QUIESCENT HEART

Assiut University

E M A D Z A R I E F 2 0 1 2

HIDDEN DANGER

CARDIAC CONDITIONING

Remote Ischemic conditioning

CONCLUSION

THE HIDDEN DANGER

(CPB) and cardioplegic arrest remain the most popular

techniques in clinical intervention during open heart surgery

However both can directly or indirectly result in cardiac

morbidity following surgery Cardioplegic arrest can render the

heart quiescent but globally ischaemic and upon reperfusion

triggers myocardial injury (reperfusion injury )

Suleiman MS Halestrap AP Griffiths EJ Mitochondria a target for myocardial protectionPharmacol Ther Jan 2001 89(1)29ndash46

E M A D Z A R I E F 2 0 1 2

For further reduction in morbidity and mortality strategies to increase tissue tolerance to ischemia or reduce damage that occurs on reperfusion to be considered

One of the strategies that tries to protect the

heart is the CARDIAC CONDITIONING

E M A D Z A R I E F 2 0 1 2

THE HIDDEN DANGER

E M A D Z A R I E F 2 0 1 2

if these tissues have

already been exposed to several minor adverse or ischaemic events

medicationstress etc ie (conditioned )

Halogenated anesthetics

Noble gas e g Xenon

Opioids

Potassium channel openers

Nitric oxide donors

Bradykinin receptor agonists

phosphodiesterase inhibitors

AMP-activated protein kinase activators

muscarinic agents

Angiotensin AT1 agonists

Endothelin

E M A D Z A R I E F 2 0 1 2

heat

stress

rapid pacing

E M A D Z A R I E F 2 0 1 2

A number of noxious stimuli when applied sparingly

can trigger myocardial preconditioning eg

Gene therapy to induce a more permanent

and long-last preconditioning phenotype

E M A D Z A R I E F 2 0 1 2

eg Gene therapy for

eNOS and iNOS

E M A D Z A R I E F 2 0 1 2

ischemic

E M A D Z A R I E F 2 0 1 2

E M A D Z A R I E F 2 0 1 2

Injury

Lack of energy substrates

Lost cell wall pump activity

Lost antioxidant defense

Lost pH and calcium homeostasis

Lost mitochondrial integrity

E M A D Z A R I E F 2 0 1 2

RIPC (inter organ) preconditioning

is a recent observation in which

brief ischemia of one organ

protection on distant organs

without direct stress to the organ

E M A D Z A R I E F 2 0 1 2

Tapuria N Kumar Y Habib MM Abu Amara M Seifalian AM Davidson BR

Remote ischemic preconditioning a novel protective method from ischemia reperfusion injury--a review

J Surg Res 2008 Dec150(2)304-30

E M A D Z A R I E F 2 0 1 2

HIDDEN DANGER

CARDIAC CONDITIONING

Remote Ischemic conditioning

CONCLUSION

THE HIDDEN DANGER

(CPB) and cardioplegic arrest remain the most popular

techniques in clinical intervention during open heart surgery

However both can directly or indirectly result in cardiac

morbidity following surgery Cardioplegic arrest can render the

heart quiescent but globally ischaemic and upon reperfusion

triggers myocardial injury (reperfusion injury )

Suleiman MS Halestrap AP Griffiths EJ Mitochondria a target for myocardial protectionPharmacol Ther Jan 2001 89(1)29ndash46

E M A D Z A R I E F 2 0 1 2

For further reduction in morbidity and mortality strategies to increase tissue tolerance to ischemia or reduce damage that occurs on reperfusion to be considered

One of the strategies that tries to protect the

heart is the CARDIAC CONDITIONING

E M A D Z A R I E F 2 0 1 2

THE HIDDEN DANGER

E M A D Z A R I E F 2 0 1 2

if these tissues have

already been exposed to several minor adverse or ischaemic events

medicationstress etc ie (conditioned )

Halogenated anesthetics

Noble gas e g Xenon

Opioids

Potassium channel openers

Nitric oxide donors

Bradykinin receptor agonists

phosphodiesterase inhibitors

AMP-activated protein kinase activators

muscarinic agents

Angiotensin AT1 agonists

Endothelin

E M A D Z A R I E F 2 0 1 2

heat

stress

rapid pacing

E M A D Z A R I E F 2 0 1 2

A number of noxious stimuli when applied sparingly

can trigger myocardial preconditioning eg

Gene therapy to induce a more permanent

and long-last preconditioning phenotype

E M A D Z A R I E F 2 0 1 2

eg Gene therapy for

eNOS and iNOS

E M A D Z A R I E F 2 0 1 2

ischemic

E M A D Z A R I E F 2 0 1 2

E M A D Z A R I E F 2 0 1 2

Injury

Lack of energy substrates

Lost cell wall pump activity

Lost antioxidant defense

Lost pH and calcium homeostasis

Lost mitochondrial integrity

E M A D Z A R I E F 2 0 1 2

RIPC (inter organ) preconditioning

is a recent observation in which

brief ischemia of one organ

protection on distant organs

without direct stress to the organ

E M A D Z A R I E F 2 0 1 2

Tapuria N Kumar Y Habib MM Abu Amara M Seifalian AM Davidson BR

Remote ischemic preconditioning a novel protective method from ischemia reperfusion injury--a review

J Surg Res 2008 Dec150(2)304-30

THE HIDDEN DANGER

(CPB) and cardioplegic arrest remain the most popular

techniques in clinical intervention during open heart surgery

However both can directly or indirectly result in cardiac

morbidity following surgery Cardioplegic arrest can render the

heart quiescent but globally ischaemic and upon reperfusion

triggers myocardial injury (reperfusion injury )

Suleiman MS Halestrap AP Griffiths EJ Mitochondria a target for myocardial protectionPharmacol Ther Jan 2001 89(1)29ndash46

E M A D Z A R I E F 2 0 1 2

For further reduction in morbidity and mortality strategies to increase tissue tolerance to ischemia or reduce damage that occurs on reperfusion to be considered

One of the strategies that tries to protect the

heart is the CARDIAC CONDITIONING

E M A D Z A R I E F 2 0 1 2

THE HIDDEN DANGER

E M A D Z A R I E F 2 0 1 2

if these tissues have

already been exposed to several minor adverse or ischaemic events

medicationstress etc ie (conditioned )

