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Kalra A, Kang JK, Wilcox C, Shou BL, Brown P, Rycus P, Anders MM, Zaaqoq AM, Brodie D, Whitman GJR, Cho SM. Pulse Pressure and Acute Brain Injury in Venoarterial Extracorporeal Membrane Oxygenation: An Extracorporeal Life Support Organization Registry Analysis. ASAIO J 2024:00002480-990000000-00547. [PMID: 39178166 DOI: 10.1097/mat.0000000000002294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/25/2024] Open
Abstract
Low pulse pressure (PP) in venoarterial-extracorporeal membrane oxygenation (VA-ECMO) is a marker of cardiac dysfunction and has been associated with acute brain injury (ABI) as continuous-flow centrifugal pump may lead to endothelial dysregulation. We retrospectively analyzed adults (≥18 years) receiving "peripheral" VA-ECMO for cardiogenic shock in the Extracorporeal Life Support Organization Registry (January 2018-July 2023). Acute brain injury (our primary outcome) included central nervous system (CNS) ischemia, intracranial hemorrhage, brain death, and seizures. Multivariable logistic regressions were performed to examine whether PP ≤10 mm Hg was associated with ABI. Of 9,807 peripheral VA-ECMO patients (median age = 57.4 years, 67% = male), 8,294 (85%) had PP >10 mm Hg versus 1,513 (15%) had PP ≤10 mm Hg. Patients with PP ≤10 mm Hg experienced ABI more frequently versus PP >10 mm Hg (15% versus 11%, p < 0.001). After adjustment, PP ≤10 mm Hg was independently associated with ABI (adjusted odds ratio [aOR] = 1.25, 95% confidence interval [CI] = 1.06-1.48, p = 0.01). Central nervous system ischemia and brain death were more common in patients with PP ≤10 versus PP >10 mm Hg (8% versus 6%, p = 0.008; 3% versus 1%, p < 0.001). Pulse pressure ≤10 mm Hg was associated with CNS ischemia (aOR = 1.26, 95% CI = 1.02-1.56, p = 0.03) but not intracranial hemorrhage (aOR = 1.14, 95% CI = 0.85-1.54, p = 0.38). Early low PP (≤10 mm Hg) at 24 hours of ECMO support was associated with ABI, particularly CNS ischemia, in peripheral VA-ECMO patients.
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Affiliation(s)
- Andrew Kalra
- From the Division of Cardiac Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Jin Kook Kang
- From the Division of Cardiac Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - Christopher Wilcox
- Department of Critical Care, Mercy Hospital of Buffalo, Buffalo, New York
| | - Benjamin L Shou
- From the Division of Cardiac Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - Patricia Brown
- From the Division of Cardiac Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - Peter Rycus
- Extracorporeal Life Support Organization, Ann Arbor, Michigan
| | - Marc M Anders
- Division of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Akram M Zaaqoq
- Division of Critical Care, Department of Anesthesiology, University of Virginia, Charlottesville, Virginia
| | - Daniel Brodie
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Glenn J R Whitman
- From the Division of Cardiac Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - Sung-Min Cho
- From the Division of Cardiac Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland
- Division of Neurosciences Critical Care, Department of Neurology, Neurosurgery, Anesthesiology and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, Maryland
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Orbegozo D, Stringari G, Damazio R, De Backer D, Vincent JL, Creteur J. Altered Microvascular Reactivity During a Skin Thermal Challenge Is Associated With Organ Dysfunction and Slow Recovery After Cardiac Surgery. J Cardiothorac Vasc Anesth 2024:S1053-0770(24)00436-1. [PMID: 39034163 DOI: 10.1053/j.jvca.2024.06.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2024] [Revised: 06/26/2024] [Accepted: 06/30/2024] [Indexed: 07/23/2024]
Abstract
OBJECTIVES To assess microvascular reactivity during a skin thermal challenge early post-cardiac surgery and its association with outcomes. DESIGN Noninvasive physiological study. SETTING Thirty-five-bed department of intensive care. PARTICIPANTS Patients admitted to the intensive care unit post-cardiac surgery. INTERVENTIONS Thermal challenge. MEASUREMENTS AND MAIN RESULTS A total of 46 patients were included; 14 needed vasoactive or ventilatory support for at least 48 hours (slow recovery), and 32 had a more rapid recovery. Skin blood flow (SBF) was measured on the anterior proximal forearm using skin laser Doppler. A thermal challenge was performed by abruptly increasing local skin temperature from 37°C to 43°C while monitoring SBF. The ratio between SBFs at 43°C and 37°C was calculated to measure microvascular reactivity. SBF at 37°C was not significantly different in patients with a slow recovery and those with a rapid recovery, but SBF after 9 minutes at 43°C was lower (48.5 [17.3-69.0] v 85.1 [45.2-125.7], p < 0.01), resulting in a lower SBF ratio (2.8 [1.5-4.7] v 4.8 [3.7-7.8], p < 0.01). Patients with lower SBF ratios were more likely to have dysfunction of at least one organ (assessed using the sequential organ dysfunction score) 48 hours post-cardiac surgery than those with higher ratios: 88% versus 40% versus 27% (p < 0.01), respectively, for the lowest, middle, and highest tertiles of SBF ratio. In multivariable analysis, a lower SBF ratio was an independent risk factor for slow recovery. CONCLUSIONS Early alterations in microvascular reactivity, evaluated by a skin thermal challenge, are correlated with organ dysfunction. These observations may help in the development of new, simple, noninvasive monitoring systems in postoperative patients.
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Affiliation(s)
- Diego Orbegozo
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Gianni Stringari
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Rafael Damazio
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Daniel De Backer
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Jacques Creteur
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium.
