1
|
Abbasciano RG, Tomassini S, Roman MA, Rizzello A, Pathak S, Ramzi J, Lucarelli C, Layton G, Butt A, Lai F, Kumar T, Wozniak MJ, Murphy GJ. Effects of interventions targeting the systemic inflammatory response to cardiac surgery on clinical outcomes in adults. Cochrane Database Syst Rev 2023; 10:CD013584. [PMID: 37873947 PMCID: PMC10594589 DOI: 10.1002/14651858.cd013584.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2023]
Abstract
BACKGROUND Organ injury is a common and severe complication of cardiac surgery that contributes to the majority of deaths. There are no effective treatment or prevention strategies. It has been suggested that innate immune system activation may have a causal role in organ injury. A wide range of organ protection interventions targeting the innate immune response have been evaluated in randomised controlled trials (RCTs) in adult cardiac surgery patients, with inconsistent results in terms of effectiveness. OBJECTIVES The aim of the review was to summarise the results of RCTs of organ protection interventions targeting the innate immune response in adult cardiac surgery. The review considered whether the interventions had a treatment effect on inflammation, important clinical outcomes, or both. SEARCH METHODS CENTRAL, MEDLINE, Embase, conference proceedings and two trial registers were searched on October 2022 together with reference checking to identify additional studies. SELECTION CRITERIA RCTs comparing organ protection interventions targeting the innate immune response versus placebo or no treatment in adult patients undergoing cardiac surgery where the treatment effect on innate immune activation and on clinical outcomes of interest were reported. DATA COLLECTION AND ANALYSIS Searches, study selection, quality assessment, and data extractions were performed independently by pairs of authors. The primary inflammation outcomes were peak IL-6 and IL-8 concentrations in blood post-surgery. The primary clinical outcome was in-hospital or 30-day mortality. Treatment effects were expressed as risk ratios (RR) and standardised mean difference (SMD) with 95% confidence intervals (CI). Meta-analyses were performed using random effects models, and heterogeneity was assessed using I2. MAIN RESULTS A total of 40,255 participants from 328 RCTs were included in the synthesis. The effects of treatments on IL-6 (SMD -0.77, 95% CI -0.97 to -0.58, I2 = 92%) and IL-8 (SMD -0.92, 95% CI -1.20 to -0.65, I2 = 91%) were unclear due to heterogeneity. Heterogeneity for inflammation outcomes persisted across multiple sensitivity and moderator analyses. The pooled treatment effect for in-hospital or 30-day mortality was RR 0.78, 95% CI 0.68 to 0.91, I2 = 0%, suggesting a significant clinical benefit. There was little or no treatment effect on mortality when analyses were restricted to studies at low risk of bias. Post hoc analyses failed to demonstrate consistent treatment effects on inflammation and clinical outcomes. Levels of certainty for pooled treatment effects on the primary outcomes were very low. AUTHORS' CONCLUSIONS A systematic review of RCTs of organ protection interventions targeting innate immune system activation did not resolve uncertainty as to the effectiveness of these treatments, or the role of innate immunity in organ injury following cardiac surgery.
