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Khosravi A, Skrabal CA, Westphal B, Kundt G, Greim B, Kunesch E, Liebold A, Steinhoff G. Evaluation of coated oxygenators in cardiopulmonary bypass systems and their impact on neurocognitive function. Perfusion 2016; 20:249-54. [PMID: 16231620 DOI: 10.1191/0267659105pf818oa] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Introduction: Coronary artery bypass graft surgery (CABG) using cardiopulmonary bypass (CPB) is assumed to be associated with a decline of neurocognitive functions. This study was designed to analyse the neurocognitive function of patients with coronary heart disease before and after CABG and to determine possible protective effects of oxygenator surface coating on neurological outcome.Methods: Forty patients scheduled for selective CABG were prospectively randomized into two groups of 20 patients each according to the type of hollow-fibre membrane oxygenator used. Non-coated oxygenators (Group A) were compared to phosphorylcholine (PC)- coated oxygenators (Group B). A battery of six neurological tests was administered preoperatively, 7 - 10 days and 4 - 6 months after surgery.Results: One patient of Group A suffered from a perioperative stroke and died on postoperative day 3, presumably because of sudden heart failure. Two patients of Group A (10%) developed a symptomatic transitory delirious psychotic syndrome (STPT) on postoperative days 3 and 5. None of the patients of Group B had perioperative complications. The test analysis revealed a trend of declined neurocognitive function early after CABG, but did not show any difference in neurocognitive outcome between the two groups.Discussion: PC coating of the oxygenators did not show any significant benefit on neurocognitive function after CABG using CPB.
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Affiliation(s)
- Amir Khosravi
- Department of Cardiac Surgery, University of Rostock, Rostock, Germany
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Törnudd M, Hahn RG, Zdolsek JH. Fluid distribution kinetics during cardiopulmonary bypass. Clinics (Sao Paulo) 2014; 69:535-41. [PMID: 25141112 PMCID: PMC4129556 DOI: 10.6061/clinics/2014(08)06] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2013] [Accepted: 03/12/2014] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE The purpose of this study was to examine the isovolumetric distribution kinetics of crystalloid fluid during cardiopulmonary bypass. METHODS Ten patients undergoing coronary artery bypass grafting participated in this prospective observational study. The blood hemoglobin and the serum albumin and sodium concentrations were measured repeatedly during the distribution of priming solution (Ringer's acetate 1470 ml and mannitol 15% 200 ml) and initial cardioplegia. The rate of crystalloid fluid distribution was calculated based on 3-min Hb changes. The preoperative blood volume was extrapolated from the marked hemodilution occurring during the onset of cardiopulmonary bypass. Clinicaltrials.gov: NCT01115166. RESULTS The distribution half-time of Ringer's acetate averaged 8 minutes, corresponding to a transcapillary escape rate of 0.38 ml/kg/min. The intravascular albumin mass increased by 5.4% according to mass balance calculations. The preoperative blood volume, as extrapolated from the drop in hemoglobin concentration by 32% (mean) at the beginning of cardiopulmonary bypass, was 0.6-1.2 L less than that estimated by anthropometric methods (p<0.02). The mass balance of sodium indicated a translocation from the intracellular to the extracellular fluid space in 8 of the 10 patients, with a median volume of 236 ml. CONCLUSIONS The distribution half-time of Ringer's solution during isovolumetric cardiopulmonary bypass was 8 minutes, which is the same as for crystalloid fluid infusions in healthy subjects. The intravascular albumin mass increased. Most patients were hypovolemic prior to the start of anesthesia. Intracellular edema did not occur.
