The Role of Dexmedetomidine as Myocardial Protector in Pediatric Cardiac Surgery Total Correction of Tetralogy of Fallot

Congenital heart disease (CHD) is the most common congenital abnormality found in newborns with Tetralogy of Fallot (TOF) being the most common cyanotic CHD. Total correction of TOF was performed using a cardiopulmonary bypass (CPB) machine. However, the use of CPB has a negative effect that causes inflammation and myocardial injury. Myocardial protection in patients undergoing total correction of TOF surgery is more difficult than other cyanotic CHD due to a hypertrophic right ventricular condition. Dexmedetomidine (DEX) is a selective α-2 adrenergic, which has major effects including hypnosis, sedation, and analgesia as well as cardiovascular effects. The sedation is induced by stimulating the α-2 adrenergic receptor in the locus coeruleus (LC) in the pons cerebri. DEX also increases the level of GABA and Galanin and reduces endogenous norepinephrine. The lower level of endogenous norepinephrine decreases the afterload of the ventricles, increases cardiac output, and reduces myocardial injury as a result. Furthermore, the peripheral effects of DEX can reduce myocardial ischemia-reperfusion (MIR) by inhibiting NF-кB pathway activation and reducing the number of pro-inflammatory cytokines released. Thus, the administration of DEX can prevent myocardial necrosis and apoptosis, also reducing reperfusion injury when using CPB machines. Research related to the effectiveness of administering DEX as a myocardial protector in classic TOF patients undergoing elective total correction cardiac surgery in Indonesia is less reported. The aim of this study is to determine the effectiveness of DEX as myocardial protector in classic TOF patients undergoing elective total correction cardiac surgery.

Study Overview

• Status: Completed
• Conditions: Tetralogy of Fallot; Cardiopulmonary Bypass; Congenital Heart Disease in Children
• Intervention / Treatment: Drug: Dexmedetomidine Hcl 100 Mcg/mL Inj; Drug: Placebo

Detailed Description

This study is a double blind randomized controlled trial to determine the effectiveness of DEX during CPB as myocardial protection between DEX group and control group. The study population is classic TOF patients who underwent elective total correction cardiac surgery. This study was approved by the research ethical committee (Institutional Review Board) of the National Cardiovascular Center Harapan Kita Jakarta (NCCHK). Before randomization, participants who are eligible based on inclusion and exclusion criterias will be given informed consent. If the guardians of the participants agree, the participants will be included in this research. Sixty-six pediatric participants with classic TOF undergoing elective total correction will be randomly divided into two groups, DEX group and control group. Dexmedetomidine HCl is provided in the form of a liquid injection (Precedex/Kabimidine 200 mcg/2 ml). For the DEX group, DEX was calculated with a priming dose of 0.5 mcg/kg in a 5 ml syringe mixed in priming fluid and 0.25 mcg/kg/hour DEX infusion diluted in 0.9% NaCl 20 ml in a 20 ml syringe administered to the CPB reservoir with an infusion rate of 10 ml/hour. For the control group, the volume of administration of 0.9% NaCl as priming and 0.9% NaCl infusion was given to the CPB machine with adjusted amount and rate same as the DEX group.

We will measure myocardial injury biomarker plasma levels (Troponin I) and cytokines proinflammatory biomarkers plasma level (IL-6) as the primary outcome of myocardial protection. Serum plasma levels of troponin I and IL-6 will be taken 4 times (T1, 5 minutes after induction as baseline level; T2,1 hour after CPB; T3, 6 hours after CPB, and T4, 24 hours after CPB). Secondary outcomes including hemodynamic profile (cardiac output, cardiac index, and systemic vascular resistance, at 5 minute before induction as baseline level, 6 hours, 24 hours, and 48 hours after CPB), serum lactate levels at 5 minutes after induction as baseline level, 1 hour, 6 hours, and 24 hours after CPB, morbidity outcomes (vasoinotropic score at 1 hour, 6 hours, and 24 hours after CPB, length of ventilator use, and length of stay in intensive care).

