Atrial nitroso-redox balance and refractoriness following on-pump cardiac surgery: a randomized trial of atorvastatin

Raja Jayaram, Michael Jones, Svetlana Reilly, Mark J Crabtree, Nikhil Pal, Nicola Goodfellow, Keshav Nahar, Jillian Simon, Ricardo Carnicer, Ravi DeSilva, Chandana Ratnatunga, Mario Petrou, Rana Sayeed, Andrea Roalfe, Keith M Channon, Yaver Bashir, Timothy Betts, Michael Hill, Barbara Casadei, Raja Jayaram, Michael Jones, Svetlana Reilly, Mark J Crabtree, Nikhil Pal, Nicola Goodfellow, Keshav Nahar, Jillian Simon, Ricardo Carnicer, Ravi DeSilva, Chandana Ratnatunga, Mario Petrou, Rana Sayeed, Andrea Roalfe, Keith M Channon, Yaver Bashir, Timothy Betts, Michael Hill, Barbara Casadei

Abstract

Aims: Systemic inflammation and increased activity of atrial NOX2-containing NADPH oxidases have been associated with the new onset of atrial fibrillation (AF) after cardiac surgery. In addition to lowering LDL-cholesterol, statins exert rapid anti-inflammatory and antioxidant effects, the clinical significance of which remains controversial.

Methods and results: We first assessed the impact of cardiac surgery and cardiopulmonary bypass (CPB) on atrial nitroso-redox balance by measuring NO synthase (NOS) and GTP cyclohydrolase-1 (GCH-1) activity, biopterin content, and superoxide production in paired samples of the right atrial appendage obtained before (PRE) and after CPB and reperfusion (POST) in 116 patients. The effect of perioperative treatment with atorvastatin (80 mg once daily) on these parameters, blood biomarkers, and the post-operative atrial effective refractory period (AERP) was then evaluated in a randomized, double-blind, placebo-controlled study in 80 patients undergoing cardiac surgery on CPB. CPB and reperfusion led to a significant increase in atrial superoxide production (74% CI 71-76%, n = 46 paired samples, P < 0.0001) and a reduction in atrial tetrahydrobiopterin (BH4) (34% CI 33-35%, n = 36 paired samples, P < 0.01), and in GCH-1 (56% CI 55-58%, n = 26 paired samples, P < 0.001) and NOS activity (58% CI 52-67%, n = 20 paired samples, P < 0.001). Perioperative atorvastatin treatment prevented the effect of CPB and reperfusion on all parameters but had no significant effect on the postoperative right AERP, troponin release, or NT-proBNP after cardiac surgery.

Conclusion: Perioperative statin therapy prevents post-reperfusion atrial nitroso-redox imbalance in patients undergoing on-pump cardiac surgery but has no significant impact on postoperative atrial refractoriness, perioperative myocardial injury, or markers of postoperative LV function.

Clinical trial registration: https://ichgcp.net/clinical-trials-registry/NCT01780740.

Keywords: Atorvastatin; Atrial refractory period; Clinical trial; Ischaemia-Reperfusion Injury; Nitric Oxide Synthase; Oxidant stress; Postoperative Atrial fibrillation.

© The Author(s) 2020. Published by Oxford University Press on behalf of the European Society of Cardiology.

