Role of Glutamine as Myocardial Protector in Elective On-Pump Coronary Artery Bypass Graft Surgery With Low Ejection Fraction
Phase: PHASE3
Conditions: Coronary Artery Bypass, Cardiopulmonary Bypass, Coronary Artery Disease
Sponsor: National Cardiovascular Center Harapan Kita Hospital Indonesia

Role of Glutamine as Myocardial Protector  
December 1, 2020 
in Elective On-Pump CABG Surgery With Low EF Protocol 
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Role of Glutamine as Myocardial Protector In  
Elective On-Pump Coronary Artery Bypass  
Graft Surgery With Low Ejection Fraction 
 
 
 
NCT04560309 
 
 
 
Primary Investigator: 
I Made Adi Parmana 
National Cardiovascular Center Harapan Kita 
LetJen S. Parman St No. Kav. 87, Jakarta, Indonesia 
Tel +62 812-4601-212 
Email adiparmana13@gmail.com 
 
 

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STUDY SUMMARY 
Title 
Myocardial Protecting Role of Glutamine in Patients with Low 
Ejection Fraction Undergoing Elective On-Pump Coronary 
Artery Bypass Graft Surgery 
Methodology 
Randomized, double blinded, controlled study 
Study Duration 
Estimated duration for the main protocol (e.g. from start of 
screening to last subject processed and finishing the study) is 
approximately 1 year 
Study Center 
National Cardiovascular Center Harapan Kita, West Jakarta, 
Jakarta, Indonesia 
Objectives 
Primary Objective: To determine whether intravenous 
glutamine could mitigate the negative impact of on-pump 
CABG procedures and provide better clinical outcome in  
patients undergoing coronary artery bypass graft surgery 
under cardiopulmonary bypass. 
 
Secondary Objective: To determine whether intravenous 
glutamine could prevent the decline of plasma glutamine 
level, reduce myocardial damage, improve hemodynamic 
profile, and reduce morbidity low ejection fraction patients 
undergoing coronary artery bypass graft surgery under 
cardiopulmonary bypass. 
Number of Subjects 
60 randomized patients divided into two groups; Glutamine 
and Control 
Diagnosis and Main 
Inclusion Criteria 
Inclusion Criteria 
− Male and female patients, aged  18 years old with 
coronary heart disease indicated for elective coronary 
artery bypass grafting under cardiopulmonary bypass 
− Left ventricle ejection fraction of 31-50%, confirmed by 
echocardiography or radionuclide imaging 
− No history of heart surgery 
− Agree to participate in the study and signed a written 
informed consent 

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Exclusion Criteria 
− Change of surgical plan from elective into emergency 
CABG surgery 
− Additional procedures other than coronary artery 
bypass graft procedure 
− Onset of myocardial infarction within the last three 
months 
− Blood creatinine level > 2 mg/dL 
− ALT/AST level > 1.5x of normal value 
− Use of preoperative intra-aortic balloon pump 
− History of stroke with onset of less than 3 months 
− Preoperative atrial fibrillation 
− Heart conduction problem or pacemaker use 
− Contraindications to pulmonary artery catheter insertion 
Drop out criteria 
− Stroke after surgery 
− Perioperative myocardial infarction based on type 5 
myocardial infarct criteria 
− Haemorrhage complications requiring repeat surgery 
− Use of continuous veno-venous hemofiltration or 
haemodialysis after coronary artery bypass graft 
surgery 
− Delayed sternal closure 
− Aortic cross-clamp duration of > 120 minutes and/or 
cardiopulmonary bypass duration of >180 minutes 
Study Product, Dose, 
Route, Regimen 
− Glutamine Group: will receive intravenous infusion of 
0.5 
mg/kgbw 
L-alanyl-L-glutamine 
dipeptide 
(Dipeptiven, Fresenius Kabi, Bad Homburg, Germany) 
diluted in normal saline up to 500 mL, started after 
induction of anesthesia for 24 hours. 

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− Control Group: will receive intravenous infusion of 500 
mL normal saline, started after induction of anesthesia 
for 24 hours 
Statistical Methodology Primary Endpoint 
Plasma glutamine before induction to anesthesia and 24 
hours after CPB, and plasma troponin I before induction to 
anesthesia, 5 minutes, 6 hours, 24 hours and 48 hours after 
CPB. 
 
Secondary Endpoint 
Alpha-Ketoglutarate, myocardial injury score, apoptosis 
index, anti-cardiac troponin I expression, ejection fraction, 
cardiac index, plasma lactate, intensive care unit ventilation 
time, intensive care unit length of stay and vasoactive 
inotropic score. 
 