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Savluk OF, Yilmaz AA, Yavuz Y, Arisut S, Ukil Isildak F, Turkmen Karaagac A, Ozbek B, Cine N, Tuncer E, Ceyran H. Assessment of microcirculatory alteration by a vascular occlusion test using near-infrared spectroscopy in pediatric cardiac surgery: effect of cardiopulmonary bypass. Expert Rev Med Devices 2024; 21:249-255. [PMID: 38217402 DOI: 10.1080/17434440.2024.2306155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 12/10/2023] [Indexed: 01/15/2024]
Abstract
OBJECTIVES Cardiopulmonary bypass cause microcirculatory alterations. Near infrared spectroscopic measurement of tissue oxygen saturation and vascular occlusion test are novel technologies for assessing the microcirculatory function of peripheral tissue specifically in patients undergoing cardiac surgery with cardiopulmonary bypass.Our study aimed to evaluate dynamic microcirculatory function using the vascular occlusion testing during cardiac surgery in pediatric patients. METHODS 120 pediatric patients were scheduled. Children had continuous regional oxygen saturation monitoring using near infrared spectroscopy and vascular occlusion test. Vascular occlusion test was performed five times; before induction (T1), after induction (T2), then during cardiopulmonary bypass with full flow (T3), after the termination of CPB (T4) and after sternum closure (T5). RESULTS Basal value was the lowest at T3 and this value was significantly different among measurements (p < 0,01).Values for maximum and minimum tissue oxygen saturation were the lowest at T3 (83,4 and 52,9%).The occlusion slope varied significantly among measurements (p < 0,01).Reperfusion slopes were significantly different among measurements (p < 0,01) with a further progressive decrease in reperfusion slope with duration of cardiopulmonary bypass. CONCLUSION Microcirculatory function can assessed using VOT with forearm Near-infrared spectroscopy derived variables during cardiopulmonary bypass in pediatric cardiac surgery. Noninvasive assessment of microcirculatory perfusion during cardiopulmonary bypass can further help evaluate and improve circulatory support techniques. TRIAL REGISTRATION The research Project was registered at ClinicalTrials.gov (NCT06191913).
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Affiliation(s)
- Omer Faruk Savluk
- Anesthesiology and Reanimation Clinic, Kartal Kosuyolu High Education and Training Hospital, Istanbul, Turkey
| | - Abdullah Arif Yilmaz
- Pediatric Cardiac Surgery Clinic, Kartal Kosuyolu High Education and Training Hospital, Istanbul, Turkey
| | - Yasemin Yavuz
- Anesthesiology and Reanimation Clinic, Kartal Kosuyolu High Education and Training Hospital, Istanbul, Turkey
| | - Seda Arisut
- Anesthesiology and Reanimation Clinic, Kartal Kosuyolu High Education and Training Hospital, Istanbul, Turkey
| | - Fatma Ukil Isildak
- Anesthesiology and Reanimation Clinic, Kartal Kosuyolu High Education and Training Hospital, Istanbul, Turkey
| | - Aysu Turkmen Karaagac
- Anesthesiology and Reanimation Clinic, Kartal Kosuyolu High Education and Training Hospital, Istanbul, Turkey
| | - Baburhan Ozbek
- Pediatric Cardiac Surgery Clinic, Kartal Kosuyolu High Education and Training Hospital, Istanbul, Turkey
| | - Nihat Cine
- Pediatric Cardiac Surgery Clinic, Kartal Kosuyolu High Education and Training Hospital, Istanbul, Turkey
| | - Eylem Tuncer
- Pediatric Cardiac Surgery Clinic, Kartal Kosuyolu High Education and Training Hospital, Istanbul, Turkey
| | - Hakan Ceyran
- Pediatric Cardiac Surgery Clinic, Kartal Kosuyolu High Education and Training Hospital, Istanbul, Turkey
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De Cuyper H, Poelaert J. Microcirculatory Alterations in Cardiac Surgery: A Comprehensive Guide. J Cardiothorac Vasc Anesth 2024; 38:829-838. [PMID: 38195271 DOI: 10.1053/j.jvca.2023.11.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 11/09/2023] [Accepted: 11/29/2023] [Indexed: 01/11/2024]
Abstract
Microcirculation is essential for cellular life and its functions. It comprises a complex network of capillaries, arterioles, and venules, which distributes oxygenated blood across and within organs based on regional metabolic demands. Because previous research indicated that organ function is linked to microcirculatory function, it is crucial to maintain sufficient and effective microcirculatory function during major surgery. Impaired microcirculation can lead to inadequate tissue perfusion, potentially resulting in perioperative complications and an unfavorable outcome. Indeed, changes in microcirculation in cardiovascular disease and cardiac surgery have a direct correlation with prolonged stays in the postoperative intensive care unit and high mortality rates within 30 days. Additionally, cardiopulmonary bypass, a regularly employed method in cardiac surgery, has been proven to induce microcirculatory malfunction and, thus, lead to postoperative multiple organ dysfunction. As global hemodynamic parameters can remain stable or improve, whereas microcirculation is still compromised, tracking microcirculatory variables could lead to the development of targeted microcirculatory treatment within hemodynamic management. Therefore, it is necessary to enhance the use of microcirculatory monitoring in the medical domain to assist physicians in the therapeutic management of patients undergoing cardiac surgery. This potentially can lead to better hemodynamic management and outcomes. This review article concentrates on the use of handheld video microscopes for real-time microcirculatory assessment of cardiac surgery patients in the immediate and early postoperative period. Emphasis is placed on integrating microcirculatory monitoring with conventional hemodynamic monitoring in the therapeutic management of patients undergoing cardiac surgery.
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Affiliation(s)
- Hélène De Cuyper
- Department Anesthesiology and Perioperative Medicine, UZ Brussels, Brussels, Belgium; Free University Brussels VUB, Brussels, Belgium.
| | - Jan Poelaert
- Free University Brussels VUB, Brussels, Belgium; Department Anesthesiology, ICU and Chronic Pain Therapy, Maria Middelares, Ghent, Belgium
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Flick M, Hilty MP, Duranteau J, Saugel B. The microcirculation in perioperative medicine: a narrative review. Br J Anaesth 2024; 132:25-34. [PMID: 38030549 DOI: 10.1016/j.bja.2023.10.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 09/25/2023] [Accepted: 10/10/2023] [Indexed: 12/01/2023] Open
Abstract
The microcirculation describes the network of the smallest vessels in our cardiovascular system. On a microcirculatory level, oxygen delivery is determined by the flow of oxygen-carrying red blood cells in a given single capillary (capillary red blood cell flow) and the density of the capillary network in a given tissue volume (capillary vessel density). Handheld vital videomicroscopy enables visualisation of the capillary bed on the surface of organs and tissues but currently is only used for research. Measurements are generally possible on all organ surfaces but are most often performed in the sublingual area. In patients presenting for elective surgery, the sublingual microcirculation is usually intact and functional. Induction of general anaesthesia slightly decreases capillary red blood cell flow and increases capillary vessel density. During elective, even major, noncardiac surgery, the sublingual microcirculation is preserved and remains functional, presumably because elective noncardiac surgery is scheduled trauma and haemodynamic alterations are immediately treated by anaesthesiologists, usually restoring the macrocirculation before the microcirculation is substantially impaired. Additionally, surgery is regional trauma and thus likely causes regional, rather than systemic, impairment of the microcirculation. Whether or not the sublingual microcirculation is impaired after noncardiac surgery remains a subject of ongoing research. Similarly, it remains unclear if cardiac surgery, especially with cardiopulmonary bypass, impairs the sublingual microcirculation. The effects of therapeutic interventions specifically targeting the microcirculation remain to be elucidated and tested. Future research should focus on further improving microcirculation monitoring methods and investigating how regional microcirculation monitoring can inform clinical decision-making and treatment.