Halogenated anesthetics

Noble gas e g Xenon

Opioids

Potassium channel openers

Nitric oxide donors

Bradykinin receptor agonists

phosphodiesterase inhibitors

AMP-activated protein kinase activators

muscarinic agents

Angiotensin AT1 agonists

Endothelin

E M A D Z A R I E F 2 0 1 2

heat

stress

rapid pacing

E M A D Z A R I E F 2 0 1 2

A number of noxious stimuli when applied sparingly

can trigger myocardial preconditioning eg

Gene therapy to induce a more permanent

and long-last preconditioning phenotype

E M A D Z A R I E F 2 0 1 2

eg Gene therapy for

eNOS and iNOS

E M A D Z A R I E F 2 0 1 2

ischemic

E M A D Z A R I E F 2 0 1 2

E M A D Z A R I E F 2 0 1 2

Injury

Lack of energy substrates

Lost cell wall pump activity

Lost antioxidant defense

Lost pH and calcium homeostasis

Lost mitochondrial integrity

E M A D Z A R I E F 2 0 1 2

RIPC (inter organ) preconditioning

is a recent observation in which

brief ischemia of one organ

protection on distant organs

without direct stress to the organ

E M A D Z A R I E F 2 0 1 2

Tapuria N Kumar Y Habib MM Abu Amara M Seifalian AM Davidson BR

Remote ischemic preconditioning a novel protective method from ischemia reperfusion injury--a review

J Surg Res 2008 Dec150(2)304-30

For further reduction in morbidity and mortality strategies to increase tissue tolerance to ischemia or reduce damage that occurs on reperfusion to be considered

One of the strategies that tries to protect the

heart is the CARDIAC CONDITIONING

E M A D Z A R I E F 2 0 1 2

THE HIDDEN DANGER

E M A D Z A R I E F 2 0 1 2

if these tissues have

already been exposed to several minor adverse or ischaemic events

medicationstress etc ie (conditioned )

Halogenated anesthetics

Noble gas e g Xenon

Opioids

Potassium channel openers

Nitric oxide donors

Bradykinin receptor agonists

phosphodiesterase inhibitors

AMP-activated protein kinase activators

muscarinic agents

Angiotensin AT1 agonists

Endothelin

E M A D Z A R I E F 2 0 1 2

heat

stress

rapid pacing

E M A D Z A R I E F 2 0 1 2

A number of noxious stimuli when applied sparingly

can trigger myocardial preconditioning eg

Gene therapy to induce a more permanent

and long-last preconditioning phenotype

E M A D Z A R I E F 2 0 1 2

eg Gene therapy for

eNOS and iNOS

E M A D Z A R I E F 2 0 1 2

ischemic

E M A D Z A R I E F 2 0 1 2

E M A D Z A R I E F 2 0 1 2

Injury

Lack of energy substrates

Lost cell wall pump activity

Lost antioxidant defense

Lost pH and calcium homeostasis

Lost mitochondrial integrity

E M A D Z A R I E F 2 0 1 2

RIPC (inter organ) preconditioning

is a recent observation in which

brief ischemia of one organ

protection on distant organs

without direct stress to the organ

E M A D Z A R I E F 2 0 1 2

Tapuria N Kumar Y Habib MM Abu Amara M Seifalian AM Davidson BR

Remote ischemic preconditioning a novel protective method from ischemia reperfusion injury--a review

J Surg Res 2008 Dec150(2)304-30

E M A D Z A R I E F 2 0 1 2

if these tissues have

already been exposed to several minor adverse or ischaemic events

medicationstress etc ie (conditioned )

Halogenated anesthetics

Noble gas e g Xenon

Opioids

Potassium channel openers

Nitric oxide donors

Bradykinin receptor agonists

phosphodiesterase inhibitors

AMP-activated protein kinase activators

muscarinic agents

Angiotensin AT1 agonists

Endothelin

E M A D Z A R I E F 2 0 1 2

heat

stress

rapid pacing

E M A D Z A R I E F 2 0 1 2

A number of noxious stimuli when applied sparingly

can trigger myocardial preconditioning eg

Gene therapy to induce a more permanent

and long-last preconditioning phenotype

E M A D Z A R I E F 2 0 1 2

eg Gene therapy for

eNOS and iNOS

E M A D Z A R I E F 2 0 1 2

ischemic

E M A D Z A R I E F 2 0 1 2

E M A D Z A R I E F 2 0 1 2

Injury

Lack of energy substrates

Lost cell wall pump activity

Lost antioxidant defense

Lost pH and calcium homeostasis

Lost mitochondrial integrity

E M A D Z A R I E F 2 0 1 2

RIPC (inter organ) preconditioning

is a recent observation in which

brief ischemia of one organ

protection on distant organs

without direct stress to the organ

E M A D Z A R I E F 2 0 1 2

Tapuria N Kumar Y Habib MM Abu Amara M Seifalian AM Davidson BR

Remote ischemic preconditioning a novel protective method from ischemia reperfusion injury--a review

J Surg Res 2008 Dec150(2)304-30

Halogenated anesthetics

Noble gas e g Xenon

Opioids

Potassium channel openers

Nitric oxide donors

Bradykinin receptor agonists

phosphodiesterase inhibitors

AMP-activated protein kinase activators

muscarinic agents

Angiotensin AT1 agonists

Endothelin

E M A D Z A R I E F 2 0 1 2

heat

stress

rapid pacing

E M A D Z A R I E F 2 0 1 2

A number of noxious stimuli when applied sparingly

can trigger myocardial preconditioning eg

Gene therapy to induce a more permanent

and long-last preconditioning phenotype

E M A D Z A R I E F 2 0 1 2

eg Gene therapy for

eNOS and iNOS

E M A D Z A R I E F 2 0 1 2

ischemic

E M A D Z A R I E F 2 0 1 2

E M A D Z A R I E F 2 0 1 2

Injury

Lack of energy substrates

Lost cell wall pump activity

Lost antioxidant defense

Lost pH and calcium homeostasis

Lost mitochondrial integrity

E M A D Z A R I E F 2 0 1 2

RIPC (inter organ) preconditioning

is a recent observation in which

brief ischemia of one organ

protection on distant organs

without direct stress to the organ

E M A D Z A R I E F 2 0 1 2

Tapuria N Kumar Y Habib MM Abu Amara M Seifalian AM Davidson BR

Remote ischemic preconditioning a novel protective method from ischemia reperfusion injury--a review

