Faculty Collaboration Database

The effect of perhexiline on myocardial protection during coronary artery surgery: a two-centre, randomized, double-blind, placebo-controlled trial. Eur J Cardiothorac Surg 2015 Mar;47(3):464-72

Date

06/21/2014

Pubmed ID

24948413

Pubmed Central ID

PMC4324609

DOI

10.1093/ejcts/ezu238

Scopus ID

2-s2.0-84928184320 (requires institutional sign-in at Scopus site)   6 Citations

Abstract

OBJECTIVES: Perhexiline is thought to modulate metabolism by inhibiting mitochondrial carnitine palmitoyltransferase-1, reducing fatty acid uptake and increasing carbohydrate utilization. This study assessed whether preoperative perhexiline improves markers of myocardial protection in patients undergoing coronary artery bypass graft surgery and analysed its effect on the myocardial metabolome.

METHODS: In a prospective, randomized, double-blind, placebo-controlled trial, patients at two centres were randomized to receive either oral perhexiline or placebo for at least 5 days prior to surgery. The primary outcome was a low cardiac output episode in the first 6 h. All pre-specified analyses were conducted according to the intention-to-treat principle with a statistical power of 90% to detect a relative risk of 0.5 and a conventional one-sided α-value of 0.025. A subset of pre-ischaemic left ventricular biopsies was analysed using mass spectrometry-based metabolomics.

RESULTS: Over a 3-year period, 286 patients were randomized, received the intervention and were included in the analysis. The incidence rate of a low cardiac output episode in the perhexiline arm was 36.7% (51/139) vs 34.7% (51/147) in the control arm [odds ratio (OR) 0.92, 95% confidence interval (CI) 0.56-1.50, P = 0.74]. Perhexiline was associated with a reduction in the cardiac index at 6 h [difference in means 0.19, 95% CI 0.07-0.31, P = 0.001] and an increase in inotropic support in the first 12 h (OR 0.55, 95% CI 0.34-0.89, P = 0.015). There were no significant differences in myocardial injury with troponin-T or electrocardiogram, reoperation, renal dysfunction or length of stay. No difference in the preischaemic left ventricular metabolism was identified between groups on metabolomics analysis.

CONCLUSIONS: Preoperative perhexiline does not improve myocardial protection in patients undergoing coronary surgery and in fact reduced perioperative cardiac output, increasing the need for inotropic support. Perhexiline has no significant effect on the mass spectrometry-visible polar myocardial metabolome in vivo in humans, supporting the suggestion that it acts via a pathway that is independent of myocardial carnitine palmitoyltransferase inhibition and may explain the lack of clinical benefit observed following surgery.

CLINICALTRIALSGOV ID: NCT00845364.

Author List

Drury NE, Howell NJ, Calvert MJ, Weber RJ, Senanayake EL, Lewis ME, Hyde JA, Green DH, Mascaro JG, Wilson IC, Graham TR, Rooney SJ, Viant MR, Freemantle N, Frenneaux MP, Pagano D, investigators

Author

Jorge G. Mascaro MD Professor in the Surgery department at Medical College of Wisconsin

MESH terms used to index this publication - Major topics in bold

Aged
Cardiac Output
Cardiotonic Agents
Coronary Artery Bypass
Coronary Vessels
Double-Blind Method
Female
Heart Ventricles
Humans
Male
Metabolome
Middle Aged
Myocardial Reperfusion Injury
Perhexiline
Placebos
Postoperative Complications
Prospective Studies