- ICH GCP
- US Clinical Trials Registry
- Clinical Trial NCT02770183
Rate of Left Ventricular Systolic Function's Recuperation After Cardiac Surgery With Extracorporeal Circulation. (Imacor-1)
Study Overview
Status
Intervention / Treatment
Detailed Description
Myocardial stunning is a secondary pathophysiologic condition for a sustained reduction in myocardial perfusion, which produces kinetic abnormalities in left ventricular wall that persist for hours or days after the reperfusion phase. The physiological elements of the stunning are: a) reduction in coronary blood flow, b) a partial or complete restoration of coronary artery circulation and c) the dysfunction of persistence for a limited period, but longer compared to recovery coronaire's flow.
Cardiac surgery with cardiopulmonary bypass is a leading cause of bewilderment myocardique. This technique associated with administering a cardioplegic solution used to stop the heart and myocardial protection on ischemia see myocardique consideration. It typically also secondary to secondary inflammatory condition in the extracorporeal circulation and the ischemia-reperfusion phenomenon (formation of free radicals), also with the important activation coagulation. Myocardial stunning occurs in suites aortic unclamping during cardiopulmonary bypass. Cold ischemia performed by a cardioplegic liquid at 4 °C results in reduced energy demands and thus to maintain some balance between metabolism, perfusion and myocardial function during coronary by-pass. When aortic unclamping, there is usually a pure myocardial stunning (without necrosis). After the coronary by-pass, the myocardial thickening fraction is unchanged in the immediate future, but significantly decreased in the hours before a full recovery between the following hours. In the factors associated with changes in systolic function, autonomic nervous system is responsible for the regulation of blood pressure and heart function in response to the stress of the coronary by-pass and the postoperative state. Reduced variability in heart rate (heart rate variability - HRV) heard how sign of autonomic dysfunction is also associated with myocardial stunning with a rate of cardiaque post-surgery complications high.
So far no group has had the opportunity to study "in vivo" the temporal evolution of myocardial stunning after the coronary by-pass as an example of myocardial stunning "controlled" in order to better understand the pathophysiology of 'event. Indeed, the basis of myocardial function recovery time following coronary by-pass is unknown and the impact of intraoperative procedures on this recovery.
Transesophageal echocardiography, that is the gold standard for assessment of systolic function, has gradually gained popularity and is used daily in the ICU to evaluate the patient's hemodynamic status and evaluation of contractile function of the left ventricle to load. One of its advantages is to measure heart activity at the bedside and assist the physician in intensive care in the management of hemodynamic acute changes. It also allows also to analyze the response to treatment defined above. Among the limitations of transesophageal echocardiography are: the need for intensivists to be relevant to this technique, the discontinuous nature of the procedure ( "one shot" monitoring) and finally semi-invasif character that make it difficult 'prolonged and repeated execution of the various measures.
Recent improvement in electronics has enabled the development of miniaturized sensors for hemodynamic transesophageal echocardiography (ImaCor® ClariTEE®), called hTEE (hemodynamic trans-esophageal echocardiography), which are used to perform an extended hemodynamic monitoring ventilated patients; these prototypes are not yet widespread in Intensive Care Unit; their diagnostic capabilities and therapeutic impacts are currently under clinical research. been studies in the past allowed us to validate the clinical image quality and how the clinical information obtained are useful for clinical management of patient. In particular, these studies have demonstrated the ease with which thanks to the small size of the probe, the feedback of the superior vena cava, the patient's volume status, left ventricular systolic function based on the Fractional Area Change, the size of the right ventricle, and a pericardial effusion and cardiac tamponade during the first test of positioning sonde.
The advantages of continuous Htee of this new technique are related to the small size of the probe, ease of positioning the probe in the esophagus, the diagnostic reliability and the ability to stay up to 72 hours because the risk of pressure sores or lesions are comparable to those of a nasogastric feeding tube (which is the same size). Compared to the conventional trans-esophageal echocardiography, hTEE offers the advantage of performing continuous monitoring rather than a case-by case basis. In particular, for the study of post-operative myocardial stunning, this technique allows for a verification of the time course of myocardial stunning, and thus describe the pathophysiology and the kinetics of recovery of left ventricular contractile function. Furthermore this technique provides the means to identify perioperative factors that can change this recovery (induce or shorten).
Study Type
Participation Criteria
Eligibility Criteria
Ages Eligible for Study
Accepts Healthy Volunteers
Genders Eligible for Study
Sampling Method
Study Population
Description
Inclusion Criteria:
- Adults (over 18 years), waiting for a heart surgery
- Patients of both sexes
- Patients hospitalized in intensive care after the operation
- Informed consent available
Exclusion Criteria:
- Patients with contraindications to the placement of a nasogastric tube for the presence of esophageal varices, esophageal lesions or esophageal-gastric complications known.
