Role of nitric oxide in regulation of systemic vascular resistance during and after cardiopulmonary bypass

Preservation of endothelium nitric oxide release during beating heart surgery with respect to continuous flow cardiopulmonary bypass

A correlation between perfusion modality and vascular dilation induced by endothelial nitric oxide (NO) release has been pointed out in the literature; nevertheless, only a few studies deal with the analysis of patients treated by cardiac surgery. The aim of this work is to analyze endothelial NO release in patients undergoing cardiac surgery under continuous flow cardiopulmonary bypass (CPB) or pulsatile perfusion. Pulsatile devices approved for clinical CPB do not accurately reproduce the physiological flow waveform provided by the left ventricle while, on the other hand, it is important to analyze pulsatile perfusion under both physiological flow waveform and pulsatile flow CPB. Physiological pulsatile perfusion (supplied by the left ventricle) was examined in this study. A total of 16 patients undergoing cardiac surgery were enrolled in the study and divided into two groups: 8 patients were put on continuous flow CPB while the others underwent beating heart surgery. Venous blood samples were withdrawn to quantify endothelial NO release through its bioactive forms in blood. Plasma was used for the chemiluminescent detection of nitrite (NO2—) and nitrate (NO3—), and the cellular component for electron spin resonance detection of nitrosylhemoglobin. Significant reduction in the intraoperative concentration with respect to the preoperative was observed only in the continuous group for both NO2— and NOx (NO2— + NO3—) concentration (p=0.003 and p=0.016, respectively). A significant difference in the intraoperative nitrite concentration was also observed between the groups (p=0.006). Nitrosylhemoglobin concentration, although not instrumentally detectable, resulted as negligible with respect to the other NO metabolites. Despite the small number of patients belonging to each group, this significant reduction of NO2— concentration under continuous flow CPB revealed a strong dependence on endothelial NO release and plasma nitrite concentration on perfusion modality.

Prostaglandin synthesis inhibitor improves hypotension during normothermic cardiopulmonary bypass

Hypotension is a major systemic side effect during cardiopu monary bypass (CPB), especially at normothermia. We previously reported that prostaglandin (PG) might play a substantial role in hypotension. The purpose of this study was to clarify whether a PG synthesis inhibitor (PGSI) could improve hypotension during CPB. Thirty-six patients undergoing cardiac surgery with normothermic CPB (35-37 degrees C) were divided into two groups: a PGSI group (n = 18), whose members wer given a PGSI before and during CPB, and a control group (n = 18). In both groups, perfusion flow was sufficient and pressure was maintained at above 45 mm Hg by infusion of metaraminol, a vasoconstrictor. The mean arterial pressure throughout CPB was significantly higher in the PGSI group than in the control group (57 +/- 4 vs. 48 +/- 3 mm Hg, p < 0.01), whereas the dose of infused metaraminol was significantly lower in the PGSI group (13 +/- 7 vs. 21 +/- 6 mg, p < 0.01). The blood base excess was not significantly different (1.0 +/- 1.6 vs. 1.7 +/- 1.9 mmol/L, p = 0.28), and urine output was significantly higher in the PGSI group (503 +/- 179 vs. 354 +/- 112 ml/hr, p < 0.01). In conclusion, PGSI can improve hypotension during CPB and increase urine output without impairing peripheral circulation.

Inducible nitric oxide production is an adaptation to cardiopulmonary bypass-induced inflammatory response

BACKGROUND

Cardiopulmonary bypass (CPB) increases nitric oxide (NO) production by the activation of NO synthases (NOS). However, the role of NO from inducible NOS (iNOS) in CPB-induced inflammatory response remains unclear. We examined the effect of a selective iNOS inhibitor, aminoguanidine, on CPB-induced inflammatory response in a rat-CPB model.

METHODS

Adult Sprague-Dawley rats underwent 60 minutes of CPB (100 mL x kg(-1) x min(-1), 34 degrees C). Group A (n = 10) received 100 mg/kg of aminoguanidine intraperitoneally 30 minutes before the initiation of CPB, and group B (n = 10) served as controls.

RESULTS

There were significant time-dependent changes in plasma interleukin (IL)-6, IL-8, nitrate + nitrite, the percentage ratio of nitrotyrosine to tyrosine (%NO2-Tyr, an indicator of peroxynitrite formation), and respiratory index (RI). Three hours after CPB termination, IL-6, IL-8, and RI were significantly higher in group A (IL-6, 397.5+/-80.6 pg/mL; IL-8, 26.99+/-6.57 ng/mL; RI, 1.87+/-0.31) than in group B (IL-6, 316.5+/-73.9 pg/mL, p <0.05; IL-8, 17.21+/-3.12 ng/mL, p < 0.01; RI, 1.57+/-0.24, p < 0.05) although nitrate + nitrite (31.8+/-4.1 micromol/L) and %NO2-Tyr (1.15%+/-0.20%) were significantly lower in group A than in group B (nitrate + nitrite, 50.2+/-5.0 micromol/L, p < 0.01; %NO2-Tyr, 1.46%+/-0.21%, p < 0.01). Western immunoblot analysis from lung tissue of group A identified marked iNOS inhibition without inhibiting endothelial-constitutive NOS, and neutrophil accumulation in the lung specimens was significantly greater in group A (6.5+/-0.7/alveoli) than in group B (4.4+/-0.4/alveoli, p < 0.01).

CONCLUSIONS

These results suggest that NO production from iNOS may be an adaptive response for attenuating the CPB-induced inflammatory response.