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Aortocoronary Bypass Interventions
with Extracorpóreal Circulation.
Study of Aldosterona Nivels

Rodríguez, Justino; Corona, Pedro;
Pérez, Miguel Angel; Pérez, José Luis;
Morillas, Ma. Consolación

Intensive Medical Unit, Clinica "San Roque", Las Palmas G.C. Intensive Medical Unit,
Hospital Militar Central "Gómez Ulla", Madrid, España

RESUMEN

SUMMARY
Objective: To analyse the aldosterona variations in interventions of aortocoronary bypass with extracorporeal circulation (CEC) during a period of 5 days.
Methods: A study prospective, without randomiser, selecting 25 patients, all of masculine sex, to those that in a programmed way a aortocoronary bypass will carry out with CEC. They are excluded those that a basal ACTH presents outside of range. They were carried out 5 extractions of blood. On 1st, the previous day to the surgery; on 2nd, during the CEC, in the moment of maximum hypothermia; on 3rd, to the arrival to the unit medical intensive; on 4th, the following day of the surgery; on 5th, five days later of surgery. The method statistical employee was the Test t Student among the different extractions accepting as significant the values from lowers than p to 0.05.
Results: The results of the different extractions were of 80.52 ± 105.31, 15.59 ± 33.10, 43.54 ± 66.78, 116 ± 106.25 and 100.92 ± 103.93. The significance was p = 0.00371, p = 0.0373, p = 0.0036 and p = 0.31. The statistical analysis demonstrated that the variations were always significant with the precedent taking, except for the last taking. Also the comparison of the basal values with those of the 5th day a p showed = 0.26. These results show us the great influence of the CEC on the aldosterona levels but they also demonstrate the existence from a complete recovery to the 5th day after the intervention.
Conclusions: A significant descent of the values of the aldosterona is demonstrated during and after an intervention of BP that recovers to the 5th day of the intervention.

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INTRODUCTION
   From the first works on the renin-angiothensin-aldosteron system and patients submissive extracorpórea circulation published by Taylor and cols, in the Seventies to most recent, an alteration in the levels of the aldosteron in the patients taken part by cardiac surgeons under circulation extracorporeal is stated, These alterations begin during the operation and still persist 24 hours after the surgery. There are no studies that extend this period.

OBJECTIVE
   To analyse the variations of the levels of aldosteron in interventions with extracorpórea circulation (CEC) during a period of 5 days.

METHOD
   Previous studies have demonstrated a persistent rise in serum aldosteron concentrations after cardiac surgery. To further investigate this finding and to evaluate that occurs with the cardiopulmonary bypass (CPB). We are drawing a prospective study without randomiser, where the concentrations of aldosteron -were studied in 25 patients, all of masculine sex, undergoing a coronary artery bypass graft surgery programmed with CEC in the Service of Surgery Cardiac of the Military Hospital; in Madrid.

   The inclusion criteria were: Age upper to 18 years. Programmed surgery. That CEC is used. To admitted alive in Intensive Medicine Unit. Is made of technical isolated of miocardical revascularization
The exclusion criteria were: Patients who analytically present levels of aldosteron upper or less at normal levels. Administration of Amiodarona in the 30 previous days to the operation. Administration of beta blockers in the 7 previous days to the operation.

   All the patients were taken part by the same surgical team and all patients received a standardized general anesthetic using a balanced technique with sufentanil, isoflurane, and midazolam, they are anaesthetized by the same anesthetist. During the operation they doing themselves: ECG. Invasive systemic and pulmonary pressure arterial. Cardiac output and mixed venous saturation in pulmonary artery. SpO2. Oxygen inspiratory fraction. End tidal CO2. Inspiration and exhalation concentration of inhaled anaesthetic gas. Temperature in blood (systemic) and vesical.

   Blood was collected preoperatively; intraoperatively during CPB; and postoperatively in the arrival to the IMU, the next day and five days after to the CPB.

    Aldosteron concentrations were measured by radioimmunoassay.