Purpose: 
The primary objective is to determine whether intravenous glutamine could prevent 
the decline of plasma glutamine level, reduce myocardial damage, improve 
hemodynamic profile, and reduce morbidity low ejection fraction patients undergoing 
coronary artery bypass graft surgery under cardiopulmonary bypass. 
 
Background: 
Coronary artery disease has the highest mortality rate worldwide and coronary artery 
bypass grafting (CABG) is the most common cardiac surgery performed in patients 
with coronary artery disease to revascularize the heart. Despite improvement in 
operation techniques, cardioplegia, cardiopulmonary bypass, myocardial injury related 
to on-pump CABG is still prominent. In patient with low ejection fraction (EF) 
undergoing on-pump CABG, myocardial injury is related to worse outcome and 
prognosis during peri-operative and postoperative period. On-pump CABG patients 
with low ejection fraction has increased (up to four times higher) postoperative in 
hospital mortality rate compared to patient with normal ejection fraction. Administration 

Role of Glutamine as Myocardial Protector  
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of intravenous glutamine had been documented in reducing myocardial damage 
during cardiac surgery and previous studies indicated that glutamine can protect 
against myocardial injury by various mechanism during ischemia and reperfusion. 
 
Goals of the study: 
To analyze the effect of intravenous glutamine in low EF patients undergoing on-pump 
CABG surgery in: 
1. Reducing myocardial damage by a decrease of myocardial injury score, 
apoptotic index and increase of anti-cardiac troponin I expression through right 
atrial appendage tissue sample, as well as decrease of troponin I level. 
2. Improving myocardial metabolism by a decrease in plasma lactate levels, 
increase of plasma glutamine levels and alpha ketoglutarate (α-KG) levels in the 
right atrial appendage tissue sample. 
3. Improving hemodynamic profile through an increase in EF and cardiac index 
after CPB 
4. Reducing postoperative morbidity by the decrease of ventilator duration, duration 
of intensive care, and use of postoperative vasoactive and inotropes 
 
Duration of the Study: 
The study is estimated to complete within 2 years from study initiation.  
 
Potential Benefits and Risks: 
Every effort is taken during the study period to maximize patient safety. To fulfil this 
goal, the study staff employs stringent procedures to reduce the risk of adverse events 
during the study period. The result of this study can be applied in clinical practice to 
ascertain the benefits of glutamine as a myocardial protector to reduce perioperative 
risks and treatment costs of elective on-pump CABG for patients with low EF. 
 

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Methods: 
Study Design 
This is a double-blind, randomized controlled trial involving sixty (60) subjects 
undergoing elective on-pump coronary artery bypass graft will be randomized into two 
groups.  
 
Study Population and Selection Criteria 
All participants will be required to sign a written informed consent, be willing and able 
to comply with all study requirements and should meet the following criteria: 
− Male and female patients, aged  18 years old with coronary heart disease 
indicated for elective coronary artery bypass grafting under cardiopulmonary 
bypass 
− Left ventricle ejection fraction of 31-50%, confirmed by echocardiography or 
radionuclide imaging 
− No history of heart surgery 
− Agree to participate in the study and signed a written informed consent 
Subjects will be excluded from the study based on the following criteria: 
− Change of surgical plan from elective into emergency CABG surgery 
− Additional procedures other than coronary artery bypass graft procedure 
− Onset of myocardial infarction within the last three months 
− Blood creatinine level > 2 mg/dL 
− ALT/AST level > 1.5x of normal value 
− Use of preoperative intra-aortic balloon pump 
− History of stroke with onset of less than 3 months 
− Preoperative atrial fibrillation 
− Heart conduction problem or pacemaker use 
− Contraindications to pulmonary artery catheter insertion 
 
Recruitment Methods 
All patients aged above 18 years old with coronary artery disease indicated for elective 
CABG surgery at the National Cardiovascular Center Harapan Kita are offered to be 

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a participant in this study. The primary investigator, dr. I Made Adi Parmana Sp.An, 
KAKV and his partners (co-investigators) will be performing the procedures 
accordingly for both control and treatment groups. 
 
