Role of nitric oxide in a temperature dependent regulation of systemic vascular resistance in cardiopulmonary bypass

Strategies to attenuate maladaptive inflammatory response associated with cardiopulmonary bypass

Cardiopulmonary bypass (CPB) initiates an intense inflammatory response due to various factors: conversion from pulsatile to laminar flow, cold cardioplegia, surgical trauma, endotoxemia, ischemia-reperfusion injury, oxidative stress, hypothermia, and contact activation of cells by the extracorporeal circuit. Redundant and overlapping inflammatory cascades amplify the initial response to produce a systemic inflammatory response, heightened by coincident activation of coagulation and fibrinolytic pathways. When unchecked, this inflammatory response can become maladaptive and lead to serious postoperative complications. Concerted research efforts have been made to identify technical refinements and pharmacologic interventions that appropriately attenuate the inflammatory response and ultimately translate to improved clinical outcomes. Surface modification of the extracorporeal circuit to increase biocompatibility, miniaturized circuits with sheer resistance, filtration techniques, and minimally invasive approaches have improved clinical outcomes in specific populations. Pharmacologic adjuncts, including aprotinin, steroids, monoclonal antibodies, and free radical scavengers, show real promise. A multimodal approach incorporating technical, circuit-specific, and pharmacologic strategies will likely yield maximal clinical benefit.

[Vasoreactivity changes during extracorporeal circulation: effects of halogenated agents]

During cardiopulmonary bypass (CPB), endothelium is exposed to multiple disturbances leading to significant vasomotor tone and vascular systemic resistances (VSR) level modifications. Properties of endothelial function on vascular tone were summarized herein. According bibliographic findings, physiological and clinical impacts of respectively halogenated agents and CPB concerning vasomotor tone were reported. Main effects of halogenated agents administered through oxygenator during CPB were also identified. Usually when administered above one MAC, halogenated agents decreased VSR during hypothermic bypass. Once those mechanisms summarized, increase of halogenated agent's effects on VSR during normothermic CPB was postulated. Assuming that decrease of VSR could be deleterious favoring severe vasoplegia event, clinical experience of administration of isoflurane during CPB among more 4000 patients was retrospectively reported. Incidence of severe vasoplegia was established to 9.5 % in the studied population and this result was similar as others. More over predicting factors of severe vasoplegia were the same as previously reported : severity of preoperative clinical status according Euroscore, hemodynamical instability before induction of anesthesia, surgical procedure complexity and CPB duration. Absence of deleterious effects in SVR decrease when administering isoflurane during normothermic CPB was assumed but prospective comparative studies comparing effects of halogenated agents and other anesthetic agents are needed in order to confirm these findings.

Hypothermia attenuates iNOS, CAT-1, CAT-2, and nitric oxide expression in lungs of endotoxemic rats

Endotoxemia stimulates endogenous nitric oxide formation, induces transcription of arginine transporters, and causes lung injury. Hypothermia inhibits nitric oxide formation and is used as a means of organ preservation. We hypothesized that hypothermia inhibits endotoxin-induced intrapulmonary nitric oxide formation and that this inhibition is associated with attenuated transcription of enzymes that regulate nitric oxide formation, such as inducible nitric oxide synthase (iNOS) and the cationic amino acid transporters 1 (CAT-1) and 2 (CAT-2). Rats were anesthetized and randomized to treatment with hypothermia (18-24 degrees C) or normothermia (36-38 degrees C). Endotoxin was administered intravascularly. Concentrations of iNOS, CAT-1, CAT-2 mRNA, iNOS protein, and nitrosylated proteins were measured in lung tissue homogenates. We found that hypothermia abrogated the endotoxin-induced increase in exhaled nitric oxide and lung tissue nitrotyrosine concentrations. Western blot analyses revealed that hypothermia inhibited iNOS, but not endothelial nitric oxide synthase, protein expression in lung tissues. CAT-1, CAT-2, and iNOS mRNA concentrations were lower in the lungs of hypothermic animals. These findings suggest that hypothermia protects against intrapulmonary nitric oxide overproduction and nitric oxide-mediated lung injury by inhibiting transcription of iNOS, CAT-1, and CAT-2.