Idar Kirkeby-Garstad

Endothelial dysfunction induced by post-prandial lipemia: complete protection afforded by high-intensity aerobic interval exercise.

OBJECTIVES This study was designed to study the effect of exercise and a high-fat meal (HFM) on endothelial function. BACKGROUND Post-prandial lipemia and exercise oppose each other in terms of cardiovascular risk; however, the mechanism of their interaction is not well understood. METHODS Endothelial function was assessed by brachial artery flow-mediated dilation (FMD) in 8 healthy men before and after an HFM preceded (16 to 18 h) by rest, a single bout of continuous moderate-intensity exercise (CME), and high-intensity interval exercise (HIIE). RESULTS Before the HFM, initial brachial artery diameters were similar in all trials (0.43 +/- 0.04 cm), but after the HFM, basal diameter decreased only in the control (0.39 +/- 0.03 cm) and CME (0.38 +/- 0.04 cm) trials. Before the HFM, FMD/shear was improved by a single bout of CME (+20%, p < 0.01) and HIIE (+45%, p < 0.01; group differences, p < 0.01), with no effect in the control trial. After the HFM (30, 120, and 240 min), FMD decayed to a lesser extent with CME, but in a similar fashion to the control trial. In contrast, FMD in the HIIE trial remained elevated following the exercise despite a clear meal-induced lipemia. Although there were no correlations between vascular function and food-induced markers of cardiovascular risk, antioxidant status was strongly correlated with FMD (r = 0.9, p < 0.001). CONCLUSIONS These findings reveal a clinically relevant protective effect of acute exercise on the vasculature that is clearly exercise intensity dependent and tightly related to exercise-induced antioxidant capacity. (Endothelial Dysfunction Induced by Postprandial Lipemia; NCT00660491).

Impact of competitive flow on wall shear stress in coronary surgery: computational fluid dynamics of a LIMA–LAD model

AIMS Competitive flow from native coronary vessels is considered a major factor in the failure of coronary bypass grafts. However, the pathophysiological effects are not fully understood. Low and oscillatory wall shear stress (WSS) is known to induce endothelial dysfunction and vascular disease, like atherosclerosis and intimal hyperplasia. The aim was to investigate the impact of competitive flow on WSS in mammary artery bypass grafts. METHODS AND RESULTS Using computational fluid dynamics, WSS was calculated in a left internal mammary artery (LIMA) graft to the left anterior descending artery in a three-dimensional in vivo porcine coronary artery bypass graft model. The following conditions were investigated: high competitive flow (non-significant coronary lesion), partial competitive flow (significant coronary lesion), and no competitive flow (totally occluded coronary vessel). Time-averaged WSS of LIMA at high, partial, and no competitive flow were 0.3-0.6, 0.6-3.0, and 0.9-3.0 Pa, respectively. Further, oscillatory WSS quantified as the oscillatory shear index (OSI) ranged from (maximum OSI = 0.5 equals zero net WSS) 0.15 to 0.35, <0.05, and <0.05, respectively. Thus, high competitive flow resulted in substantial oscillatory and low WSS. Moderate competitive flow resulted in WSS and OSI similar to the no competitive flow condition. CONCLUSION Graft flow is highly dependent on the degree of competitive flow. High competitive flow was found to produce unfavourable WSS consistent with endothelial dysfunction and subsequent graft narrowing and failure. Partial competitive flow, however, may be better tolerated as it was found to be similar to the ideal condition of no competitive flow.

Guiding Surgical Cannulation of the Inferior Vena Cava with Transesophageal Echocardiography

We studied 150 adult cardiac surgery patients to assess visualization of the venous cannula and the venous system by intraoperative transesophageal echocardiography and to register the incidence of cannulation of hepatic veins. The quality of images, the dimensions of the venous system, the position of the venous cannula, and the adequacy of venous return were registered. Acceptable image quality of the inferior vena cava and the right hepatic vein (RHV) was obtained in 95% and 87% of cases, respectively. Considerable individual variations were found in the dimensions of the venous system. The cannula position could be determined in 99% of the cases. Ten percent of venous cannulae were primarily placed in the RHV. A short distance between the eustachian valve and the RHV possibly predisposes to cannulation of the RHV. No other patient-related factors were associated with cannula position. Placement of the cannula deep in the inferior vena cava was associated with reduced venous return and may be a more important cause of reduced return than a cannula positioned in a hepatic vein.

