Kardioprotektivni efekat udaljenog ishemijskog prekondicioniranja tokom hirurške revaskularizacije miokarda kod bolesnika sa akutnim koronarnim sindromom bez elevacije ST segmenta
Sažetak
Uvod/Cilj. Zaštita srca i drugih organa od ishemijsko-reperfuzonih oštećenja može biti obezbeđena udaljenim ishemijskim prekondicioniranjem (remote ischemic preconditioning – RIPC) sa kratkim epizodama ishemije i reperfuzije u udaljenim tkivima. Cilj rada bio je da se utvrdi efekat RIPC na rane rezultate hirurške revaskularizacije miokarda kod bolesnika sa akutnim koronarnim sindromom bez elevacije ST segmenta. Metode. Studijom su bila obuhvaćena 42 bolesnika koji su bili randomizovani u dve grupe: grupu 1 koja je bila tretirana sa RIPC i grupu 2 bez RIPC (kontrolna grupa). Poređeni su pre-, intra- i postoperativni parametri, ali je glavni cilj bio miokardna lezija koja se odražava kroz vrednosti koncentracije troponina I merenih preoperativno i 1, 6, 12, 24, 48 i 72 sata postoperativno. Analizirani su vrednosti hemodinamskih parametara, krvarenje, vreme lečenja u jedinici intenzivne nege, mortalitet i ostalo. Rezultati. Grupe 1 i 2 bile su slične po preoperativnim karakteristikama, kao što su životna dob, New York Heart Association (NYHA) klasa, EuroSCORE II i ejekciona frakcija leve komore. Jedina razlika među grupama bila je u zastupljenosti trosudovne koronarne bolesti sa dominacijom u RIPC grupi [20 (100%) vs. 17 (77,3%), p = 0,049]. Vreme kardiopulmonalnog bajpasa [srednja vrednost (± standardna devijacija): 83,0 (22,9) vs. 67,0 (17,4) minuta, p = 0,015], vreme kleme na aorti [57,9 (15,4) vs. 44,3 (14,3) minuta, p = 0,005] i broj graftova [medijan (25–75. percentil): 3,5 (3–4) vs. 3 (2–3), p = 0,002] bili su različiti. Ostale intra- i postoperativne varijable se nisu razlikovale među grupama. Nije bilo razlike u vrednostima C reaktivnog proteina i postoperativnih hemodinamskih parametara. Srednje vrednosti troponina u svim ispitivanim vremenskim intervalima nisu pokazale značajnu razliku među grupama (p0h = 0,740, p1h = 0,212, p6h = 0,504, p12h = 0,597, p24h = 0,562, p48h = 0,465 i p72h = 0,715). Takođe, nije bilo značajne razlike u pojavi neželjenih događaja, dužini trajanja bolničkog lečenja i mortalitetu između grupa. Zaključak. Primena RIPC tokom hirurške revaskularizacije miokarda kod bolesnika sa akutnim korornarnim sindromom bez elevacije ST segmenta ne obezbeđuje bolju miokardnu zaštitu i hemodinamske kararkteristike, ali su neophodne veće randomizovane studije da bi se dokazao pravi efekat RIPC.
Reference
Thielmann M, Kottenberg E, Kleinbongard P, Wendt D, Gedik N, Pasa S, et al. Cardioprotective and prognostic effects of re-mote ischaemic preconditioning in patients undergoing coro-nary artery bypass surgery: a single-centre randomised, double-blind, controlled trial. Lancet 2013; 382(9892): 597‒604.
Cheung MM, Kharbanda RK, Konstantinov IE, Shimizu M, Frndova H, Li J, et al. Randomized controlled trial of the effects of remote ischemic preconditioning on children undergoing car-diac surgery: first clinical application in humans. J Am Coll Cardiol 2006; 47(11): 2277‒82.
Hausenloy DJ, Mwamure PK, Venugopal V, Harris J, Barnard M, Grundy E, et al. Effect of remote ischaemic preconditioning on myocardial injury in patients undergoing coronary artery bypass graft surgery: a randomised controlled trial. Lancet 2007; 370(9587): 575‒9.