• Study Type: Interventional
• Enrollment (Actual): 66
• Phase: Phase 2; Phase 3

Contacts and Locations

• Study Contact: Name: Dian Kesumarini, MD; Phone Number: +6281367697904; Email: diankesumarini@gmail.com

Study Locations

• Indonesia
  • Jakarta, Indonesia, 11420
    • National Cardiovascular Center Harapan Kita Hospital Indonesia

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 1 year to 16 years (Child, Adult)
• Accepts Healthy Volunteers: No

Description

Inclusion Criteria:

• The patient's parents or person in charge is willing to participate in the study
• Patients with classic TOF undergoing elective total correction cardiac surgery
• Aged 1 month - 18 years old

Exclusion Criteria:

• The patient experiences a change in the surgical plan from elective to immediate or emergency
• Patients with preoperative infection characterized by procalcitonin >0.5ng/mL
• Patients with impaired liver function characterized by an increase in Serum Glutamic Oxaloacetic Transaminase (SGOT)/Serum Glutamic Pyruvic Transaminase (SGPT) more than 1.5 times the upper limit of normal
• Impaired renal function characterized by creatinine > 2 mg/dL
• Patients with coagulation disorders characterized by International Normalized Ratio (INR) > 1.5

Drop-out Criteria:

• Duration of CPB and/or Aortic cross-clamp time exceeding 120 minutes
• Surgery requires more than two attempts of CPB
• Patient fails to wean from CPB
• Patient requires ECMO (Extracorporeal Membrane Oxygenator) postoperatively
• Patients with postoperative reperfusion injury characterized by pulmonary hemorrhage
• Patients with residual lesions in the form of moderate-severe pulmonary stenosis and moderate-severe pulmonary regurgitation.
• Patient dies on the operating table

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Quadruple

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: DEX Group; Priming Dexmedetomidine 0.5 mcg/kg, Infusion Dexmedetomidine 0.25 mcg/kg/hour	Drug: Dexmedetomidine Hcl 100 Mcg/mL Inj; Priming dose of 0.5 mcg/kg in a 5 ml syringe mixed in priming fluid and 0.25 mcg/kg/hour DEX infusion diluted in 0.9% NaCl 20 ml in a 20 ml syringe administered to the CPB reservoir with an infusion rate of 10 ml/hour; Other Names: Precedex; Kabimidine
Placebo Comparator: Control Group; NaCl 0.9% with adjusted amount and rate same as the DEX group	Drug: Placebo; Priming dose of NaCl 0.9% in a 5 ml syringe mixed in priming fluid and NaCl 0.9% 20 ml in a 20 ml syringe administered to the CPB reservoir with an infusion rate of 10 ml/hour; Other Names: NaCl 0.9%

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Serum Troponin I at baseline	Troponin I serum concentration will be measured using ELABSCIENCE E-EL-H0649 reagent (ng/mL)	5 minutes after induction of anesthesia (T1)
Serum Troponin I at 1 hour after cardiopulmonary bypass	Troponin I serum concentration will be measured using ELABSCIENCE E-EL-H0649 reagent (ng/mL)	1 hour after cardiopulmonary bypass (T2)
Serum Troponin I at 6 hours after cardiopulmonary bypass	Troponin I serum concentration will be measured using ELABSCIENCE E-EL-H0649 reagent (ng/mL)	6 hours after cardiopulmonary bypass (T3)
Serum Troponin I at 24 hours after cardiopulmonary bypass	Troponin I serum concentration will be measured using ELABSCIENCE E-EL-H0649 reagent (ng/mL)	24 hours after cardiopulmonary bypass (T4)
Serum IL-6 at baseline	IL-6 serum concentration will measured using RnD Quantikine D6050 IL-6 reagent (pg/mL)	5 minutes after induction of anesthesia (T1)
Serum IL-6 at 1 hour after cardiopulmonary bypass	IL-6 serum concentration will measured using RnD Quantikine D6050 IL-6 reagent (pg/mL)	1 hour after cardiopulmonary bypass (T2)
Serum IL-6 at 6 hours after cardiopulmonary bypass	IL-6 serum concentration will measured using RnD Quantikine D6050 IL-6 reagent (pg/mL)	6 hours after cardiopulmonary bypass (T3)
Serum IL-6 at 24 hours after cardiopulmonary bypass	IL-6 serum concentration will measured using RnD Quantikine D6050 IL-6 reagent (pg/mL)	24 hours after cardiopulmonary bypass (T4)