- Patients with severe sepsis or septic shock, according to international definitions.
- Patients with severe coagulopathy defined as a lower thrombocytopenia at 20 G / L and / or INR> 2.5 and / or aPTT in the therapeutic range and / or an anti-Xa activity in the ultra-therapeutic range and / or a fibrinogen value less than 1 g / L.
- Patients with poor prognosis.
Study Plan
How is the study designed?
Design Details
- Observational Models: Cohort
- Time Perspectives: Prospective
Cohorts and Interventions
Group / Cohort |
Intervention / Treatment |
---|---|
Consecutive patients
Consecutive patients waiting to have elective cardiac surgery will be eligible. Each week the principal investigator will track patients in the operating program. The day of the consultation or the day before the operation, one of the investigators will have a talk with the patient to provide information and clarify doubts, also allowing the patient to read and look good all the details before giving its approval. For the screening, the principal investigator will use the criteria of inclusion and exclusion to select patients for the study. The screening uses clinical, laboratory or without other biological information. To minimize confounding factors, it will be taken consecutive patients, that will also be analyzed regarding all known variables that can affect the systolic function, as non-modifiable (age, cardiovascular risk factors, heart-rate variability and preoperative basal systolic function) and modifiable. |
In ICU, the doctors in charge places the probe in the esophagus, executing a series of morphological evaluations and semi-quantitative evaluations. Each image is saved as a video loop or a static image, to have a basic data for each patient and perform an off-line analysis. At the end of the first recording, the esophageal probe is left in the neutral position in the stomach, to eliminate any risk associated with a local increase of pressure. During the stay in the intensive care unit until the end of the study, the esophageal probe will be left in the neutral position, to run every two hours a new echocardiographic assessment on the main window, similar to the first evaluation, always recording loop-video and photographs, to have a time course of recovery of cardiac contractile function. All images will be stored in a digital archive.
Other Names:
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What is the study measuring?
Primary Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
---|---|---|
Fractional Area Change analysis
Time Frame: 72 hours
|
Primary outcome is the evolution of Fractional Area Change for the duration of the study.
The assessment of cardiac contractile function, which method is better described below, will be based mainly on a serial analysis of the Fractional Area Change and semi-quantitative assessment of ejection fraction in projection 4 cavities.
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72 hours
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Secondary Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
---|---|---|
Stratify patients
Time Frame: 72 hours
|
Identify the presence of specific subgroups of patients, that will correlate the recovery rate of the systolic function with all other clinical, demographic and operational variables, as biologic parameters (age, sex), clinical parameters (like preoperative disease, use of B-blockers, preoperative left-ventricular-ejection-fraction, any dysfunction of sinoatrial node or the recovery of heart rate variability) and peri-operative parameters (like duration of extra-corporeal circulation, type of cardioplegia, duration of surgery, use of amine, hemoglobin values after surgery, etc...)
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72 hours
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Collaborators and Investigators
Sponsor
Investigators
- Study Director: Karim Bendjelid, Prof., Hôpitaux universitaires de Genève
Publications and helpful links
General Publications
- Wan S, LeClerc JL, Vincent JL. Inflammatory response to cardiopulmonary bypass: mechanisms involved and possible therapeutic strategies. Chest. 1997 Sep;112(3):676-92. doi: 10.1378/chest.112.3.676.
- Heyndrickx GR, Millard RW, McRitchie RJ, Maroko PR, Vatner SF. Regional myocardial functional and electrophysiological alterations after brief coronary artery occlusion in conscious dogs. J Clin Invest. 1975 Oct;56(4):978-85. doi: 10.1172/JCI108178.
- Braunwald E, Kloner RA. The stunned myocardium: prolonged, postischemic ventricular dysfunction. Circulation. 1982 Dec;66(6):1146-9. doi: 10.1161/01.cir.66.6.1146.
- Marban E. Myocardial stunning and hibernation. The physiology behind the colloquialisms. Circulation. 1991 Feb;83(2):681-8. doi: 10.1161/01.cir.83.2.681. No abstract available.
- Bolli R. Myocardial 'stunning' in man. Circulation. 1992 Dec;86(6):1671-91. doi: 10.1161/01.cir.86.6.1671. No abstract available.
- Warren OJ, Watret AL, de Wit KL, Alexiou C, Vincent C, Darzi AW, Athanasiou T. The inflammatory response to cardiopulmonary bypass: part 2--anti-inflammatory therapeutic strategies. J Cardiothorac Vasc Anesth. 2009 Jun;23(3):384-93. doi: 10.1053/j.jvca.2008.09.007. Epub 2008 Dec 3. No abstract available.
