Cardioprotective effects of acute normovolemic hemodilution in patients with severe aortic stenosis undergoing valve replacement

Authors

  • Marc Licker,

    1. From the Department of Anesthesiology, Pharmacology and Surgical Intensive Care and the Department of Cardiovascular Surgery, University Hospital of Geneva, Geneva, Switzerland.
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  • Jorge Sierra,

    1. From the Department of Anesthesiology, Pharmacology and Surgical Intensive Care and the Department of Cardiovascular Surgery, University Hospital of Geneva, Geneva, Switzerland.
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  • Afksendiyos Kalangos,

    1. From the Department of Anesthesiology, Pharmacology and Surgical Intensive Care and the Department of Cardiovascular Surgery, University Hospital of Geneva, Geneva, Switzerland.
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  • Aristote Panos,

    1. From the Department of Anesthesiology, Pharmacology and Surgical Intensive Care and the Department of Cardiovascular Surgery, University Hospital of Geneva, Geneva, Switzerland.
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  • John Diaper,

    1. From the Department of Anesthesiology, Pharmacology and Surgical Intensive Care and the Department of Cardiovascular Surgery, University Hospital of Geneva, Geneva, Switzerland.
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  • Christoph Ellenberger

    1. From the Department of Anesthesiology, Pharmacology and Surgical Intensive Care and the Department of Cardiovascular Surgery, University Hospital of Geneva, Geneva, Switzerland.
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Errata

This article is corrected by:

  1. Errata: Erratum Volume 54, Issue 11, 3019–3020, Article first published online: 26 January 2014

  • This study was supported by institutional department funds.

Marc Licker, Department of Anesthesiology, Pharmacology and Surgical Intensive Care, Hôpital Universitaire, rue Micheli-Ducrest, CH-1211 Genève 14, Switzerland; e-mail: marc-joseph.licker@hcuge.ch.

Abstract

BACKGROUND: After acute normovolemic hemodilution (ANH), improvement of the rheologic conditions may contribute to optimize tissue oxygen delivery and attenuate ischemia-reperfusion injuries. It was hypothesized that ANH would confer additional cardioprotection in patients with ventricular hypertrophy undergoing open heart surgery.

STUDY DESIGN AND METHODS: This study was a randomized controlled trial. Forty patients scheduled for elective aortic valve replacement were randomly assigned to a control group (standard care) or an ANH group (target hematocrit level of 28%). All patients were managed with standard myocardial preservation techniques (cold blood cardioplegia, anesthetic preconditioning). The outcome measures included the release of myocardial enzymes, perioperative hemodynamic changes, the need for pharmacologic cardiovascular support, and cardiac complications.

RESULTS: In the ANH group, the postoperative release of troponin I (mean peak plasma concentrations, 1.7 ng/mL; 95% confidence interval, 1.4-2.1 ng/mL) and myocardial fraction of creatine kinase (22 U/L; range, 18-24 U/L) was significantly lower than in the control group (3.6 [range, 3.0-4.2] ng/mL and 45 [range, 39-51] U/L, respectively). In addition, requirement for inotropic support was significantly lower and fewer hemodiluted patients presented adverse cardiac events. After ANH, there was a significant decrease in heart rate (−11 ± 6%) and rate-pressure product (−16 ± 8%) until the aortic cross-clamping time and, at the end of surgery, the circulating levels of erythropoietin (EPO) were higher than in control patients (13.6 ± 4.2 mUI/mL vs. 7.3 ± 2.4 mUI/mL; p < 0.05).

CONCLUSIONS: Besides conventional cardiac preservation techniques, preoperative ANH further attenuates myocardial injuries. Optimization of preischemic myocardial oxygen delivery and/or consumption and the postconditioning effects of endogenous EPO are potential mechanisms for ANH-induced cardioprotection.

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