J Surg Res 2008 Dec150(2)304-30

heat

stress

rapid pacing

E M A D Z A R I E F 2 0 1 2

A number of noxious stimuli when applied sparingly

can trigger myocardial preconditioning eg

Gene therapy to induce a more permanent

and long-last preconditioning phenotype

E M A D Z A R I E F 2 0 1 2

eg Gene therapy for

eNOS and iNOS

E M A D Z A R I E F 2 0 1 2

ischemic

E M A D Z A R I E F 2 0 1 2

E M A D Z A R I E F 2 0 1 2

Injury

Lack of energy substrates

Lost cell wall pump activity

Lost antioxidant defense

Lost pH and calcium homeostasis

Lost mitochondrial integrity

E M A D Z A R I E F 2 0 1 2

RIPC (inter organ) preconditioning

is a recent observation in which

brief ischemia of one organ

protection on distant organs

without direct stress to the organ

E M A D Z A R I E F 2 0 1 2

Tapuria N Kumar Y Habib MM Abu Amara M Seifalian AM Davidson BR

Remote ischemic preconditioning a novel protective method from ischemia reperfusion injury--a review

J Surg Res 2008 Dec150(2)304-30

Gene therapy to induce a more permanent

and long-last preconditioning phenotype

E M A D Z A R I E F 2 0 1 2

eg Gene therapy for

eNOS and iNOS

E M A D Z A R I E F 2 0 1 2

ischemic

E M A D Z A R I E F 2 0 1 2

E M A D Z A R I E F 2 0 1 2

Injury

Lack of energy substrates

Lost cell wall pump activity

Lost antioxidant defense

Lost pH and calcium homeostasis

Lost mitochondrial integrity

E M A D Z A R I E F 2 0 1 2

RIPC (inter organ) preconditioning

is a recent observation in which

brief ischemia of one organ

protection on distant organs

without direct stress to the organ

E M A D Z A R I E F 2 0 1 2

Tapuria N Kumar Y Habib MM Abu Amara M Seifalian AM Davidson BR

Remote ischemic preconditioning a novel protective method from ischemia reperfusion injury--a review

J Surg Res 2008 Dec150(2)304-30

E M A D Z A R I E F 2 0 1 2

ischemic

E M A D Z A R I E F 2 0 1 2

E M A D Z A R I E F 2 0 1 2

Injury

Lack of energy substrates

Lost cell wall pump activity

Lost antioxidant defense

Lost pH and calcium homeostasis

Lost mitochondrial integrity

E M A D Z A R I E F 2 0 1 2

RIPC (inter organ) preconditioning

is a recent observation in which

brief ischemia of one organ

protection on distant organs

without direct stress to the organ

E M A D Z A R I E F 2 0 1 2

Tapuria N Kumar Y Habib MM Abu Amara M Seifalian AM Davidson BR

Remote ischemic preconditioning a novel protective method from ischemia reperfusion injury--a review

J Surg Res 2008 Dec150(2)304-30

E M A D Z A R I E F 2 0 1 2

E M A D Z A R I E F 2 0 1 2

Injury

Lack of energy substrates

Lost cell wall pump activity

Lost antioxidant defense

Lost pH and calcium homeostasis

Lost mitochondrial integrity

E M A D Z A R I E F 2 0 1 2

RIPC (inter organ) preconditioning

is a recent observation in which

brief ischemia of one organ

protection on distant organs

without direct stress to the organ

E M A D Z A R I E F 2 0 1 2

Tapuria N Kumar Y Habib MM Abu Amara M Seifalian AM Davidson BR

Remote ischemic preconditioning a novel protective method from ischemia reperfusion injury--a review

J Surg Res 2008 Dec150(2)304-30

E M A D Z A R I E F 2 0 1 2

Injury

Lack of energy substrates

Lost cell wall pump activity

Lost antioxidant defense

Lost pH and calcium homeostasis

Lost mitochondrial integrity

E M A D Z A R I E F 2 0 1 2

RIPC (inter organ) preconditioning

is a recent observation in which

brief ischemia of one organ

protection on distant organs

without direct stress to the organ

E M A D Z A R I E F 2 0 1 2

Tapuria N Kumar Y Habib MM Abu Amara M Seifalian AM Davidson BR

Remote ischemic preconditioning a novel protective method from ischemia reperfusion injury--a review

J Surg Res 2008 Dec150(2)304-30

E M A D Z A R I E F 2 0 1 2

RIPC (inter organ) preconditioning

is a recent observation in which

brief ischemia of one organ

protection on distant organs

without direct stress to the organ

E M A D Z A R I E F 2 0 1 2

Tapuria N Kumar Y Habib MM Abu Amara M Seifalian AM Davidson BR

Remote ischemic preconditioning a novel protective method from ischemia reperfusion injury--a review

J Surg Res 2008 Dec150(2)304-30

RIPC (inter organ) preconditioning

is a recent observation in which

brief ischemia of one organ

protection on distant organs

without direct stress to the organ

E M A D Z A R I E F 2 0 1 2

Tapuria N Kumar Y Habib MM Abu Amara M Seifalian AM Davidson BR

Remote ischemic preconditioning a novel protective method from ischemia reperfusion injury--a review

J Surg Res 2008 Dec150(2)304-30

E M A D Z A R I E F 2 0 1 2

Skeletal muscle

Kidney

intestine

E M A D Z A R I E F 2 0 1 2

E M A D Z A R I E F 2 0 1 2

ischemic protection

E M A D Z A R I E F 2 0 1 2

Brief ischemic episodes

cGMP-dependent protein kinase (cGMPPKG) pathway

reperfusion injury salvage kinase (RISK) pathway

survivor activating factor enhancement (SAFE) pathway

E M A D Z A R I E F 2 0 1 2

ischemic protection

E M A D Z A R I E F 2 0 1 2

YELLON D M DOWNEY J M Physiol Rev 2003831113-1151

The effects of the lsquofirst windowrsquo

or early preconditioning last 1ndash2 h

after which the protection wanes

The lsquosecond windowrsquo or late

preconditioning occurs 24 h

following the initial preconditioning

ischaemia and lasts for 48ndash72 h20

E M A D Z A R I E F 2 0 1 2

YELLON D M DOWNEY J M Physiol Rev 2003831113-1151

EARLY PHASE

where cellular signaling

cascades +amplification

immediate

cardioprotection

(SWOP) later phase

genetic re-programming

+ de novo synthesis of proteins

sustained cardioprotection

E M A D Z A R I E F 2 0 1 2

E M A D Z A R I E F 2 0 1 2

Tapuria N Kumar Y Habib MM Abu Amara M Seifalian AM Davidson BR

Remote ischemic preconditioning a novel protective method from ischemia reperfusion injury--a review

