Serum butyrylcholinesterase predicts survival after extracorporeal membrane oxygenation after cardiovascular surgery

Klaus Distelmaier, Max-Paul Winter, Kurt Rützler, Gottfried Heinz, Irene M Lang, Gerald Maurer, Herbert Koinig, Barbara Steinlechner, Alexander Niessner, Georg Goliasch, Klaus Distelmaier, Max-Paul Winter, Kurt Rützler, Gottfried Heinz, Irene M Lang, Gerald Maurer, Herbert Koinig, Barbara Steinlechner, Alexander Niessner, Georg Goliasch

Abstract

Introduction: Risk stratification in patients undergoing extracorporeal membrane oxygenation (ECMO) support after cardiovascular surgery remains challenging, because data on specific outcome predictors are limited. Serum butyrylcholinesterase demonstrated a strong inverse association with all-cause and cardiovascular mortality in non-critically ill patients. We therefore evaluated the predictive value of preoperative serum butyrylcholinesterase levels in patients undergoing venoarterial ECMO support after cardiovascular surgery.

Methods: We prospectively included 191 patients undergoing venoarterial ECMO therapy after cardiovascular surgery at a university-affiliated tertiary care center in our registry.

Results: All-cause and cardiovascular mortality were defined as primary study end points. During a median follow-up time of 51 months (IQR, 34 to 71) corresponding to 4,197 overall months of follow-up, 65% of patients died. Cox proportional hazard regression analysis revealed a significant and independent inverse association between higher butyrylcholinesterase levels and all-cause mortality with an adjusted hazard ratio (HR) of 0.44 (95% CI, 0.25 to 0.78; P = 0.005), as well as cardiovascular mortality, with an adjusted HR of 0.38 (95% CI, 0.21 to 0.70; P = 0.002), comparing the third with the first tertile. Survival rates were higher in patients within the third tertile of butyrylcholinesterase compared with patients within the first tertile at 30 days (68% versus 44%) as well as at 6 years (47% versus 21%).

Conclusions: The current study revealed serum butyrylcholinesterase as a strong and independent inverse predictor of all-cause and cardiovascular mortality in patients undergoing venoarterial ECMO therapy after cardiovascular surgery. These findings advance the limited knowledge on risk stratification in patients undergoing ECMO support and represent a valuable addition for a comprehensive decision making before ECMO implantation.

Figures

Figure 1
Figure 1
Confounder-adjusted survival curves of all-cause and cardiovascular mortality according to tertiles of butyrylcholinesterase. Adjusted survival curves demonstrated a significant decrease of 30-day (A, P = 0.017) and long-term (B, P = 0.019) all-cause mortality, as well as a significant decrease of 30-day (C, P = 0.008) and long-term (D, P = 0.007) cardiovascular mortality with increasing serum levels of butyrylcholinesterase.