Figures

Graphical abstract
Graphical abstract
Figure 1
Figure 1
Superoxide (O2-) production in right atrial samples obtained before (PRE) and after CPB and reperfusion (POST) measured by lucigenin-enhanced chemiluminescence (n = 46 paired samples from 23 patients; A) and by HPLC detection of 2-OH ethidium (n = 26 paired samples from 13 patients; B), respectively. ****P < 0.0001 vs. PRE, by Wilcoxon matched-pairs signed rank test (A) or the paired Student’s t-test (B). The contribution of mitochondrial complex I (n = 20 paired samples from 10 patients; C) or NOX2 oxidase (n = 22 paired samples from 11 patients; D) expressed as the rotenone-inhibitable fraction of lucigenin-enhanced chemiluminescence and the gp91 tat-inhibitable fraction of 2OH-ethidium by HPLC, respectively, were increased in POST atrial samples. **P < 0.01 and ***P < 0.001 vs. PRE, by the Wilcoxon matched-pairs signed rank test (C) or the paired Student’s t-test (D). Data are shown as median and IQR (A and C) or mean and SD (B and D). RLU, relative light units.
Figure 2
Figure 2
Atrial NOS activity significantly decreased in POST samples (n = 20 paired samples from 10 patients; A). ***P < 0.001 vs. PRE, by paired Student’s t-test. Atrial nNOS and eNOS protein content was unaltered after CPB and reperfusion (B and C) while iNOS protein was absent (D) and mRNA below the detection threshold (E, n = 14–40 samples from 7 to 20 patients). There were no significant differences between PRE and POST (Band C) by paired Student’s t-test. Data are shown as mean and SD (A–D). nNOS positive control (+) was murine brain tissue; iNOS positive control (+) were primary murine macrophages treated with LPS; Negative control (−) were primary murine macrophage in the absence of LPS stimulation. eNOS positive control (+) was human saphenous vein homogenate.
Figure 3
Figure 3
Atrial BH4 content decreased after CPB and reperfusion (A), whereas BH2 (C) and biopterin levels (D) were unaltered resulting in a reduction in the ratio of BH4 to BH2 + Biopterin (B), n = 36 paired samples from 18 patients. **P < 0.01, *P < 0.05 vs. PRE in A and B by Wilcoxon matched pairs sign rank test. C and D PRE-POST differences were not significant by paired Student’s t -test (C) or the Wilcoxon matched pairs sign rank test (D). Data are shown as median and IQR (A–D) or mean and SD (C).
Figure 4
Figure 4
(A) Atrial GCH-1 activity decreased after CPB and reperfusion, n = 26 paired samples from 13 patients. ***P < 0.001 vs. PRE, by paired Student’s t test. (B) The atrial protein level of GCH-1 was unaltered whereas atrial GFRP (C) was significantly increased after CPB and reperfusion, n = 16—20 samples from 8 to 10 patients. **P < 0.01 vs. PRE by paired Student’s t-test. Data are shown as mean and SD.
Figure 5
Figure 5
(A) The reduction in atrial NOS activity in POST samples (n = 18 paired samples from 9 patients) is not abolished by pre-treatment with BH4, **P < 0.01 vs. PRE by Wilcoxon matched pairs sign rank test. (B) Treatment with the reducing agent, dithiothreitol (DTT) restored NOS activity in POST samples, n = 12 paired samples from 6 patients; ****P < 0.0001, by analysis of covariance (ANCOVA) adjusted for PRE measurements, whereas (C) NOX2 inhibition with gp91ds tat vs. scrambled peptide did not, n = 16 paired samples from 8 patients by ANCOVA adjusted for PRE measurements. Data are expressed as median and IQR (A) or mean and SD (B and C).
Figure 6
Figure 6
Differences between right atrial superoxide production, NOS activity, BH4 content and GCH-1 activity in PRE and POST samples from patients allocated to atorvastatin (80 mg od) or placebo. Treatment with atorvastatin prevented the increase in superoxide production (A) in POST atrial samples vs. placebo (n = 60 paired samples from 30 patients in each group; **P < 0.01, by ANCOVA) and the reduction in NOS activity (B, n = 24 paired samples from 12 patients; *P < 0.05 vs. placebo, by ANCOVA). Atorvastatin prevented the reduction in atrial BH4 content (n = 28 paired samples from 14 patients; C) and GCH-1 activity (n = 18 paired samples from 9 patients; D) in POST samples vs. placebo. **P < 0.01, *P < 0.05 vs. placebo, by ANCOVA. Data are shown as median and IQR (A, B, and D) or mean and SD (C).
Figure 7
Figure 7
Average right atrial effective refractory period on first four postoperative days at three pacing cycle lengths. (A) pacing cycle length 500 ms, 14 patients allocated to atorvastatin and 15 patients allocated to placebo; (B) pacing cycle length 600 ms, 14 patients allocated to atorvastatin and 15 patients allocated to placebo; (C) pacing cycle length 700 ms, 10 patients allocated to atorvastatin, and 12 patients allocated to placebo; P  = 0.83, P  = 0.87 and P  = 0.75 by mixed model linear regression analysis after log transformation. Back transformed data are shown as geometric mean ± 95% confidence interval. AERP, atrial effective refractory period; PCL, pacing cycle length.

