Asymmetric dimethylarginine: Is it a risk facgtor in the repair of aortic coarctation?

Abstract

Background Asymmetric dimethylarginine (ADMA), an endogenous inhibitor of nitric oxide synthase, causes endothelial dysfunction which is an important risk factor for mortality in adult cardiovascular diseases. We aimed to investigate whether there was a relationship between the aortic cross‐clamping (ACC) time and serum ADMA level in aortic coarctation surgery and importance of the serum ADMA level as a marker of mortality and morbidity. Method Twenty‐two patients undergoing surgery for aortic coarctation in the neonatal and early infant period were included in the study, and the patients were divided into two groups according to the aortic cross‐clamping time (Group I: <20‐min, Group II: >20‐min). Results In Group I, preoperative and postoperative mean ADMA values of the patients were 0.57 ± 0.78 and 0.54 ± 0.83 µmol/L, respectively. In Group II, preoperative and postoperative mean ADMA values of the patients were 0.69 ± 0.93 and 1.10 ± 0.30 µmol/L, respectively. Preoperative‐postoperative change of ADMA correlates with ACC time (r = .802, p < .005) and duration of postoperative inotropic support (r = .719, p < .05). Also a high correlation has been found between the ACC time and duration of inotropic support in both groups (r = .689, p < .05). Conclusion Perioperative serum ADMA levels could be used as a prognostic bio‐marker in the patients undergoing aortic coarctation repair. Treatments to reduce serum ADMA levels can be valuable for preventing mortality and morbidity which develop after surgeries in a transient ischemia setting by clamping the aorta.

Invited commentary for asymmetric dimethylarginine (ADMA): Is it a risk factor in the repair of aortic coarctation?

“…However, NO production differs in cases of physical insult (surgery or trauma). 2 After surgery, immature myeloid cells express arginase 1 within 12 h, which increases arginine metabolism as seen by Bas et al, 1 depletes arginine and suppresses T-lymphocyte function. 2,3 In instances of limited arginine availability, arginase decreases NO production and impairs normal vasoactivity.…”

“…ADMA can accumulate because of increased protein turnover (as is observed during illness) and/or in patients with renal impairment. 5,6 It is thus possible that the report from Bas et al 1 demonstrating increased levels of ADMA as a predictor of poor clinical outcome reflects that this cohort of patients was "sicker" to start with. Interestingly, the provision of supplemental arginine in the diet improves arginine:ADMA ratios providing an interesting possibility of effective nutritional intervention in this patient population.…”

“…The authors noted that data from previous studies indicated a secure and effective aortic cross-clamp time of 20 min. 1 The study consisted of two groups of patients defined by the authors' cross-clamp time.…”

“…Interestingly, the provision of supplemental arginine in the diet improves arginine:ADMA ratios providing an interesting possibility of effective nutritional intervention in this patient population. 7 The variability in end-to-side and extended end-to-end repair techniques used by Bas et al 1 may amplify ADMA level differences.…”

“…The field of congenital heart disease has benefited from diagnostic modalities of fetal echocardiography and cardiac echocardiography, as well as the perioperative use of prostaglandin. Bas et al 1 introduced an innovative concept of ADMA measurement. More research is required, and a detailed investigation of the perioperative benefit of ADMA will aid clinical teams as they collaboratively devise next-generation treatment strategies for infants and children with complex congenital heart disease.…”