J Surg Res 2008 Dec150(2)304-30

E M A D Z A R I E F 2 0 1 2

E M A D Z A R I E F 2 0 1 2

ischemic protection

E M A D Z A R I E F 2 0 1 2

Brief ischemic episodes

cGMP-dependent protein kinase (cGMPPKG) pathway

reperfusion injury salvage kinase (RISK) pathway

survivor activating factor enhancement (SAFE) pathway

E M A D Z A R I E F 2 0 1 2

ischemic protection

E M A D Z A R I E F 2 0 1 2

YELLON D M DOWNEY J M Physiol Rev 2003831113-1151

The effects of the lsquofirst windowrsquo

or early preconditioning last 1ndash2 h

after which the protection wanes

The lsquosecond windowrsquo or late

preconditioning occurs 24 h

following the initial preconditioning

ischaemia and lasts for 48ndash72 h20

E M A D Z A R I E F 2 0 1 2

YELLON D M DOWNEY J M Physiol Rev 2003831113-1151

EARLY PHASE

where cellular signaling

cascades +amplification

immediate

cardioprotection

(SWOP) later phase

genetic re-programming

+ de novo synthesis of proteins

sustained cardioprotection

E M A D Z A R I E F 2 0 1 2

E M A D Z A R I E F 2 0 1 2

Tapuria N Kumar Y Habib MM Abu Amara M Seifalian AM Davidson BR

Remote ischemic preconditioning a novel protective method from ischemia reperfusion injury--a review

J Surg Res 2008 Dec150(2)304-30

E M A D Z A R I E F 2 0 1 2

ischemic protection

E M A D Z A R I E F 2 0 1 2

Brief ischemic episodes

cGMP-dependent protein kinase (cGMPPKG) pathway

reperfusion injury salvage kinase (RISK) pathway

survivor activating factor enhancement (SAFE) pathway

E M A D Z A R I E F 2 0 1 2

ischemic protection

E M A D Z A R I E F 2 0 1 2

YELLON D M DOWNEY J M Physiol Rev 2003831113-1151

The effects of the lsquofirst windowrsquo

or early preconditioning last 1ndash2 h

after which the protection wanes

The lsquosecond windowrsquo or late

preconditioning occurs 24 h

following the initial preconditioning

ischaemia and lasts for 48ndash72 h20

E M A D Z A R I E F 2 0 1 2

YELLON D M DOWNEY J M Physiol Rev 2003831113-1151

EARLY PHASE

where cellular signaling

cascades +amplification

immediate

cardioprotection

(SWOP) later phase

genetic re-programming

+ de novo synthesis of proteins

sustained cardioprotection

E M A D Z A R I E F 2 0 1 2

E M A D Z A R I E F 2 0 1 2

Tapuria N Kumar Y Habib MM Abu Amara M Seifalian AM Davidson BR

Remote ischemic preconditioning a novel protective method from ischemia reperfusion injury--a review

J Surg Res 2008 Dec150(2)304-30

E M A D Z A R I E F 2 0 1 2

Brief ischemic episodes

cGMP-dependent protein kinase (cGMPPKG) pathway

reperfusion injury salvage kinase (RISK) pathway

survivor activating factor enhancement (SAFE) pathway

E M A D Z A R I E F 2 0 1 2

ischemic protection

E M A D Z A R I E F 2 0 1 2

YELLON D M DOWNEY J M Physiol Rev 2003831113-1151

The effects of the lsquofirst windowrsquo

or early preconditioning last 1ndash2 h

after which the protection wanes

The lsquosecond windowrsquo or late

preconditioning occurs 24 h

following the initial preconditioning

ischaemia and lasts for 48ndash72 h20

E M A D Z A R I E F 2 0 1 2

YELLON D M DOWNEY J M Physiol Rev 2003831113-1151

EARLY PHASE

where cellular signaling

cascades +amplification

immediate

cardioprotection

(SWOP) later phase

genetic re-programming

+ de novo synthesis of proteins

sustained cardioprotection

E M A D Z A R I E F 2 0 1 2

E M A D Z A R I E F 2 0 1 2

Tapuria N Kumar Y Habib MM Abu Amara M Seifalian AM Davidson BR

Remote ischemic preconditioning a novel protective method from ischemia reperfusion injury--a review

J Surg Res 2008 Dec150(2)304-30

cGMP-dependent protein kinase (cGMPPKG) pathway

reperfusion injury salvage kinase (RISK) pathway

survivor activating factor enhancement (SAFE) pathway

E M A D Z A R I E F 2 0 1 2

ischemic protection

E M A D Z A R I E F 2 0 1 2

YELLON D M DOWNEY J M Physiol Rev 2003831113-1151

The effects of the lsquofirst windowrsquo

or early preconditioning last 1ndash2 h

after which the protection wanes

The lsquosecond windowrsquo or late

preconditioning occurs 24 h

following the initial preconditioning

ischaemia and lasts for 48ndash72 h20

E M A D Z A R I E F 2 0 1 2

YELLON D M DOWNEY J M Physiol Rev 2003831113-1151

EARLY PHASE

where cellular signaling

cascades +amplification

immediate

cardioprotection

(SWOP) later phase

genetic re-programming

+ de novo synthesis of proteins

sustained cardioprotection

E M A D Z A R I E F 2 0 1 2

E M A D Z A R I E F 2 0 1 2

Tapuria N Kumar Y Habib MM Abu Amara M Seifalian AM Davidson BR

Remote ischemic preconditioning a novel protective method from ischemia reperfusion injury--a review