Collapse
Affiliation(s)
| | | | - Marius A Roman
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Angelica Rizzello
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Suraj Pathak
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Joussi Ramzi
- Leicester Medical School, University of Leicester, Leicester, UK
| | - Carla Lucarelli
- Department of Cardiac Surgery, University of Verona, Verona, Italy
| | - Georgia Layton
- University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Ayesha Butt
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Florence Lai
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Tracy Kumar
- Leicester Clinical Trials Unit, University of Leicester, Leicester, UK
| | - Marcin J Wozniak
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Gavin J Murphy
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| |
Collapse
|
2
|
Esper SA, Welsby IJ, Subramaniam K, John Wallisch W, Levy JH, Waters JH, Triulzi DJ, Hayanga JWA, Schears GJ. Adult extracorporeal membrane oxygenation: an international survey of transfusion and anticoagulation techniques. Vox Sang 2017; 112:443-452. [DOI: 10.1111/vox.12514] [Citation(s) in RCA: 66] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Revised: 01/25/2017] [Accepted: 02/21/2017] [Indexed: 01/27/2023]
Affiliation(s)
- S. A. Esper
- Department of Anesthesiology; University of Pittsburgh; Pittsburgh PA USA
| | - I. J. Welsby
- Department of Anesthesiology; Duke University; Durham NC USA
| | - K. Subramaniam
- Department of Anesthesiology; University of Pittsburgh; Pittsburgh PA USA
| | - W. John Wallisch
- Department of Anesthesiology; University of Pittsburgh; Pittsburgh PA USA
| | - J. H. Levy
- Department of Anesthesiology; Duke University; Durham NC USA
| | - J. H. Waters
- Department of Anesthesiology; University of Pittsburgh; Pittsburgh PA USA
| | - D. J. Triulzi
- Department of Pathology; University of Pittsburgh; Pittsburgh PA USA
| | - J. W. A. Hayanga
- Department of Surgery; University of Pittsburgh; Pittsburgh PA USA
| | - G. J. Schears
- Department of Anesthesiology; Mayo Clinic; Rochester MN USA
| |
Collapse
|
3
|
Lavery KS, Rhodes C, Mcgraw A, Eppihimer MJ. Anti-thrombotic technologies for medical devices. Adv Drug Deliv Rev 2017; 112:2-11. [PMID: 27496703 DOI: 10.1016/j.addr.2016.07.008] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2016] [Revised: 06/03/2016] [Accepted: 07/26/2016] [Indexed: 01/08/2023]
Abstract
Thrombosis associated with medical devices may lead to dramatic increases in morbidity, mortality and increased health care costs. Innovative strategies are being developed to reduce this complication and provide a safe biocompatible interface between device and blood. This article aims to describe the biological phenomena underlying device-associated thrombosis, and surveys the literature describing current and developing technologies designed to overcome this challenge. To reduce thrombosis, biomaterials with varying topographical properties and incorporating anti-thrombogenic substances on their surface have demonstrated potential. Overall, there is extensive literature describing technical solutions to reduce thrombosis associated with medical devices, but clinical results are required to demonstrate significant long-term benefits.
Collapse
Affiliation(s)
- Karen S Lavery
- Preclinical Sciences, Boston Scientific Corporation, 100 Boston Scientific Way, Marlborough, MA 01752-1234, United States
| | - Candace Rhodes
- Preclinical Sciences, Boston Scientific Corporation, 100 Boston Scientific Way, Marlborough, MA 01752-1234, United States
| | - Adam Mcgraw
- Preclinical Sciences, Boston Scientific Corporation, 100 Boston Scientific Way, Marlborough, MA 01752-1234, United States
| | - Michael J Eppihimer
- Preclinical Sciences, Boston Scientific Corporation, 100 Boston Scientific Way, Marlborough, MA 01752-1234, United States
| |
Collapse
|
4
|
Affiliation(s)
- Stephen A Esper
- Department of Anesthesiology, University of Pittsburgh, 200 Lothrop Street, Pittsburgh, PA 15213, USA.
| |
Collapse
|
5
|
Esper SA, Levy JH, Waters JH, Welsby IJ. Extracorporeal Membrane Oxygenation in the Adult. Anesth Analg 2014; 118:731-43. [DOI: 10.1213/ane.0000000000000115] [Citation(s) in RCA: 133] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
|
6
|
Sniecinski RM, Chandler WL. Activation of the Hemostatic System During Cardiopulmonary Bypass. Anesth Analg 2011; 113:1319-33. [DOI: 10.1213/ane.0b013e3182354b7e] [Citation(s) in RCA: 149] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
|
7
|
Molecular dynamics study of heparin based coatings. Biomaterials 2008; 29:4463-9. [DOI: 10.1016/j.biomaterials.2008.08.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2008] [Accepted: 08/04/2008] [Indexed: 11/20/2022]
|
8
|
Cabric S, Eich T, Sanchez J, Nilsson B, Korsgren O, Larsson R. A New Method for Incorporating Functional Heparin onto the Surface of Islets of Langerhans. Tissue Eng Part C Methods 2008; 14:141-7. [DOI: 10.1089/ten.tec.2007.0312] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Affiliation(s)
- Sanja Cabric