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Affiliation(s)
- Mattias Törnudd
- Departments of Cardiovascular and Thoracic Anesthesia, Faculty of Health Sciences, Linköping University, Linköping, Sweden
| | - Robert G Hahn
- Department of Anesthesia and Intensive Care, Faculty of Health Sciences, Linköping University, Linköping, Sweden
| | - Joachim H Zdolsek
- Department of Anesthesia and Intensive Care, Faculty of Health Sciences, Linköping University, Linköping, Sweden
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Bierbach B, Meier M, Kasper-König W, Heimann A, Alessandri B, Horstick G, Oelert H, Kempski O. Emboli formation rather than inflammatory mediators are responsible for increased cerebral water content after conventional and assisted beating-heart myocardial revascularization in a porcine model. Stroke 2007; 39:213-9. [PMID: 18063820 DOI: 10.1161/strokeaha.107.496620] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Emboli and proinflammatory mediators are suspected of generating cerebral edema after coronary surgery. In contrast to cardiopulmonary bypass (CPB), off-pump coronary artery bypass surgery (OPCAB) reduces microemboli count and proinflammatory mediator release but carries the risk of hemodynamic instability. A microaxial blood pump can augment cardiac output. METHODS Coronary bypasses were constructed in pigs with CPB and cardioplegia (n=9), OPCAB (n=9), or blood-pump support CAB (n=9). Nine animals underwent sham operation. Embolus count was monitored and regional cerebral blood flow was assessed with microspheres in 21 brain specimens per animal (n=189 per group). Interleukins 6 and 8 and tumor necrosis factor-alpha concentrations were determined. These variables were studied before, during, and for 4 hours after surgery. Finally, cerebral water content was determined. RESULTS During CPB and blood-pump CAB, a significant number of emboli were counted in contrast to OPCAB and controls (P<0.05). During CPB, regional cerebral blood flow was affected (32 of 189) and showed reactive hyperemia except in 10 specimens after aortic cross-clamp release. This impairment persisted in 20 specimens. During and after OPCAB, regional cerebral blood flow remained nearly unchanged but showed low flow during (58 of 189) and after (35 of 189) the blood-pump run. A significant increase in proinflammatory mediators was observed only in the CPB group. CPB and blood-pump CAB significantly increased cerebral water content (P<0.05). A strong correlation between embolic load and cerebral water content was observed in all groups. No correlation between proinflammatory mediator release and cerebral water content was detected. CONCLUSIONS Emboli formation rather than inflammatory mediators are responsible for increased cerebral water content after conventional and assisted beating-heart myocardial revascularization.
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Affiliation(s)
- Benjamin Bierbach
- Department of Cardiothoracic and Vascular Surgery, University Hospital Mainz, Mainz, Germany.
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Abstract
This review focuses on the effects of cardiac surgery and cardiopulmonary bypass on the brain, with special emphasis on the results of recently conducted studies. The incidence of postoperative neurological and neuropsychological deficits and risk factors for cerebral injury are reviewed. The relationships between cerebral embolic load, release of biochemical markers of brain injury and cognitive dysfunction after cardiac surgery are also reviewed. Finally, recently gained information on the management of cardiopulmonary bypass is discussed, along with the results of recent pharmacological neuroprotective trials in patients undergoing cardiac surgery.
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Affiliation(s)
- S E Ricksten
- Department of Cardiothoracic Anesthesia and Intensive Care, Sahlgrenska University, Göteborg, Sweden.
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Dixon B, Santamaria J, Campbell D. Coagulation Activation and Organ Dysfunction Following Cardiac Surgery. Chest 2005; 128:229-36. [PMID: 16002940 DOI: 10.1378/chest.128.1.229] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
STUDY OBJECTIVES Cardiac surgery with cardiopulmonary bypass (CPB) is associated with major inflammatory triggers that cause marked activation of the microcirculation. This inflammatory response is associated with significant organ dysfunction. How this response causes organ dysfunction is not well understood; consequently, few interventions exist to prevent or treat it. In other acute inflammatory conditions, such as sepsis, increased coagulation activation in the microcirculation may be a cause of organ injury. We documented the association between coagulation activation and organ dysfunction to investigate whether coagulation activation also plays a role in organ injury following cardiac surgery with CPB. DESIGN Prospective study of 30 patients undergoing cardiac surgery with CPB. Prothrombin fragment (PTF) 1 + 2 and plasminogen activator inhibitor (PAI) activity were measured, and levels correlated with postoperative measures of organ function including the left-ventricular stroke work index, the Pao(2)/fraction of inspired oxygen (Fio(2)) ratio, and creatinine levels. RESULTS PTF levels increased eightfold (p < 0.05), and PAI activity increased threefold (p < 0.05) over the first 4 h after CPB. PTF levels were correlated with deteriorations in the left-ventricular stroke work index (p = 0.04), the Pao(2)/Fio(2) ratio (p = 0.02), and creatinine levels (p = 0.02). CONCLUSIONS Levels of coagulation activation are associated with markers of postoperative organ dysfunction. Additional studies are warranted to investigate whether strategies that limit coagulation activation are associated with reductions in postoperative organ dysfunction.