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Affiliation(s)
- Moritz Flick
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - Matthias P Hilty
- Institute of Intensive Care Medicine, University Hospital of Zurich, Zurich, Switzerland
| | - Jacques Duranteau
- Department of Anesthesiology and Intensive Care, Paris-Saclay University, Bicêtre Hospital, Assistance Publique Hôpitaux de Paris (AP-HP), Le Kremlin-Bicêtre, France
| | - Bernd Saugel
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Outcomes Research Consortium, Cleveland, OH, USA
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Mattimore D, Fischl A, Christophides A, Cuenca J, Davidson S, Jin Z, Bergese S. Delirium after Cardiac Surgery-A Narrative Review. Brain Sci 2023; 13:1682. [PMID: 38137130 PMCID: PMC10741583 DOI: 10.3390/brainsci13121682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 12/04/2023] [Accepted: 12/05/2023] [Indexed: 12/24/2023] Open
Abstract
Postoperative delirium (POD) after cardiac surgery is a well-known phenomenon which carries a higher risk of morbidity and mortality. Multiple patient-specific risk factors and pathophysiologic mechanisms have been identified and therapies have been proposed to mitigate risk of delirium development postoperatively. Notably, cardiac surgery frequently involves the use of an intraoperative cardiopulmonary bypass (CPB), which may contribute to the mechanisms responsible for POD. Despite our greater understanding of these causative factors, a substantial reduction in the incidence of POD remains high among cardiac surgical patients. Multiple therapeutic interventions have been implemented intraoperatively and postoperatively, many with conflicting results. This review article will highlight the incidence and impact of POD in cardiac surgical patients. It will describe some of the primary risk factors associated with POD, as well as anesthetic management and therapies postoperatively that may help to reduce delirium.
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Affiliation(s)
| | | | | | | | | | | | - Sergio Bergese
- Department of Anesthesiology, Stony Brook University Hospital, Stony Brook, NY 11794, USA; (D.M.); (A.F.); (A.C.); (J.C.); (S.D.); (Z.J.)
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Kalra A, Kang JK, Wilcox C, Brown P, Rycus P, Anders MM, Zaaqoq AM, Brodie D, Whitman GJR, Cho SM. Impact of Pulse Pressure on Acute Brain Injury in Venoarterial ECMO Patients with Cardiogenic Shock During the First 24 Hours of ECMO Cannulation: Analysis of the Extracorporeal Life Support Organization Registry. RESEARCH SQUARE 2023:rs.3.rs-3646443. [PMID: 38045281 PMCID: PMC10690326 DOI: 10.21203/rs.3.rs-3646443/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/05/2023]
Abstract
Background Low pulse pressure (PP) in venoarterial-extracorporeal membrane oxygenation (VA-ECMO) is a marker of cardiac dysfunction and has been associated with acute brain injury (ABI) as continuous-flow centrifugal pump may lead to endothelial dysregulation. Methods We retrospectively analyzed adults (≥18 years) on "peripheral" VA-ECMO support for cardiogenic shock in the Extracorporeal Life Support Organization Registry (1/2018-7/2023). Cubic splines were used to establish a threshold (PP≤10 mmHg at 24 hours of ECMO support) for "early low" PP. ABI included central nervous system (CNS) ischemia, intracranial hemorrhage, brain death, and seizures. Multivariable logistic regressions were performed to examine whether PP≤10 mmHg was associated with ABI. Covariates included age, sex, body mass index, pre-ECMO variables (temporary mechanical support, vasopressors, cardiac arrest), on-ECMO variables (pH, PaO2, PaCO2), and on-ECMO complications (hemolysis, arrhythmia, renal replacement therapy). Results Of 9,807 peripheral VA-ECMO patients (median age=57.4 years, 67% male), 8,294 (85%) had PP>10 mmHg vs. 1,513 (15%) had PP≤10 mmHg. Patients with PP≤10 mmHg experienced ABI more frequently vs. PP>10 mmHg (15% vs. 11%, p<0.001). After adjustment, PP≤10 mmHg was independently associated with ABI (adjusted odds ratio [aOR]=1.25, 95% confidence interval [CI]=1.06-1.48, p=0.01). CNS ischemia and brain death were more common in patients with PP≤10 mmHg vs. PP>10 mmHg (8% vs. 6%, p=0.008; 3% vs. 1%, p<0.001). PP≤10 mmHg was associated with CNS ischemia (aOR=1.26, 95%CI=1.02-1.56, p=0.03) but not intracranial hemorrhage (aOR=1.14, 95%CI=0.85-1.54, p=0.38). Conclusions Early low PP (≤10 mmHg) at 24 hours of ECMO support was associated with ABI, particularly CNS ischemia, in peripheral VA-ECMO patients.