J Surg Res 2008 Dec150(2)304-30

E M A D Z A R I E F 2 0 1 2

YELLON D M DOWNEY J M Physiol Rev 2003831113-1151

The effects of the lsquofirst windowrsquo

or early preconditioning last 1ndash2 h

after which the protection wanes

The lsquosecond windowrsquo or late

preconditioning occurs 24 h

following the initial preconditioning

ischaemia and lasts for 48ndash72 h20

E M A D Z A R I E F 2 0 1 2

YELLON D M DOWNEY J M Physiol Rev 2003831113-1151

EARLY PHASE

where cellular signaling

cascades +amplification

immediate

cardioprotection

(SWOP) later phase

genetic re-programming

+ de novo synthesis of proteins

sustained cardioprotection

E M A D Z A R I E F 2 0 1 2

E M A D Z A R I E F 2 0 1 2

Tapuria N Kumar Y Habib MM Abu Amara M Seifalian AM Davidson BR

Remote ischemic preconditioning a novel protective method from ischemia reperfusion injury--a review

J Surg Res 2008 Dec150(2)304-30

E M A D Z A R I E F 2 0 1 2

YELLON D M DOWNEY J M Physiol Rev 2003831113-1151

EARLY PHASE

where cellular signaling

cascades +amplification

immediate

cardioprotection

(SWOP) later phase

genetic re-programming

+ de novo synthesis of proteins

sustained cardioprotection

E M A D Z A R I E F 2 0 1 2

E M A D Z A R I E F 2 0 1 2

Tapuria N Kumar Y Habib MM Abu Amara M Seifalian AM Davidson BR

Remote ischemic preconditioning a novel protective method from ischemia reperfusion injury--a review

J Surg Res 2008 Dec150(2)304-30

E M A D Z A R I E F 2 0 1 2

E M A D Z A R I E F 2 0 1 2

Tapuria N Kumar Y Habib MM Abu Amara M Seifalian AM Davidson BR

Remote ischemic preconditioning a novel protective method from ischemia reperfusion injury--a review

J Surg Res 2008 Dec150(2)304-30

E M A D Z A R I E F 2 0 1 2

Tapuria N Kumar Y Habib MM Abu Amara M Seifalian AM Davidson BR

Remote ischemic preconditioning a novel protective method from ischemia reperfusion injury--a review

J Surg Res 2008 Dec150(2)304-30

E M A D Z A R I E F 2 0 1 2

E M A D Z A R I E F 2 0 1 2

E M A D Z A R I E F 2 0 1 2

E M A D Z A R I E F 2 0 1 2

E M A D Z A R I E F 2 0 1 2

E M A D Z A R I E F 2 0 1 2

Hausenloy DJ Mwamure PK Venugopal V Harris J Barnard M Grundy E et al Effect of remote ischaemic

preconditioning on myocardial injury in patients undergoing coronary artery bypass graft surgery a randomised

controlled trial Lancet 2007370575ndash9

RIPC CLASSIC

EARLY AND LATE PRECONDITIONING

E M A D Z A R I E F 2 0 1 2

Zhou WW Zeng DB Chen RW Liu J Yang GX Liu PB et al Limb ischemic preconditioning reduces heart and lung injury after an open

heart operation in infants

RI PRE AND POST CONDITIONING

E M A D Z A R I E F 2 0 1 2

Luo W Zhu M Huang R Zhang Y A comparison of cardiac postconditioning and remote pre-

conditioning in paediatric cardiac surgery Cardiol Young 201121266ndash70

CONCLUSION Endogenous lsquoconditioningrsquo

strategies can be applied prior to

or during ischaemia or at the

onset of reperfusion

RIPC beneficial in cardiac

surgery AAA surgery elective

PCI PPCI

Potential benefit in cardiac

arrest cardiac transplantation

stroke and other surgical

settings

E M A D Z A R I E F 2 0 1 2

REFERENCES

Asger Granfeldt1 David J Lefer2 and Jakob Vinten-Johansen Protective ischaemia in patients preconditioning

and Postconditioning Cardiovascular Research (2009) 83 234ndash246

Hausenloy DJ Mwamure PK Venugopal V Harris J Barnard M Grundy E et al Effect of remote ischaemic

preconditioning on myocardial injury in patients undergoing coronary artery bypass graft surgery a randomised

controlled trial Lancet 2007370575ndash9

XIONG Jun LIAO Xu XUE Fu-shan YUAN Yu-jing WANG Qiang and LIU Jian-hua Remote ischemia conditioningmdashan

endogenous cardioprotective strategy from outside the heart Chinese Medical Journal 2011124(14)2209-2215

Robert Loveridge MA and Frank Schroeder MD DEAA Anaesthetic preconditioning Continuing Education in

Anaesthesia Critical Care amp Pain | Volume 10 Number 2 2010

Jakub Marczaka Rafał Nowickia Julita Kulbackab and Jolanta Saczkob Is remote ischaemic preconditioning of

benefit to patients undergoing cardiac surgery Interactive CardioVascular and Thoracic Surgery 14 (2012) 634ndash

639

E M A D Z A R I E F 2 0 1 2

EMAD ZARIEF 2012

E M A D Z A R I E F 2 0 1 2

E M A D Z A R I E F 2 0 1 2

E M A D Z A R I E F 2 0 1 2

E M A D Z A R I E F 2 0 1 2

E M A D Z A R I E F 2 0 1 2

Hausenloy DJ Mwamure PK Venugopal V Harris J Barnard M Grundy E et al Effect of remote ischaemic

preconditioning on myocardial injury in patients undergoing coronary artery bypass graft surgery a randomised

controlled trial Lancet 2007370575ndash9

RIPC CLASSIC

EARLY AND LATE PRECONDITIONING

E M A D Z A R I E F 2 0 1 2

Zhou WW Zeng DB Chen RW Liu J Yang GX Liu PB et al Limb ischemic preconditioning reduces heart and lung injury after an open

heart operation in infants

RI PRE AND POST CONDITIONING

E M A D Z A R I E F 2 0 1 2

Luo W Zhu M Huang R Zhang Y A comparison of cardiac postconditioning and remote pre-

conditioning in paediatric cardiac surgery Cardiol Young 201121266ndash70

CONCLUSION Endogenous lsquoconditioningrsquo

strategies can be applied prior to

or during ischaemia or at the

onset of reperfusion

RIPC beneficial in cardiac

surgery AAA surgery elective

PCI PPCI

Potential benefit in cardiac

arrest cardiac transplantation

stroke and other surgical

settings

E M A D Z A R I E F 2 0 1 2

REFERENCES

Asger Granfeldt1 David J Lefer2 and Jakob Vinten-Johansen Protective ischaemia in patients preconditioning

and Postconditioning Cardiovascular Research (2009) 83 234ndash246

Hausenloy DJ Mwamure PK Venugopal V Harris J Barnard M Grundy E et al Effect of remote ischaemic

preconditioning on myocardial injury in patients undergoing coronary artery bypass graft surgery a randomised

controlled trial Lancet 2007370575ndash9

XIONG Jun LIAO Xu XUE Fu-shan YUAN Yu-jing WANG Qiang and LIU Jian-hua Remote ischemia conditioningmdashan

endogenous cardioprotective strategy from outside the heart Chinese Medical Journal 2011124(14)2209-2215

