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Renin in Interventions of Valvular Cardiac
Replace with Extracorporeal Circulation

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 variations in the rennin levels in interventions of heart valvular substitution (RVC) with circulation extracorpórea (CEC) during a period of 5 days.
Methods: I study prospective, without randomiser, selecting 25 patients, 11 males and 14 females, to those that were carried out a RVC with CEC in a programmed way. They are excluded those that present an basal renin 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: 15.73 ± 16.14, 22.04 ± 17.83, 23.98 ± 20.67, 25.18 ± 23.42 and 18.31 ± 16.11. The statistical analysis demonstrated an absence of significance of any taking with regard to the following one, but yes it demonstrated a difference between the basal values and the 3rd and 4th takings (p = 0.045 and p = 0.005) recovering the normality on 5th day of the intervention (p = 0.158). These results demonstrate us the important influence of the intervention with CEC on the renin levels but they also demonstrate the existence from a complete recovery on 5th day after the intervention.
Conclusions: A significant ascent of the values of the rennin is demonstrated after an intervention of substitution low heart valvular CEC that is normalised five days later of the intervention.

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INTRODUCTION
   The metabolic changes that occur after cardiac surgery with extracorporeal circulation result from a complex interaction between the effects of surgery and extracorporeal circulation per se, the inflammatory response to surgical trauma and extracorporeal circulation, perioperative use of hypothermia, the cardiovascular and neuroendocrine responses characteristic to cardiac surgery, and the drugs and blood products used to support circulation during and after operation.

   From the first works on the renin-angiothensin-aldosteron system and patients submissive extracorporea 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 hour after the surgery. There are no studies that extend this period.

OBJETIVE
   To analyze the variations in the renin levels in interventions of heart valvular substitution (RVC) with circulation extracorporea (CEC) during a period of 5 days.

METHODS
   Previous studies have demonstrated a persistent rise in serum renin 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 renin -were studied in 25 patients, 11 males and 14 females, undergoing a cardiac valvular replacement in a programmed way surgery with extracorporeal circulation in the Service of Cardiac Surgery 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: They are excluded those that present a basal renin outside of range. 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 anaesthetist. 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.

   Renin concentrations were measured by radioimmunoassay.

RESULTS
   The blood takings already followed the defined protocol in the method. The results of the different extractions were: 15,73 ± 16,14 in the first taking, 22,04 ± 17,83 in the second taking, 23,98 ± 20,67 in the third taking, 25,18 ± 23,42 in fourth taking and 18,31 ± 16,11 in the fifth takes.

   The statistical analysis did not demonstrate significant difference between the first and second taking. Nevertheless if it showed differences between the first taking compared with third and fourth where they observed significant statistical results with p = 0,045 comparing the first taking with a third and probability of p = 0,005 if we compared the fourth taking with the basal one. Also we can observe that it does not exist significant difference between the basal values and the final values since the probability was equal to 0.158. It is necessary to indicate that in it completes taking, is to say to on fifth day of the intervention with circulation extracorporeal the values were 20 % upper to the initial values but the strict used statistical method (in this case the method of the T of Student for twin values) makes difficult that it is arrived at the statistical meaning.

   Considering the exposed thing previously we can estimate that if we used Tests less strict we could arrive at the meaning. We have tried to put in front the puridad to obtain doubtful statistical results. The obtained results have been according to the forecasts since the normal answer from the organism to a situation of stress or important operation is the increase of the renin to cause maintenance of the arterial pressure by the activation of the angiothensin. Although it is necessary to consider that other factors like cortisol or the ACTH exist that collaborates in the maintenance of the constants, exist few factors with as fast influence as the mechanism of the renin, if we excepted the adrenalin or the dopamine. In this sense it is necessary to take with precaution the interpretation from the results since if we took them separately they can take to erroneous conclusions. In any case, we can observe the correct adaptive answer of the renin during and in first day after the intervention. In this period it is when plus the organism needs to protect the vital devices (brain, heart and kidney) and therefore the answer must be greater. It satisfies us to verify that the situation is regularized to on fifth day after the intervention, although this fact could have been demonstrated for on first time in our work. We thought that later studies could deepen in the study of the mechanism of regulation which could derive in an improvement of the clinical parameters improving the survival and diminishing the substitute drug use that nowadays we used.

CONCLUSIONS
   An increase of the values of renina plasmatic in the course and after an intervention can be observed available of cardiac valvular with circulation extracorporeal. Nevertheless in fifth day after the intervention the values do not show significant differences with the basal ones although they follow but high discreetly.

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Renina en Intervenciones de Reemplazo Valvular Cardiaco con Circulación Extracorpórea

RESUMEN
Objetivo: Analizar las variaciones en los niveles de renina en intervenciones de reemplazo valvular cardiaco (RVC) con circulación extracorpórea (CEC) durante un periodo de 5 días.
Métodos: Estudio prospectivo, sin randomizar, seleccionando 25 pacientes, 11 varones y 14 mujeres, a los que de forma programada se les realizó un RVC con CEC. Están excluidos los que presenten una renina 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: 15.73 ± 16.14, 22.04 ± 17.83, 23.98 ± 20.67, 25.18 ± 23.42 y 18.31 ± 16.11. El análisis estadístico demostró una ausencia de significación de cualquier toma con respecto a la siguiente, pero sí demostró una diferencia entre los valores basales y la 3ª y 4ª tomas (p = 0.045 y p = 0.005) restableciéndose la normalidad al 5º día de la intervención (p = 0.158). Estos resultados nos demuestran la importante influencia de la intervención con CEC sobre los niveles de renina pero también demuestran la existencia de una recuperación completa al 5º día después de la intervención.
Conclusiones: Se demuestra un ascenso significativo de los valores de la renina después de una intervención de reemplazo valvular cardiaco bajo CEC que se normaliza 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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