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Cardiac output	Cardiac output will be measured using transthoracic echocardiography (L/min)	5 minutes after induction of anesthesia (T1), 6 hours (T3), 24 hours (T4), and 48 hours (T5) after cardiopulmonary bypass
Cardiac Index	Cardiac index will be measured using transthoracic echocardiography (L/min)	5 minutes after induction of anesthesia (T1), 6 hours (T3), 24 hours (T4), and 48 hours (T5) after cardiopulmonary bypass
Systemic Vascular Resistance (SVR)	SVR will be measured using transthoracic echocardiography (L/min)	5 minutes after induction of anesthesia (T1), 6 hours (T3), 24 hours (T4), and 48 hours (T5) after cardiopulmonary bypass
Serum Lactate	Serum lactate will be measured using an enzymatic method with a blood gas analyzer machine (mmol/L)	5 minutes after anesthesia induction (T1), and then 1 hour (T2), 6 hours (T3), and 24 hours (T4) after cardiopulmonary bypass
VIS Score	Vasoinotropic score will be measured using the VIS formula	1 hour (T2), 6 hours (T3), 24 hours (T4) after cardiopulmonary bypass
Mechanical ventilation time	Mechanical ventilation time will be measured from the moment the patient arrives at the intensive care unit until the patient is extubated	3 days (or until the patient is extubated)
Length of stay in the intensive care unit	Length of stay in the intensive care unit will be measured from the moment the patient is admitted to the intensive care unit after the surgery until discharge from intensive care unit	7 days (or until the patient is discharge from intensive care unit)
Mortality	Mortality will be measured as long as patient is hospitalized until 30 days postoperative	30 days post-operative

Collaborators and Investigators

• Sponsor: National Cardiovascular Center Harapan Kita Hospital Indonesia
• Investigators: Principal Investigator: Dian Kesumarini, MD, National Cardiovascular Center Harapan Kita Hospital Indonesia

Study record dates

Study Major Dates

• Study Start (Actual): October 10, 2022
• Primary Completion (Actual): April 10, 2023
• Study Completion (Actual): June 10, 2023

Study Registration Dates

• First Submitted: October 11, 2022
• First Submitted That Met QC Criteria: October 11, 2022
• First Posted (Actual): October 14, 2022

Study Record Updates

• Last Update Posted (Actual): August 24, 2023
• Last Update Submitted That Met QC Criteria: August 22, 2023
• Last Verified: August 1, 2023

More Information

Terms related to this study

• Keywords: Dexmedetomidine; Cardiopulmonary Bypass; Tetralogy of Fallot; Myocardial Protection; Total Correction; Double Blind Randomized Controlled Trial
• Additional Relevant MeSH Terms: Cardiovascular Diseases; Congenital Abnormalities; Cardiovascular Abnormalities; Heart Diseases; Tetralogy of Fallot; Heart Defects, Congenital; Physiological Effects of Drugs; Adrenergic Agents; Neurotransmitter Agents; Molecular Mechanisms of Pharmacological Action; Central Nervous System Depressants; Peripheral Nervous System Agents; Analgesics; Sensory System Agents; Analgesics, Non-Narcotic; Adrenergic alpha-2 Receptor Agonists; Adrenergic alpha-Agonists; Adrenergic Agonists; Hypnotics and Sedatives; Dexmedetomidine
• Other Study ID Numbers: LB.02.01/Vll/011/KEP011/2022 (Other Identifier: National Cardiovascular Center Harapan Kita Hospital Indonesia)

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No