- The Rudbeck Laboratory, Division of Clinical Immunology, Department of Oncology, Radiology, and Clinical Immunology, Uppsala University, Uppsala, Sweden
| | - Torsten Eich
- The Rudbeck Laboratory, Division of Clinical Immunology, Department of Oncology, Radiology, and Clinical Immunology, Uppsala University, Uppsala, Sweden
| | - Javier Sanchez
- The Rudbeck Laboratory, Division of Clinical Immunology, Department of Oncology, Radiology, and Clinical Immunology, Uppsala University, Uppsala, Sweden
| | - Bo Nilsson
- The Rudbeck Laboratory, Division of Clinical Immunology, Department of Oncology, Radiology, and Clinical Immunology, Uppsala University, Uppsala, Sweden
| | - Olle Korsgren
- The Rudbeck Laboratory, Division of Clinical Immunology, Department of Oncology, Radiology, and Clinical Immunology, Uppsala University, Uppsala, Sweden
| | - Rolf Larsson
- The Rudbeck Laboratory, Division of Clinical Immunology, Department of Oncology, Radiology, and Clinical Immunology, Uppsala University, Uppsala, Sweden
- Corline System AB, Uppsala, Sweden
| |
Collapse
|
9
|
Veldman A, Neuhaeuser C, Akintuerk H, Thul J, Gehron J, Schranz D, Michel-Behnke I. rFVIIa in the treatment of persistent hemorrhage in pediatric patients on ECMO following surgery for congenital heart disease. Paediatr Anaesth 2007; 17:1176-81. [PMID: 17986036 DOI: 10.1111/j.1460-9592.2007.02328.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Patients who require extracorporeal membrane oxygenation (ECMO) postsurgery for congenital heart disease (CHD) frequently experience severe bleeding episodes. Whereas recombinant-activated factor VII (rFVIIa) has proven efficacy in counteracting intractable hemorrhage in various scenarios, its use in patients on ECMO is limited by the increased risk for thrombotic events. METHODS Between December 2004 and January 2006, ECMO was used in 10 pediatric patients following cardiac surgery, of whom seven were treated with rFVIIa because of intractable hemorrhage. Their medical records were reviewed with respect to variations in chest tube output and transfusion requirements, occlusion of or thrombus formation in the ECMO circuit and the occurrence of thromboembolic events. Outcome and rate of ECMO circuit occlusion were compared with historic controls. RESULTS Three patients died, and four survived (none of the deaths was attributable to thrombus formation or bleeding). All patients were treated with aprotinin prior to and during rFVIIa therapy. Two patients developed an occlusion of the oxygenator, one after receiving co-medication with a FXIII concentrate, another after RBC transfusion in the ECMO system. In two patients, thrombus formation was observed in the ECMO system on inspection after discontinuation. Thromboembolic events were not observed. CONCLUSIONS Recombinant-activated factor VII in a median dosage of 90 microg.kg(-1) was used in seven pediatric patients on ECMO. Rates of ECMO system occlusions and mortality did not differ from historic controls. Neither the reduction of chest tube output nor the blood product transfusion requirements did reach statistical significance.
Collapse
Affiliation(s)
- Alex Veldman
- Department of Pediatrics, Pediatric Heart Center, University Hospital Giessen, Germany.
| | | | | | | | | | | | | |
Collapse
|
10
|
Klinth JE, Larsson R, Andersson PO, Ekdahl KN. A novel application of multi-wavelength TIRF spectroscopy for real time monitoring of antithrombin interactions with immobilized heparin. Biosens Bioelectron 2006; 21:1973-80. [PMID: 16289605 DOI: 10.1016/j.bios.2005.10.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2005] [Revised: 09/29/2005] [Accepted: 10/03/2005] [Indexed: 11/22/2022]
Abstract
Real time interactions of antithrombin (AT) with Corline Heparin Surfaces (CHS) with one and two layers of heparin conjugate have been examined using a multi-wavelength TIRF spectroscopy technique with continuous flow. Fluorescently labeled AT, adsorbed from citrated human blood plasma, showed significantly higher signals on CHS compared to the cationic surface used to attach the heparin conjugate. The AT binding to CHS was very stable, also after exposure to soluble heparin at a concentration of 1.5 IU/mL. Only a few percent of the bound AT were displaced from the surfaces by AT present in plasma after long-term exposure to plasma. In contrast, larger amounts of the freshly added AT had adsorbed to the surfaces, especially to the surface with two layers of heparin conjugate, indicating the presence of unsaturated AT binding sites. The amount of AT bound to the different surfaces was quantified after elution using an enzyme immunoassay (EIA). Characteristic emission spectra of proteins and fluorophores of labeled proteins, obtained at the surfaces after a long-term exposure to plasma, confirmed their presence at the surfaces. The multi-wavelength TIRF technique proved to be a useful tool when combined with other techniques to study the time course of interactions of fluorescently labeled proteins with biomaterials, even in a complex environment such as plasma.
