Czy nowatorski system krążenia pozaustrojowego z wypełnieniem krwią pacjenta może się stać nowym standardem w chirurgii wieńcowej?

Background: Commonly used cardiopulmonary bypass systems with cardiotomy reservoir, oxygenator, and roller pump require preoperative crystalloid filling. Radical reduction of the filling fluid volume and replacing it with the patient’s own blood has a fundamental impact on the outcome. Aim: A comparison of cardiopulmonary bypass filled with the patient’s blood, applied in Poland for the first time, and the classical system filled with crystalloids. Methods: Non-randomised trial in which patients undergoing coronary artery bypass grafting were divided into two groups: first operated on with use of cardiopulmonary bypass system with the patient’s own blood priming, and a control group operated on with standard technique. Levels of haemoglobin (HGB), haematocrit (HCT), platelets, leukocytes, creatinine, protein, C-reactive protein, procalcitonin, volume of transfused blood products, postoperative drain output, time to extubation, and consumption of catecholamines were compared. Results: The results of a study comparing the classical system with the blood-filled system (n = 60) showed a significantly smaller decrease in HGB and HCT levels (p = 0.001), resulting in reduction of blood product transfusions by 75% (p = 0.03). The new type of extracorporeal circulation reduced the total postoperative drain output by approximately 28% (p = 0.003). The systemic inflammatory response syndrome (SIRS) was less pronounced and the tissue perfusion was better due to smaller degree of haemodilution leading to better organ and heart protection. The patients required shorter mechanical ventilation times in the perioperative period. Conclusions: The use of a new system of cardiopulmonary bypass filled with the patient’s blood reduces the postoperative decrease in HGB and HCT, the amount of transfused blood products, and total postoperative drain output. It also shortens the time spent on mechanical ventilatory support.Wstęp i cel: Powszechnie stosowane układy do krążenia pozaustrojowego ze zbiornikiem kardiotomijnym, oksygenatorem i pompą perystaltyczną wymagają przed rozpoczęciem pracy zalania krystaloidami. Radykalne zredukowanie objętości wymaganego do zalania płynu i pomysłowe zastąpienie tego wypełnienia krwią własną pacjenta ma istotny wpływ na wyniki leczenia. Materiał i wyniki: Wyniki wstępne badania porównującego system klasyczny z systemem wypełnionym krwią (n = 44) pokazują znacznie mniejsze spadki stężenia hemoglobiny i hematokrytu (p = 0,05), co pozwala na redukcję ilości przetoczeń preparatów krwiopochodnych o 75% (p = 0,03). Nowy rodzaj krążenia pozaustrojowego zmniejsza całkowity drenaż pooperacyjny o ok. 28% (p = 0,01). Występuje istotnie mniejsza uogólniona reakcja zapalna, a lepsza perfuzja tkankowa dzięki zmniejszeniu hemodilucji zapewnia lepszą protekcję narządów wewnętrznych i serca. Chorzy wymagają w okresie okołooperacyjnym znacznie mniejszych dawek amin katecholowych i krótszego czasu intubacji dotchawiczej. Wnioski: Metoda ta, zastosowana po raz pierwszy w Polsce, jest bezpieczna, mimo że jest bardziej wymagająca dla zespołu uczestniczącego w zabiegu. Jest szczególnie przydatna u świadków Jehowy lub chorych z niskim stężeniem hemoglobiny ze względu na mechanizm protekcyjny krwi

Cigarette smoking decreases global microRNA expression in human alveolar macrophages.

Human alveolar macrophages are critical components of the innate immune system. Cigarette smoking-induced changes in alveolar macrophage gene expression are linked to reduced resistance to pulmonary infections and to the development of emphysema/COPD. We hypothesized that microRNAs (miRNAs) could control, in part, the unique messenger RNA (mRNA) expression profiles found in alveolar macrophages of cigarette smokers. Activation of macrophages with different stimuli in vitro leads to a diverse range of M1 (inflammatory) and M2 (anti-inflammatory) polarized phenotypes that are thought to mimic activated macrophages in distinct tissue environments. Microarray mRNA data indicated that smoking promoted an "inverse" M1 mRNA expression program, defined by decreased expression of M1-induced transcripts and increased expression of M1-repressed transcripts with few changes in M2-regulated transcripts. RT-PCR arrays identified altered expression of many miRNAs in alveolar macrophages of smokers and a decrease in global miRNA abundance. Stratification of human subjects suggested that the magnitude of the global decrease in miRNA abundance was associated with smoking history. We found that many of the miRNAs with reduced expression in alveolar macrophages of smokers were predicted to target mRNAs upregulated in alveolar macrophages of smokers. For example, miR-452 is predicted to target the transcript encoding MMP12, an important effector of smoking-related diseases. Experimental antagonism of miR-452 in differentiated monocytic cells resulted in increased expression of MMP12. The comprehensive mRNA and miRNA expression profiles described here provide insight into gene expression regulation that may underlie the adverse effects cigarette smoking has on alveolar macrophages

Inhibition of miRNA-452 results in increased MMP12 expression.