Robert Loveridge MA and Frank Schroeder MD DEAA Anaesthetic preconditioning Continuing Education in

Anaesthesia Critical Care amp Pain | Volume 10 Number 2 2010

Jakub Marczaka Rafał Nowickia Julita Kulbackab and Jolanta Saczkob Is remote ischaemic preconditioning of

benefit to patients undergoing cardiac surgery Interactive CardioVascular and Thoracic Surgery 14 (2012) 634ndash

639

E M A D Z A R I E F 2 0 1 2

EMAD ZARIEF 2012

E M A D Z A R I E F 2 0 1 2

E M A D Z A R I E F 2 0 1 2

E M A D Z A R I E F 2 0 1 2

E M A D Z A R I E F 2 0 1 2

Hausenloy DJ Mwamure PK Venugopal V Harris J Barnard M Grundy E et al Effect of remote ischaemic

preconditioning on myocardial injury in patients undergoing coronary artery bypass graft surgery a randomised

controlled trial Lancet 2007370575ndash9

RIPC CLASSIC

EARLY AND LATE PRECONDITIONING

E M A D Z A R I E F 2 0 1 2

Zhou WW Zeng DB Chen RW Liu J Yang GX Liu PB et al Limb ischemic preconditioning reduces heart and lung injury after an open

heart operation in infants

RI PRE AND POST CONDITIONING

E M A D Z A R I E F 2 0 1 2

Luo W Zhu M Huang R Zhang Y A comparison of cardiac postconditioning and remote pre-

conditioning in paediatric cardiac surgery Cardiol Young 201121266ndash70

CONCLUSION Endogenous lsquoconditioningrsquo

strategies can be applied prior to

or during ischaemia or at the

onset of reperfusion

RIPC beneficial in cardiac

surgery AAA surgery elective

PCI PPCI

Potential benefit in cardiac

arrest cardiac transplantation

stroke and other surgical

settings

E M A D Z A R I E F 2 0 1 2

REFERENCES

Asger Granfeldt1 David J Lefer2 and Jakob Vinten-Johansen Protective ischaemia in patients preconditioning

and Postconditioning Cardiovascular Research (2009) 83 234ndash246

Hausenloy DJ Mwamure PK Venugopal V Harris J Barnard M Grundy E et al Effect of remote ischaemic

preconditioning on myocardial injury in patients undergoing coronary artery bypass graft surgery a randomised

controlled trial Lancet 2007370575ndash9

XIONG Jun LIAO Xu XUE Fu-shan YUAN Yu-jing WANG Qiang and LIU Jian-hua Remote ischemia conditioningmdashan

endogenous cardioprotective strategy from outside the heart Chinese Medical Journal 2011124(14)2209-2215

Robert Loveridge MA and Frank Schroeder MD DEAA Anaesthetic preconditioning Continuing Education in

Anaesthesia Critical Care amp Pain | Volume 10 Number 2 2010

Jakub Marczaka Rafał Nowickia Julita Kulbackab and Jolanta Saczkob Is remote ischaemic preconditioning of

benefit to patients undergoing cardiac surgery Interactive CardioVascular and Thoracic Surgery 14 (2012) 634ndash

639

E M A D Z A R I E F 2 0 1 2

EMAD ZARIEF 2012

E M A D Z A R I E F 2 0 1 2

E M A D Z A R I E F 2 0 1 2

E M A D Z A R I E F 2 0 1 2

Hausenloy DJ Mwamure PK Venugopal V Harris J Barnard M Grundy E et al Effect of remote ischaemic

preconditioning on myocardial injury in patients undergoing coronary artery bypass graft surgery a randomised

controlled trial Lancet 2007370575ndash9

RIPC CLASSIC

EARLY AND LATE PRECONDITIONING

E M A D Z A R I E F 2 0 1 2

Zhou WW Zeng DB Chen RW Liu J Yang GX Liu PB et al Limb ischemic preconditioning reduces heart and lung injury after an open

heart operation in infants

RI PRE AND POST CONDITIONING

E M A D Z A R I E F 2 0 1 2

Luo W Zhu M Huang R Zhang Y A comparison of cardiac postconditioning and remote pre-

conditioning in paediatric cardiac surgery Cardiol Young 201121266ndash70

CONCLUSION Endogenous lsquoconditioningrsquo

strategies can be applied prior to

or during ischaemia or at the

onset of reperfusion

RIPC beneficial in cardiac

surgery AAA surgery elective

PCI PPCI

Potential benefit in cardiac

arrest cardiac transplantation

stroke and other surgical

settings

E M A D Z A R I E F 2 0 1 2

REFERENCES

Asger Granfeldt1 David J Lefer2 and Jakob Vinten-Johansen Protective ischaemia in patients preconditioning

and Postconditioning Cardiovascular Research (2009) 83 234ndash246

Hausenloy DJ Mwamure PK Venugopal V Harris J Barnard M Grundy E et al Effect of remote ischaemic

preconditioning on myocardial injury in patients undergoing coronary artery bypass graft surgery a randomised

controlled trial Lancet 2007370575ndash9

XIONG Jun LIAO Xu XUE Fu-shan YUAN Yu-jing WANG Qiang and LIU Jian-hua Remote ischemia conditioningmdashan

endogenous cardioprotective strategy from outside the heart Chinese Medical Journal 2011124(14)2209-2215

Robert Loveridge MA and Frank Schroeder MD DEAA Anaesthetic preconditioning Continuing Education in