Data Collection 
Data on sex, age, weight, height and preoperative EF are collected through direct 
history-taking and preoperative medical records. Data on CPB time, aortic cross-
clamping time, number of distal coronary artery grafts are collected from surgery 
reports. Arterial blood sampling for troponin I levels measurement are collected: (1) 
before induction, (2) at 5 minutes, (3) at 6 hours, (4) at 24 hours, and (5) at 48 hours 
after CPB. Plasma troponin I is measured using the troponin I (human) ELISA kit 
(Abnova, KA0233) with colorimetry method. Arterial blood samples for plasma 
glutamine levels measurement are collected before induction and 24 hours after the 
CPB. Plasma glutamine levels is measured using the Sigma–Aldrich GLN1 
glutamine/glutamate determination kit (Sigma–Aldrich, GLN1-1KT) using colorimetry 
method. To obtain plasma samples, blood is centrifuged for 15 minutes at a speed of 
3500 X G within a maximum period of 30 minutes after collection and is stored at -
80oC. 
A 5×5 mm sample of the right atrial appendage tissue are collected at 5 minutes after 
CPB and are immediately transported to the laboratory at 4oC within 30 minutes of 
collection. The tissue sample is divided for α-ketoglutarate (α-KG) measurement and 
paraffin block preparation for histopathological examinations. A total of 20 mg of tissue 
is homogenized and centrifuged to obtain the supernatant. A protease inhibitor is 
added to the supernatant and then stored at -80oC until cellular α-KG levels are 
examined. The examination of α-KG is performed using α-KG assay kit (Abcam, 
ab83431) with colorimetry method.  
Myocardial injury score is measured on preparations stained with hematoxylin and 
eosin (H&E) with a scoring system from 0 to 3 as follows: 0 = no change; 1 = slight 
changes: focal myocyte damage or small multifocal degeneration with slight degree of 
inflammation; 2 = moderate changes: extensive myofibrillar degeneration and/or 
diffuse inflammatory process; 3 = severe changes: necrosis with diffuse inflammatory 
process.12 Terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate 
nick end-labelling (TUNEL) staining is performed using the TUNEL assay kit (Abcam, 
ab206386). Cell nuclei with positive TUNEL staining is colored brown. The apoptotic 

Role of Glutamine as Myocardial Protector  
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index is calculated based on the average number of cells with positive TUNEL 
staining.12 Expression of anti-cardiac troponin I is observed using anti-cardiac troponin 
I antibody (Abcam, ab47003). Measurement of anti-cardiac troponin I expression is 
performed on preparations stained with anti-cardiac troponin I antibody using a scoring 
system ranging from 0 to -3, as follows: 0 = no loss of staining; -1 = minimal decrease 
in staining, compared to normally stained tissue; -2 = clear decrease in staining with 
some positivity (brown color) remaining; -3 = no positive (brown color) staining.13 For 
quantitative analysis, histopathological examinations are made on as many as six 
fields of view per specimen under a light microscope (Olympus BX50, Tokyo, Japan) 
and photographed for further analysis. The histopathological specimens are assessed 
separately by two blinded examiners to get an average score. 
Arterial blood samples for plasma lactate levels measurement are collected: (1) before 
induction, (2) at 5 minutes, (3) at 6 hours, (4) at 24 hours, and (5) at 48 hours after 
CPB. Lactate examination is performed using the Nova Biomedical Stat 
Profile® pHOX Ultra analyzer (Nova Biomedical, Waltham, MA, USA) with basic 
enzymatic method.  
Ejection fraction measurements are taken: (1) after induction and (2) at 5 minutes after 
CPB, through TEE examination using the modified Simpson method. Cardiac index 
(CI) measurements are taken: (1) after induction, (2) at 5 minutes, (3) at 2 hours, (4) 
at 6 hours, and (5) at 24 hours after CPB. The values are obtained from calculating 
cardiac output (CO) per body surface area (in m2). Cardiac output is measured via a 
pulmonary artery catheter using thermodilution method. The measurements are 
performed three times, averaged, and considered valid if the variation between the 
three values is less than 10%. Body surface area is calculated using the Mosteller 
formula. Morbidity variables consist of ventilator time, postoperative use of vasoactive 
and inotropic agents, and duration of intensive care are collected from the medical 
record. Vasoactive and inotropic score (VIS) is calculated (VIS = dopamine dose [μg 
kg-1 min-1] + dobutamine [μg kg-1 min-1] + 100 × epinephrine dose [μg kg-1 min-1] + 
10,000 × vasopressin [units kg-1 min-1] + 100 × norepinephrine dose [μg kg-1 min-1]) 
using the maximum dosing rates of vasoactive and inotropic medications (μg kg-1 min-
1 or IU kg-1 min-1) during the first 24 hours after postoperative ICU admission. 
 