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Bertini P, Guarracino F. Pro: Pulsatile Flow During Cardiopulmonary Bypass. J Cardiothorac Vasc Anesth 2023; 37:2370-2373. [PMID: 37258366 DOI: 10.1053/j.jvca.2023.04.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 04/11/2023] [Accepted: 04/25/2023] [Indexed: 06/02/2023]
Affiliation(s)
- Pietro Bertini
- Department of Anesthesia and Critical Care Medicine, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy.
| | - Fabio Guarracino
- Department of Anesthesia and Critical Care Medicine, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
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Li ZQ, Zhang W, Guo Z, Du XW, Wang W. Risk factors of gastrointestinal bleeding after cardiopulmonary bypass in children: a retrospective study. Front Cardiovasc Med 2023; 10:1224872. [PMID: 37795489 PMCID: PMC10545956 DOI: 10.3389/fcvm.2023.1224872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 09/08/2023] [Indexed: 10/06/2023] Open
Abstract
Background During cardiac surgery that involved cardiopulmonary bypass (CPB) procedure, gastrointestinal (GI) system was known to be vulnerable to complications such as GI bleeding. Our study aimed to determine the incidence and risk factors associated with GI bleeding in children who received CPB as part of cardiac surgery. Methods This retrospective study enrolled patients aged <18 years who underwent cardiac surgery with CPB from 2013 to 2019 at Shanghai Children's Medical Center. The primary outcome was the incidence of postoperative GI bleeding in children, and the associated risk factors with postoperative GI bleeding episodes were evaluated. Results A total of 21,893 children who underwent cardiac surgery with CPB from 2013 to 2019 were included in this study. For age distribution, 636 (2.9%) were neonates, 10,984 (50.2%) were infants, and 10,273 (46.9%) were children. Among the 410 (1.9%) patients with GI bleeding, 345 (84.2%) survived to hospital discharge. Incidence of GI bleeding in neonates, infants and children were 22.6% (144/636), 2.0% (217/10,984) and 0.5% (49/10,273), respectively. The neonates (22.6%) group was associated with highest risk of GI bleeding. Patients with GI bleeding showed longer length of hospital stays (25.8 ± 15.9 vs. 12.5 ± 8.9, P < 0.001) and higher mortality (15.9% vs. 1.8%, P < 0.001). Multivariate logistic regression analysis showed that age, weight, complicated surgery, operation time, use of extracorporeal membrane oxygenation (ECMO), low cardiac output syndrome (LCOS), hepatic injury, artery lactate level, and postoperative platelet counts were significantly associated with increased risk of GI bleeding in children with congenital heart disease (CHD) pediatric patients that underwent CPB procedure during cardiac surgery. Conclusion The study results suggest that young age, low weight, long operation time, complicated surgery, use of ECMO, LCOS, hepatic injury, high arterial lactate level, and low postoperative platelet counts are independently associated with GI bleeding after CPB in children.
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Affiliation(s)
| | | | | | | | - Wei Wang
- Department of Cardiothoracic Surgery, Shanghai Children’s Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
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Jacquet-Lagrèze M, Magnin M, Allaouchiche B, Abrard S. Is handheld video microscopy really the future of microcirculation monitoring? Crit Care 2023; 27:352. [PMID: 37700327 PMCID: PMC10498643 DOI: 10.1186/s13054-023-04642-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 09/08/2023] [Indexed: 09/14/2023] Open
Affiliation(s)
- Matthias Jacquet-Lagrèze
- Service d'Anesthésie-Réanimation, Hôpital Louis Pradel, Hospices Civils de Lyon, 59, Boulevard Pinel, 69677, Bron Cedex, France
- Faculté de Médecine Lyon Est, Université Claude Bernard Lyon 1, 8, Avenue Rockefeller, 69373, Lyon Cedex 08, France
- Laboratoire CarMeN, Inserm UMR 1060, Université Claude Bernard, Lyon 1, Lyon, France
| | - Mathieu Magnin
- Unité de Physiologie, Pharmacodynamie et Thérapeutique, VetAgro Sup, Université de Lyon, 1 Avenue Bourgelat, 69280, Marcy L'Etoile, France
- Pulmonary and Cardiovascular Aggression in Sepsis APCSe, UPSP 2021.A101, Université de Lyon, VetAgro Sup, Campus Vétérinaire de Lyon, 69280, Marcy L'Étoile, France
| | - Bernard Allaouchiche
- Faculté de Médecine Lyon Est, Université Claude Bernard Lyon 1, 8, Avenue Rockefeller, 69373, Lyon Cedex 08, France
- Pulmonary and Cardiovascular Aggression in Sepsis APCSe, UPSP 2021.A101, Université de Lyon, VetAgro Sup, Campus Vétérinaire de Lyon, 69280, Marcy L'Étoile, France
- Centre Hospitalier Lyon-Sud, Service de Réanimation, Hospices Civils de Lyon, 69310, Pierre-Bénite, France
| | - Stanislas Abrard
- Faculté de Médecine Lyon Est, Université Claude Bernard Lyon 1, 8, Avenue Rockefeller, 69373, Lyon Cedex 08, France.
- Service d'Anesthésie-Réanimation, Hospices Civils de Lyon, Hôpital Edouard Herriot, 5 Pl d'Arsonval, 69437, Lyon, France.
- Institut MitoVasc, INSERM 1083 ‑ CNRS 6015, Université d'Angers, 3 Rue Roger Amsler, 49100, Angers, France.
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Zieger B, Schneider D, Brixius SJ, Scherer C, Buchwald A, Trummer G, Czerny M, Beyersdorf F, Busch HJ, Benk C, Pooth JS. Development of an in-vitro model for extracorporeal blood pumps to study the effects of artificial pulsatility on human blood. Front Med (Lausanne) 2023; 10:1237002. [PMID: 37711739 PMCID: PMC10497958 DOI: 10.3389/fmed.2023.1237002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 08/10/2023] [Indexed: 09/16/2023] Open
Abstract
Introduction The application of extracorporeal circulation (ECC) systems is known to be associated with several implications regarding hemolysis, inflammation, and coagulation. In the last years, systems with pulsatile blood flow are increasingly used with the intention to improve hemodynamics in reperfusion. However, their implications on the aforementioned aspects remain largely unknown. To investigate the effects of pulsatility, this ex-vivo study was initiated. Methods Test circuits (primed with human whole blood) were set up in accordance with the recommendations of international standards for in-vitro evaluation of new components and systems of ECC. Diagonal pumps were either set up with non-pulsatile (n = 5, NPG) or pulsatile (n = 5, PG) pump settings and evaluated for 6 h. All analyses were conducted with human whole blood. Blood samples were repeatedly drawn from the test circuits and analyzed regarding free hemoglobin, interleukin 8 (IL-8), platelet aggregation and acquired von Willebrand syndrome (AVWS). Results After 1 h of circulation, a significant coagulation impairment (impaired platelet function and AVWS) was observed in both groups. After 6 h of circulation, increased IL-8 concentrations were measured in both groups (NPG: 0.05 ± 0.03 pg./mL, PG: 0.03 ± 0.01 pg./mL, p = 0.48). Pulsatile pump flow resulted in significantly increased hemolysis after 6 h of circulation (NPG: 37.3 ± 12.4 mg/100 L; PG: 59.6 ± 14.5 mg/100 L; p < 0.05). Conclusion Our results indicate that the coagulative impairment takes place in the early phase of ECC. Pulsatility did not affect the occurrence of AVWS ex-vivo. Prolonged durations of pulsatile pump flow led to increased hemolysis and therefore, its prolonged use should be employed cautiously in clinical practice with appropriate monitoring.