RESULTS
   The results of the different takings were of 80,52 ± 105,31 for first, 15,59 ± 33,10 for second, 43,54 ± 66,78 for third, 116 ± 106,25 for fourth and 100,92 ± 103,93 for the fifth takes. Respectively the meaning was p = 0,00371 between the first and second taking, p = 0,0373 between second and third, p = 0,0036 between third and fourth and p = 0,31 between the fourth and fifth. Consequently the statistical analysis demonstrated that the variations were always significant with the preceding taking, with exception of the last taking. If we compared the values of it completes taking with the initials we can observe that the results show to one p = 0,26 soon no significant one. It is necessary to indicate that the function of the aldosterone is to maintain the balance between the normal sodium concentration in the extracellular liquids and a normal volume of extracellular fluid. In this sense we must understand that the variations between individuals can as much be ample since the sodium concentrations as the volume of extracellular fluid vary physiologically of important form. On the other hand we must consider that another one of the mechanisms that influence the aldosteron levels is the cardiac output that depend, partly, of the sanguineous volume and the arterial pressure since we know that the diminution of the tissue circulation causes an increase in the aldosterone levels. The results demonstrate well these variations since we were values, that initial and finally, they can be considered like within normality but with very important standard deviations since in all the cases they surpass the average values and in several they even duplicate them. The most important cases we found them during the period of pump and in the immediately following takings. This phenomenon is logical since the interindividual answers are very different due to several factors and in special from the cardiovascular state in which each patient arrives at the intervention. The answer of each patient to the same one is very different since, often, the homeostatic balance previous to the intervention is, in general, precarious. Another one of the factors that we must have in consideration is the one that the secretion of aldosterone and the consequences which they entail not make with the speed of other adreno-cortical degradation products as the glucocorticoids reason why the response time are also but high. In summary, at sight of the results we can affirm that the CEC has a great influence on the aldosteron levels but also they demonstrate the recovery it is total and it completes on fifth day after the intervention reason why we understand that the control of the regulating mechanisms this then already recovered. We cannot avoid the fact that does not exist significant differences between fourth and fifth takes reason why we can estimate a fast recovery that totally completes to the fifth day post-intervention.

CONCLUSIONS
   A significant reduction of the values of the aldosteron is demonstrated during and after an aortocoronary intervention of by-pass that recovers, partially, in the first day after the intervention and more completely on fifth day after the intervention.

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Intervenciones de Bypass Aortocoronario con Circulación Extracorpórea. Estudio de los Niveles de Aldosterona

RESUMEN
Objetivo: Analizar las variaciones de aldosterona en intervenciones de bypass aortocoronario (BP) con circulación extracorpórea (CEC) durante un periodo de 5 días.
Métodos: Estudio prospectivo, sin randomizar, seleccionando 25 pacientes, todos de sexo masculino, a los que de forma programada se les va a realizar un BP con CEC. Están excluidos los que presenten una aldosterona basal fuera de rango. Se realizaron 5 tomas de sangre. La 1ª toma el día previo a la cirugía; la 2ª toma durante la CEC en el momento de máxima hipotermia; la 3ª toma a la llegada a la UMI; la 4ª toma al día siguiente de la cirugía; la 5ª toma al 5º día de la cirugía. El método estadístico empleado fue el Test de la t de Student entre las diferentes tomas aceptando como significativos los valores de p inferiores a 0.05.
Resultados: Los resultados de las diferentes tomas fueron de 80.52 ± 105.31, 15.59 ± 33.10, 43.54 ± 66.78, 116 ± 106.25 y 100.92 ± 103.93. La significación fue p = 0.00371, p = 0.0373, p = 0.0036 y p = 0.31. El análisis estadístico demostró que las variaciones eran siempre significativas con la toma precedente, con excepción de la última toma. Asimismo la comparación de los valores basales con los del 5º día mostró una p = 0.26. Estos resultados nos muestran la gran influencia de la CEC sobre los niveles de aldosterona pero también demuestran la existencia de una recuperación completa al 5º día después de la intervención.
Conclusiones: Se demuestra un descenso significativo de los valores de la aldosterona durante y después de una intervención de BP que se recupera al 5º día de la intervención.

 

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2nd Virtual Congress of Cardiology

Dr. Florencio Garófalo
Steering Committee
President
Dr. Raúl Bretal
Scientific Committee
President
Dr. Armando Pacher
Technical Committee - CETIFAC
President
fgaro@fac.org.ar
fgaro@satlink.com
rbretal@fac.org.ar
rbretal@netverk.com.ar
apacher@fac.org.ar
apacher@satlink.com

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