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The Journal of Cardiovascular Surgery 1999 April;40(2):203-10


language: English

Stunned myocardium and cellular damage in patients undergoing valvular cardiac surgery and pretreated with captopril

Ruíz Ros J. A., Ortega V. V. *, Martínez J. A. **, Tovar I. ***, Nuño J. A. ****, Florenciano R., Fuentes M. **, Ruipérez J. A.

From the Service of Cardiology ** Cardiovascular Surgery *** Laboratory and **** Nuclear Medicine Hospital Universitario Arrixaca * Department of Histology Faculty of Medicine, Murcia, Spain


Background. Following extra­cor­po­real car­diac sur­gery, tran­sient myo­car­dial dys­func­tion (stun­ning) and cel­lu­lar dam­age may devel­op in rela­tion, ­among oth­er mech­a­nisms, to the pro­duc­tion of ­free rad­i­cals (FR) dur­ing reper­fu­sion. The pur­pose of ­this ­study is to eval­u­ate wheth­er cap­to­pril (CTP), an angio­ten­sin con­vert­ing ­enzyme inhib­i­tor ­with a thi­ol­ic ­group, ­which has ­been ­shown to be use­ful as an anti­ox­i­dant ­agent ­both in in ­vitro and in ­vivo stud­ies, can pre­vent emer­gence of ­those prob­lems ­when ­used as pre­treat­ment with­in 24 ­hours in ­patients under­go­ing val­vu­lar car­diac sur­gery.
Methods. Experimental ­design: prospective and ran­dom­ized ­study. Comparison of ­data pre-ischem­ic (pre-aor­tic clamp­ing) and ­post-reper­fu­sion (­post-car­diac rewarm­ing) was per­formed. Ejection frac­tion was com­pared pre-sur­gery, ­after sur­gery and ­after 3 ­months. Setting: cardiology and car­di­o­vas­cu­lar sur­gery ser­vic­es in a gen­er­al hos­pi­tal. Patients or par­tic­i­pants: thirty ­patients who had to under­go val­vu­lar replace­ment sur­gery ­were ran­dom­ly allo­cat­ed to two sim­i­lar ­groups, one ­group pre­treat­ed ­with cap­to­pril (CTP ­group, n=15) and the oth­er ­group with­out it (CON ­group, n=15). Exclusion cri­te­ria (­left ven­tric­u­lar ejec­tion frac­tion <40%, evi­dence of angio­graph­ic cor­o­nary dis­ease or ­prior myo­car­dial infarc­tion and per­op­er­ative myo­car­dial infarc­tion). Intervention: in CTP ­group, the ­dose of cap­to­pril admin­is­tered was 12.5 mg eve­ry 8 ­hours oral­ly, ­from 24 ­hours ­before. Measures: using elec­tron micros­co­py of myo­car­dial biop­sies tak­en ­prior to aor­tic clamp­ing and ­post-reper­fu­sion, a ­semi-quan­ti­ta­tive anal­y­sis was per­formed on the ­degree of myo­cyt­ic dam­age (MD), mit­o­chon­dri­al swell­ing (MS), sar­co­plas­mic retic­u­lum swell­ing (SRS) and con­tent in gly­co­gen gran­ules (GLY). Left ven­tric­u­lar ejec­tion frac­tion was eval­u­at­ed iso­top­i­cal­ly at ­three time­points, pre­op­er­a­tive­ly (EF1), at 2-3 ­days (EF2) and at 3 ­months (EF3). Also, ana­lyt­i­cal ­data were col­lect­ed ­from the cor­o­nary ­sinus to deter­mine crea­tine phos­phok­i­nase (CPK) and activ­ity of the angio­ten­sin con­vert­ing ­enzyme (ACE).
Results. We not­ed ­that, in gen­er­al, cel­lu­lar dam­age result­ing ­from val­vu­lar sur­gery is low, the ­degree of MS and SRS ­being low­er in the CTP ­group. In the CTP ­group, how­ev­er, ­there is a stun­ning phe­nom­e­non (EF1: 54.9±6.9%; EF2: 50.8±8.5%; EF3: 57.7±7.7%) ­which ­does not ­occur in the CON ­group (EF1: 58.0±8.3%; EF2: 60.8±10.9%; EF3: 63.0±9.3%).
Conclusions. We con­clude ­that the cel­lu­lar dam­age ­caused dur­ing val­vu­lar replace­ment sur­gery is ­small, and empha­size ­that pre­treat­ment ­with CTP fur­ther min­i­miz­es ­both MS and SRS; how­ev­er, for rea­sons as yet ­unknown, CTP pre­treat­ment may ­induce myo­car­dial stun­ning, an indi­ca­tion ­that at ­these low ­rates of cel­lu­lar dam­age, CTP has no ben­e­fi­cial ­effect, ­either ­because it is inef­fec­tive as an anti­ox­i­dant ­agent or ­because FR for­ma­tion has lit­tle reper­cus­sion in ­human ­beings, point­ing out to the like­ly exis­tence of oth­er mech­a­nisms ­that may ­induce an appear­ance of post­sur­gi­cal myo­car­dial stun­ning.

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