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Affiliation(s)
- Barbara Zieger
- Department of Pediatrics and Adolescent Medicine, University Medical Centre Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Denise Schneider
- Department of Cardiovascular Surgery, University Medical Centre Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Sam Joé Brixius
- Department of Cardiovascular Surgery, University Medical Centre Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Christian Scherer
- Department of Cardiovascular Surgery, University Medical Centre Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Armin Buchwald
- Institute for Clinical Chemistry and Laboratory Medicine, University Medical Centre Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Georg Trummer
- Department of Cardiovascular Surgery, University Medical Centre Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Martin Czerny
- Department of Cardiovascular Surgery, University Medical Centre Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Friedhelm Beyersdorf
- Department of Cardiovascular Surgery, University Medical Centre Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Hans-Jörg Busch
- Department of Emergency Medicine, University Medical Centre Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Christoph Benk
- Department of Cardiovascular Surgery, University Medical Centre Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Jan-Steffen Pooth
- Department of Emergency Medicine, University Medical Centre Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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Shou BL, Wilcox C, Florissi I, Kalra A, Caturegli G, Zhang LQ, Bush E, Kim B, Keller SP, Whitman GJR, Cho SM. Early Low Pulse Pressure in VA-ECMO Is Associated with Acute Brain Injury. Neurocrit Care 2023; 38:612-621. [PMID: 36167950 PMCID: PMC10040467 DOI: 10.1007/s12028-022-01607-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 09/06/2022] [Indexed: 10/14/2022]
Abstract
BACKGROUND Pulse pressure is a dynamic marker of cardiovascular function and is often impaired in patients on venoarterial extracorporeal membrane oxygenation (VA-ECMO). Pulsatile blood flow also serves as a regulator of vascular endothelium, and continuous-flow mechanical circulatory support can lead to endothelial dysfunction. We explored the impact of early low pulse pressure on occurrence of acute brain injury (ABI) in VA-ECMO. METHODS We conducted a retrospective analysis of adults with VA-ECMO at a tertiary care center between July 2016 and January 2021. Patients underwent standardized multimodal neuromonitoring throughout ECMO support. ABI included intracranial hemorrhage, ischemic stroke, hypoxic ischemic brain injury, cerebral edema, seizure, and brain death. Blood pressures were recorded every 15 min. Low pulse pressure was defined as a median pulse pressure < 20 mm Hg in the first 12 h of ECMO. Multivariable logistic regression was performed to investigate the association between pulse pressure and ABI. RESULTS We analyzed 5138 blood pressure measurements from 123 (median age 63; 63% male) VA-ECMO patients (54% peripheral; 46% central cannulation), of whom 41 (33%) experienced ABI. Individual ABIs were as follows: ischemic stroke (n = 18, 15%), hypoxic ischemic brain injury (n = 14, 11%), seizure (n = 8, 7%), intracranial hemorrhage (n = 7, 6%), cerebral edema (n = 7, 6%), and brain death (n = 2, 2%). Fifty-eight (47%) patients had low pulse pressure. In a multivariable model adjusting for preselected covariates, including cannulation strategy (central vs. peripheral), lactate on ECMO day 1, and left ventricle venting strategy, low pulse pressure was independently associated with ABI (adjusted odds ratio 2.57, 95% confidence interval 1.05-6.24). In a model with the same covariates, every 10-mm Hg decrease in pulse pressure was associated with 31% increased odds of ABI (95% confidence interval 1.01-1.68). In a sensitivity analysis model adjusting for systolic pressure, pulse pressure remained significantly associated with ABI. CONCLUSIONS Early low pulse pressure (< 20 mm Hg) was associated with ABI in VA-ECMO patients. Low pulse pressure may serve as a marker of ABI risk, which necessitates close neuromonitoring for early detection.
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Affiliation(s)
- Benjamin L Shou
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins Hospital, 1800 Orleans St, Zayed 7107, Baltimore, MD, 21287, USA.