 

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Expected Outcomes 
It is the investigator’s expectation that administration of intravenous glutamine will be 
beneficial as a myocardial protector in low EF patients undergoing on-pump CABG 
surgery. 
 
Adverse Reactions 
There is no expectation of any adverse outcomes or reactions, should there be any 
adverse outcome or reactions, necessary management and will be taken in 
accordance with the standard medical protocol at the National Cardiovascular Center 
Harapan Kita Hospital. All participants will be given access to contact information of 
the primary investigator performing this study. Any adverse reactions will be reported 
immediately to the primary investigator or co-investigators. 
 
Reasons for Withdrawal or Termination: 
A subject may be discontinued from the study at any time if the subject or the 
investigator feels that it is not in the subject’s best interest to continue. The following 
is a list of possible reasons the subjects will be dropped out from the study: 
− Stroke after surgery 
− Perioperative myocardial infarction based on type 5 myocardial infarct criteria 
− Haemorrhage complications requiring repeat surgery 
− Use of continuous veno-venous hemofiltration or haemodialysis after coronary 
artery bypass graft surgery 
− Delayed sternal closure 
− Aortic cross-clamp duration of > 120 minutes and/or cardiopulmonary bypass 
duration of >180 minutes 
All subjects are free to withdraw from participation at any time, for any reason, 
specified or unspecified, and without prejudice. Reasonable attempts will be made by 
the investigator to provide a reason for subject withdrawals. The reason for the 
subject’s withdrawal from the study will be specified in the subject’s source documents 
and the Case Report Form (CRF). If a subject is withdrawn from treatment due to and 
adverse event, the subject will be followed and treated by the investigator until the 
adverse event has resolved or stabilized. 
 

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Handling of Participant Withdrawals or Termination: 
Although subjects may withdraw from the study at any time and for any reason, (or 
may be withdrawn at the investigator’s discretion), subject withdrawal should be 
avoided as much as reasonably possible. In any case, appropriate follow-up for 
withdrawals or termination. Subjects who are discontinued are not to be replaced. For 
subjects considered discontinued, the CRF must be completed up to the last visit 
performed. 
 
Methods of Intervention: 
Subjects eligible for the study will review and undergo informed consent. Once 
consented, subjects will be  randomly assigned to undergo: 
− 
Glutamine Group, blind: will receive intravenous infusion of 0.5 mg/kgbw L-
alanyl-L-glutamine dipeptide (Dipeptiven, Fresenius Kabi, Bad Homburg, 
Germany) diluted in normal saline up to 500 mL, started after induction of 
anesthesia for 24 hours 
− 
Control Group, blind: will receive intravenous infusion of 500 mL normal saline, 
started after induction of anesthesia for 24 hours 
 
 

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STATISTICAL ANALYSIS PLAN 
RANDOMIZATION 
Subjects who meet all inclusion and exclusion criteria will be randomized into two 
groups, glutamine and control group. Subject allocation will be carried out through 
block randomization and known only by the pharmacist, and the confidentiality are 
maintained so that subjects, doctors/nurses, researchers, and data analysers does 
not know the allocation of each subject. 
 
SAMPLE SIZE JUSTIFICATION 
Sample size calculations 
The sample size of this study is obtained from the two-way hypothesis testing formula 
for the two mean values in two independent groups with a confidence index (α) of 95% 
and power of 80%. Results are considered statistically significant if p < 0.05. The 
details of the estimated size of the research subject are as follows: 
n1 = n2 = 2 [
(𝑍𝛼+ 𝑍𝛽 )𝑠
(𝑋1 −𝑋2) ]
2
=  2 [(1,96 +  0,84) 0,04
(0,032)
]
2
  
n1 = n2 = 24,5 subjects → 25 subjects per group 
Legend: 
n1 
: Number of subjects in the intervention group (glutamine group) 
n2 
: Number of subjects in the control group 
s 
: Standard deviation = 0.0415 
Z 
: Z value in 95% confidence index = 1.96 
Z 
: Z value of test power = 0.84 
X1 − X2 
: Difference in mean value = 0.032  
 
Assuming a 20% drop out event, the final sample size are: 
n = 50 + (50 * 20%) 
n = 50 + 10 
n = 60 subjects 
 
 

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For a fixed sample size design, the sample size required to achieve a power of 1-
=0.84 for a two sided t-test at level α=0.05 under these assumptions amounts to a 
total of 60 patients, or 30 patients in each treatment group. 
Primary Endpoint 
Plasma glutamine before induction to anesthesia and 24 hours after CPB, and plasma 
troponin I before induction to anesthesia, 5 minutes, 6 hours, 24 hours and 48 hours 
after CPB. 
 