Kharbanda RK, Nielsen TT, Redington AN. Translation of re-mote ischaemic preconditioning into clinical practice. Lancet 2009; 374(9700): 1557‒65.
Roffi M, Patrono C, Collet JP, Mueller C, Valgimigli M, Andreotti F, et al. 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: Task Force for the Management of Acute Coronary Syndromes in Patients Presenting without Persistent ST-Segment Elevation of the European Society of Cardiology (ESC). Eur Heart J 2016; 37(3): 267‒315.
Ranasinghe I, Alprandi-Costa B, Chow V, Elliott JM, Waites J, Counsell JT, et al. Risk stratification in the setting of non-ST elevation acute coronary syndromes 1999-2007. Am J Cardiol 2011; 108(5): 617‒24.
Venugopal V, Hausenloy DJ, Ludman A, Di Salvo C, Kolvekar S, Yap J, et al. Remote ischaemic preconditioning reduces myo-cardial injury in patients undergoing cardiac surgery with cold-blood cardioplegia: a randomised controlled trial. Heart 2009; 95(19): 1567‒71.
Li L, Luo W, Huang L, Zhang W, Gao Y, Jiang H, et al. Remote perconditioning reduces myocardial injury in adult valve re-placement: a randomized controlled trial. J Surg Res 2010; 164(1): e21‒6.
Xie JJ, Liao XL, Chen WG, Huang DD, Chang FJ, Chen W, et al. Remote ischaemic preconditioning reduces myocardial inju-ry in patients undergoing heart valve surgery: randomised con-trolled trial. Heart 2012; 98(5): 384‒8.
Ali ZA, Callaghan CJ, Lim E, Ali AA, Nouraei SA, Akthar AM, et al. Remote ischemic reconditioning reduces myocardi-al and renal injury after elective abdominal aortic aneurysm repair: a randomized controlled trial. Circulation 2007; 116(11 Suppl): I98‒105.
Kharbanda RK, Mortensen UM, White PA, Kristiansen SB, Schmidt MR, Hoschtitzky JA, et al. Transient limb ischemia induces re-mote ischemic preconditioning in vivo. Circulation 2002; 106(23): 2881‒3.
Meybohm P, Bein B, Brosteanu O, Cremer J, Gruenewald M, Stoppe C, et al. A A Multicenter Trial of Remote Ischemic Precondi-tioning for Heart Surgery. N Engl J Med 2015; 373(15): 1397‒407.
Hausenloy DJ, Candilio L, Evans R, Ariti C, Jenkins DP, Kolvekar S, et al. Remote Ischemic Preconditioning and Outcomes of Cardiac Surgery. N Engl J Med 2015; 373(15): 1408‒17.
Rahman IA, Mascaro JG, Steeds RP, Frenneaux MP, Nightingale P, Gosling P, et al. Remote ischemic preconditioning in human coronary artery bypass surgery: from promise to isappoint-ment? Circulation 2010; 122(11 Suppl): S53‒9.
Walsh M, Whitlock R, Garg AX, Légaré JF, Duncan AE, Zim-merman R, et al. Effects of remote ischemic preconditioning in high-risk patients undergoing cardiac surgery (Remote IM-PACT): a randomized controlled trial. CMAJ 2016; 188(5): 329‒36
Young PJ, Dalley P, Garden A, Horrocks C, La Flamme A, Mahon B, et al. A pilot study investigating the effects of remote is-chemic preconditioning in high-risk cardiac surgery using a randomised controlled double-blind protocol. Basic Res Car-diol 2012; 107(3): 256.
Ghosh S, Galiñanes M. Protection of the human heart with is-chemic preconditioning during cardiac surgery: role of cardio-pulmonary bypass. J Thorac Cardiovasc Surg 2003; 126(1): 133‒42.
Thielmann M, Kottenberg E, Boengler K, Raffelsieper C, Neuhaeuser M, Peters J, et al. Remote ischemic preconditioning reduces myocardial injury after coronary artery bypass surgery with crystalloid cardioplegic arrest. Basic Res Cardiol 2010; 105(5): 657‒64.Received on April 14, 2018.