| | - Christopher Wilcox
- Division of Neurosciences Critical Care, Department of Neurology, Neurosurgery, Anesthesiology, Critical Care Medicine, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Isabella Florissi
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins Hospital, 1800 Orleans St, Zayed 7107, Baltimore, MD, 21287, USA
| | - Andrew Kalra
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins Hospital, 1800 Orleans St, Zayed 7107, Baltimore, MD, 21287, USA
| | - Giorgio Caturegli
- Division of Neurosciences Critical Care, Department of Neurology, Neurosurgery, Anesthesiology, Critical Care Medicine, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Lucy Q Zhang
- Division of Neurosciences Critical Care, Department of Neurology, Neurosurgery, Anesthesiology, Critical Care Medicine, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Errol Bush
- Division of General Thoracic Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Bo Kim
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Steven P Keller
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Glenn J R Whitman
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins Hospital, 1800 Orleans St, Zayed 7107, Baltimore, MD, 21287, USA
| | - Sung-Min Cho
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins Hospital, 1800 Orleans St, Zayed 7107, Baltimore, MD, 21287, USA
- Division of Neurosciences Critical Care, Department of Neurology, Neurosurgery, Anesthesiology, Critical Care Medicine, Johns Hopkins Hospital, Baltimore, MD, USA
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13
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Yang L, Mo L, Li F, Zhu F, Bai Y. Application of ultrasound microbubble contrast to evaluate the effect of sitaxentan on renal microvascular perfusion in beagles undergoing cardiopulmonary bypass. Clin Hemorheol Microcirc 2023; 85:115-121. [PMID: 37599525 DOI: 10.3233/ch-221600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/22/2023]
Abstract
BACKGROUND & OBJECTIVE We aimed to evaluate the effect of sitaxentan on renal microvascular perfusion via application of ultrasound microbubble contrast. METHODS Male beagles were randomly divided into: Sham, cardiopulmonary bypass (CPB) and sitaxentan-infused (Sit) groups (n = 6). The ascending slope rate (ASR), area under the curve (AUC), derived peak intensity, and time to peak (TTP) were obtained via ultrasound microbubble contrast before CPB (T1), after 1 h CPB (T2), at end of CPB (T3), and 2 h after CPB (T4). RESULTS Compared with the Sham group, the CPB group had lower ASR of the renal cortex and medulla at T2 - 4, higher AUC and TTP at T3 - 4, and lower derived peak intensity at T4. The ASR at T2 - 4 in the Sit group was lower, TTP was higher at T2 - 4, and AUC was higher at T3 - 4 (P < 0.05). Compared with the CPB group, the Sit group had higher ASR of the renal cortex and medulla at T3 - 4 and AUC and TTP at T3 - 4 (P < 0.05). Compared with that at T1, the ASR of the renal cortex and medulla at T2 - 4 in the CPB group was lower, and AUC and TTP were higher at T3 - 4. The ASR of the renal cortex and medulla at T2 - 4 in the Sit group was lower, TTP was higher at T2 - 4, and AUC was higher at T4 (P < 0.05). CONCLUSIONS Ultrasound microbubble contrast could be effectively used to evaluate renal microvascular perfusion peri-CPB in beagles, which was prone to decrease and could be improved via pretreatment with sitaxentan.
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Affiliation(s)
- Lu Yang
- Department of Anesthesiology, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Liqun Mo
- Department of Anesthesiology, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Fuyu Li
- Department of Anesthesiology, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Fuzu Zhu
- Department of Anesthesiology, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Yiping Bai
- Department of Anesthesiology, Affiliated Hospital of Southwest Medical University, Luzhou, China
- Anesthesiology and Critical Care Medicine Key Laboratory of Luzhou, Luzhou, China
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14
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Affiliation(s)
- Mark A Chaney
- Department of Anesthesia and Critical Care, University of Chicago, Chicago, Illinois
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15
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Hemodynamic Effect of Pulsatile on Blood Flow Distribution with VA ECMO: A Numerical Study. Bioengineering (Basel) 2022; 9:bioengineering9100487. [PMID: 36290455 PMCID: PMC9598990 DOI: 10.3390/bioengineering9100487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 08/20/2022] [Accepted: 09/09/2022] [Indexed: 11/20/2022] Open
Abstract
The pulsatile properties of arterial flow and pressure have been thought to be important. Nevertheless, a gap still exists in the hemodynamic effect of pulsatile flow in improving blood flow distribution of veno-arterial extracorporeal membrane oxygenation (VA ECMO) supported by the circulatory system. The finite-element models, consisting of the aorta, VA ECMO, and intra-aortic balloon pump (IABP) are proposed for fluid-structure interaction calculation of the mechanical response. Group A is cardiogenic shock with 1.5 L/min of cardiac output. Group B is cardiogenic shock with VA ECMO. Group C is added to IABP based on Group B. The sum of the blood flow of cardiac output and VA ECMO remains constant at 4.5 L/min in Group B and Group C. With the recovery of the left ventricular, the flow of VA ECMO declines, and the effective blood of IABP increases. IABP plays the function of balancing blood flow between left arteria femoralis and right arteria femoralis compared with VA ECMO only. The difference of the equivalent energy pressure (dEEP) is crossed at 2.0 L/min to 1.5 L/min of VA ECMO. PPI’ (the revised pulse pressure index) with IABP is twice as much as without IABP. The intersection with two opposing blood generates the region of the aortic arch for the VA ECMO (Group B). In contrast to the VA ECMO, the blood intersection appears from the descending aorta to the renal artery with VA ECMO and IABP. The maximum time-averaged wall shear stress (TAWSS) of the renal artery is a significant difference with or not IABP (VA ECMO: 2.02 vs. 1.98 vs. 2.37 vs. 2.61 vs. 2.86 Pa; VA ECMO and IABP: 8.02 vs. 6.99 vs. 6.62 vs. 6.30 vs. 5.83 Pa). In conclusion, with the recovery of the left ventricle, the flow of VA ECMO declines and the effective blood of IABP increases. The difference between the equivalent energy pressure (EEP) and the surplus hemodynamic energy (SHE) indicates the loss of pulsation from the left ventricular to VA ECMO. 2.0 L/min to 1.5 L/min of VA ECMO showing a similar hemodynamic energy loss with the weak influence of IABP.
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16
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Arterial Pulsatility Augments Microcirculatory Perfusion and Maintains the Endothelial Integrity during Extracorporeal Membrane Oxygenation via hsa_circ_0007367 Upregulation in a Canine Model with Cardiac Arrest. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2022; 2022:1630918. [PMID: 35222790 PMCID: PMC8881135 DOI: 10.1155/2022/1630918] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 01/29/2022] [Indexed: 12/12/2022]
Abstract
Background The impairment of microcirculation is associated with the unfavorable outcome for extracorporeal membrane oxygenation (ECMO) patients. Studies revealed that pulsatile modification improves hemodynamics and attenuates inflammation during ECMO support. However, whether flow pattern impacts microcirculation and endothelial integrity is rarely documented. The objective of this work was to explore how pulsatility affects microcirculation during ECMO. Methods Canine animal models with cardiac arrest were supported by ECMO, with the i-Cor system used to generate nonpulsatile or pulsatile flow. The sublingual microcirculation parameters were examined using the CytoCam microscope system. The expression of hsa_circ_0007367, a circular RNA, was measured during ECMO support. In vitro validation was performed in pulmonary vascular endothelial cells (PMVECs) exposed to pulsatile or nonpulsatile flow, and the expressions of hsa_circ_0007367, endothelial tight junction markers, endothelial adhesive molecules, endothelial nitric oxide synthases (eNOS), and NF-κB signaling activity were analyzed. Results The pulsatile modification of ECMO enhanced microcirculatory perfusion, attenuated pulmonary inflammation, and stabilized endothelial integrity in animal models; meanwhile, the expression of hsa_circ_0007367 was significantly upregulated both in animals and PMVECs exposed to pulsatile flow. In particular, upregulation of hsa_circ_0007367 stabilized the expressions of endothelial tight junction markers zonula occludens- (ZO-) 1 and occludin, followed by modulating the endothelial nitric oxide synthases (eNOS) activity and inhibiting the NF-κB signaling pathway. Conclusion The modification of pulsatility contributes to microcirculatory perfusion and endothelial integrity during ECMO. The expression of hsa_circ_0007367 plays a pivotal role in this protective mechanism.
