The organ-protective effects of nitric oxide in adult patients undergoing cardiac surgery with cardiopulmonary bypass: a systematic review and meta-analysis
Abstract Background Postoperative organ dysfunction remains a major challenge in adult cardiac surgery with cardiopulmonary bypass (CPB), frequently involving the kidneys, heart, and lungs. These complications are primarily driven by hemolysis, ischemia-reperfusion injury, and systemic inflammation...
Saved in:
| Main Authors: | , , , , , , , , , , |
|---|---|
| Format: | Article |
| Language: | English |
| Published: |
BMC
2025-07-01
|
| Series: | BMC Anesthesiology |
| Subjects: | |
| Online Access: | https://doi.org/10.1186/s12871-025-03207-7 |
| Tags: |
Add Tag
No Tags, Be the first to tag this record!
|
| _version_ | 1849334235499855872 |
|---|---|
| author | Jieru Zhang Han Zhang Jing Wang Tianlong Wang Luyu Bian Zhenzhen Li Jian Wang Yuan Teng Gang Liu Shujie Yan Bingyang Ji |
| author_facet | Jieru Zhang Han Zhang Jing Wang Tianlong Wang Luyu Bian Zhenzhen Li Jian Wang Yuan Teng Gang Liu Shujie Yan Bingyang Ji |
| author_sort | Jieru Zhang |
| collection | DOAJ |
| description | Abstract Background Postoperative organ dysfunction remains a major challenge in adult cardiac surgery with cardiopulmonary bypass (CPB), frequently involving the kidneys, heart, and lungs. These complications are primarily driven by hemolysis, ischemia-reperfusion injury, and systemic inflammation triggered by CPB. Nitric oxide (NO), known for its vasodilatory, anti-inflammatory, and antioxidant properties, has been proposed as a perioperative strategy to protect vital organs. However, evidence regarding its efficacy remains inconclusive. Methods We followed PRISMA guidelines and systematically searched PubMed, Embase, Cochrane Library, and Web of Science for randomized controlled trials (RCTs) published up to March 1, 2025. Subgroup analyses were conducted based on NO dosage and timing of administration. To explore potential effect modifiers and assess subgroup interaction, we performed meta-regression analyses. The GRADE approach was used to assess the certainty of evidence. Sensitivity analyses and publication bias assessments (funnel plots and trim-and-fill method) were also conducted to evaluate the robustness of the findings. Results Ten RCTs involving 838 patients were included. NO administration was associated with a reduced incidence of acute kidney injury (AKI) (RR: 0.78; 95% CI: 0.64–0.94; p = 0.010), and the effect remained after trim-and-fill adjustment. mechanical ventilation (MV) duration was slightly shortened (SMD: − 0.17; 95% CI: − 0.31 to − 0.02; p = 0.025), particularly with postoperative administration (SMD: − 0.39; 95% CI: − 0.67 to − 0.12; p = 0.005). NO also reduced cardiac troponin I (cTnI) levels. No significant effects were observed for low cardiac output syndrome (LCOS), mortality, intensive care unit (ICU) length of stay (LOS), or hospital LOS. Conclusion Inhaled NO may offer organ-specific benefits in adults undergoing cardiac surgery with CPB, such as reduced AKI incidence and lower cTnI levels. However, these effects did not consistently translate into improved clinical outcomes. The observed reduction in MV duration was not significant after adjusting for publication bias, suggesting a possible overestimation. Current evidence is limited by small sample sizes and small-study effects. Further large, high-quality trials in high-risk populations are needed to confirm these findings. PROSPERO registration This review was prospectively registered in PROSPERO (ID: CRD42025649095). |
| format | Article |
| id | doaj-art-2e044898533e4ad997db352fc9acc1cc |
| institution | Kabale University |
| issn | 1471-2253 |
| language | English |
| publishDate | 2025-07-01 |
| publisher | BMC |
| record_format | Article |
| series | BMC Anesthesiology |