Secondary Endpoint 
Alpha-Ketoglutarate, myocardial injury score, apoptosis index, anti-cardiac troponin I 
expression, ejection fraction, cardiac index, plasma lactate, intensive care unit 
ventilation time, intensive care unit length of stay and vasoactive inotropic score. 
 
ASSESSMENT OF SAFETY 
Adverse events will be monitored and collected by the study team from the point of 
signed consent until the adverse event(s) are resolved and subjects are stabilized. For 
each adverse event, a detailed explanation will be obtained from the subject and 
subject’s medical record. All adverse events will be recorded on the CRFs. 
 
DATA MONITORING 
The principal investigator will be responsible to ensure the study is conducted in 
accordance with the protocol, Declaration of Helsinki, and that the data recorded is 
valid. To achieve this objective the study will be continuously monitored and reviewed 
by the study team. 
Clinical site monitoring is conducted to ensure that the rights and well-being of human 
subjects are protected, that the reported trial data are accurate, complete, and 
verifiable, and that the conduct of the trial is in compliance with the currently approved 
protocol/amendment(s) with the Good Clinical Practice (GCP). 
 
 

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DATA HANDLING AND RECORD KEEPING 
The collection of personal patient information will be limited to the amount necessary 
to achieve the aims of the research, so that no unneeded sensitive information is being 
collected. Only study personnel will collect data. Collected data will be de-identified 
and to be used for statistical analysis. 
 
INSTITUTIONAL REVIEW BOARD 
The protocol, informed consent form(s), and all participant materials will be submitted 
to the Ethics Committee for review and approval. Approval of both the protocol and 
consent form must be obtained before any participant is enrolled. Any amendment to 
the protocol will require review and approval before the changes are implemented to 
the study. 
 
CONSENT PROCESS 
Subjects will be approached when they come through the hospital for treatment and 
considered for elective CABG surgery. Each potential subject must provide written 
informed consent with full knowledge of the procedures involved. The informed 
consent must be fully explained by the investigator or member of the study staff 
including the study aims, methods, benefits and risks, and signed by the subject before 
enrollment into the study. Potential subjects will be informed that study participation is 
voluntary and that they may withdraw at any time. The subjects will be told that 
choosing against participation will not affect the care received for treatment. The 
subjects will be informed that they will be authorizing access of investigational staff to 
confidential medical records. The subjects will be given sufficient time to read the 
consent and ask any questions. Once the informed consent is signed, the subject will 
be given a copy of the document. 
 
STUDY PERSONNEL AND ROLES 
I Made Adi Parmana, MD 
Primary investigator 
Responsible for all study 
related issues 
 
CONFLICT OF INTEREST 
No conflicts of interest have been reported 
 

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APPENDIX I: INFORMED CONSENT FORM 
 
Myocardial Protecting Role of Glutamine in Patients with Low Ejection Fraction 
Undergoing Elective On-Pump Coronary Artery Bypass Graft Surgery 
Research Explanation 
 
I, the research team led by dr. I Made Adi Parmana from Cardiovascular Anesthesia 
Department of National Cardiovascular Center Harapan Kita will conduct a study to 
examine the role of glutamine as a myocardial protector in low ejection patients 
undergoing elective on-pump coronary artery bypass graft surgery. The coronary 
artery bypass graft surgery is one of the most common procedures performed at the 
National Cardiovascular Center Harapan Kita for cardiac revascularization and is often 
performed with a cardiopulmonary bypass machine to take over the functions of the 
heart and lungs during surgery. Coronary artery bypass graft surgery done with the 
cardiopulmonary bypass machine requires cardiac protection to reduce the negative 
impact of the procedure. Cardiac protection serves a major role in patients with low 
cardiac function (low cardiac ejection fraction). 
This research aims to assess the role of glutamine in myocardial protection during 
coronary artery bypass graft surgery with a cardiopulmonary bypass machine in 
patients with low ejection fraction. Myocardial protection arising from glutamine 
administration is expected to improve cardiac function after surgery thereby reducing 
the burden for patients after surgery. A total of 60 patients with low ejection fraction 
indicated for coronary artery bypass graft surgery using a cardiopulmonary bypass 
machine will participate in this research with a participation period during the patients’ 
stay in the National Cardiovascular Center Harapan Kita. 
You are one of the patients fitting these indications so we are inviting you to be a 
participant in this research. You are free to participate in this research without coercion 
after getting a full explanation of this research. Should you be willing to participate, 
you are also entitled to resign at any time without any consequences or any decrease 
in quality of service from the doctors. If you refuse to participate in the research, you 
will still receive services from doctors of the highest quality and standard in National 
Cardiovascular Center Harapan Kita Hospital. 