Collapse
Affiliation(s)
- J E Klinth
- Department of Chemistry and Biomedical Sciences, University of Kalmar, SE 39182 Kalmar, Sweden
| | | | | | | |
Collapse
|
11
|
Thorslund S, Sanchez J, Larsson R, Nikolajeff F, Bergquist J. Functionality and stability of heparin immobilized onto poly(dimethylsiloxane). Colloids Surf B Biointerfaces 2005; 45:76-81. [PMID: 16144760 DOI: 10.1016/j.colsurfb.2005.07.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2005] [Revised: 06/28/2005] [Accepted: 07/07/2005] [Indexed: 10/25/2022]
Abstract
Poly(dimethylsiloxane) (PDMS) has become an attractive material when working in the field of microfluidics, mainly because of the rapid prototyping process it involves. The increased surface volume ratio in microchannels makes the interaction between sample and material surface highly important, evident when handling complex biological samples such as plasma or blood. This study demonstrates a new grade of non-covalent heparin surface that adds efficient anticoagulant property to the PDMS material. The surface modification is a simple and fast one-step process performed at neutral pH, optimal when working with closed microsystems. The heparin formed a uniform and functional coating on hydrophobic PDMS with comparatively high level of antithrombin-binding capacity. In addition, long-term studies revealed that the immobilized heparin was more or less stable in the microchannels over a time of three weeks. Recalcified plasma in contact with native PDMS showed complete coagulation after 1h, while no fibrin formation was detected in plasma incubated on heparin-coated PDMS within the same time. In conclusion, we see the heparin coating developed and evaluated in this study as a tool that greatly facilitates the use of PDMS in microfluidics dealing with plasma or blood samples.
Collapse
Affiliation(s)
- Sara Thorslund
- Department of Engineering Sciences, Angström Laboratory, Uppsala University, Box 534, SE-751 21 Uppsala, Sweden
| | | | | | | | | |
Collapse
|
12
|
Hattori T, Khan MMH, Colman RW, Edmunds LH. Plasma Tissue Factor Plus Activated Peripheral Mononuclear Cells Activate Factors VII and X in Cardiac Surgical Wounds. J Am Coll Cardiol 2005; 46:707-13. [PMID: 16098440 DOI: 10.1016/j.jacc.2005.05.040] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2005] [Revised: 04/28/2005] [Accepted: 05/03/2005] [Indexed: 11/21/2022]
Abstract
OBJECTIVES The purpose of this study was to test the hypothesis that activated monocytes with soluble plasma tissue factor (pTF) activate factors VII and X to generate thrombin. BACKGROUND Despite heparin, thrombin is progressively generated during cardiac surgery with cardiopulmonary bypass (CPB), produces intravascular fibrin and fibrinolysis, and causes serious thromboembolic and nonsurgical bleeding complications. Thrombin is primarily produced in the surgical wound, but mechanisms are unclear. METHODS In 13 patients, interactions of mononuclear cells, platelets, pTF, and pTF fractions to activate factors VII and X were evaluated in pre-bypass, perfusate, and pericardial wound blood before and during CPB. RESULTS Monocytes are activated in wound, but not in pre-bypass or perfusate plasma (monocyte chemotactic protein-1 = 29.5 +/- 2.1 pmoles/l vs. 2.8 +/- 1.2 pmoles/l and 3.3 +/-1.4 pmoles/l, respectively). Wound pTF is substantially elevated compared to other locations (3.64 +/- 0.45 pmoles/l vs. 0.71 +/- 0.65 pmoles/l and 1.31 +/- 1.4 pmoles/l). Supernatant wound pTF contains 81.7% of TF antigen; wound microparticle pTF contains 18.3%. Wound monocytes and all C5a-stimulated monocytes (but not activated platelets) completely convert factor VII to factor VIIa with wound pTF. Activated monocytes more efficiently activate factor X with wound supernatant TF/factor VII(VIIa) complex than with wound microparticle TF/factor VII(fVIIa). The correlation coefficient (r) between wound thrombin generation (F1.2) and wound pTF concentration is 0.944 (p = 0.0004). CONCLUSIONS During cardiac surgery with CPB, wound monocytes plus wound pTF or wound microparticle-free supernatant pTF preferentially accelerate activation of factor VII and factor X. This system represents a novel mechanism for thrombin generation via the TF coagulation pathway.