<p>RNA was collected from PMA-differentiated THP1 cells at 24 hours post-transfection with either a control miRNA inhibitor or a miR-452 inhibitor. Quantitative RT-PCR was used to determine the expression of putative miR-452 target. The mean expression with SEM from three independent experiments is shown for MMP12 and TM7SF4 as a ratio to HPRT for each sample.</p

Expression profiling indicates similar numbers of mRNAs are upregulated and downreglated in alveolar macrophages of cigarette smokers and nonsmokers.

<p>Smoker-to-nonsmoker mRNA expression ratios were determined using RNA from alveolar macrophages as template in GeneChip Human Exon 1.0 ST cDNA microarrays (Affymetrix). The RNA was collected from alveolar macrophages directly isolated from four nonsmokers and four smokers (cohort 1). <b>A)</b> Smoker-to-nonsmoker expression ratios are represented by black circles in order from lowest to highest for the 17,860 detected cDNAs. The arrow indicates the point where specific mRNA expression ratios in smokers and nonsmokers = 1. <b>B)</b> The expression ratios are shown for several commonly used endogenous controls. (ACTB = actin, beta; B2M = beta-2-microglobulin; GAPDHS = glyceraldehyde-3-phosphate dehydrogenase, spermatogenic; PGK1 = phosphoglycerate kinase 1; peptidylprolyl isomerase A; RPLP0 = ribosomal protein, large, P0; TBP = TATA box-binding protein).</p

Downregulated miRNAs in alveolar macrophages of smokers and corresponding predicted mRNA targets with upregulated expression.

a<p>Gene symbols of putative miRNA targets with the prediction algorithm indicated within parenthesis (“M” = MicroCosm; “T” = TargetScan). Text in bold identifies genes tested in correlation assays (see <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0044066#pone-0044066-g005" target="_blank">Figure 5</a>).</p

Expression profiling results were validated for select miRNAs in samples from the original alveolar macrophage donors and additional, non-redundant donors.

<p>Individual miRNA qRT-PCR expression assays were used to evaluate the expression of miR-146b-3p, miR-150, and miR-210. Expression of these miRNAs was determined using <b>A)</b> RNA analyzed previously in the TLDA assays (cohort 1) and <b>B)</b> RNA obtained from an independent set of donors (cohort 2). The mean expression with SEM of each miRNA is shown as a ratio to RNU48 for each sample.</p

miRNAs upregulated >2-fold in alveolar macrophages of smokers.

<p>miRNAs upregulated >2-fold in alveolar macrophages of smokers.</p

Expression profiling indicates a global repression of total miRNA abundance in alveolar macrophages of cigarette smokers.

<p>Smoker-to-nonsmoker miRNA expression ratios were determined using RNA from alveolar macrophages as template in TaqMan Low Density Array v2.0 RT-qPCR assays (ABI). The endogenous control, RNU48, was used to normalize the data. The eight RNA samples used as template in <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0044066#pone-0044066-g001" target="_blank">figure 1</a> were also used in these TLDA assays (cohort 1). <b>A)</b> Smoker-to-nonsmoker expression ratios are represented by black circles in order from lowest to highest for the 481 detected miRNAs. The arrow indicates the point where miRNA expression ratios in smokers and nonsmokers = 1. <b>B)</b> The expression ratios are shown for three additional endogenous control options provided with the TLDA assay are shown. <b>C)</b> The expression ratios and p-values of the 481 detected miRNAs are shown using a volcano plot. The significantly upregulated (red) and downregulated (blue) miRNAs are indicated along with the endogenous controls (green). <b>D)</b> The 54 miRNAs with smokers-to-nonsmokers expression ratios greater than 2 are shown following principle component analysis (PCA) with MATLAB software. This analysis identified a representative miRNA within each cluster with the highest Pearson correlation between its expression profile and the first principal component from our PCA analysis. <b>E)</b> Clustering analysis of the 54 regulated miRNAs was performed using CiMminer based on ΔCt-values of the TLDA results. The 4 clusters identified by PCA are labeled. Upregulated miRNAs are designated by various shades of red and downregulated miRNAs by various shades of blue.</p

miRNAs downregulated >2-fold in alveolar macrophages of smokers.

a<p>Family names as specified by miRBase release 18.</p>b<p>Clustered miRNAs described in miRBase release 18 were assumed to be polycistronic pri-miRNAs.</p>c<p>Fold change indicates miRNA expression in alveolar macrophages of smokers compared to nonsmokers.</p