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17
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Niezen CK, Massari D, Vos JJ, Scheeren TWL. The use of a vascular occlusion test combined with near-infrared spectroscopy in perioperative care: a systematic review. J Clin Monit Comput 2022; 36:933-946. [PMID: 34982349 DOI: 10.1007/s10877-021-00779-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 11/12/2021] [Indexed: 11/30/2022]
Abstract
In the perioperative phase oxygen delivery and consumption can be influenced by different factors, i.e. type of surgery, anesthetic and cardiovascular drugs, or fluids. By combining near-infrared spectroscopy (NIRS) monitoring of regional tissue oxygen saturation (StO2) with an ischemic provocation test, the vascular occlusion test (VOT), local tissue oxygen consumption and vascular reactivity at the microcirculatory level can be assessed. This systematic review aims to give an overview of the clinical information that VOT-derived NIRS values can provide in the perioperative period. After performing a systematic literature search, we included 29 articles. It was not possible to perform a meta-analysis because of the lack of comparable data and the observational nature of the majority of the included articles. We have clustered the found articles in two groups: non-cardiac surgery and cardiac surgery. We found that VOT-derived NIRS values show a wide variability and are influenced by the effects of anesthetics, cardiovascular drugs, fluids, and by the type of surgery. Additionally, deviations in VOT-derived NIRS values are also associated with adverse patients' outcomes, such as postoperative complications, prolonged mechanical ventilation and prolonged hospital length of stay. However, given the variability in VOT-derived NIRS values, clinical applicability remains elusive. Future clinical interventional trials might provide additional insight into the potential of VOT associated with NIRS to optimize perioperative care by targeting specific interventions to optimize the function of the microvasculature.
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Affiliation(s)
- C K Niezen
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, PO Box 30 001, 9700 RB, Groningen, The Netherlands.
| | - D Massari
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, PO Box 30 001, 9700 RB, Groningen, The Netherlands
| | - J J Vos
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, PO Box 30 001, 9700 RB, Groningen, The Netherlands
| | - T W L Scheeren
- Department of Anesthesiology, University Medical Center Groningen, University of Groningen, PO Box 30 001, 9700 RB, Groningen, The Netherlands
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18
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Augoustides JG. Protecting the Central Nervous System During Cardiac Surgery. Perioper Med (Lond) 2022. [DOI: 10.1016/b978-0-323-56724-4.00022-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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19
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Kvernebo AK, Miyamoto T, Drolsum L, Moe MC, Måsøy SE, Sunagawa G, Dessoffy R, Karimov JH, Fukamachi K, Kvernebo K. Ocular surface microcirculation is better preserved with pulsatile versus continuous flow during cardiopulmonary bypass-An experimental pilot. Artif Organs 2021; 46:786-793. [PMID: 34866193 DOI: 10.1111/aor.14137] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 08/29/2021] [Accepted: 11/29/2021] [Indexed: 01/08/2023]
Abstract
BACKGROUND Non-pulsatile cardiopulmonary bypass (CPB) may induce microvascular dysregulation. In piglets, we compared ocular surface microcirculation during pulsatile versus continuous flow (CF) bypass. METHODS Ocular surface microcirculation in small tissue volumes (~0.1 mm3 ) at limbus (high metabolic rate) and bulbar conjunctiva (low metabolic rate) was examined in a porcine model using computer assisted video microscopy and diffuse reflectance spectroscopy, before and after 3 and 6 h of pulsatile (n = 5 piglets) or CF (n = 3 piglets) CPB. Functional capillary density, capillary flow velocity and microvascular oxygen saturation were quantified. RESULTS At limbus, velocities improved with pulsatility (p < 0.01) and deteriorated with CF (p < 0.01). In bulbar conjunctiva, velocities were severely reduced with CF (p < 0.01), accompanied by an increase in capillary density (p < 0.01). Microvascular oxygen saturation decreased in both groups. CONCLUSION Ocular surface capillary densities and flow patterns are better preserved with pulsatile versus CF during 6 h of CPB in sleeping piglets.