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If you choose to agree to participate in this research, you will be asked to sign this 
informed consent form in duplicate, one for your keeping and one for the 
research team. The next procedures are: 
• You will be interviewed by the doctor to ask about your: name, age, medical history, 
history of drug use, history of allergies, smoking habits, alcohol consumption habits. 
• Undergo a physical examination by the doctor to check your health status. 
• Undergo pre-operative procedures and preparation according to National 
Cardiovascular Center Harapan Kita Hospital protocol until the D-day of surgery. 
• Glutamine administration in liquid given via venous access route that will be done 
before surgery. Because there will be a group that will not be given medication or 
treatment in this research, it is possible that the liquid given to you will not contain 
glutamine. 
• Undergo coronary artery bypass graft surgery with a cardiopulmonary bypass 
machine in accordance with the standards and protocol of the National 
Cardiovascular Center Harapan Kita Hospital. 
• Blood sampling will be carried out five times during the research period by way of a 
vascular access routinely used in standard cardiac surgery services at National 
Cardiovascular Center Harapan Kita Hospital. First blood sampling will be taken 
shortly before surgery of approximately two tablespoons. Subsequent blood 
sampling of approximately two tablespoons each time will be taken at: 5 minutes 
after cardiopulmonary bypass, 6 hours after cardiopulmonary bypass, 24 hours 
after cardiopulmonary bypass and 48 hours after cardiopulmonary bypass. Blood 
collection will be carried out by experienced doctors/nurses who are accustomed to 
taking blood. 
• Heart function measurement during the research will be carried out in accordance 
with standard cardiac surgery services at the National Cardiovascular Center 
Harapan Kita Hospital. Cardiac ejection fraction will be assessed twice using 
standard equipment at the National Cardiovascular Center Harapan Kita Hospital: 
shortly before surgery and 5 minutes after cardiopulmonary bypass. Heart pump 
function will be measured five times during the research: shortly before surgery, 5 
minutes after cardiopulmonary bypass, 2 hours after cardiopulmonary bypass, 6 
hours after cardiopulmonary bypass and 24 hours after cardiopulmonary bypass. 

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• Heart tissue sampling will be taken during surgery, using right atrial tissue and will 
be done by experienced cardiac surgeons who are accustomed with the procedure. 
As a research sample, you are obliged to follow the procedures and pre-surgical 
preparations according to the National Cardiovascular Center Harapan Kita Hospital 
protocol. Glutamine administration so far has been widely used and does not provide 
significant side effects, but in some cases drug allergies could occur. Administration 
of glutamine at the dose used in this research never caused significant side effects in 
previous studies. Blood collection from blood vessel is not dangerous and is a routine 
procedure. Circulatory function monitoring device setup are generally harmless and 
beneficial as an effort to monitor patients with decreased cardiac function. Heart tissue 
sampling is not dangerous and so far has not caused any side effects or decreased 
cardiac function after surgery. During the research, the research will also prepare the 
necessary protection and guidance in case something untoward happens, in 
accordance with the medical protocol at the National Cardiovascular Center Harapan 
Kita Hospital. 
All research information/data will be kept confidential (known only to researchers and 
research staff). The information will be treated with care in order to maintain the 
confidentiality of your identity so that people outside the research will not know the 
data of your identity. The research outcome will be deidentified and published. 
Participation in this research will be free of charge and independently funded by the 
research team.  
You are given the opportunity to ask everything you want to know and you feel are not 
clear regarding this research. If at any given time side effects are to occur or if you 
need further explanation, feel free to contact dr. I Made Adi Parmana Sp.An, KAKV at 
the Cardiovascular Anesthesia Department of National Cardiovascular Center 
Harapan Kita Hospital, or via phone at 08124601212. 
You can also inquire about our research to the National Cardiovascular Center 
Harapan Kita Hospital Ethics Committee, via tel. 568111 ext. 2837/2831 or via email: 
irb.kometik_rsjpdhk@gmail.com. 
 