Collapse
Affiliation(s)
- Takashi Hattori
- Harrison Department of Surgical Research, School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | | | | |
Collapse
|
13
|
Johnell M, Larsson R, Siegbahn A. The influence of different heparin surface concentrations and antithrombin-binding capacity on inflammation and coagulation. Biomaterials 2005; 26:1731-9. [PMID: 15576147 DOI: 10.1016/j.biomaterials.2004.05.029] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2004] [Accepted: 05/12/2004] [Indexed: 11/15/2022]
Abstract
The corline heparin surface (CHS) used in the extracorporeal circuit during coronary artery bypass grafting is shown to decrease the activation of inflammation and coagulation. Synchrotron radiation studies have shown that a single layer of the CHS may not completely cover the substrate surface. However, a double layer of CHS results in a uniform surface. We investigated the effect of surfaces with different surface concentrations of heparin on cell activation and coagulation compared to an uncoated surface. The CHS is prepared by a conditioning layer of polymeric amine onto which a macromolecular heparin conjugate is attached. We used PVC tubing, uncoated or modified with a single or double layer of the CHS, and circulated fresh whole blood from healthy volunteers in a loop model system at 37 degrees C up to 4 h. Blood was drawn from the loops at different times and activation of inflammation and coagulation was studied by real-time PCR, flow cytometry and ELISA. The activation of leukocytes and platelets and formation of leukocyte-platelet aggregates were reduced by use of the single-layered CHS compared to the uncoated surface. Use of double-layered CHS resulted in significantly reduced cell activation and thrombin generation. Development of the CHS obtained by the double layer of the coating has improved the biocompatibility of the surface.
Collapse
Affiliation(s)
- M Johnell
- Laboratory for Coagulation Research, Clinical Chemistry, Department of Medical Sciences, Uppsala University, Akademiska Hospital, SE-751 85 Uppsala, Sweden
| | | | | |
Collapse
|
14
|
Sturk-Maquelin KN, Nieuwland R, Romijn FPHTM, Eijsman L, Hack CE, Sturk A. Pro- and non-coagulant forms of non-cell-bound tissue factor in vivo. J Thromb Haemost 2003; 1:1920-6. [PMID: 12941032 DOI: 10.1046/j.1538-7836.2003.00361.x] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Concentrations of non-cell-bound (NCB; soluble) tissue factor (TF) are elevated in blood collecting in the pericardial cavity of patients during cardiopulmonary bypass (CPB). Previously, we reported microparticles supporting thrombin generation in such blood samples. In this study we investigated the extent of microparticle association of the NCB form of TF in pericardial and systemic blood, and whether this microparticle-associated form is active in thrombin generation compared with non-microparticle-bound, (fluid-phase) TF. METHODS Systemic and pericardial blood samples were collected before and during CPB from six patients undergoing cardiac surgery. Microparticles were isolated by differential centrifugation and their thrombin-generating capacity measured in a chromogenic assay. Microparticle-associated and fluid-phase forms of NCB TF were measured by ELISA. Microparticle-associated TF was visualized by flow cytometry. RESULTS In pericardial samples, 45-77% of NCB TF was microparticle-associated, and triggered factor VII (FVII)-mediated thrombin generation in vitro. Microparticles from systemic samples triggered thrombin generation independently of FVII, except at the end of bypass (P = 0.003). The fluid-phase form of TF did not initiate thrombin generation. Both forms of NCB TF were, at least in part, antigenically cryptic. CONCLUSIONS We demonstrate the occurrence of two forms of NCB TF. One form, which is microparticle-associated, supports thrombin generation via FVII. The other form, which is fluid-phase, does not stimulate thrombin formation. We hypothesize that the microparticle-associated form of NCB TF may be actively involved in postoperative thromboembolic processes when pericardial blood is returned into the patients.
Collapse
Affiliation(s)
- K N Sturk-Maquelin
- Department of Cardiothoracic Surgery, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | | | | | | | | | | |
Collapse
|