Abstract
Objective: Transapical aortic valve implantation (TA-AVI) has become a fast growing alternative to conventional aortic valve replacement (cAVR) particularly for patients burdened with serious comorbidities. We investigated whether the inflammatory response triggered by TA-AVI reflects the less invasive nature of this procedure. Method: In this prospective observational study 25 patients undergoing aortic valve replacement (AVR; 15 cAVR and 10 TA-AVI) were included. Serial plasma cytokine concentrations (IL-6, IL-8, and IL-10) were measured by commercially available enzyme-linked immunosorbent assay kits at six different time points before, during, and after surgery. Results: Plasma levels of all three cytokines increased during and after both procedures and returned to baseline before the patient's discharge. Peak values of IL-6 were 258 ± 113 pg/mL in AVR patients versus 111 ± 101 pg/mL in TA-AVI patients and were reached 12 hours after surgery. For IL-8, peak values were 51 ± 29 pg/mL 1 hour after surgery in AVR patients versus 15 ± 20 pg/mL on wound closure in TA-AVI patients. Plasma levels of IL-6 and IL-8 were significantly reduced in the TA-AVI group as compared with cAVR. IL-10 is markedly activated in both groups yet its induction is more prominent in AVR patients with peak values of 51 ± 28 pg/mL for AVR versus 24 ± 18 pg/mL for TA-AVI on wound closure. Conclusion: TA-AVI compared with cAVR results in a significant reduction but not elimination of a systemic inflammatory response, which is attributable to cardiopulmonary bypass-dependent and bypass-independent factors.
Key words
aortic valve and root - inflammation - systemic (includes cells - mediators) - heart valve - transapical - percutaneous
References
-
1
Iung B, Baron G, Butchart E G et al.
A prospective survey of patients with valvular heart disease in Europe: the Euro Heart Survey on Valvular Heart Disease.
Eur Heart J.
2003;
24
(13)
1231-1243
-
2
Bonow R O, Carabello B A, Chatterjee K et al.
2006 Writing Committee Members; American College of Cardiology/American Heart Association Task Force. 2008 Focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons.
Circulation.
2008;
118
(15)
e523-e661
-
3
Wendt D, Osswald B R, Kayser K et al.
Society of Thoracic Surgeons score is superior to the EuroSCORE determining mortality in high risk patients undergoing isolated aortic valve replacement.
Ann Thorac Surg.
2009;
88
(2)
468-475
-
4
Iung B, Cachier A, Baron G et al.
Decision-making in elderly patients with severe aortic stenosis: why are so many denied surgery?.
Eur Heart J.
2005;
26
(24)
2714-2720
-
5
Paparella D, Yau T M, Young E.
Cardiopulmonary bypass induced inflammation: pathophysiology and treatment. An update.
Eur J Cardiothorac Surg.
2002;
21
(2)
232-244
-
6
Laffey J G, Boylan J F, Cheng D C.
The systemic inflammatory response to cardiac surgery: implications for the anesthesiologist.
Anesthesiology.
2002;
97
(1)
215-252
-
7
Butler J, Rocker G M, Westaby S.
Inflammatory response to cardiopulmonary bypass.
Ann Thorac Surg.
1993;
55
(2)
552-559
-
8
Levy J H, Tanaka K A.
Inflammatory response to cardiopulmonary bypass.
Ann Thorac Surg.
2003;
75
(2)
S715-S720
-
9
Kukielka G L, Smith C W, Manning A M, Youker K A, Michael L H, Entman M L.
Induction of interleukin-6 synthesis in the myocardium. Potential role in postreperfusion inflammatory injury.
Circulation.
1995;
92
(7)
1866-1875
-
10
Frering B, Philip I, Dehoux M, Rolland C, Langlois J M, Desmonts J M.
Circulating cytokines in patients undergoing normothermic cardiopulmonary bypass.
J Thorac Cardiovasc Surg.
1994;
108
(4)
636-641
-
11
Walther T, Dewey T, Borger M A et al.
Transapical aortic valve implantation: step by step.
Ann Thorac Surg.
2009;
87
(1)
276-283
-
12
Franke A, Lante W, Fackeldey V et al.
Pro-inflammatory cytokines after different kinds of cardio-thoracic surgical procedures: is what we see what we know?.
Eur J Cardiothorac Surg.
2005;
28
(4)
569-575
-
13
Wan S, Izzat M B, Lee T W, Wan I Y, Tang N L, Yim A P.
Avoiding cardiopulmonary bypass in multivessel CABG reduces cytokine response and myocardial injury.
Ann Thorac Surg.
1999;
68
(1)
52-57
-
14
Wan I Y, Arifi A A, Wan S et al.
Beating heart revascularization with or without cardiopulmonary bypass: evaluation of inflammatory response in a prospective randomized study.
J Thorac Cardiovasc Surg.
2004;
127
(6)
1624-1631
-
15
Wan S, DeSmet J M, Barvais L, Goldstein M, Vincent J L, LeClerc J L.
Myocardium is a major source of proinflammatory cytokines in patients undergoing cardiopulmonary bypass.
J Thorac Cardiovasc Surg.
1996;
112
(3)
806-811
-
16
Biancari F, Lahtinen J, Lepojärvi S et al.
Preoperative C-reactive protein and outcome after coronary artery bypass surgery.
Ann Thorac Surg.
2003;
76
(6)
2007-2012
-
17
Eppinger M J, Ward P A, Bolling S F, Deeb G M.
Regulatory effects of interleukin-10 on lung ischemia-reperfusion injury.
J Thorac Cardiovasc Surg.
1996;
112
(5)
1301-1306
-
18
Frangogiannis N G, Mendoza L H, Lindsey M L et al.
IL-10 is induced in the reperfused myocardium and may modulate the reaction to injury.
J Immunol.
2000;
165
(5)
2798-2808
-
19
Allan C K, Newburger J W, McGrath E et al.
The relationship between inflammatory activation and clinical outcome after infant cardiopulmonary bypass.
Anesth Analg.
2010;
111
(5)
1244-1251
-
20
Gormley S M, Armstrong M A, McMurray T J, McBride W T.
The effect of methylprednisolone on cytokine concentration and leukocyte adhesion molecule expression in an isolated cardiopulmonary bypass system.
Cytokine.
2003;
22
(5)
149-155
-
21
Bedi A, McBride W T, Armstrong M A, Murray J M, Fee J P.
Xenon has no effect on cytokine balance and adhesion molecule expression within an isolated cardiopulmonary bypass system.
Br J Anaesth.
2002;
89
(4)
546-550
-
22
Wan S, LeClerc J L, Vincent J L.
Inflammatory response to cardiopulmonary bypass: mechanisms involved and possible therapeutic strategies.
Chest.
1997;
112
(3)
676-692
-
23
Gormley S M, McBride W T, Armstrong M A et al.
Plasma and urinary cytokine homeostasis and renal function during cardiac surgery without cardiopulmonary bypass.
Cytokine.
2002;
17
(2)
61-65
-
24
McBride W T, Armstrong M A, Crockard A D, McMurray T J, Rea J M.
Cytokine balance and immunosuppressive changes at cardiac surgery: contrasting response between patients and isolated CPB circuits.
Br J Anaesth.
1995;
75
(6)
724-733
Dr. Andreas Goetzenich, MD
Department of Anesthesiology
Research Fellow & Specialist in Anesthesiology
University Clinic RWTH Aachen
Pauwellstr. 30
52074 Aachen
Germany
Phone: +49 24 18 00
Fax: +49 24 13 33 55 56
Email: agoetzenich@ukaachen.de