 

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INFORMED CONSENT 
 
Participant number 
 : _____ _____ _____(to be filled by researcher) 
I hereby signed below: 
Name 
………………………………………………………. 
Place/Date of Birth 
: ………………………………………………………. 
Address 
: ………………………………………………………. 
 
 
  ………………………………………………………. 
 
 
  ………………………………………………………. 
 
 
  ………………………………………………………. 
 
Relation to participant : ………………………………………………………. 
 
 
  (leave empty if respondent is participant) 
Claim that: 
1. I have received an explanation regarding every aspect of the research: 
“Myocardial Protecting Role of Glutamine in Patients with Low Ejection 
Fraction Undergoing Elective On-Pump Coronary Artery Bypass Graft 
Surgery”. If during the research period adverse events are to occur, follow-up 
will be carried out in accordance with the standing medical protocol at National 
Cardiovascular Center Harapan Kita. 
2. After understanding the research, I voluntarily agree without coercion to 
participate in the research with: 
a. All data obtained during research to be kept confidential and used only 
for scientific purposes. 
b. No fees charged for examinations and management in this study 
3. I allow myself or my family member to be a participant of the research until the 
end of time limit set by the researcher.  
 
Jakarta, …………………… 
 
Witness 
Respondent 
 
 
 
(……………………………) 
(…………………………) 
 
 

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APPENDIX II: CASE REPORT FORM (CRF) 
 
CASE REPORT FORM (CRF) 
MYOCARDIAL PROTECTING ROLE OF GLUTAMINE IN PATIENTS WITH LOW 
EJECTION FRACTION UNDERGOING ELECTIVE ON-PUMP CORONARY 
ARTERY BYPASS GRAFT SURGERY  
 
 
Respondent code : …… …… …… 
Name 
:  ....................................................................................  
Medical record no. :  ....................................................................................  
Attending doctor :  ....................................................................................  
Date of birth / age :  ……/……/…………  
……… years old 
Sex 
: Male/ female 
(cross as not applicable) 
Weight 
: …  …  … kg 
Height 
: …  …  … cm 
Address 
:  ...................................................................................  
 
   ...................................................................................  
 
Telephone number :  .................................................................................  .......... 
Alternative number :  .................................................................................  .......... 
Diagnosis 
:  ....................................................................................  
 
 ...................................................................................  
Note: 
 
 
 
 
 
 
 
 
 

Role of Glutamine as Myocardial Protector  
December 1, 2020 
in Elective On-Pump CABG Surgery With Low EF Protocol 
Confidential 
Page 19 of 24 
Pre-Operative Laboratory Parameters 
Parameters 
Value 
Hb 
 
Hct 
 
Leukocyte 
 
Trombocyte 
 
SGOT 
 
SGPT 
 
Ur 
 
Cr 
 
Albumin 
 
pH 
 
pCO2 
 
pO2 
 
FiO2 
 
Na+ 
 
K+ 
 
HCO3- 
 
SatO2 
 
Lactate 
 
CRP 
 
HIV 
 
Hepatitis B 
 
Hepatitis C 
 
 
ECG: 
 
CXR: 
 
 
 

Role of Glutamine as Myocardial Protector  
December 1, 2020 
in Elective On-Pump CABG Surgery With Low EF Protocol 
Confidential 
Page 20 of 24 
Surgical Procedure, Aortic Cross-Clamp and CPB 
Parameters 
Date 
Time 
No. of distal coronary 
artery graft 
……………………….. 
Induction start 
……/……/………. 
….  :  .… 
Intervention 
administration 
Bottle no. : _____ 
……/……/………. 
….  :  .… 
Incision 
……/……/………. 
….  :  .… 
Start of CPB 
……/……/………. 
….  :  .… 
Aortic cross-clamp start 
……/……/………. 
….  :  .… 
Aortic cross-clamp end 
……/……/………. 
….  :  .… 
End of CPB 
……/……/………. 
….  :  .… 
Skin closure suture 
……/……/………. 
….  :  .… 
Operating room 
departure 
……/……/………. 
….  :  .… 
ICU admission 
……/……/………. 
….  :  .… 
Extubation 
……/……/………. 
….  :  .… 
ICU discharge 
……/……/………. 
….  :  .… 
 
 