References

    1. Bartlett RH, Roloff DW, Custer JR, Younger JG, Hirschl RB. Extracorporeal life support: the University of Michigan experience. JAMA. 2000;283:904–908. doi: 10.1001/jama.283.7.904.
    1. Combes A, Leprince P, Luyt CE, Bonnet N, Trouillet JL, Leger P, Pavie A, Chastre J. Outcomes and long-term quality-of-life of patients supported by extracorporeal membrane oxygenation for refractory cardiogenic shock. Crit Care Med. 2008;36:1404–1411. doi: 10.1097/CCM.0b013e31816f7cf7.
    1. Calderon-Margalit R, Adler B, Abramson JH, Gofin J, Kark JD. Butyrylcholinesterase activity, cardiovascular risk factors, and mortality in middle-aged and elderly men and women in Jerusalem. Clin Chem. 2006;52:845–852. doi: 10.1373/clinchem.2005.059857.
    1. Goliasch G, Haschemi A, Marculescu R, Endler G, Maurer G, Wagner O, Huber K, Mannhalter C, Niessner A. Butyrylcholinesterase activity predicts long-term survival in patients with coronary artery disease. Clin Chem. 2012;58:1055–1058. doi: 10.1373/clinchem.2011.175984.
    1. Stedman E, Easson LH. Choline-esterase: an enzyme present in the blood-serum of the horse. Biochem J. 1932;26:2056–2066.
    1. Darvesh S, Hopkins DA, Geula C. Neurobiology of butyrylcholinesterase. Nat Rev Neurosci. 2003;4:131–138. doi: 10.1038/nrn1035.
    1. Bretlau C, Kryspin Soerensen M, Zimling Vedersoe AL, Simon Rasmussen L, Ring Gatke M. Response to succinylcholine in patients carrying the k-variant of the butyrylcholinesterase gene. Anesth Analg. 2013;116:596–601. doi: 10.1213/ANE.0b013e318280a3f3.
    1. Gatke MR, Bundgaard JR, Viby-Mogensen J. Two novel mutations in the BCHE gene in patients with prolonged duration of action of mivacurium or succinylcholine during anaesthesia. Pharmacogenet Genom. 2007;17:995–999. doi: 10.1097/FPC.0b013e3282f06646.
    1. Gatke MR, Viby-Mogensen J, Ostergaard D, Bundgaard JR. Response to mivacurium in patients carrying the k variant in the butyrylcholinesterase gene. Anesthesiology. 2005;102:503–508. doi: 10.1097/00000542-200503000-00005.
    1. Distelmaier K, Niessner A, Haider D, Lang IM, Heinz G, Maurer G, Koinig H, Steinlechner B, Goliasch G. Long-term mortality in patients with chronic obstructive pulmonary disease following extracorporeal membrane oxygenation for cardiac assist after cardiovascular surgery. Intensive Care Med. 2013;39:1444–1451. doi: 10.1007/s00134-013-2931-y.
    1. den Blaauwen DH, Poppe WA, Tritschler W. Cholinesterase (EC 3.1.1.8) with butyrylthiocholine-iodide as substrate: references depending on age and sex with special reference to hormonal effects and pregnancy. J Clin Chem Clin Biochem. 1983;21:381–386.
    1. Le Gall JR, Lemeshow S, Saulnier F. A new Simplified Acute Physiology Score (SAPS II) based on a European/North American multicenter study. JAMA. 1993;270:2957–2963. doi: 10.1001/jama.1993.03510240069035.
    1. Roques F, Nashef SA, Michel P, Gauducheau E, de Vincentiis C, Baudet E, Cortina J, David M, Faichney A, Gabrielle F. et al.Risk factors and outcome in European cardiac surgery: analysis of the EuroSCORE multinational database of 19030 patients. Eur J Cardiothorac Surg. 1999;15:816–822. doi: 10.1016/S1010-7940(99)00106-2. discussion 822–813.
    1. Rastan AJ, Dege A, Mohr M, Doll N, Falk V, Walther T, Mohr FW. Early and late outcomes of 517 consecutive adult patients treated with extracorporeal membrane oxygenation for refractory postcardiotomy cardiogenic shock. J Thorac Cardiovasc Surg. 2010;139:302–311. doi: 10.1016/j.jtcvs.2009.10.043. 311 e301.
    1. Smedira NG, Blackstone EH. Postcardiotomy mechanical support: risk factors and outcomes. Ann Thorac Surg. 2001;71:S60–S66. doi: 10.1016/S0003-4975(00)02626-6. discussion S82–65.
    1. Wang JG, Han J, Jia YX, Zeng W, Hou XT, Meng X. Outcome of veno-arterial extracorporeal membrane oxygenation for patients undergoing valvular surgery. PLoS One. 2013;8:e63924. doi: 10.1371/journal.pone.0063924.
    1. Chang WW, Tsai FC, Tsai TY, Chang CH, Jenq CC, Chang MY, Tian YC, Hung CC, Fang JT, Yang CW. et al.Predictors of mortality in patients successfully weaned from extracorporeal membrane oxygenation. PLoS One. 2012;7:e42687. doi: 10.1371/journal.pone.0042687.
    1. Hubbard RE, O’Mahony MS, Calver BL, Woodhouse KW. Plasma esterases and inflammation in ageing and frailty. Eur J Clin Pharmacol. 2008;64:895–900. doi: 10.1007/s00228-008-0499-1.
    1. Summerbell J, Wynne H, Hankey CR, Williams FM. The effect of age and frailty upon blood esterase activities and their response to dietary supplementation. Br J Clin Pharmacol. 1993;36:399–404. doi: 10.1111/j.1365-2125.1993.tb00387.x.
    1. Cerejeira J, Batista P, Nogueira V, Firmino H, Vaz-Serra A, Mukaetova-Ladinska EB. Low preoperative plasma cholinesterase activity as a risk marker of postoperative delirium in elderly patients. Age Ageing. 2011;40:621–626. doi: 10.1093/ageing/afr053.
    1. Kemkes-Matthes B, Preissner KT, Langenscheidt F, Matthes KJ, Muller-Berghaus G. S protein/vitronectin in chronic liver diseases: correlations with serum cholinesterase, coagulation factor X and complement component C3. Eur J Haematol. 1987;39:161–165.
    1. Ogunkeye OO, Roluga AI. Serum cholinesterase activity helps to distinguish between liver disease and non-liver disease aberration in liver function tests. Pathophysiology. 2006;13:91–93. doi: 10.1016/j.pathophys.2006.01.002.
    1. Aubron C, Cheng AC, Pilcher D, Leong T, Magrin G, Cooper DJ, Scheinkestel C, Pellegrino V. Factors associated with outcomes of patients on extracorporeal membrane oxygenation support: a 5-year cohort study. Crit Care. 2013;17:R73. doi: 10.1186/cc12681.
    1. Mc IRB, Timpa JG, Kurundkar AR, Holt DW, Kelly DR, Hartman YE, Neel ML, Karnatak RK, Schelonka RL, Anantharamaiah GM. et al.Plasma concentrations of inflammatory cytokines rise rapidly during ECMO-related SIRS due to the release of preformed stores in the intestine. Lab Invest. 2010;90:128–139. doi: 10.1038/labinvest.2009.119.
    1. Masson P. A naturally occurring molecular form of human plasma cholinesterase is an albumin conjugate. Biochim Biophys Acta. 1989;998:258–266. doi: 10.1016/0167-4838(89)90282-3.
    1. Hsu PS, Chen JL, Hong GJ, Tsai YT, Lin CY, Lee CY, Chen YG, Tsai CS. Extracorporeal membrane oxygenation for refractory cardiogenic shock after cardiac surgery: predictors of early mortality and outcome from 51 adult patients. Eur J Cardiothorac Surg. 2010;37:328–333.
    1. Slottosch I, Liakopoulos O, Kuhn E, Deppe AC, Scherner M, Madershahian N, Choi YH, Wahlers T. Outcomes after peripheral extracorporeal membrane oxygenation therapy for postcardiotomy cardiogenic shock: a single-center experience. J Surg Res. 2013;181:e47–e55. doi: 10.1016/j.jss.2012.07.030.

Source: PubMed

Sponsoren und Mitarbeiter

Krankheiten

Drogeninterventionen

3
Abonnieren