title: Remote preconditioning and major clinical complications following adult cardiovascular surgery: systematic review and meta-analysis.
abstract: BACKGROUND
  A number of 'proof-of-concept' trials suggest that remote ischaemic preconditioning (RIPC) reduces surrogate markers of end-organ injury in patients undergoing major cardiovascular surgery. To date, few studies have involved hard clinical outcomes as primary end-points.
  
  
  METHODS
  Randomised clinical trials of RIPC in major adult cardiovascular surgery were identified by a systematic review of electronic abstract databases, conference proceedings and article reference lists. Clinical end-points were extracted from trial reports. In addition, trial principal investigators provided unpublished clinical outcome data.
  
  
  RESULTS
  In total, 23 trials of RIPC in 2200 patients undergoing major adult cardiovascular surgery were identified. RIPC did not have a significant effect on clinical end-points (death, peri-operative myocardial infarction (MI), renal failure, stroke, mesenteric ischaemia, hospital or critical care length of stay).
  
  
  CONCLUSIONS
  Pooled data from pilot trials cannot confirm that RIPC has any significant effect on clinically relevant end-points. Heterogeneity in study inclusion and exclusion criteria and in the type of preconditioning stimulus limits the potential for extrapolation at present. An effort must be made to clarify the optimal preconditioning stimulus. Following this, large-scale trials in a range of patient populations are required to ascertain the role of this simple, cost-effective intervention in routine practice.
authors.affiliation: University of Limerick, Ireland. Electronic address: donagh1@hotmail.com.
authors.forename: D A
authors.initials: DA
authors.lastname: Healy
authors.affiliation: University of Limerick, Ireland.
authors.forename: W A
authors.initials: WA
authors.lastname: Khan
authors.affiliation: University of Limerick, Ireland.
authors.forename: C S
authors.initials: CS
authors.lastname: Wong
authors.affiliation: University of Limerick, Ireland.
authors.forename: M Clarke
authors.initials: MC
authors.lastname: Moloney
authors.affiliation: University of Limerick, Ireland.
authors.forename: P A
authors.initials: PA
authors.lastname: Grace
authors.affiliation: University of Limerick, Ireland.
authors.forename: J C
authors.initials: JC
authors.lastname: Coffey
authors.affiliation: University of Limerick, Ireland.
authors.forename: C
authors.initials: C
authors.lastname: Dunne
authors.affiliation: National University of Ireland Galway, Ireland.
authors.forename: S R
authors.initials: SR
authors.lastname: Walsh
authors.affiliation: Addenbrooke's Hospital, Cambridge, United Kingdom.
authors.forename: U
authors.initials: U
authors.lastname: Sadat
authors.affiliation: Addenbrooke's Hospital, Cambridge, United Kingdom.
authors.forename: M E
authors.initials: ME
authors.lastname: Gaunt
authors.affiliation: Central South University, Hunan, China.
authors.forename: S
authors.initials: S
authors.lastname: Chen
authors.affiliation: Hatter Cardiovascular Institute, University College London, United Kingdom.
authors.forename: S
authors.initials: S
authors.lastname: Tehrani
authors.affiliation: Hatter Cardiovascular Institute, University College London, United Kingdom.
authors.forename: D J
authors.initials: DJ
authors.lastname: Hausenloy
authors.affiliation: Hatter Cardiovascular Institute, University College London, United Kingdom.
authors.forename: D M
authors.initials: DM
authors.lastname: Yellon
authors.affiliation: Maine Medical Centre, ME, United States.
authors.forename: R S
authors.initials: RS
authors.lastname: Kramer
authors.affiliation: Maine Medical Centre, ME, United States.
authors.forename: R F
authors.initials: RF
authors.lastname: Zimmerman
authors.affiliation: Novosibirsk State Research Institute of Circulation Pathology, Novosibirsk, Russia.
authors.forename: V V
authors.initials: VV
authors.lastname: Lomivorotov
authors.affiliation: Novosibirsk State Research Institute of Circulation Pathology, Novosibirsk, Russia.
authors.forename: V A
authors.initials: VA
authors.lastname: Shmyrev
authors.affiliation: Novosibirsk State Research Institute of Circulation Pathology, Novosibirsk, Russia.
authors.forename: D N
authors.initials: DN
authors.lastname: Ponomarev
authors.affiliation: Queen Elizabeth Medical Centre, Birmingham, United Kingdom.
authors.forename: I A
authors.initials: IA
authors.lastname: Rahman
authors.affiliation: Queen Elizabeth Medical Centre, Birmingham, United Kingdom.
authors.forename: J G
authors.initials: JG
authors.lastname: Mascaro
authors.affiliation: Queen Elizabeth Medical Centre, Birmingham, United Kingdom.
authors.forename: R S
authors.initials: RS
authors.lastname: Bonser
authors.affiliation: Seoul National University Hospital, Seoul, South Korea.
authors.forename: Y
authors.initials: Y
authors.lastname: Jeon
authors.affiliation: Seoul National University Hospital, Seoul, South Korea.
authors.forename: D M
authors.initials: DM
authors.lastname: Hong
authors.affiliation: St. Anne's University Hospital, Brno, Czech Republic.
authors.forename: R
authors.initials: R
authors.lastname: Wagner
authors.affiliation: University Hospital Essen, Essen, Germany.
authors.forename: M
authors.initials: M
authors.lastname: Thielmann
authors.affiliation: University Hospital Essen, Essen, Germany.
authors.forename: G
authors.initials: G
authors.lastname: Heusch
authors.affiliation: University Hospital Frankfurt, Germany.
authors.forename: K
authors.initials: K
authors.lastname: Zacharowski
authors.affiliation: University Hospital Frankfurt, Germany; University Hospital Schleswig-Holstein, Kiel, Germany.
authors.forename: P
authors.initials: P
authors.lastname: Meybohm
authors.affiliation: University Hospital Schleswig-Holstein, Kiel, Germany.
authors.forename: B
authors.initials: B
authors.lastname: Bein
authors.affiliation: Changi General Hospital, Singapore.
authors.forename: T Y
authors.initials: TY
authors.lastname: Tang
mesh_terms: D000328:Adult; D006348:Cardiac Surgical Procedures / Q000009:adverse effects*; D002318:Cardiovascular Diseases / Q000175:diagnosis / Q000601:surgery*; D057286:Electronic Health Records; D006801:Humans; D019157:Ischemic Preconditioning, Myocardial / Q000379:methods*; D011183:Postoperative Complications / Q000175:diagnosis / Q000209:etiology; D016032:Randomized Controlled Trials as Topic / Q000379:methods
keywords: Cardioprotection; Cardiovascular surgery; Ischaemic preconditioning; Remote ischaemic preconditioning; Systematic review