Effects of transcutaneous electrical nerve stimulation on myocardial protection in patients undergoing aortic valve replacement: a randomized clinical trial

Youn Joung Cho, Dhong-Eun Jung, Karam Nam, Jinyoung Bae, Seohee Lee, Yunseok Jeon, Youn Joung Cho, Dhong-Eun Jung, Karam Nam, Jinyoung Bae, Seohee Lee, Yunseok Jeon

Abstract

Background: Cardiopulmonary bypass-related myocardial ischemia-reperfusion injury is a major contributor to postoperative morbidity. Although transcutaneous electrical nerve stimulation (TENS) has been found to have cardioprotective effects in animal studies and healthy volunteers, its effects on cardiac surgery under cardiopulmonary bypass patients have not been evaluated. We investigated the effects of TENS on myocardial protection in patients undergoing aortic valve replacement surgery using cardiopulmonary bypass.

Methods: Thirty patients were randomized to receive TENS or sham in three different anesthetic states - pre-anesthesia, sevoflurane, or propofol (each n = 5). TENS was applied with a pulse width of 385 μs and a frequency of 10 Hz using two surface electrodes at the upper arm for 30 min. Sham treatment was provided without stimulation. The primary outcome was the difference in myocardial infarct size following ischemia-reperfusion injury in rat hearts perfused with pre- and post-TENS plasma dialysate obtained from the patients using Langendorff perfusion system. The cardioprotective effects of TENS were determined by assessing reduction in infarct size following treatment.

Results: There were no differences in myocardial infarct size between pre- and post-treatment in any group (41.4 ± 4.3% vs. 36.7 ± 5.3%, 39.8 ± 7.3% vs. 27.8 ± 12.0%, and 41.6 ± 2.2% vs. 37.8 ± 7.6%; p = 0.080, 0.152, and 0.353 in the pre-anesthesia, sevoflurane, and propofol groups, respectively).

Conclusions: In our study, TENS did not show a cardioprotective effect in patients undergoing aortic valve replacement surgery.

Trial registration: This study was registered at clinicaltrials.gov ( NCT03859115 , on March 1, 2019).

Keywords: Aortic valve replacement; Cardiac surgery; Ischemia reperfusion injury; Myocardial protection; Transcutaneous electrical nerve stimulation.

Conflict of interest statement

The authors declare that they have no competing interests.

© 2022. The Author(s).

Figures

Fig. 1
Fig. 1
CONSORT flow diagram. TENS, transcutaneous electrical nerve stimulation; PRE, pre-anesthesia; s-, sham; SEVO, sevoflurane; PPF, propofol
Fig. 2
Fig. 2
Study flow. PRE, pre-anesthesia; s-, sham; SEVO, sevoflurane; PPF, propofol; TENS, transcutaneous electrical nerve stimulation
Fig. 3
Fig. 3
A Langendorff apparatus for rat heart ischemia-reperfusion injury model. B Ischemia-reperfusion injury protocol using Langendorff rat heart model. KHB, Krebs-Henseleit buffer
Fig. 4
Fig. 4
Comparisons of rat myocardial infarct size before and after TENS in three different anesthesia groups. TENS, transcutaneous electrical nerve stimulation
Fig. 5
Fig. 5
Myocardial infarct size of rat hearts following pre- and post-TENS/sham treatment regardless of anesthetic state. TENS, transcutaneous electrical nerve stimulation