Anaesthesia Critical Care amp Pain | Volume 10 Number 2 2010

Jakub Marczaka Rafał Nowickia Julita Kulbackab and Jolanta Saczkob Is remote ischaemic preconditioning of

benefit to patients undergoing cardiac surgery Interactive CardioVascular and Thoracic Surgery 14 (2012) 634ndash

639

E M A D Z A R I E F 2 0 1 2

EMAD ZARIEF 2012

E M A D Z A R I E F 2 0 1 2

E M A D Z A R I E F 2 0 1 2

Hausenloy DJ Mwamure PK Venugopal V Harris J Barnard M Grundy E et al Effect of remote ischaemic

preconditioning on myocardial injury in patients undergoing coronary artery bypass graft surgery a randomised

controlled trial Lancet 2007370575ndash9

RIPC CLASSIC

EARLY AND LATE PRECONDITIONING

E M A D Z A R I E F 2 0 1 2

Zhou WW Zeng DB Chen RW Liu J Yang GX Liu PB et al Limb ischemic preconditioning reduces heart and lung injury after an open

heart operation in infants

RI PRE AND POST CONDITIONING

E M A D Z A R I E F 2 0 1 2

Luo W Zhu M Huang R Zhang Y A comparison of cardiac postconditioning and remote pre-

conditioning in paediatric cardiac surgery Cardiol Young 201121266ndash70

CONCLUSION Endogenous lsquoconditioningrsquo

strategies can be applied prior to

or during ischaemia or at the

onset of reperfusion

RIPC beneficial in cardiac

surgery AAA surgery elective

PCI PPCI

Potential benefit in cardiac

arrest cardiac transplantation

stroke and other surgical

settings

E M A D Z A R I E F 2 0 1 2

REFERENCES

Asger Granfeldt1 David J Lefer2 and Jakob Vinten-Johansen Protective ischaemia in patients preconditioning

and Postconditioning Cardiovascular Research (2009) 83 234ndash246

Hausenloy DJ Mwamure PK Venugopal V Harris J Barnard M Grundy E et al Effect of remote ischaemic

preconditioning on myocardial injury in patients undergoing coronary artery bypass graft surgery a randomised

controlled trial Lancet 2007370575ndash9

XIONG Jun LIAO Xu XUE Fu-shan YUAN Yu-jing WANG Qiang and LIU Jian-hua Remote ischemia conditioningmdashan

endogenous cardioprotective strategy from outside the heart Chinese Medical Journal 2011124(14)2209-2215

Robert Loveridge MA and Frank Schroeder MD DEAA Anaesthetic preconditioning Continuing Education in

Anaesthesia Critical Care amp Pain | Volume 10 Number 2 2010

Jakub Marczaka Rafał Nowickia Julita Kulbackab and Jolanta Saczkob Is remote ischaemic preconditioning of

benefit to patients undergoing cardiac surgery Interactive CardioVascular and Thoracic Surgery 14 (2012) 634ndash

639

E M A D Z A R I E F 2 0 1 2

EMAD ZARIEF 2012

E M A D Z A R I E F 2 0 1 2

Hausenloy DJ Mwamure PK Venugopal V Harris J Barnard M Grundy E et al Effect of remote ischaemic

preconditioning on myocardial injury in patients undergoing coronary artery bypass graft surgery a randomised

controlled trial Lancet 2007370575ndash9

RIPC CLASSIC

EARLY AND LATE PRECONDITIONING

E M A D Z A R I E F 2 0 1 2

Zhou WW Zeng DB Chen RW Liu J Yang GX Liu PB et al Limb ischemic preconditioning reduces heart and lung injury after an open

heart operation in infants

RI PRE AND POST CONDITIONING

E M A D Z A R I E F 2 0 1 2

Luo W Zhu M Huang R Zhang Y A comparison of cardiac postconditioning and remote pre-

conditioning in paediatric cardiac surgery Cardiol Young 201121266ndash70

CONCLUSION Endogenous lsquoconditioningrsquo

strategies can be applied prior to

or during ischaemia or at the

onset of reperfusion

RIPC beneficial in cardiac

surgery AAA surgery elective

PCI PPCI

Potential benefit in cardiac

arrest cardiac transplantation

stroke and other surgical

settings

E M A D Z A R I E F 2 0 1 2

REFERENCES

Asger Granfeldt1 David J Lefer2 and Jakob Vinten-Johansen Protective ischaemia in patients preconditioning

and Postconditioning Cardiovascular Research (2009) 83 234ndash246

Hausenloy DJ Mwamure PK Venugopal V Harris J Barnard M Grundy E et al Effect of remote ischaemic

preconditioning on myocardial injury in patients undergoing coronary artery bypass graft surgery a randomised

controlled trial Lancet 2007370575ndash9

XIONG Jun LIAO Xu XUE Fu-shan YUAN Yu-jing WANG Qiang and LIU Jian-hua Remote ischemia conditioningmdashan

endogenous cardioprotective strategy from outside the heart Chinese Medical Journal 2011124(14)2209-2215

Robert Loveridge MA and Frank Schroeder MD DEAA Anaesthetic preconditioning Continuing Education in

Anaesthesia Critical Care amp Pain | Volume 10 Number 2 2010

Jakub Marczaka Rafał Nowickia Julita Kulbackab and Jolanta Saczkob Is remote ischaemic preconditioning of

benefit to patients undergoing cardiac surgery Interactive CardioVascular and Thoracic Surgery 14 (2012) 634ndash

639

E M A D Z A R I E F 2 0 1 2

EMAD ZARIEF 2012

EARLY AND LATE PRECONDITIONING

E M A D Z A R I E F 2 0 1 2

Zhou WW Zeng DB Chen RW Liu J Yang GX Liu PB et al Limb ischemic preconditioning reduces heart and lung injury after an open

heart operation in infants

RI PRE AND POST CONDITIONING

E M A D Z A R I E F 2 0 1 2

Luo W Zhu M Huang R Zhang Y A comparison of cardiac postconditioning and remote pre-

conditioning in paediatric cardiac surgery Cardiol Young 201121266ndash70

CONCLUSION Endogenous lsquoconditioningrsquo

strategies can be applied prior to

or during ischaemia or at the

onset of reperfusion

RIPC beneficial in cardiac

surgery AAA surgery elective

PCI PPCI

Potential benefit in cardiac

arrest cardiac transplantation

stroke and other surgical

settings

E M A D Z A R I E F 2 0 1 2

REFERENCES

Asger Granfeldt1 David J Lefer2 and Jakob Vinten-Johansen Protective ischaemia in patients preconditioning

and Postconditioning Cardiovascular Research (2009) 83 234ndash246

Hausenloy DJ Mwamure PK Venugopal V Harris J Barnard M Grundy E et al Effect of remote ischaemic

preconditioning on myocardial injury in patients undergoing coronary artery bypass graft surgery a randomised

controlled trial Lancet 2007370575ndash9

XIONG Jun LIAO Xu XUE Fu-shan YUAN Yu-jing WANG Qiang and LIU Jian-hua Remote ischemia conditioningmdashan

endogenous cardioprotective strategy from outside the heart Chinese Medical Journal 2011124(14)2209-2215