| spelling | doaj-art-2e044898533e4ad997db352fc9acc1cc2025-08-20T03:45:36ZengBMCBMC Anesthesiology1471-22532025-07-0125111210.1186/s12871-025-03207-7The organ-protective effects of nitric oxide in adult patients undergoing cardiac surgery with cardiopulmonary bypass: a systematic review and meta-analysisJieru Zhang0Han Zhang1Jing Wang2Tianlong Wang3Luyu Bian4Zhenzhen Li5Jian Wang6Yuan Teng7Gang Liu8Shujie Yan9Bingyang Ji10Department of Cardiopulmonary Bypass, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Cardiovascular Diseases, Fuwai HospitalDepartment of Cardiopulmonary Bypass, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Cardiovascular Diseases, Fuwai HospitalDepartment of Cardiopulmonary Bypass, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Cardiovascular Diseases, Fuwai HospitalDepartment of Cardiopulmonary Bypass, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Cardiovascular Diseases, Fuwai HospitalDepartment of Cardiopulmonary Bypass, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Cardiovascular Diseases, Fuwai HospitalDepartment of Cardiopulmonary Bypass, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Cardiovascular Diseases, Fuwai HospitalDepartment of Cardiopulmonary Bypass, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Cardiovascular Diseases, Fuwai HospitalDepartment of Cardiopulmonary Bypass, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Cardiovascular Diseases, Fuwai HospitalDepartment of Cardiopulmonary Bypass, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Cardiovascular Diseases, Fuwai HospitalDepartment of Cardiopulmonary Bypass, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Cardiovascular Diseases, Fuwai HospitalDepartment of Cardiopulmonary Bypass, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Cardiovascular Diseases, Fuwai HospitalAbstract Background Postoperative organ dysfunction remains a major challenge in adult cardiac surgery with cardiopulmonary bypass (CPB), frequently involving the kidneys, heart, and lungs. These complications are primarily driven by hemolysis, ischemia-reperfusion injury, and systemic inflammation triggered by CPB. Nitric oxide (NO), known for its vasodilatory, anti-inflammatory, and antioxidant properties, has been proposed as a perioperative strategy to protect vital organs. However, evidence regarding its efficacy remains inconclusive. Methods We followed PRISMA guidelines and systematically searched PubMed, Embase, Cochrane Library, and Web of Science for randomized controlled trials (RCTs) published up to March 1, 2025. Subgroup analyses were conducted based on NO dosage and timing of administration. To explore potential effect modifiers and assess subgroup interaction, we performed meta-regression analyses. The GRADE approach was used to assess the certainty of evidence. Sensitivity analyses and publication bias assessments (funnel plots and trim-and-fill method) were also conducted to evaluate the robustness of the findings. Results Ten RCTs involving 838 patients were included. NO administration was associated with a reduced incidence of acute kidney injury (AKI) (RR: 0.78; 95% CI: 0.64–0.94; p = 0.010), and the effect remained after trim-and-fill adjustment. mechanical ventilation (MV) duration was slightly shortened (SMD: − 0.17; 95% CI: − 0.31 to − 0.02; p = 0.025), particularly with postoperative administration (SMD: − 0.39; 95% CI: − 0.67 to − 0.12; p = 0.005). NO also reduced cardiac troponin I (cTnI) levels. No significant effects were observed for low cardiac output syndrome (LCOS), mortality, intensive care unit (ICU) length of stay (LOS), or hospital LOS. Conclusion Inhaled NO may offer organ-specific benefits in adults undergoing cardiac surgery with CPB, such as reduced AKI incidence and lower cTnI levels. However, these effects did not consistently translate into improved clinical outcomes. The observed reduction in MV duration was not significant after adjusting for publication bias, suggesting a possible overestimation. Current evidence is limited by small sample sizes and small-study effects. Further large, high-quality trials in high-risk populations are needed to confirm these findings. PROSPERO registration This review was prospectively registered in PROSPERO (ID: CRD42025649095).https://doi.org/10.1186/s12871-025-03207-7Nitric oxideCardiac surgeryCardiopulmonary bypassAcute kidney injuryOrgan-protection |
| spellingShingle | Jieru Zhang Han Zhang Jing Wang Tianlong Wang Luyu Bian Zhenzhen Li Jian Wang Yuan Teng Gang Liu Shujie Yan Bingyang Ji The organ-protective effects of nitric oxide in adult patients undergoing cardiac surgery with cardiopulmonary bypass: a systematic review and meta-analysis BMC Anesthesiology Nitric oxide Cardiac surgery Cardiopulmonary bypass Acute kidney injury Organ-protection |
