• Marlieke Visser, Mariska Davids, Hein J Verberne, Wouter E M Kok, Robert Tepaske, Riccardo Cocchieri, Elles M Kemper, Tom Teerlink, Marianne A Jonker, Willem Wisselink, Bas A J M de Mol, and Paul A M van Leeuwen.
• From the Departments of Surgery (MV, WW, and PAMvL), Clinical Chemistry (MD and TT), and Epidemiology and Biostatistics (MAJ), VU University Medical Center, Amsterdam, Netherlands, and the Departments of Cardio-thoracic Surgery (MV, RC, and BAJMdM), Nuclear Medicine (HJV), Cardiology (WEMK), and Pharmacy (EMK) and the Intensive Care Unit (RT), Academic Medical Center University of Amsterdam, Amsterdam, Netherlands.
• Am. J. Clin. Nutr. 2014 Jun 1; 99 (6): 1440-9.

BackgroundNitric oxide (NO) is essential for the optimal perfusion of the heart and its vasculature. NO may be insufficient in surgical patients because its precursor arginine is decreased, and the inhibitor of NO synthesis asymmetric dimethylarginine (ADMA) is increased. Besides arginine, the presence of other amino acids essential for the proper metabolism of cardiac cells may be decreased too. Supplementation of these amino acids with enteral and parenteral nutrition before, during, and after surgery may augment the myocardial and plasma arginine:ADMA ratio and availability of amino acids. Myocardial glucose metabolism and nutritional conditioning may result in a reduction of cardiac injury and support rapid recovery after major surgery.ObjectiveWe investigated the effect of nutrition before, during, and after surgery on amino acids and the myocardial arginine:ADMA ratio and its relation to myocardial glucose metabolism.DesignIn this trial, 33 patients who were undergoing off-pump coronary artery bypass grafting (CABG) were randomly assigned between enteral, parenteral, or no nutrition (control) from 2 d before, during, and until 2 d after surgery. Both enteral and parenteral solutions were prepared with commercially available products and included proteins or amino acids, glucose, vitamins, and minerals. Concentrations of amino acids including ADMA were analyzed in myocardial tissue and plasma samples. ¹⁸F-fluorodeoxyglucose positron emission tomography was performed before and after surgery to assess myocardial glucose metabolism.ResultsThe myocardial arginine:ADMA ratio increased during surgery and was significantly higher in the enteral and parenteral groups than in the control group [median (IQR): 115.0 (98.0-142.2) (P = 0.012), 116.9 (100.3-135.3) (P = 0.004), and 93.3 (82.7-101.1), respectively]. Furthermore, the change in the preoperative to postoperative plasma arginine:ADMA ratio correlated with the change in myocardial glucose metabolism in positron emission tomography (r = 0.427, P = 0.033).ConclusionEnteral or parenteral nutrition before, during, and after CABG may positively influence myocardial glucose metabolism by increasing the plasma and myocardial arginine:ADMA ratio.© 2014 American Society for Nutrition.

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