- Day JR, Taylor KM. The systemic inflammatory response syndrome and cardiopulmonary bypass. Int J Surg. 2005;3(2):129-40. doi: 10.1016/j.ijsu.2005.04.002. Epub 2005 Aug 1.
- Dixon B, Santamaria J, Campbell D. Coagulation activation and organ dysfunction following cardiac surgery. Chest. 2005 Jul;128(1):229-36. doi: 10.1378/chest.128.1.229.
- Esmon CT. The interactions between inflammation and coagulation. Br J Haematol. 2005 Nov;131(4):417-30. doi: 10.1111/j.1365-2141.2005.05753.x.
- Compostella L, Russo N, Compostella C, Setzu T, D'Onofrio A, Isabella G, Tarantini G, Iliceto S, Gerosa G, Bellotto F. Impact of type of intervention for aortic valve replacement on heart rate variability. Int J Cardiol. 2015 Oct 15;197:11-5. doi: 10.1016/j.ijcard.2015.06.004. Epub 2015 Jun 14.
- Vieillard-Baron A, Prin S, Chergui K, Dubourg O, Jardin F. Hemodynamic instability in sepsis: bedside assessment by Doppler echocardiography. Am J Respir Crit Care Med. 2003 Dec 1;168(11):1270-6. doi: 10.1164/rccm.200306-816CC. No abstract available.
- Etchecopar-Chevreuil C, Francois B, Clavel M, Pichon N, Gastinne H, Vignon P. Cardiac morphological and functional changes during early septic shock: a transesophageal echocardiographic study. Intensive Care Med. 2008 Feb;34(2):250-6. doi: 10.1007/s00134-007-0929-z. Epub 2007 Nov 15.
- Vignon P, Mentec H, Terre S, Gastinne H, Gueret P, Lemaire F. Diagnostic accuracy and therapeutic impact of transthoracic and transesophageal echocardiography in mechanically ventilated patients in the ICU. Chest. 1994 Dec;106(6):1829-34. doi: 10.1378/chest.106.6.1829.
- Slama MA, Novara A, Van de Putte P, Diebold B, Safavian A, Safar M, Ossart M, Fagon JY. Diagnostic and therapeutic implications of transesophageal echocardiography in medical ICU patients with unexplained shock, hypoxemia, or suspected endocarditis. Intensive Care Med. 1996 Sep;22(9):916-22. doi: 10.1007/BF02044116.
- Vieillard-Baron A, Slama M, Mayo P, Charron C, Amiel JB, Esterez C, Leleu F, Repesse X, Vignon P. A pilot study on safety and clinical utility of a single-use 72-hour indwelling transesophageal echocardiography probe. Intensive Care Med. 2013 Apr;39(4):629-35. doi: 10.1007/s00134-012-2797-4. Epub 2013 Jan 4.
- Treskatsch S, Balzer F, Knebel F, Habicher M, Braun JP, Kastrup M, Grubitzsch H, Wernecke KD, Spies C, Sander M. Feasibility and influence of hTEE monitoring on postoperative management in cardiac surgery patients. Int J Cardiovasc Imaging. 2015 Oct;31(7):1327-35. doi: 10.1007/s10554-015-0689-8. Epub 2015 Jun 6.
- Begot E, Dalmay F, Etchecopar C, Clavel M, Pichon N, Francois B, Lang R, Vignon P. Hemodynamic assessment of ventilated ICU patients with cardiorespiratory failure using a miniaturized multiplane transesophageal echocardiography probe. Intensive Care Med. 2015 Nov;41(11):1886-94. doi: 10.1007/s00134-015-3998-4. Epub 2015 Aug 8.
- Imren Y, Tasoglu I, Oktar GL, Benson A, Naseem T, Cheema FH, Unal Y. The importance of transesophageal echocardiography in diagnosis of pericardial tamponade after cardiac surgery. J Card Surg. 2008 Sep-Oct;23(5):450-3. doi: 10.1111/j.1540-8191.2008.00581.x. Epub 2008 May 7. Erratum In: J Card Surg. 2010 Jan-Feb;25(1):135. Cheema, Faisal [corrected to Cheema, Faisal H].
Study record dates
Study Major Dates
Study Start (Anticipated)
Primary Completion (Anticipated)
Study Completion (Anticipated)
Study Registration Dates
First Submitted
First Submitted That Met QC Criteria
First Posted (Estimate)
Study Record Updates
Last Update Posted (Actual)
Last Update Submitted That Met QC Criteria
Last Verified
More Information
Terms related to this study
Additional Relevant MeSH Terms
Other Study ID Numbers
- CERU-1601
Plan for Individual participant data (IPD)
Plan to Share Individual Participant Data (IPD)?
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