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Bilateral Common Carotid Artery Occlusion as an Adequate Preconditioning Stimulus to Induce Early Ischemic Tolerance to Focal Cerebral Ischemia
Published on: May 9, 2013
Bilateral remote ischemic conditioning in children: A two-center, double-blind, randomized controlled trial in young
Nigel E Drury1,2, Carin van Doorn3, Rebecca L Woolley4,5
1Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom.
Insights
Bilateral remote ischemic preconditioning did not protect young children from heart injury during congenital heart defect surgery. The intervention showed no benefit and potential harm in some cases, so it is not recommended.
Area of Science:
- Cardiology
- Pediatric Cardiac Surgery
- Ischemic Preconditioning
Background:
- Congenital heart defects are common in children.
- Surgical repair is often necessary.
- Myocardial protection strategies are crucial during pediatric cardiac surgery.
Purpose of the Study:
- To evaluate the cardioprotective effects of bilateral remote ischemic preconditioning (BRIP) in children undergoing surgery for congenital heart defects.
- To determine if BRIP reduces myocardial injury.
Main Methods:
- Prospective, double-blind, randomized controlled trial involving 120 children (3-36 months).
- Participants underwent tetralogy of Fallot repair or ventricular septal defect closure.
- Randomized to BRIP or sham intervention; primary outcome was troponin-T levels.
Main Results:
- BRIP did not attenuate myocardial injury, with higher troponin-T levels observed in the preconditioning group (P=0.04).
- No differential effect seen based on oxygen saturation.
- Evidence of potential harm in unstented tetralogy of Fallot subgroup.
Conclusions:
- Bilateral remote ischemic preconditioning is not cardioprotective in pediatric cardiac surgery.
- Routine use of BRIP for myocardial protection in this population cannot be recommended.
- Further investigation into potential harm is warranted.
Objective:
The study objective was to determine whether adequately delivered bilateral remote ischemic preconditioning is cardioprotective in young children undergoing surgery for 2 common congenital heart defects with or without cyanosis.
Methods:
We performed a prospective, double-blind, randomized controlled trial at 2 centers in the United Kingdom. Children aged 3 to 36 months undergoing tetralogy of Fallot repair or ventricular septal defect closure were randomized 1:1 to receive bilateral preconditioning or sham intervention. Participants were followed up until hospital discharge or 30 days. The primary outcome was area under the curve for high-sensitivity troponin-T in the first 24 hours after surgery, analyzed by intention-to-treat. Right atrial biopsies were obtained in selected participants.
Results:
Between October 2016 and December 2020, 120 eligible children were randomized to receive bilateral preconditioning (n = 60) or sham intervention (n = 60). The primary outcome, area under the curve for high-sensitivity troponin-T, was higher in the preconditioning group (mean: 70.0 ± 50.9 μg/L/h, n = 56) than in controls (mean: 55.6 ± 30.1 μg/L/h, n = 58) (mean difference, 13.2 μg/L/h; 95% CI, 0.5-25.8; P = .04). Subgroup analyses did not show a differential treatment effect by oxygen saturations (pinteraction = .25), but there was evidence of a differential effect by underlying defect (pinteraction = .04). Secondary outcomes and myocardial metabolism, quantified in atrial biopsies, were not different between randomized groups.
Conclusions:
Bilateral remote ischemic preconditioning does not attenuate myocardial injury in children undergoing surgical repair for congenital heart defects, and there was evidence of potential harm in unstented tetralogy of Fallot. The routine use of remote ischemic preconditioning cannot be recommended for myocardial protection during pediatric cardiac surgery.