References

    1. Kim YM, Kattach H, Ratnatunga C, Pillai R, Channon KM, Casadei B. Association of atrial nicotinamide adenine dinucleotide phosphate oxidase activity with the development of atrial fibrillation after cardiac surgery. J Am Coll Cardiol 2008;51:68–74.
    1. Maesen B, Nijs J, Maessen J, Allessie M, Schotten U. Post-operative atrial fibrillation: a maze of mechanisms. Europace 2012;14:159–174.
    1. Levitsky S. Protecting the myocardial cell during coronary revascularization. The William W. L. Glenn Lecture. Circulation 2006;114:I339–I343.
    1. Zweier JL, Kuppusamy P, Lutty GA. Measurement of endothelial cell free radical generation: evidence for a central mechanism of free radical injury in postischemic tissues. Proc Natl Acad Sci USA 1988;85:4046–4050.
    1. Bolli R, Jeroudi MO, Patel BS, DuBose CM, Lai EK, Roberts R, McCay PB. Direct evidence that oxygen-derived free radicals contribute to postischemic myocardial dysfunction in the intact dog. Proc Natl Acad Sci USA 1989;86:4695–4699.
    1. Dumitrescu C, Biondi R, Xia Y, Cardounel AJ, Druhan LJ, Ambrosio G, Zweier JL. Myocardial ischemia results in tetrahydrobiopterin (BH4) oxidation with impaired endothelial function ameliorated by BH4. Proc Natl Acad Sci USA 2007;104:15081–15086.
    1. Vasquez-Vivar J, Kalyanaraman B, Martasek P, Hogg N, Masters BSS, Karoui H, Tordo P, Pritchard KA Jr. Superoxide generation by endothelial nitric oxide synthase: the influence of cofactors. Proc Natl Acad Sci USA 1998;95:9220–9225.
    1. Antoniades C, Demosthenous M, Reilly S, Margaritis M, Zhang MH, Antonopoulos A, Marinou K, Nahar K, Jayaram R, Tousoulis D, Bakogiannis C, Sayeed R, Triantafyllou C, Koumallos N, Psarros C, Miliou A, Stefanadis C, Channon KM, Casadei B. Myocardial redox state predicts in-hospital clinical outcome after cardiac surgery effects of short-term pre-operative statin treatment. J Am Coll Cardiol 2012;59:60–70.
    1. Rodrigo R, Korantzopoulos P, Cereceda M, Asenjo R, Zamorano J, Villalabeitia E, Baeza C, Aguayo R, Castillo R, Carrasco R, Gormaz JG. A randomized controlled trial to prevent post-operative atrial fibrillation by antioxidant reinforcement. J Am Coll Cardiol 2013;62:1457–1465.
    1. Anderson EJ, Efird JT, Davies SW, O'Neal WT, Darden TM, Thayne KA, Katunga LA, Kindell LC, Ferguson TB, Anderson CA, Chitwood WR, Koutlas TC, Williams JM, Rodriguez E, Kypson AP. Monoamine oxidase is a major determinant of redox balance in human atrial myocardium and is associated with postoperative atrial fibrillation. J Am Heart Assoc 2014;3:e000713.
    1. Reilly SN, Liu X, Carnicer R, Recalde A, Muszkiewicz A, Jayaram R, Carena MC, Wijesurendra R, Stefanini M, Surdo NC, Lomas O, Ratnatunga C, Sayeed R, Krasopoulos G, Rajakumar T, Bueno-Orovio A, Verheule S, Fulga TA, Rodriguez B, Schotten U, Casadei B. Up-regulation of miR-31 in human atrial fibrillation begets the arrhythmia by depleting dystrophin and neuronal nitric oxide synthase. Sci Transl Med 2016;8:340ra374.
    1. Maack C, Kartes T, Kilter H, SchäFers H-J, Nickenig G, BöHm M, Laufs U. Oxygen free radical release in human failing myocardium is associated with increased activity of rac1-GTPase and represents a target for statin treatment. Circulation 2003;108:1567–1574.
    1. Reilly SN, Jayaram R, Nahar K, Antoniades C, Verheule S, Channon KM, Alp NJ, Schotten U, Casadei B. Atrial sources of reactive oxygen species vary with the duration and substrate of atrial fibrillation: implications for the antiarrhythmic effect of statins. Circulation 2011;124:1107–1117.
