The Study Of The Perioperative Expression Variations Of Treg/Th17 Cells And Its Relevance With The Postcardiotomy Lung Injury In Cardiac Surgery With Cardiopulmonary Bypass

1、The Initial Analysis of Validation of Different Risk Scoring Systems in Predicting Postcardiotomy Lung Injury in Cardiac Surgery with Cardiopulmonary BypassObj ectiveTo compare the five risk scoring systems the Euroscore Ⅱ,the Sequential Organ Failure Assessment(SOFA),the Acute Physiology and Chronic Health Evaluation System Ⅱ(APACHE Ⅱ),the Systemic Inflammatory Response Syndrome(SIRS),Cardiac Surgery Score System(CASUS)in predicting the clinical outcome and postcardiotomy lung injury in cardiac surgery with cardiopulmonary bypass.MethodA prospective study of 56 consecutive patients who planned for the selective valves surgery at department of Cardiac Surgery Shanghai Chest Hospital during October,2015 and May,2016 were recruited in the study.Each patient’s baseline as well perioperative laboratory and clinical data were collected.Euroscore Ⅱ,APACHE Ⅱ,SOFA,SIRS and CASUS score were calculated at the 2h and 24h after admitted into ICU and were recorded as Euroscore Ⅱ-1/2,APACHE Ⅱ-1/2,SOFA-1/2,SIRS-1/2 and CASUS-1/2.Patients were divided into two groups:normal CSICU LOS,prolonged CSICU LOS(prolonged CSICU LOS was considered as CSICU LOS>mean CSICU LOS).The patients also were divided into three groups:no lung inj ury,mild lung inj ury,moderate lung inj ury accroding to the Berlin Definition(2012)for the diagnosis of ARDS at the 24 hours after admited into ICU.Then compared the calibration and discrimination of the five different risk scoring systems using Hosmer-Lemeshow goodness-of-fit and receiver operating characteristic(ROC)curve.ResultOn the basis of the mean CSICU LOS of all patients(48.7±28.33h),15 patients were classified as prolonged CSICU LOS group,41 patients were classified as normal CSICU LOS group.The baseline material of patients between the two group had no statistical significance.The Ej ection Friction(EF)and New York Heart Assosiation(NYHA)before surgery,the bypass time,aortic-clamp time and lowest Hct during surgery,mechanical ventilation time after surgery(P=0.049,0.046,0.05,0.044,0.049,0.027)were influencing factors of CSICU LOS.In prolonged CSICU LOS group,the SIRS-1/2 and CASUS-1/2 scorewere significantly higher than normal CSICU LOS group(P=0.04,0.006,0.001,0.001).For predicting CSICU LOS,ROC value of the scoring system at 2h after operation was Euroscore Ⅱ 0.491,APACHE Ⅱ-1 0.698,SOFA 0.546,SIRS-1 0.644,CASUS-1 0.806,SIRS+CASUS-10.830;ROC value of the score system at 24h after operation was APACHE Ⅱ-20.715,SOFA-2 0.674,SIRS-2 0.781,CASUS-2 0.831,SIRS+CASUS-2 0.907.There were 27 patients classified as no lung injury group,21 patients classified as mild lung injury group,8 patients classified as moderate lung injury group.In the moderate lung injury group,the age of patients was older and the EF of patients was lower,patients also experienced longer aortic-clamping time during operation and longer CSICU LOS(P=0.014,0.002,0.001,0.000),compared with the no lung injury or mild lung injury groups.For predicting lung injury,ROC value of the scoring system at 2h after operation was Euroscore Ⅱ 0.510,APACHE Ⅱ-1 0.524,SOFA-1 0.563,SIRS-10.792,CASUS-1 0.609;ROC value of the score system 24h after operation was APACHE Ⅱ-2 0.524,SOFA-2 0.568,SIRS-2 0.793,CASUS-2 0.587.ConclusionAfter cardiac surgery with cardiopulmonary bypass,the severer inflammatory response the patients developed the severer lung injury the patients would suffer.Also the lung injury after surgery was one of the important reasons for prolonged CSICU LOS.As for the single scoring system,CASUS perforemed best in predicting prolonged CSICU LOS,and CASUS in combination with SIRS was better than CASUS alone.Among the five scoring systems,SIRS score was the only scoring system performed effectively in predicting of postcardiotomy lung injury after 24h admited into ICU.2、The Study of the Perioperative Expression Variations of Treg/Th17 Cells and Its Relevance with the Postcardiotomy Lung Injury in Cardiac Surgery with Cardiopulmonary BypassObjectiveWe aimed to observe the expression change of the percentage of CD4+CD25+CD127lowTreg and Th17 of CD4+T cells,the ratio of Treg/Th17 and the function change of Treg cells in patients without lung injury or develop vary degree of postcardiotomy lung injury in cardiac surgery with cardiopulmonary bypass.MethodEach patient recruited in the study,the patient’s demographic as well perioperative laboratory and clinical data were collected.Patients’ perioperative lab experiment results and variables such as total bypass time,incubated time,length of intensive care unit stay,PaO2/FiO2 and so on were also recorded.The blood samples were taken for the test of Treg and Th17 cells with flow cytometer at these time points:before anesthetization(T1),30min after heparin neutralization(T2)and 1(T3),3 days(T4)post-surgery.The stored plasma was analyzed for Treg and Thl7 cells function correlated cytokines(IL-10 and IL-17A)by ELISA.The function of Treg cells was tested pre and post operation.The patients also were divided into three groups:no lung inj ury,mild lung inj ury,moderate lung inj ury accroding to the Berlin Definition for the diagnosis of ARDS at the 24 hours after admitted into ICU.ResultCompared with the no lung injury or mild lung injury groups,the percentage of CD4+CD25+CD127loWTreg and Th17 of CD4+T cells at T1 and T2 is lower(P=0.007,P=0.001),the ratio of Treg/Th 17 at T1 was lower(P=0.001)and the concentration of IL-17Ain the plasm was higher(P=0.001)in moderate lung inj ury group.The percentage of CD4+CD25+CD127l0WTreg of CD4+T cells at T1 and T2 was positively correlated with PaO2/FiO2(r=0.428 P<0.02;r=0.549 P<0.001).The area under the curve(AUC)of the percentage of CD4+CD25+CD127loWTreg of CD4+T cells and the ratio of Treg/Th17 at T1 and T2 were 0.722(95%CI 0.557 0.888),0.787(95%CI 0.639 0.934),0.751(95%CI 0.593 0.919),0.551(95%CI 0.3660.735,P=0.587).Before anesthesia,a 20.45±3.78%reduction of the Teff proliferation rate was observed,after co-culturing with Treg cells,and this was further reduced(36.27±4.34%)after heparin neutralization.ConclusionAs for the patients underwent cardiac surgery with cardiopulmonary bypass,the quantity and function of Treg cells in peripheral blood of patients was improved.Treg cells in favor of the protection and repairment of lung tissue.We speculate the decrease of the percentage of Treg in CD4+T cells and the ratio of Treg/Th17 before the inducement of anesthesia and 30min after heparin neutralization may be the potential predictor for patients suffered from lung injury undergoing cardiopulmonary bypass and was more accurate than Euroscore Ⅱ,APACHE Ⅱ,SOFA and CASUS score systems.