Butyrylcholinesterase as a perioperative complication marker in patients after transcatheter aortic valve implantation: a prospective observational study

Bernhard Michels, Andreas Holzamer, Bernhard M Graf, Andre Bredthauer, Walter Petermichl, Anika Müller, York Alexander Zausig, Diane Inge Bitzinger, Bernhard Michels, Andreas Holzamer, Bernhard M Graf, Andre Bredthauer, Walter Petermichl, Anika Müller, York Alexander Zausig, Diane Inge Bitzinger

Abstract

Objectives: Transcatheter aortic valve implantation (TAVI) is performed in elderly patients with severe aortic valve stenosis and increased operative risks. We tested the hypothesis that acetylcholinesterase (AChE) and butyrylcholinesterase (BChE) have a predictive value for prevalent complications after TAVI and could serve as indicators of systemic inflammation in the early postoperative period.

Design: Prospective observational study.

Setting: This study is a secondary analysis of multicentre CESARO- study.

Participants: 48 patients with TAVI were included and 43 obtained the complete assessment.

Primary and secondary outcome measures: Patients' clinical parameters, demographic data, peripheral AChE and BChE activities and routine blood markers were assessed throughout the perioperative period using bedside point-of-care measurements for AChE and BChE. Postoperative complication screening was conducted up to the third postoperative day and included infections, delirium and heart-rhythm disturbances. After assessment, the patients were divided into complication and noncomplication group.

Results: Of 43 patients, 24 developed postsurgical complications (55.8%). Preoperative assessment showed no significant differences regarding demographic data and laboratory markers, but preoperative BChE levels were significantly lower in patients who developed postoperative complications (complication group 2589.2±556.4 vs noncomplication group 3295.7±628.0, Cohen's r=0.514, p<0.001). In complication group, we observed an early, sustained reduction in BChE activity from preoperative to postoperative period. In complication group, BChE levels were significantly lower at each time point compared with noncomplication group. AChE activity showed no significant difference between both groups. Complication group also had longer stay in hospital overall.

Conclusion: BChE could be a useful perioperative biomarker to identify patients with a higher risk for postoperative complications after TAVI. By using point-of-care measurements, the levels of BChE are fast available and can lead to an early targeted therapy. Predicting the length of the hospital stay might play an important role in staff and resource management for these patients.

Trial registration number: NCT01964274; Post-results.

Keywords: adult cardiology; adult intensive & critical care; anaesthesia in cardiology; valvular heart disease.

Conflict of interest statement

Competing interests: None declared.

© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

Figures

Figure 1
Figure 1
Timeline of measurements of BChE and AChE: blood samples were taken 1 day preoperative (D O), shortly before anaesthetic induction (D 1), on admission to ICU (POD 0), 1 day after surgery (POD 1) and 2 days after surgery (POD 2). If the measuremnets could not be conducted immediatley, the samples have been cooled in a refrigerator and the measurement was performed up to 2 hours later. AChE, acetylcholinesterase; BChE, butyrylcholinesterase; ICU, intensive care unit, POD, Postoperative Day.
Figure 2
Figure 2
Time trajectories of BChE activities in patients with TAVI (n=43). Pre-operative (DO), shortly before anaesthetic induction (D 1), on admission to ICU (POD 0), 1 day after surgery (POD 1) and 2 days after surgery (POD 2) measurements in patients with (dashed) and without (solid) complication. Data are presented as median ±SD. *Difference between groups; # Difference within groups. BChE, butyrylcholinesterase; TAVI, transcatheter aortic valve implantation.
Figure 3
Figure 3
Time trajectories of AChE activities in patients with TAVI (n=43). Pre-operative (DO), shortly before anaesthetic induction (D 1), on admission to ICU (POD 0), 1 day after surgery (POD 1) and 2 days after surgery (POD 2) measurements in patients with (dashed) and without (solid) complication. Data are presented as median ±SD. AChE, acetylcholinesterase; TAVI, transcatheter aortic valve implantation.

