Abstract
BackgroundPatients with left ventricular (LV) hypertrophy may suffer ischemia-reperfusion injuries at the time of cardiac surgery with impairment in left ventricular function. Using transesophageal echocardiography (TEE), we evaluated the impact of glucose-insulin potassium (GIK) on LV performances in patients undergoing valve replacement for aortic stenosis.MethodsIn this secondary analysis of a double-blind randomized trial, moderate-to-high risk patients were assigned to receive GIK (20 IU insulin with 10 mEq KCL in 50 ml glucose 40%) or saline over 60 min upon anesthetic induction. The primary outcomes were the early changes in 2-and 3-dimensional left ventricular ejection fraction (2D and 3D-LVEF), peak global longitudinal strain (PGLS) and transmitral flow propagation velocity (Vp).ResultsAt the end of GIK infusion, LV-FAC and 2D- and 3D-LVEF were unchanged whereas Vp (mean difference [MD + 7.9%, 95% confidence interval [CI] 3.2 to 12.5%; P < 0.001) increased compared with baseline values. After Placebo infusion, there was a decrease in LV-FAC (MD -2.9%, 95%CI − 4.8 to − 1.0%), 2D-LVEF (MD -2.0%, 95%CI − 2.8 to − 1.3%, 3D-LVEF (MD -3.0%, 95%CI − 4.0 to − 2.0%) and Vp (MD − 4.5 cm/s, 95%CI − 5.6 to − 3.3 cm/s).After cardiopulmonary bypass, GIK pretreatment was associated with preserved 2D and 3D-LVEF (+ 0.4%, 95% 95%CI − 0.8 to 1.7% and + 0.4%, 95%CI − 1.3 to 2.0%), and PGLS (− 0.9, 95%CI − 1.6 to − 0.2) as well as higher Vp (+ 5.1 cm/s, 95%CI 2.9 to 7.3), compared with baseline. In contrast, in the Placebo group, 2D-LVEF (− 2.2%, 95%CI − 3.4 to − 1.0), 3D-LVEF (− 6.0%, 95%CI − 7.8 to − 4.2), and Vp (− 7.6 cm/s, 95%CI − 9.4 to − 5.9), all decreased after bypass.ConclusionsAdministration of GIK before aortic cross-clamping resulted in better preservation of systolic and diastolic ventricular function in patients with LV hypertrophy undergoing aortic valve replacement.Trial registrationClinicalTrials.gov: NCT00788242, registered on November 10, 2008.
Highlights
Aortic valve replacement (AVR) remains the standard of care to treat patients with severe aortic valvular stenosis, elderly and high-risk patients may benefit from a lesser invasive transarterialThe term “postcardiotomy ventricular dysfunction” (PCVD) has been coined to define new onset or worsening heart failure that develops following weaning from cardiopulmonary bypass (CPB) and that requires supportLicker et al BMC Anesthesiology (2019) 19:175 with inotropes [4]
At the end of GIK infusion, left ventricular (LV)-FAC and 2D- and 3D-left ventricular ejection fraction (LVEF) were unchanged whereas transmitral flow propagation velocity (Vp) increased compared with baseline values
GIK pretreatment was associated with preserved 2D and 3D-LVEF (+ 0.4%, 95% 95%CI − 0.8 to 1.7% and + 0.4%, 95%CI − 1.3 to 2.0%), and peak global longitudinal strain (PGLS) (− 0.9, 95%CI − 1.6 to − 0.2) as well as higher Vp (+ 5.1 cm/ s, 95%CI 2.9 to 7.3), compared with baseline
Summary
Aortic valve replacement (AVR) remains the standard of care to treat patients with severe aortic valvular stenosis, elderly and high-risk patients may benefit from a lesser invasive transarterialThe term “postcardiotomy ventricular dysfunction” (PCVD) has been coined to define new onset or worsening heart failure that develops following weaning from cardiopulmonary bypass (CPB) and that requires supportLicker et al BMC Anesthesiology (2019) 19:175 with inotropes [4]. Transesophageal echocardiography (TEE) coupled with haemodynamic monitoring allows the cardiac team to distinguish PCVD from other functional or structural abnormalities such as valve prosthesis/patient mismatch, myocardial ischemia or systolic anterior motion of the anterior mitral leaflet [5, 6]. In animal models of ischemia-reperfusion, there is strong evidence that the infusion of glucose-insulin-potassium (GIK) minimizes myocardial injuries [7, 8]. In patients undergoing open heart surgery, the administration of GIK has been shown to improve cardiac output, few and conflicting results have been reported regarding functional ventricular performances [9, 10]. Using transesophageal echocardiography (TEE), we evaluated the impact of glucose-insulin potassium (GIK) on LV performances in patients undergoing valve replacement for aortic stenosis
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