| title | The organ-protective effects of nitric oxide in adult patients undergoing cardiac surgery with cardiopulmonary bypass: a systematic review and meta-analysis |
| title_full | The organ-protective effects of nitric oxide in adult patients undergoing cardiac surgery with cardiopulmonary bypass: a systematic review and meta-analysis |
| title_fullStr | The organ-protective effects of nitric oxide in adult patients undergoing cardiac surgery with cardiopulmonary bypass: a systematic review and meta-analysis |
| title_full_unstemmed | The organ-protective effects of nitric oxide in adult patients undergoing cardiac surgery with cardiopulmonary bypass: a systematic review and meta-analysis |
| title_short | The organ-protective effects of nitric oxide in adult patients undergoing cardiac surgery with cardiopulmonary bypass: a systematic review and meta-analysis |
| title_sort | organ protective effects of nitric oxide in adult patients undergoing cardiac surgery with cardiopulmonary bypass a systematic review and meta analysis |
| topic | Nitric oxide Cardiac surgery Cardiopulmonary bypass Acute kidney injury Organ-protection |
| url | https://doi.org/10.1186/s12871-025-03207-7 |
| work_keys_str_mv | AT jieruzhang theorganprotectiveeffectsofnitricoxideinadultpatientsundergoingcardiacsurgerywithcardiopulmonarybypassasystematicreviewandmetaanalysis AT hanzhang theorganprotectiveeffectsofnitricoxideinadultpatientsundergoingcardiacsurgerywithcardiopulmonarybypassasystematicreviewandmetaanalysis AT jingwang theorganprotectiveeffectsofnitricoxideinadultpatientsundergoingcardiacsurgerywithcardiopulmonarybypassasystematicreviewandmetaanalysis AT tianlongwang theorganprotectiveeffectsofnitricoxideinadultpatientsundergoingcardiacsurgerywithcardiopulmonarybypassasystematicreviewandmetaanalysis AT luyubian theorganprotectiveeffectsofnitricoxideinadultpatientsundergoingcardiacsurgerywithcardiopulmonarybypassasystematicreviewandmetaanalysis AT zhenzhenli theorganprotectiveeffectsofnitricoxideinadultpatientsundergoingcardiacsurgerywithcardiopulmonarybypassasystematicreviewandmetaanalysis AT jianwang theorganprotectiveeffectsofnitricoxideinadultpatientsundergoingcardiacsurgerywithcardiopulmonarybypassasystematicreviewandmetaanalysis AT yuanteng theorganprotectiveeffectsofnitricoxideinadultpatientsundergoingcardiacsurgerywithcardiopulmonarybypassasystematicreviewandmetaanalysis AT gangliu theorganprotectiveeffectsofnitricoxideinadultpatientsundergoingcardiacsurgerywithcardiopulmonarybypassasystematicreviewandmetaanalysis AT shujieyan theorganprotectiveeffectsofnitricoxideinadultpatientsundergoingcardiacsurgerywithcardiopulmonarybypassasystematicreviewandmetaanalysis AT bingyangji theorganprotectiveeffectsofnitricoxideinadultpatientsundergoingcardiacsurgerywithcardiopulmonarybypassasystematicreviewandmetaanalysis AT jieruzhang organprotectiveeffectsofnitricoxideinadultpatientsundergoingcardiacsurgerywithcardiopulmonarybypassasystematicreviewandmetaanalysis AT hanzhang organprotectiveeffectsofnitricoxideinadultpatientsundergoingcardiacsurgerywithcardiopulmonarybypassasystematicreviewandmetaanalysis AT jingwang organprotectiveeffectsofnitricoxideinadultpatientsundergoingcardiacsurgerywithcardiopulmonarybypassasystematicreviewandmetaanalysis AT tianlongwang organprotectiveeffectsofnitricoxideinadultpatientsundergoingcardiacsurgerywithcardiopulmonarybypassasystematicreviewandmetaanalysis AT luyubian organprotectiveeffectsofnitricoxideinadultpatientsundergoingcardiacsurgerywithcardiopulmonarybypassasystematicreviewandmetaanalysis AT zhenzhenli organprotectiveeffectsofnitricoxideinadultpatientsundergoingcardiacsurgerywithcardiopulmonarybypassasystematicreviewandmetaanalysis AT jianwang organprotectiveeffectsofnitricoxideinadultpatientsundergoingcardiacsurgerywithcardiopulmonarybypassasystematicreviewandmetaanalysis AT yuanteng organprotectiveeffectsofnitricoxideinadultpatientsundergoingcardiacsurgerywithcardiopulmonarybypassasystematicreviewandmetaanalysis AT gangliu organprotectiveeffectsofnitricoxideinadultpatientsundergoingcardiacsurgerywithcardiopulmonarybypassasystematicreviewandmetaanalysis AT shujieyan organprotectiveeffectsofnitricoxideinadultpatientsundergoingcardiacsurgerywithcardiopulmonarybypassasystematicreviewandmetaanalysis AT bingyangji organprotectiveeffectsofnitricoxideinadultpatientsundergoingcardiacsurgerywithcardiopulmonarybypassasystematicreviewandmetaanalysis |