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Affiliation(s)
- Barry Dixon
- Intensive Care, St. Vincent's Hospital, 41 Victoria Parade, Fitzroy, Melbourne, Victoria 3065, Australia.
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Karamlou T, Hickey E, Silliman CC, Shen I, Ungerleider RM. Reducing risk in infant cardiopulmonary bypass: the use of a miniaturized circuit and a crystalloid prime improves cardiopulmonary function and increases cerebral blood flow. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2005:3-11. [PMID: 15818352 DOI: 10.1053/j.pcsu.2005.01.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
Advances in perfusion strategies have played an important role in improving outcomes following repair of complex congenital heart defects. The influence of cooling strategy, temperature, duration of circulatory arrest, and specific method of cerebral perfusion on neurologic morbidity have been extensively characterized. Similarly, the ability of pharmacologic agents to modulate the post-cardiopulmonary bypass (CPB) inflammatory response has been previously elucidated in both the laboratory and clinical arena. However, modification of the circuit and priming components have received comparably less attention. We recently showed that employment of a miniaturized circuit and a bloodless prime reduce inflammation and have salutary effects on cardiopulmonary function following hypothermic low-flow perfusion (HLF), and that this circuit may also improve cerebral protection following both deep hypothermic circulatory arrest and HLF. The current report, therefore, reviews current strategies utilized to minimize post-CPB inflammation and highlights the empirical evidence from our laboratory demonstrating the beneficial role of a miniaturized extracorporeal circuit in this context.
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Affiliation(s)
- Tara Karamlou
- Division of Cardiovascular Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada
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Brix-Christensen V. The systemic inflammatory response after cardiac surgery with cardiopulmonary bypass in children. Acta Anaesthesiol Scand 2001; 45:671-9. [PMID: 11421823 DOI: 10.1034/j.1399-6576.2001.045006671.x] [Citation(s) in RCA: 99] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Paediatric cardiac surgery often requires cardiopulmonary bypass (CPB) during the surgical intervention. CPB is known to elicit a systemic inflammatory response with activation of the complement and coagulation systems, stimulation of cytokine production, cellular entrapment in organs, neutrophil activation with degranulation, platelet activation, and endothelial dysfunction. These changes are associated with a risk of postoperative organ dysfunction and increased morbidity and mortality in the postoperative period. Clinical studies have concentrated on measurement of inflammatory markers and mediators in peripheral blood, where the systemic inflammatory response in the paediatric cardiac patient seems to be different from the adult case. Looking at the organ level, experimental studies have the advantage of providing information contributing to a better understanding of the pathological events that may lead to the deteriorated organ function. This review focuses on the systemic inflammatory response after cardiac surgery with CPB in children and experimental CPB models.
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Affiliation(s)
- V Brix-Christensen
- Department of Anaesthesiology and Institute of Experimental Clinical Research, Aarhus University Hospital, Denmark.
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Joffs C, Gunasinghe HR, Multani MM, Dorman BH, Kratz JM, Crumbley AJ, Crawford FA, Spinale FG. Cardiopulmonary bypass induces the synthesis and release of matrix metalloproteinases. Ann Thorac Surg 2001; 71:1518-23. [PMID: 11383793 DOI: 10.1016/s0003-4975(01)02442-0] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND A number of cellular and molecular events can be induced after cardiac procedures requiring cardiopulmonary bypass (CPB). The matrix metalloproteinases (MMPs) are a recently discovered family of enzymes that degrade the extracellular matrix, but expression during and after CPB is unknown. METHODS Systemic plasma MMP levels were measured in patients (n = 28, 63 +/- 1 years) undergoing elective coronary revascularization requiring CPB at baseline, termination of CPB, and 30 minutes, 6 and 24 hours after CPB. Representative classes of MMP species known to degrade matrix and basement membrane components were selected for study. Specifically, the interstitial collagenases MMP-8 and MMP-13, and the gelatinases MMP-2 and MMP-9 were determined by internally validated enzyme-linked immunosorbent assay. RESULTS The MMP-8 levels increased by fourfold at separation from CPB, and returned to within normal values within 30 minutes after CPB. The proenzyme forms of MMP-13 and MMP-9 increased by more than twofold at cross-clamp release and returned within normal limits within 6 hours after CPB. The proform of MMP-2 increased from baseline values at 6 and 24 hours postoperatively; likely indicative of de novo synthesis. CONCLUSIONS A specific portfolio of MMPs are released and synthesized during and after CPB. Because MMPs can degrade extracellular proteins essential for maintaining normal cellular architecture and function, enhanced MMP release and activation may contribute to alterations in tissue homeostasis in the early postoperative period.