Robert Loveridge MA and Frank Schroeder MD DEAA Anaesthetic preconditioning Continuing Education in

Anaesthesia Critical Care amp Pain | Volume 10 Number 2 2010

Jakub Marczaka Rafał Nowickia Julita Kulbackab and Jolanta Saczkob Is remote ischaemic preconditioning of

benefit to patients undergoing cardiac surgery Interactive CardioVascular and Thoracic Surgery 14 (2012) 634ndash

639

E M A D Z A R I E F 2 0 1 2

EMAD ZARIEF 2012

RI PRE AND POST CONDITIONING

E M A D Z A R I E F 2 0 1 2

Luo W Zhu M Huang R Zhang Y A comparison of cardiac postconditioning and remote pre-

conditioning in paediatric cardiac surgery Cardiol Young 201121266ndash70

CONCLUSION Endogenous lsquoconditioningrsquo

strategies can be applied prior to

or during ischaemia or at the

onset of reperfusion

RIPC beneficial in cardiac

surgery AAA surgery elective

PCI PPCI

Potential benefit in cardiac

arrest cardiac transplantation

stroke and other surgical

settings

E M A D Z A R I E F 2 0 1 2

REFERENCES

Asger Granfeldt1 David J Lefer2 and Jakob Vinten-Johansen Protective ischaemia in patients preconditioning

and Postconditioning Cardiovascular Research (2009) 83 234ndash246

Hausenloy DJ Mwamure PK Venugopal V Harris J Barnard M Grundy E et al Effect of remote ischaemic

preconditioning on myocardial injury in patients undergoing coronary artery bypass graft surgery a randomised

controlled trial Lancet 2007370575ndash9

XIONG Jun LIAO Xu XUE Fu-shan YUAN Yu-jing WANG Qiang and LIU Jian-hua Remote ischemia conditioningmdashan

endogenous cardioprotective strategy from outside the heart Chinese Medical Journal 2011124(14)2209-2215

Robert Loveridge MA and Frank Schroeder MD DEAA Anaesthetic preconditioning Continuing Education in

Anaesthesia Critical Care amp Pain | Volume 10 Number 2 2010

Jakub Marczaka Rafał Nowickia Julita Kulbackab and Jolanta Saczkob Is remote ischaemic preconditioning of

benefit to patients undergoing cardiac surgery Interactive CardioVascular and Thoracic Surgery 14 (2012) 634ndash

639

E M A D Z A R I E F 2 0 1 2

EMAD ZARIEF 2012

CONCLUSION Endogenous lsquoconditioningrsquo

strategies can be applied prior to

or during ischaemia or at the

onset of reperfusion

RIPC beneficial in cardiac

surgery AAA surgery elective

PCI PPCI

Potential benefit in cardiac

arrest cardiac transplantation

stroke and other surgical

settings

E M A D Z A R I E F 2 0 1 2

REFERENCES

Asger Granfeldt1 David J Lefer2 and Jakob Vinten-Johansen Protective ischaemia in patients preconditioning

and Postconditioning Cardiovascular Research (2009) 83 234ndash246

Hausenloy DJ Mwamure PK Venugopal V Harris J Barnard M Grundy E et al Effect of remote ischaemic

preconditioning on myocardial injury in patients undergoing coronary artery bypass graft surgery a randomised

controlled trial Lancet 2007370575ndash9

XIONG Jun LIAO Xu XUE Fu-shan YUAN Yu-jing WANG Qiang and LIU Jian-hua Remote ischemia conditioningmdashan

endogenous cardioprotective strategy from outside the heart Chinese Medical Journal 2011124(14)2209-2215

Robert Loveridge MA and Frank Schroeder MD DEAA Anaesthetic preconditioning Continuing Education in

Anaesthesia Critical Care amp Pain | Volume 10 Number 2 2010

Jakub Marczaka Rafał Nowickia Julita Kulbackab and Jolanta Saczkob Is remote ischaemic preconditioning of

benefit to patients undergoing cardiac surgery Interactive CardioVascular and Thoracic Surgery 14 (2012) 634ndash

639

E M A D Z A R I E F 2 0 1 2

EMAD ZARIEF 2012

REFERENCES

Asger Granfeldt1 David J Lefer2 and Jakob Vinten-Johansen Protective ischaemia in patients preconditioning

and Postconditioning Cardiovascular Research (2009) 83 234ndash246

Hausenloy DJ Mwamure PK Venugopal V Harris J Barnard M Grundy E et al Effect of remote ischaemic

preconditioning on myocardial injury in patients undergoing coronary artery bypass graft surgery a randomised

controlled trial Lancet 2007370575ndash9

XIONG Jun LIAO Xu XUE Fu-shan YUAN Yu-jing WANG Qiang and LIU Jian-hua Remote ischemia conditioningmdashan

endogenous cardioprotective strategy from outside the heart Chinese Medical Journal 2011124(14)2209-2215

Robert Loveridge MA and Frank Schroeder MD DEAA Anaesthetic preconditioning Continuing Education in

Anaesthesia Critical Care amp Pain | Volume 10 Number 2 2010

Jakub Marczaka Rafał Nowickia Julita Kulbackab and Jolanta Saczkob Is remote ischaemic preconditioning of

benefit to patients undergoing cardiac surgery Interactive CardioVascular and Thoracic Surgery 14 (2012) 634ndash

639

E M A D Z A R I E F 2 0 1 2

EMAD ZARIEF 2012

EMAD ZARIEF 2012