    1. Antoniades C, Bakogiannis C, Leeson P, Guzik TJ, Zhang MH, Tousoulis D, Antonopoulos AS, Demosthenous M, Marinou K, Hale A, Paschalis A, Psarros C, Triantafyllou C, Bendall J, Casadei B, Stefanadis C, Channon KM. Rapid, direct effects of statin treatment on arterial redox state and nitric oxide bioavailability in human atherosclerosis via tetrahydrobiopterin-mediated endothelial nitric oxide synthase coupling. Circulation 2011;124:335–345.
    1. Shiroshita-Takeshita A, Schram G, Lavoie J, Nattel S. Effect of simvastatin and antioxidant vitamins on atrial fibrillation promotion by atrial-tachycardia remodeling in dogs. Circulation 2004;110:2313–2319.
    1. Zheng Z, Jayaram R, Jiang L, Emberson J, Zhao Y, Li Q, Du J, Guarguagli S, Hill M, Chen Z, Collins R, Casadei B. Perioperative rosuvastatin in cardiac surgery. N Engl J Med 2016; 374:1744–1753.
    1. Zhen-Han L, Rui S, Dan C, Xiao-Li Z, Qing-Chen W, Bo F. Perioperative statin administration with decreased risk of postoperative atrial fibrillation, but not acute kidney injury or myocardial infarction: a meta-analysis. Sci Rep 2017;7:10091.
    1. An J, Shi F, Liu S, Ma J, Ma Q. Preoperative statins as modifiers of cardiac and inflammatory outcomes following coronary artery bypass graft surgery: a meta-analysis. Interact Cardiovasc Thorac Surg 2017;25:958–965.
    1. Khan JA, Laurikka JO, Järvinen OH, Khan NK, Järvelä KM. Early postoperative statin administration does not affect the rate of atrial fibrillation after cardiac surgery. Eur J Cardiothorac Surg 2020;57:1154–1159.
    1. Durand M, Machuron C, Guillet L, Moury PH, Martin C, Payen JF, Chavanon O, Albaladejo P. Preoperative statin treatment is not associated with reduced postoperative mortality or morbidity in patients undergoing isolated valve surgery. Heart Surg Forum 2019;22:E057–E062.
    1. Tyerman Z, Hawkins RB, Mehaffey JH, Quader M, Speir A, Yarboro LT, Ailawadi G. Preoperative statin use not associated with improved outcomes after ascending aortic repair. Semin Thorac Cardiovasc Surg 2018;30:421–426.
    1. Kuhn EW, Liakopoulos OJ, Choi YH, Rahmanian P, Eghbalzadeh K, Slottosch I, Deppe AC, Wahlers TCW. Preoperative statin therapy for atrial fibrillation and renal failure after cardiac surgery. Thorac Cardiovasc Surg 2020. doi:10.1055/s-0040-1710322.
    1. Harada T, Kagamiyama H, Hatakeyama K. Feedback regulation mechanisms for the control of GTP cyclohydrolase I activity. Science 1993;260:1507–1510.
    1. Wang P, Zweier JL. Measurement of nitric oxide and peroxynitrite generation in the postischemic heart. Evidence for peroxynitrite-mediated reperfusion injury. J Biol Chem 1996;271:29223–29230.
    1. Giokas DL, Vlessidis AG, Evmiridis NP. On-line selective detection of antioxidants free-radical scavenging activity based on Co(II)/EDTA-induced luminol chemiluminescence by flow injection analysis. Anal Chim Acta 2007;589:59–65.
    1. Guzik TJ, Channon KM, Measurement of vascular reactive oxygen species production by chemiluminescence. In: Fennell JP, Baker AH, eds. Hypertension: Methods and Protocols. Totowa, NJ: Humana Press, 2005:73–89.
    1. Chen C-A, Wang T-Y, Varadharaj S, Reyes LA, Hemann C, Talukder MAH, Chen Y-R, Druhan LJ, Zweier JL. S-glutathionylation uncouples eNOS and regulates its cellular and vascular function. Nature 2010;468:1115–1118.
    1. De Pascali F, Hemann C, Samons K, Chen CA, Zweier JL. Hypoxia and reoxygenation induce endothelial nitric oxide synthase uncoupling in endothelial cells through tetrahydrobiopterin depletion and S-glutathionylation. Biochemistry 2014;53:3679–3688.
    1. Carnicer R, Hale AB, Suffredini S, Liu X, Reilly S, Zhang MH, Surdo NC, Bendall JK, Crabtree MJ, Lim GB, Alp NJ, Channon KM, Casadei B. Cardiomyocyte GTP cyclohydrolase 1 and tetrahydrobiopterin increase NOS1 activity and accelerate myocardial relaxation. Circ Res 2012;111:718–727.