High intensity knee extensor training restores skeletal muscle function in copd patients

Improving reduced skeletal muscle function is important for optimising exercise tolerance and quality of life in chronic obstructive pulmonary disease (COPD) patients. By applying high-intensity training to a small muscle group, we hypothesised a normalisation of muscle function. Seven patients with COPD performed 6 weeks (3 days·week−1) of high-intensity interval aerobic knee extensor exercise training. Five age-matched healthy individuals served as a reference group. Muscle oxygen uptake and mitochondrial respiration of the vastus lateralis muscle were measured before and after the 6-week training programme. Initial peak work and maximal mitochondrial respiration were reduced in COPD patients and improved significantly after the training programme. Peak power and maximal mitochondrial respiration in vastus lateralis muscle increased to the level of the control subjects and were mainly mediated via improved complex I respiration. Furthermore, when normalised to citrate synthase activity, no difference in maximal respiration was found either after the intervention or compared to controls, suggesting normal functioning mitochondrial complexes. The present study shows that high-intensity training of a restricted muscle group is highly effective in restoring skeletal muscle function in COPD patients.

Different graft flow patterns due to competitive flow or stenosis in the coronary anastomosis assessed by transit-time flowmetry in a porcine model,

OBJECTIVE To assess whether coronary graft flow patterns are affected differently by native coronary competitive flow or by stenosis of the coronary anastomosis. METHODS Nine pigs (65-70 kg) underwent off-pump grafting of the left internal mammary artery to the left anterior descending artery (LAD). Transit-time flow patterns in the mammary grafts were recorded under four different conditions: (1) baseline flow (proximal LAD occluded), (2) full competitive flow, (3) partial competitive flow and (4) after creation of a stenosis in the anastomosis. Competitive flow was achieved by an adjustable occluder on the left anterior descending artery. The mean luminal stenosis of the anastomosis was 75+/-11%, calculated by epicardial ultrasound. Mean flow, systolic and diastolic antegrade and retrograde flow during different flow conditions were calculated as ratios of baseline flow and compared. Different derived flow indexes were calculated and compared in the same manner. Friedmans test and post hoc analyses by Wilcoxon signed-ranks were performed without correction for multiple comparisons. RESULTS Mean graft flow was more reduced by competitive flow than by a stenotic anastomosis of 75+/-11%. Competitive flow significantly decreased diastolic antegrade flow and both diastolic and systolic maximum peak flows, but increased retrograde flow, compared with baseline and stenosis. Furthermore, competitive flow and stenosis could be distinguished by analysis of several derived indexes. Pulsatility index (maximum-minimum flow/mean flow) and insufficiency percent (retrograde flow as fraction of total flow) was increased significantly more by competitive flow than by stenosis. Diastolic filling percent was significantly reduced at competitive flow compared with stenosis and baseline. CONCLUSIONS The mammary graft flow was significantly reduced by native coronary competitive flow, but marginally decreased by a stenotic anastomosis of 75% mean luminal stenosis. Reduction of graft flow due to competition was particularly evident in diastole. A detailed flow pattern analysis may differentiate between competitive flow and stenosis of the anastomosis.

The marked reduction in mixed venous oxygen saturation during early mobilization after cardiac surgery: the effect of posture or exercise?