References

    1. Royster RL. Myocardial dysfunction following cardiopulmonary bypass: recovery patterns, predictors of inotropic need, theoretical concepts of inotropic administration. J Cardiothorac Vasc Anesth. 1993;7:19–25. doi: 10.1016/1053-0770(93)90093-Z.
    1. De Hert S, Moerman A. Myocardial injury and protection related to cardiopulmonary bypass. Best Pract Res Clin Anaesthesiol. 2015;29:137–149. doi: 10.1016/j.bpa.2015.03.002.
    1. Sluka KA, Walsh D. Transcutaneous electrical nerve stimulation: basic science mechanisms and clinical effectiveness. J Pain. 2003;4:109–121. doi: 10.1054/jpai.2003.434.
    1. Bayindir O, Paker T, Akpinar B, Erenturk S, Askin D, Aytac A. Use of transcutaneous electrical nerve stimulation in the control of postoperative chest pain after cardiac surgery. J Cardiothorac Vasc Anesth. 1991;5:589–591. doi: 10.1016/1053-0770(91)90012-I.
    1. Cipriano G, Jr, de Camargo Carvalho AC, Bernardelli GF, Tayar Peres PA. Short-term transcutaneous electrical nerve stimulation after cardiac surgery: effect on pain, pulmonary function and electrical muscle activity. Interact Cardiovasc Thorac Surg. 2008;7:539–543. doi: 10.1510/icvts.2007.168542.
    1. Merlocco AC, Redington KL, Disenhouse T, et al. Transcutaneous electrical nerve stimulation as a novel method of remote preconditioning: in vitro validation in an animal model and first human observations. Basic Res Cardiol. 2014;109:406. doi: 10.1007/s00395-014-0406-0.
    1. Cho YJ, Nam K, Kim TK, et al. Sevoflurane, Propofol and Carvedilol block myocardial protection by limb remote ischemic preconditioning. Int J Mol Sci. 2019;20:269. doi: 10.3390/ijms20020269.
    1. Murphy GJ, Angelini GD. Side effects of cardiopulmonary bypass: what is the reality? J Card Surg. 2004;19:481–488. doi: 10.1111/j.0886-0440.2004.04101.x.
    1. Heusch G, Botker HE, Przyklenk K, Redington A, Yellon D. Remote ischemic conditioning. J Am Coll Cardiol. 2015;65:177–195. doi: 10.1016/j.jacc.2014.10.031.
    1. Zhou H, Yang L, Wang G, et al. Remote ischemic preconditioning prevents postoperative acute kidney injury after open total aortic arch replacement: a double-blind, randomized, sham-controlled trial. Anesth Analg. 2019;129:287–293. doi: 10.1213/ANE.0000000000004127.
    1. Przyklenk K, Bauer B, Ovize M, Kloner RA, Whittaker P. Regional ischemic 'preconditioning' protects remote virgin myocardium from subsequent sustained coronary occlusion. Circulation. 1993;87:893–899. doi: 10.1161/01.CIR.87.3.893.
    1. Botker HE, Kharbanda R, Schmidt MR, et al. Remote ischaemic conditioning before hospital admission, as a complement to angioplasty, and effect on myocardial salvage in patients with acute myocardial infarction: a randomised trial. Lancet. 2010;375:727–734. doi: 10.1016/S0140-6736(09)62001-8.
    1. Pickard JM, Davidson SM, Hausenloy DJ, Yellon DM. Co-dependence of the neural and humoral pathways in the mechanism of remote ischemic conditioning. Basic Res Cardiol. 2016;111:50. doi: 10.1007/s00395-016-0568-z.
    1. Donato M, Buchholz B, Rodriguez M, et al. Role of the parasympathetic nervous system in cardioprotection by remote hindlimb ischaemic preconditioning. Exp Physiol. 2013;98:425–434. doi: 10.1113/expphysiol.2012.066217.
    1. Gourine A, Gourine AV. Neural mechanisms of cardioprotection. Physiology (Bethesda) 2014;29:133–140.
    1. Redington KL, Disenhouse T, Li J, et al. Electroacupuncture reduces myocardial infarct size and improves post-ischemic recovery by invoking release of humoral, dialyzable, cardioprotective factors. J Physiol Sci. 2013;63:219–223. doi: 10.1007/s12576-013-0259-6.
    1. Ni X, Xie Y, Wang Q, et al. Cardioprotective effect of transcutaneous electric acupoint stimulation in the pediatric cardiac patients: a randomized controlled clinical trial. Paediatr Anaesth. 2012;22:805–811. doi: 10.1111/j.1460-9592.2012.03822.x.
    1. Jensen RV, Stottrup NB, Kristiansen SB, Botker HE. Release of a humoral circulating cardioprotective factor by remote ischemic preconditioning is dependent on preserved neural pathways in diabetic patients. Basic Res Cardiol. 2012;107:285. doi: 10.1007/s00395-012-0285-1.