    1. Chen CA, Druhan LJ, Varadharaj S, Chen YR, Zweier JL. Phosphorylation of endothelial nitric-oxide synthase regulates superoxide generation from the enzyme. J Biol Chem 2008;283:27038–27047.
    1. Xia Y, Dawson VL, Dawson TM, Snyder SH, Zweier JL. Nitric oxide synthase generates superoxide and nitric oxide in arginine-depleted cells leading to peroxynitrite-mediated cellular injury. Proc Natl Acad Sci USA 1996;93:6770–6774.
    1. Dikalov S. Cross talk between mitochondria and NADPH oxidases. Free Radic Biol Med 2011;51:1289–1301.
    1. Schulz E, Wenzel P, Munzel T, Daiber A. Mitochondrial redox signaling: interaction of mitochondrial reactive oxygen species with other sources of oxidative stress. Antioxid Redox Signal 2014;20:308–324.
    1. Bendall JK, Douglas G, McNeill E, Channon K, Crabtree MJ. Tetrahydrobiopterin in cardiovascular health and disease. Antioxid Redox Signal 2013;20:3040–3077.
    1. Nandi M, Kelly P, Vallance P, Leiper J. Over-expression of GTP-cyclohydrolase 1 feedback regulatory protein attenuates LPS and cytokine-stimulated nitric oxide production. Vasc Med 2008;13:29–36.
    1. Kalivendi S, Hatakeyama K, Whitsett J, Konorev E, Kalyanaraman B, Vasquez-Vivar J. Changes in tetrahydrobiopterin levels in endothelial cells and adult cardiomyocytes induced by LPS and hydrogen peroxide–a role for GFRP? Free Radic Biol Med 2005;38:481–491.
    1. Wei CC, Wang ZQ, Hemann C, Hille R, Stuehr DJ. A tetrahydrobiopterin radical forms and then becomes reduced during Nomega-hydroxyarginine oxidation by nitric-oxide synthase. J Biol Chem 2003;278:46668–46673.
    1. Xie L, Talukder MA, Sun J, Varadharaj S, Zweier JL. Liposomal tetrahydrobiopterin preserves eNOS coupling in the post-ischemic heart conferring in vivo cardioprotection. J Mol Cell Cardiol 2015;86:14–22.
    1. Pinho-Gomes AC, Reilly S, Brandes RP, Casadei B. Targeting inflammation and oxidative stress in atrial fibrillation: role of 3-hydroxy-3-methylglutaryl-coenzyme a reductase inhibition with statins. Antioxid Redox Signal 2014;20:1268–1285.
    1. Almansob MA, Xu B, Zhou L, Hu XX, Chen W, Chang FJ, Ci HB, Yao JP, Xu YQ, Yao FJ, Liu DH, Zhang WB, Tang BY, Wang ZP, Ou JS. Simvastatin reduces myocardial injury undergoing noncoronary artery cardiac surgery: a randomized controlled trial. Arterioscler Thromb Vasc Biol 2012;32:2304–2313.
    1. Carnes CA, Chung MK, Nakayama T, Nakayama H, Baliga RS, Piao S, Kanderian A, Pavia S, Hamlin RL, McCarthy PM, Bauer JA, Van Wagoner DR. Ascorbate attenuates atrial pacing-induced peroxynitrite formation and electrical remodeling and decreases the incidence of postoperative atrial fibrillation. Circ Res 2001;89:E32–E38.
    1. Kumagai K, Nakashima H, Saku K. The HMG-CoA reductase inhibitor atorvastatin prevents atrial fibrillation by inhibiting inflammation in a canine sterile pericarditis model. Cardiovasc Res 2004;62:105–111.
    1. Bencsik P, Sasi V, Kiss K, Kupai K, Kolossváry M, Maurovich-Horvat P, Csont T, Ungi I, Merkely B, Ferdinandy P. Serum lipids and cardiac function correlate with nitrotyrosine and MMP activity in coronary artery disease patients. Eur J Clin Invest 2015;45:692–701.
    1. Sakamoto S, Yamauchi S, Yamashita H, Imura H, Maruyama Y, Ogasawara H, Hatori N, Shimizu K. Intraoperative mapping of the right atrial free wall during sinus rhythm: variety of activation patterns and incidence of postoperative atrial fibrillation. Eur J Cardiothorac Surg 2006;30:132–139.

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