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Affiliation(s)
- C Joffs
- Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston 29425, USA
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Brix-Christensen V, Petersen TK, Ravn HB, Hjortdal VE, Andersen NT, Tønnesen E. Cardiopulmonary bypass elicits a pro- and anti-inflammatory cytokine response and impaired neutrophil chemotaxis in neonatal pigs. Acta Anaesthesiol Scand 2001; 45:407-13. [PMID: 11300377 DOI: 10.1034/j.1399-6576.2001.045004407.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Cardiopulmonary bypass (CPB) induces a systemic inflammatory response and organ dysfunction, especially in children. Plasma concentration of inflammatory markers are increased in response to the trauma of cardiac surgery and CPB. The aim of the present study was to investigate whether the CPB procedure in itself elicits increased levels of inflammatory markers in neonatal pigs. METHODS The inflammatory response was measured in piglets undergoing sternotomy alone (sham group, n=13) or sternotomy and CPB (n=14). Inflammatory mediators were measured at baseline and at fixed time-points during and after CPB. IL-8, IL-10 and TNF-alpha levels and C-reactive protein (CRP) concentrations were measured in plasma samples. Polymorphonuclear neutrophils (PMN) chemotaxis was measured ex vivo, and CD-18 expression using an immunofluorescence technique. RESULTS Immediately after the CPB procedure increased IL-8 levels were found in the CPB group, but not in sham operated animals (P=0.005). Simultaneously, a marked IL-10 response was measured in the CPB group. Concurrently, PMN chemotaxis decreased in CPB animals but not in the sham group (P=0.04). CD-18 expression and CRP levels were not significantly different between groups and TNF-alpha showed no changes in either group. The chemotactic response did not correlate with plasma IL-8 or IL-10, nor with CD-18 expression. CONCLUSION The CPB procedure elicited a systemic inflammatory response in terms of significantly elevated plasma levels of IL-8 and IL-10. Furthermore, a temporary and simultaneous decrease in PMN chemotaxis was observed immediately after CPB.
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Affiliation(s)
- V Brix-Christensen
- Department of Anesthesia and Intensive Care, Aarhus University Hospital, Denmark.
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Sanders DB, Larson DF, Hunter K, Gorman M, Yang B. Comparison of tumor necrosis factor-alpha effect on the expression of iNOS in macrophage and cardiac myocytes. Perfusion 2001; 16:67-74. [PMID: 11192310 DOI: 10.1177/026765910101600110] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Proinflammatory cytokines, including tumor necrosis factor-alpha (TNF-alpha), are elevated during cardiopulmonary bypass (CPB), heart failure, and inflammatory cardiac and systemic diseases. Elevated TNF-alpha has been linked to diminished cardiac function, decreased systemic vascular resistance, as well as renal and pulmonary dysfunction. It is understood that myocardial tissues can express TNF-alpha, which results in the induction of inducible nitric oxide synthase (iNOS) leading to a significant decline in cardiac function and other direct effects. The hypothesis of this study was to determine if TNF-alpha would stimulate iNOS and its product nitric oxide (NO) similarly in immortalized macrophage and cardiac myocytes. Cultured macrophages (RAW 264.7) and cardiac myocytes (HL-1) were placed into two treatment groups and a control. The treatments included: (1) TNF-alpha and lipopolysaccharide (LPS); and (2) LPS, TNF-alpha, interleukin-1beta (IL-1beta) and interferon-gamma (IFN-gamma) incubated for 8 h. The macrophage expression of iNOS increased by 365% (p < 0.01) and its product, NO, increased proportionally. The expression of iNOS in the cardiac myocyte did not increase with TNF-alpha and LPS. However, with the addition of IFN-alpha and IL-1beta iNOS increased to 140% of control (p < 0.05). Myocyte cGMP and NO did not increase significantly with TNF-alpha treatment. This study suggests that HL-1 myocyte iNOS cannot be induced by TNF-alpha, unlike macrophage iNOS. Furthermore, the resultant cardiac dysfunction, secondary to proinflammatory cytokines effects, is regulated via diverse pathways.
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Affiliation(s)
- D B Sanders
- Circulatory Sciences Graduate Perfusion Program, Sarver Heart Center, University of Arizona, Tucson 85724, USA
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