Preoperative endothelial dysfunction in cutaneous microcirculation is associated with postoperative organ injury after cardiac surgery using extracorporeal circulation: a prospective cohort study

Stanislas Abrard, Olivier Fouquet, Jérémie Riou, Emmanuel Rineau, Pierre Abraham, Cyril Sargentini, Yannick Bigou, Christophe Baufreton, Sigismond Lasocki, Samir Henni, Stanislas Abrard, Olivier Fouquet, Jérémie Riou, Emmanuel Rineau, Pierre Abraham, Cyril Sargentini, Yannick Bigou, Christophe Baufreton, Sigismond Lasocki, Samir Henni

Abstract

Background: Cardiac surgery is known to induce acute endothelial dysfunction, which may be central to the pathophysiology of postoperative complications. Preoperative endothelial dysfunction could also be implicated in the pathophysiology of postoperative complications after cardiac surgery. However, the relationship between preoperative endothelial function and postoperative outcomes remains unknown. The primary objective was to describe the relationship between a preoperative microcirculatory dysfunction identified by iontophoresis of acetylcholine (ACh), and postoperative organ injury in patients scheduled for cardiac surgery using cardiopulmonary bypass (CPB).

Methods: Sixty patients undergoing elective cardiac surgery using CPB were included in the analysis of a prospective, observational, single-center cohort study conducted from January to April 2019. Preoperative microcirculation was assessed with reactivity tests on the forearm (iontophoresis of ACh and nitroprusside). Skin blood flow was measured by laser speckle contrast imaging. Postoperative organ injury, the primary outcome, was defined as a Sequential Organ Failure Assessment score (SOFA) 48 h after surgery greater than 3.

Results: Organ injury at 48 h occurred in 29 cases (48.3%). Patients with postoperative organ injury (SOFA score > 3 at 48 h) had a longer time to reach the peak of preoperative iontophoresis of acetylcholine (133 s [104-156] vs 98 s [76-139] than patients without, P = 0.016), whereas endothelium-independent vasodilation to nitroprusside was similar in both groups. Beyond the proposed threshold of 105 s for time to reach the peak of preoperative endothelium-dependent vasodilation, three times more patients presented organ dysfunction at 48 h (76% vs 24% below or equal 105 s). In multivariable model, the time to reach the peak during iontophoresis of acetylcholine was an independent predictor of postoperative organ injury (odds ratio = 4.81, 95% confidence interval [1.16-19.94]; P = 0.030).

Conclusions: Patients who postoperatively developed organ injury (SOFA score > 3 at 48 h) had preoperatively a longer time to reach the peak of endothelium-dependent vasodilation. Trial registration Clinical-Trials.gov, NCT03631797. Registered 15 August 2018, https://ichgcp.net/clinical-trials-registry/NCT03631797.

Keywords: Cardiac surgery; Endothelial function; Organ dysfunction; Preoperative evaluation.

Conflict of interest statement

The authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
Evaluation of cutaneous microcirculation. a Iontophoresis in combination with blood perfusion imager. b Incident light from the laser (thick red arrows) are scattered back (dotted arrows) from red blood cells flowing in the microvessels. c Typical dose–response-related vasodilatation as a response to ACh (blue) and SNP (red)—blood perfusion imaging. Photos reproduced with the permission of Perimed (Järfälla, Sweden)
Fig. 2
Fig. 2
Study flowchart. CPB cardiopulmonary bypass, CABG coronary arterial bypass grafting
Fig. 3
Fig. 3
ROC curves for primary judgement criteria

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