Early mobilization after cardiac surgery induces a marked reduction in mixed venous oxygen saturation (Svo2). Using pulmonary artery catheters and indirect calorimetry, we investigated the effects of exercise and postural change on cardiac index (CI) and Svo2 before and on the first morning after coronary artery bypass surgery. Sixteen patients with an ejection fraction >0.50 were studied at rest, during supine bicycle exercise, and during passive standing. Supine cycling at 30 W increased CI by 1.5 ± 0.8 L · min−1 · m−2 before and 0.9 ± 0.7 L · min−1 · m−2 after surgery (P < 0.05), whereas Svo2 was reduced from 80% ± 4% at rest to 63 ± 6% preoperatively (P < 0.05) and from 71% ± 5% to 46% ± 11% postoperatively (P < 0.05). Passive standing reduced CI by 0.8 ± 0.5 L · min−1 · m−2 before and 0.3 ± 0.4 L · min−1 · m−2 after surgery (P < 0.05). Svo2 was reduced from 79% ± 5% to 64% ± 7% preoperatively (P < 0.05) and from 72% ± 6% to 60% ± 6% postoperatively (P < 0.05). The exercise challenge revealed an altered cardiovascular response after surgery, causing a larger reduction in Svo2 for the same workload. Passive standing significantly reduced Svo2 both days, but this effect was less pronounced after surgery. The response to postural change and exercise was altered after surgery and may both contribute to the reduction in Svo2 during postoperative mobilization.

Mixed venous oxygen desaturation during early mobilization after coronary artery bypass surgery

Background:  Early postoperative mobilization induces a marked reduction in mixed venous oxygen saturation (SvO2) after aortic valve replacement. We investigated whether a similar desaturation occurs among coronary artery bypass grafting (CABG) patients, and if the desaturation was related to the preoperative ejection fraction (EF).

Post-operative myocardial dysfunction does not affect the physiological response to early mobilization after coronary artery bypass grafting.

Background:  An acute increase in oxygen demand can be compensated for either by increased cardiac index (CI) or increased oxygen extraction, resulting in reduced mixed venous oxygen saturation (SvO2). We tested the hypothesis that post‐operative cardiac dysfunction may explain why oxygen extraction alone is increased during early mobilization after cardiac surgery.

Prophylactic treatment with levosimendan: a retrospective matched-control study of patients with reduced left ventricular function

OBJECTIVE Levosimendan is a calcium-sensitising inotropic agent and a vasodilator used in the treatment of heart failure. Post-cardiotomy cardiac failure is more common in patients with a low preoperative left ventricular ejection fraction (LVEF). We aim at investigating how prophylactic treatment with levosimendan before weaning from cardiopulmonary bypass (CPB) affects postoperative haemodynamics and outcome in patients with low preoperative LVEF. METHODS Patients with a preoperative LVEF < or =30% treated with levosimendan before weaning from CPB were included in the study. Each patient was matched to a control patient with respect to the following criteria: surgical procedure, EuroSCORE, age, gender and the use of intra-aortic balloon pump. We investigated postoperative haemodynamics in the intensive care unit (ICU) at time points: 1, arrival; 2, approximately 7h after arrival; and 3, the first postoperative morning. In addition, mortality was evaluated. RESULTS Thirty patients treated with levosimendan and 30 matched controls were enrolled in the study. No statistically significant differences in cardiac index (CI) (l min(-1)m(-2)), stroke volume index (SVI) (mlm(-2)), mixed venous O(2)-saturation (SvO(2)) (%) or heart rate (HR) (beats per minute) between the two groups measured at the three time points 1-3 were registered. Mean arterial blood pressure (MAP) (mmHg) was lower in the levosimendan group both at time points 2 (68, range: 65-71 vs 75, range: 72-78; p=0.009) and 3 (72, range: 69-74 vs 78, range: 74-82; p=0.01), despite a higher dose of norepinephrine in the treatment group (p=0.021). A significantly higher number of control patients were treated with classic adrenergic inotropes both in the operating room (p=0.013) and in the ICU (p<0.001). Thirty days mortality was the same in both groups (7%). CONCLUSIONS Prophylactic infusion of levosimendan initiated before weaning from CPB did not lead to superior haemodynamic parameters (CI, SVI, SvO(2)) compared to controls. Levosimendan reduced MAP and increased the need for norepinephrine postoperatively.

Mixed venous oxygen saturation during mobilization after cardiac surgery: are reflectance oximetry catheters reliable?

Background: Oximetry catheters immediately reflect changes in mixed venous oxygen saturation (Sv¯O2). We have used the Baxter 2‐SAT system to register changes in Sv¯O2 during early mobilizations after cardiac surgery. To assess catheter reliability, readings were compared to blood gases.