    1. Basalay MV, Davidson SM, Gourine AV, Yellon DM. Neural mechanisms in remote ischaemic conditioning in the heart and brain: mechanistic and translational aspects. Basic Res Cardiol. 2018;113:25. doi: 10.1007/s00395-018-0684-z.
    1. Sbruzzi G, Silveira SA, Silva DV, Coronel CC, Plentz RD. Transcutaneous electrical nerve stimulation after thoracic surgery: systematic review and meta-analysis of 11 randomized trials. Rev Bras Cir Cardiovasc. 2012;27:75–87. doi: 10.5935/1678-9741.20120012.
    1. Wang Z, Yu L, Wang S, et al. Chronic intermittent low-level transcutaneous electrical stimulation of auricular branch of vagus nerve improves left ventricular remodeling in conscious dogs with healed myocardial infarction. Circ Heart Fail. 2014;7:1014–1021. doi: 10.1161/CIRCHEARTFAILURE.114.001564.
    1. Mo Y, Chen S, Yang L, et al. The effect of transcutaneous electrical Acupoint stimulation on inflammatory response in patients undergoing limb ischemia-reperfusion. Mediat Inflamm. 2017;2017:8369737. doi: 10.1155/2017/8369737.
    1. Johnson M. Transcutaneous electrical nerve stimulation: mechanisms, Clinical Application and Evidence. Rev Pain. 2007;1:7–11. doi: 10.1177/204946370700100103.
    1. Rossello X, Yellon DM. Cardioprotection: the disconnect between bench and bedside. Circulation. 2016;134:574–575. doi: 10.1161/CIRCULATIONAHA.116.022829.
    1. Rossaint J. Propofol anesthesia and remote ischemic preconditioning: an unfortunate relationship. Anesth Analg. 2018;126:1118–1120. doi: 10.1213/ANE.0000000000002825.
    1. Behmenburg F, van Caster P, Bunte S, et al. Impact of anesthetic regimen on remote ischemic preconditioning in the rat heart in vivo. Anesth Analg. 2018;126:1377–1380. doi: 10.1213/ANE.0000000000002563.
    1. Cho YJ, Lee E-H, Lee K, et al. Long-term clinical outcomes of remote ischemic preconditioning and Postconditioning outcome (RISPO) trial in patients undergoing cardiac surgery. Int J Cardiol. 2017;231:84–89. doi: 10.1016/j.ijcard.2016.12.146.
    1. Yang L, Yang J, Wang Q, et al. Cardioprotective effects of electroacupuncture pretreatment on patients undergoing heart valve replacement surgery: a randomized controlled trial. Ann Thorac Surg. 2010;89:781–786. doi: 10.1016/j.athoracsur.2009.12.003.
    1. Wang Z, Yu L, Chen M, Wang S, Jiang H. Transcutaneous electrical stimulation of auricular branch of vagus nerve: a noninvasive therapeutic approach for post-ischemic heart failure. Int J Cardiol. 2014;177:676–677. doi: 10.1016/j.ijcard.2014.09.165.
    1. Wang K, Ju Z, Chen C, et al. Cardioprotective effect of electroacupuncture in cardiopulmonary bypass through apelin/APJ signaling. Life Sci. 2020;242:117208. doi: 10.1016/j.lfs.2019.117208.
    1. Tsou MT, Huang CH, Chiu JH. Electroacupuncture on PC6 (Neiguan) attenuates ischemia/reperfusion injury in rat hearts. Am J Chin Med. 2004;32:951–965. doi: 10.1142/S0192415X04002557.
    1. Zeng Q, He H, Wang XB, Zhou YQ, et al. Electroacupuncture preconditioning improves myocardial infarction injury via enhancing AMPK-dependent autophagy in rats. Biomed Res Int. 2018;2018:1238175.
    1. Dong JH, Liu YX, Zhao J, Ma HJ, Guo SM, He RR. High-frequency electrical stimulation of femoral nerve reduces infarct size following myocardial ischemia-reperfusion in rats. Sheng Li Xue Bao. 2004;56:620–624.
    1. Brown L, Tabasam G, Bjordal JM, Johnson MI. An investigation into the effect of electrode placement of transcutaneous electrical nerve stimulation (TENS) on experimentally induced ischemic pain in healthy human participants. Clin J Pain. 2007;23:735–743. doi: 10.1097/AJP.0b013e31814b86a9.
    1. Schulman D, Latchman DS, Yellon DM. Effect of aging on the ability of preconditioning to protect rat hearts from ischemia-reperfusion injury. Am J Physiol Heart Circ Physiol. 2001;281:H1630–H1636. doi: 10.1152/ajpheart.2001.281.4.H1630.
    1. Gao J, Fu W, Jin Z, Yu X. A preliminary study on the cardioprotection of acupuncture pretreatment in rats with ischemia and reperfusion: involvement of cardiac beta-adrenoceptors. J Physiol Sci. 2006;56:275–279. doi: 10.2170/physiolsci.RP006606.

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