Role of Glutamine as Myocardial Protector  
December 1, 2020 
in Elective On-Pump CABG Surgery With Low EF Protocol 
Confidential 
Page 21 of 24 
Cardiac Index and Ejection Fraction Measurement 
Parameters 
Pre-operation 
Time after CPB  
5 minutes 30 minutes 
2 
hours 
6 
hours 
24 
hours 
Cardiac Index 
1: 
2: 
3:  
1: 
2: 
3:   
1: 
2: 
3:   
1: 
2: 
3:   
1: 
2: 
3:  
1: 
2: 
3:  
Ejection 
Fraction (EF) 
  
  
  
  
  
 
Echocardiograph
y Operator 
EF 1: 
 
dr._________________________________________________
_ 
 
EF 2: 
  
dr._________________________________________________
_ 
Right Atrial Appendage Tissue Examination 
Parameters 
Results 
α-KG level 
1: 
2: 
Myocardial injury 
score 
1: 
2: 
Apoptotic index 
1: 
2: 
Anti-cardiac 
troponin I 
expression 
1: 
2: 
 
 

Role of Glutamine as Myocardial Protector  
December 1, 2020 
in Elective On-Pump CABG Surgery With Low EF Protocol 
Confidential 
Page 22 of 24 
Post-Operative Vasoactive and Inotropes 
Parameters 
1 
4 
6 
8 
12 
18 
24 
36 
48 
Dobutamine 
(mcg/kg/minute) 
  
Epinephrine 
(mcg/kg/minute) 
  
Milrinon 
(mcg/kg/minute) 
  
Vasopressin 
(unit/kg/minute) 
  
Norepinephrine 
(mcg/kg/minute) 
  
VIS* 
 
 
 
 
 
 
 
 
 
*VIS = dopamine dose (in mcg/kg/minute) + dobutamine dose (in mcg/kg/minute) + 
100 x epinephrine dose (in mcg/kg/minute) + 10 x milrinone doses (in mcg/kg/minute) 
+ 10.000 x vasopressin dose (in unit/kg/minute) + 100 x norepinephrine dose (in 
mcg/kg/minute) 
Surgery Duration, Aortic Cross-Clamp Duration, ICU Care Duration and 
Ventilator Usage Duration 
Parameters 
Results 
Surgery duration 
(Incision – skin closure suture) 
 
……… 
minutes 
Aortic cross-clamp duration 
(Aortic cross clamp start – Aortic cross clamp 
end) 
 
……… 
minutes 
CPB duration 
(Start of CPB – End of CPB) 
 
……… 
minutes 
ICU care duration 
(ICU admission – ICU discharge) 
 
……… 
hours 
Ventilator usage duration 
(ICU admission – Extubation) 
 
……… 
minutes 
 
 

Role of Glutamine as Myocardial Protector  
December 1, 2020 
in Elective On-Pump CABG Surgery With Low EF Protocol 
Confidential 
Page 23 of 24 
Research Sample Outcomes 
Criteria 
Yes 
No 
Post CABG surgery stroke 
 
 
Perioperative MI (based on type 5 MI criteria) 
 
 
Hemorrhage complication requiring repeat surgery 
 
 
Require CVVH / HD after surgery 
 
 
Delayed sternal closure 
 
 
AoX >120 minutes / CPB time >180 minutes 
 
 
Mortality 
• Time: ______________________________ 
• Cause: 
_______________________________ 
 
 
Sepsis 
 
 
Post-operative arrhythmia 
 
 
• Onset 
• Arrhythmia type 
• Duration 
 
 
Acute renal failure 
 
 
Intubation 
 
 
• Onset 
• Duration 
• Reason 
 
 
Post-operative IABP usage 
 
 
• Onset 
• Duration 
 
 
 
Note: 
 
 
 
 
 
 

Role of Glutamine as Myocardial Protector  
December 1, 2020 
in Elective On-Pump CABG Surgery With Low EF Protocol 
Confidential 
Page 24 of 24 
Research CRF Checklist 
Sample characteristics 
 
Preoperative laboratory parameters 
 
Surgical procedure, aortic cross-clamp and CPB 
 
Intervention liquid bottle number: __________ 
 
Right atrial appendage tissue biopsy 
 
• a-KG level 
 
• Myocardial injury score 
 
• Apoptotic index 
 
• Anti-cardiac troponin I expression 
 
Plasma glutamine levels 
 
Troponin I levels 
 
Lactate levels 
 
Ejection Fraction 
 
Cardiac Index 
 
Post-operative vasoactive and inotropes 
 
Surgery duration, aortic cross-clamp duration, ICU care duration 
and ventilator usage duration 
 
Research sample outcomes 
 
 
Researcher: _________________  Date: _________________ Signature: _______