References

    1. Rodés-Cabau J, Webb JG, Cheung A, et al. . Transcatheter aortic valve implantation for the treatment of severe symptomatic aortic stenosis in patients at very high or prohibitive surgical risk: acute and late outcomes of the multicenter Canadian experience. J Am Coll Cardiol 2010;55:1080–90. 10.1016/j.jacc.2009.12.014
    1. Zahn R, Gerckens U, Grube E, et al. . Transcatheter aortic valve implantation: first results from a multi-centre real-world registry. Eur Heart J 2011;32:198–204. 10.1093/eurheartj/ehq339
    1. Leon MB, Smith CR, Mack M, et al. . Transcatheter aortic-valve implantation for aortic stenosis in patients who cannot undergo surgery. N Engl J Med 2010;363:1597–607. 10.1056/NEJMoa1008232
    1. Würschinger F, Wittmann S, Goldfuß S, et al. . Complications after transcatheter aortic valve implantation using Transfemoral and transapical approach in general anaesthesia. PLoS One 2018;13:e0193558. 10.1371/journal.pone.0193558
    1. Covello RD, Ruggeri L, Landoni G, et al. . Transcatheter implantation of an aortic valve: anesthesiological management. Minerva Anestesiol 2010;76:100–8.
    1. Maniar HS, Lindman BR, Escallier K, et al. . Delirium after surgical and transcatheter aortic valve replacement is associated with increased mortality. J Thorac Cardiovasc Surg 2016;151:815–23. 10.1016/j.jtcvs.2015.10.114
    1. Chiarla C, Giovannini I, Giuliante F, et al. . Plasma cholinesterase correlations in acute surgical and critical illness. Minerva Chir 2011;66:323–7.
    1. Al-Kassab AS, Vijayakumar E. Profile of serum cholinesterase in systemic sepsis syndrome (septic shock) in intensive care unit patients. Clin Chem Lab Med 1995;33:245. 10.1515/cclm.1995.33.1.11
    1. Das UN. Acetylcholinesterase and butyrylcholinesterase as possible markers of low-grade systemic inflammation. Med Sci Monit 2007;13:RA214–21.
    1. Distelmaier K, Winter M-P, Rützler K, et al. . Serum butyrylcholinesterase predicts survival after extracorporeal membrane oxygenation after cardiovascular surgery. Crit Care 2014;18:R24. 10.1186/cc13711
    1. Lampón N, Hermida-Cadahia EF, Riveiro A, et al. . Association between butyrylcholinesterase activity and low-grade systemic inflammation. Ann Hepatol 2012;11:356–63. 10.1016/S1665-2681(19)30932-9
    1. Zivkovic AR, Bender J, Brenner T, et al. . Reduced butyrylcholinesterase activity is an early indicator of trauma-induced acute systemic inflammatory response. J Inflamm Res 2016;9:221–30. 10.2147/JIR.S117590
    1. Zivkovic AR, Schmidt K, Sigl A, et al. . Reduced serum butyrylcholinesterase activity indicates severe systemic inflammation in critically ill patients. Mediators Inflamm 2015;2015:1–11. 10.1155/2015/274607
    1. Kamolz L-P, Andel H, Greher M, et al. . Serum cholinesterase activity in patients with burns. Clin Chem Lab Med 2002;40:60–4. 10.1515/CCLM.2002.012
    1. Zivkovic AR, Decker SO, Zirnstein AC, et al. . A sustained reduction in serum cholinesterase enzyme activity predicts patient outcome following sepsis. Mediators Inflamm 2018;2018:1–10. 10.1155/2018/1942193
    1. Cerejeira J, Batista P, Nogueira V, et al. . Low preoperative plasma cholinesterase activity as a risk marker of postoperative delirium in elderly patients. Age Ageing 2011;40:621–6. 10.1093/ageing/afr053
    1. John M, Ely EW, Halfkann D, et al. . Acetylcholinesterase and butyrylcholinesterase in cardiosurgical patients with postoperative delirium. J Intensive Care 2017;5:29. 10.1186/s40560-017-0224-1
    1. Carnahan RM, Lund BC, Perry PJ, et al. . The anticholinergic drug scale as a measure of drug-related anticholinergic burden: associations with serum anticholinergic activity. J Clin Pharmacol 2006;46:1481–6. 10.1177/0091270006292126
    1. Radtke FM, Franck M, Schneider M, et al. . Comparison of three scores to screen for delirium in the recovery room. Br J Anaesth 2008;101:338–43. 10.1093/bja/aen193
    1. Cerejeira J, Nogueira V, Luís P, et al. . The cholinergic system and inflammation: common pathways in delirium pathophysiology. J Am Geriatr Soc 2012;60:669–75. 10.1111/j.1532-5415.2011.03883.x
    1. Zivkovic AR, Schmidt K, Stein T, et al. . Bedside-measurement of serum cholinesterase activity predicts patient morbidity and length of the intensive care unit stay following major traumatic injury. Sci Rep 2019;9:10437. 10.1038/s41598-019-46995-y
    1. Santarpia L, Grandone I, Contaldo F, et al. . Butyrylcholinesterase as a prognostic marker: a review of the literature. J Cachexia Sarcopenia Muscle 2013;4:31–9. 10.1007/s13539-012-0083-5
    1. De Magistris L, Paquette B, Orry D, et al. . Preoperative inflammation increases the risk of infection after elective colorectal surgery: results from a prospective cohort. Int J Colorectal Dis 2016;31:1611–7. 10.1007/s00384-016-2620-8
    1. Klugkist M, Sedemund-Adib B, Schmidtke C, et al. . Confusion assessment method for the intensive care unit (CAM-ICU): Diagnostik des postoperativen delirs bei kardiochirurgischen Patienten. Anaesthesist 2008;57:464–74.
    1. Koster S, Oosterveld FGJ, Hensens AG, et al. . Delirium after cardiac surgery and predictive validity of a risk checklist. Ann Thorac Surg 2008;86:1883–7. 10.1016/j.athoracsur.2008.08.020
    1. Tilley E, Psaltis PJ, Loetscher T, et al. . Meta-Analysis of prevalence and risk factors for delirium after transcatheter aortic valve implantation. Am J Cardiol 2018;122:1917–23. 10.1016/j.amjcard.2018.08.037
    1. Nashef SA, Roques F, Michel P, et al. . European system for cardiac operative risk evaluation (EuroSCORE). Eur J Cardiothorac Surg 1999;16:9–13. 10.1016/S1010-7940(99)00134-7

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