Kardioprotektivni efekat udaljenog ishemijskog prekondicioniranja tokom hirurške revaskularizacije miokarda u akutnom koronarnom sindromu bez ST elevacije

Abstract

Ranije studije su prikazale kontroverzne rezultate protektivnog dejstva udaljenog ishemijskog prekondicioniranja (RICP) na ishemični miokard u različitim populacijama bolesnika tokom kardiohirurških operacija. Cilj ovog rada je da prikaže efekte udaljenog ishemijskog prekondicioniranja na rane rezultate hirurške revaskularizacije miokarda u bolesnika sa akutnim koronarnim sindromom bez ST segment elevacije (NSTEMI AKS). Metode: Ova studija obuhvatila je 60 bolesnika koji su randomizovani u dve grupe: Grupa 1 koja je tertirana sa RICP i Grupa 2 bez RICP (kontrolna grupa). Poređeni su pre, intra i postoperativni klinički parametri ali je glavni cilj miokardna lezija koja se odražava kroz vrednosti koncentracije Troponina I merenih preoperativno i 1, 6, 12, 24, 48 i 72h postoperativno. Sekundarni ciljevi su bili hemodinamski parametri, krvarenje, vreme lečenja u jedinici intenzivne nege i mortalitet. Rezultati: Grupe 1 i 2 su bile slične po preoperativnim karakteristikama kao što su životna dob, NYHA klasa, EuroSCORE II, ejekciona frakcija leve komore i u zastupljenosti trosudovne koronarne bolesti. Vreme kardiopulmonalnog bajpasa (86.90±29.60 vs 66.47 ±20.90, p=0.003), vreme klemovanja aorte (57.50±18.32 vs 46.37±14.78, p=0.012) i broj graftova (3.5(3-4) vs 2,83(2-3), p<0.001) bili su različiti. Ostale intra i postoperativne varijable se nisu razlikovale među grupama. Nije bilo razlike u vrednostima C reaktivnog proteina (CRP) i postoperativnih hemodinamskih parametara. Vrednosti Troponina I su ispitivane u sedam vremenskih intervala i nisu pokazale značajnu razliku među grupama (preoperativno 0,61±1,45 vs 0,79±1,95; 1h 2,15±4,67 vs 1,14±1,33; 6h 4,59±6,36 vs 3,39±2,79; 12h 3,59±2,68 vs 3,87±3,65; 24h 2,94±3,02 vs 4,00±4,60; 48h 1,71±1,67 vs 2,13±2,32 i 72h postoperativno 1,18±1,40 vs 1,24±1,45). Takođe nije bilo značajne razlike u pojavi neželjenih događaja, dužini trajanja bolničkog lečenja i mortalitetu među grupama. Zaključak: Udaljeno ishemijsko prekondicioniranje tokom hirurške revaskularizacije miokarda u akutnom korornarnom sindromu bez ST segment elevacije ne obezbeđuje bolju protekciju miokarda i hemodinamske kararkteristike ali su neophodne veće randomizovane studije da bi se dokazao pravi efekat RICP.

Previous studies have shown controversial results of the protective effect of remote ischemic preconditioning (RICP) on ischemic myocardium in different patient populations during cardiac surgery. The aim of this study was to assess effects of remote ischemic preconditioning on early outcomes in patients undergoing coronary bypass surgery (CABG) following acute coronary syndrome without persistent ST segment elevation (NSTEMI ACS). Methods: This trial included 60 patients randomized into two groups: Group 1 received RICP and Group 2 had no RICP (control group). Pre, intra and postoperative clinical parameters were compared but primary endpoint was myocardial injury reflected as the value of Troponin I (cTnI) measured preoperatively and 1, 6, 12, 24, 48 and 72h postoperatively. The secondary endpoints were hemodynamic parameters, blood loss, intensive care unit (ICU) stay and mortality. Results: Groups 1 and 2 were similar regarding preoperative characteristics including age, NYHA class, EuroSCORE II, left ventricular ejection fraction and the presence of triple vessel coronary disease. Cardiopulmonary bypass time (86.90±29.60 vs 66.47±20.90, p=0.003), cross clamp time (57.50±18.32 vs 46.37±14.78, p=0.012) and number of conduits (3.5(3-4) vs 2.83(2-3), p<0.001) were different. Other intra and postoperative variables did not differ between groups. There were no differences in C reactive protein (CRP) levels and postoperative hemodynamic parameters. Troponin values were examined at seven time points and revealed no significant differences between groups (preoperatively 0,61±1,45 vs 0,79±1,95; 1h 2,15±4,67 vs 1,14±1,33; 6h 4,59±6,36 vs 3,39±2,79; 12h 3,59±2,68 vs 3,87±3,65; 24h 2,94±3,02 vs 4,00±4,60; 48h 1,71±1,67 vs 2,13±2,32 and 72h postoperatively 1,18±1,40 vs 1,24±1,45). Furthermore, there were no significant differences in adverse events, hospital stay and mortality between groups. Conclusions: Treatment with RICP during CABG following NSTEMI ACS did not provide better myocardial protection and hemodynamics characteristics but further larger randomized studies are needed to prove its real value.