A Randomised Controlled Double-Blind Study of Remote Ischaemic Preconditioning in High-Risk Cardiac Surgery

Anterior cervicothoracic approach to an upper thoracic spinal endodermal cyst

Validation of the Cardiac Prioritisation Score for Heart Valve Surgery

Comparison of a New Clinical Score with Individual Clinician Judgement for Assigning Priority for Heart Valve Surgery

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