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Affiliation(s)
- Anne Kari Kvernebo
- Department of Ophthalmology, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway.,The Circulation Laboratory, Department of Cardiothoracic Surgery, Oslo University Hospital, Oslo, Norway
| | - Takuma Miyamoto
- Department of Biomedical Engineering, Cleveland Clinic Lerner Research Institute, Cleveland, Ohio, USA
| | - Liv Drolsum
- Department of Ophthalmology, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Morten Carstens Moe
- Department of Ophthalmology, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | | | - Gengo Sunagawa
- Department of Biomedical Engineering, Cleveland Clinic Lerner Research Institute, Cleveland, Ohio, USA
| | - Raymond Dessoffy
- Department of Biomedical Engineering, Cleveland Clinic Lerner Research Institute, Cleveland, Ohio, USA
| | - Jamshid H Karimov
- Department of Biomedical Engineering, Cleveland Clinic Lerner Research Institute, Cleveland, Ohio, USA
| | - Kiyotaka Fukamachi
- Department of Biomedical Engineering, Cleveland Clinic Lerner Research Institute, Cleveland, Ohio, USA
| | - Knut Kvernebo
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway.,The Circulation Laboratory, Department of Cardiothoracic Surgery, Oslo University Hospital, Oslo, Norway.,ODI Medical AS, Oslo, Norway
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20
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Miyamoto T, Sunagawa G, Dessoffy R, Karimov JH, Grady P, Naber JP, Vincent D, Sale SM, Kvernebo K, Tran VNP, Moazami N, Fukamachi K. Hemodynamic evaluation of a new pulsatile blood pump during low flow cardiopulmonary bypass support. Artif Organs 2021; 46:643-652. [PMID: 34780074 DOI: 10.1111/aor.14119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 10/05/2021] [Accepted: 11/11/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND The VentriFlo® True Pulse Pump (VentriFlo, Inc, Pelham, NH, USA) is a new pulsatile blood pump intended for use during short-term circulatory support. The purpose of this study was to evaluate the feasibility of the VentriFlo and compare it to a conventional centrifugal pump (ROTAFLOW, Getinge, Gothenberg, Sweden) in acute pig experiments. METHODS Pigs (40-45 kg) were supported by cardiopulmonary bypass (CPB) with the VentriFlo (n = 9) or ROTAFLOW (n = 5) for 6 h. Both VentriFlo and ROTAFLOW circuits utilized standard CPB components. We evaluated hemodynamics, blood chemistry, gas analysis, plasma hemoglobin, and microcirculation at the groin skin with computer-assisted video microscopy (Optilia, Sollentuna, Sweden). RESULTS Pigs were successfully supported by CPB for 6 h without any pump-related complications in either group. The VentriFlo delivered an average stroke volume of 29.2 ± 4.8 ml. VentriFlo delivered significantly higher pulse pressure (29.1 ± 7.2 mm Hg vs. 4.4 ± 7.0 mm Hg, p < 0.01) as measured in the carotid artery, with mean aortic pressure and pump flow comparable with those in ROTAFLOW. In blood gas analysis, arterial pH was significantly lower after five hours support in the VentriFlo group (7.30 ± 0.07 vs. 7.43 ± 0.03, p = 0.001). There was no significant difference in plasma hemoglobin level in both groups after six hours of CPB support. In microcirculatory assessment, VentriFlo tended to keep normal capillary flow, but it was not statistically significant. CONCLUSIONS VentriFlo-supported pigs showed comparable hemodynamic parameters with significantly higher pulse pressure compared to ROTAFLOW without hemolysis.
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Affiliation(s)
- Takuma Miyamoto
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Gengo Sunagawa
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Raymond Dessoffy
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Jamshid H Karimov
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Patrick Grady
- Department of Thoracic and Cardiovascular Surgery, Miller Family Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | | | | | - Shiva M Sale
- Department of Cardiothoracic Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Knut Kvernebo
- Department of Cardio-thoracic Surgery, Oslo University Hospital, Ullevaal, Oslo, Norway
| | - Van N P Tran
- Department of Cardio-thoracic Surgery, Oslo University Hospital, Ullevaal, Oslo, Norway
| | - Nader Moazami
- Department of Cardiothoracic surgery, New York University's Langone Health, New York, New York, USA
| | - Kiyotaka Fukamachi
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
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21
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Chalkias A, Papagiannakis N, Mavrovounis G, Kolonia K, Mermiri M, Pantazopoulos I, Laou E, Arnaoutoglou E. Sublingual microcirculatory alterations during the immediate and early postoperative period: A systematic review and meta-analysis. Clin Hemorheol Microcirc 2021; 80:253-265. [PMID: 34719484 DOI: 10.3233/ch-211214] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND The incidence of postoperative microcirculatory flow alterations and their effect on outcome have not been studied extensively. OBJECTIVE This systematic review and meta-analysis was designed to investigate the presence of sublingual microcirculatory flow alterations during the immediate and early postoperative period and their correlation with complications and survival. METHODS A systematic search of PubMed, Scopus, Embase, PubMed Central, and Google Scholar was conducted for relevant articles from January 2000 to March 2021. Eligibility criteria were randomized controlled and non-randomized trials. Case reports, case series, review papers, animal studies and non-English literature were excluded. The primary outcome was the assessment of sublingual microcirculatory alterations during the immediate and early postoperative period in adult patients undergoing surgery. Risk of bias was assessed with the Ottawa-Newcastle scale. Standard meta-analysis methods (random-effects models) were used to assess the difference in microcirculation variables. RESULTS Thirteen studies were included. No statistically significant difference was found between preoperative and postoperative total vessel density (p = 0.084; Standardized Mean Difference (SMD): -0.029; 95%CI: -0.31 to 0.26; I2 = 22.55%). Perfused vessel density significantly decreased postoperatively (p = 0.035; SMD: 0.344; 95%CI: 0.02 to 0.66; I2 = 65.66%), while perfused boundary region significantly increased postoperatively (p = 0.031; SMD: -0.415; 95%CI: -0.79 to -0.03; I2 = 37.21%). Microvascular flow index significantly decreased postoperatively (p = 0.028; SMD: 0.587; 95%CI: 0.06 to 1.11; I2 = 86.09%), while no statistically significant difference was found between preoperative and postoperative proportion of perfused vessels (p = 0.089; SMD: 0.53; 95%CI: -0.08 to 1.14; I2 = 70.71%). The results of the non-cardiac surgery post-hoc analysis were comparable except that no statistically significant difference in perfused vessel density was found (p = 0.69; SMD: 0.07; 95%CI: -0.26 to 0.39; I2 = 0%). LIMITATIONS The included studies investigate heterogeneous groups of surgical patients. There were no randomized controlled trials. CONCLUSIONS Significant sublingual microcirculatory flow alterations are present during the immediate and early postoperative period. Further research is required to estimate the correlation of sublingual microcirculatory flow impairment with complications and survival.
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Affiliation(s)
- Athanasios Chalkias
- Department of Anesthesiology, University ofThessaly, Faculty of Medicine, Larisa, Greece.,Outcomes Research Consortium, Cleveland, OH, USA
| | - Nikolaos Papagiannakis
- First Department of Neurology, National and Kapodistrian University of Athens, Medical School, Athens, Greece
| | - Georgios Mavrovounis
- Department of Emergency Medicine, University of Thessaly, Faculty of Medicine, Larisa, Greece
| | - Konstantina Kolonia
- Department of Anesthesiology, University ofThessaly, Faculty of Medicine, Larisa, Greece
| | - Maria Mermiri
- Department of Anesthesiology, University ofThessaly, Faculty of Medicine, Larisa, Greece
| | - Ioannis Pantazopoulos
- Department of Emergency Medicine, University of Thessaly, Faculty of Medicine, Larisa, Greece
| | - Eleni Laou
- Department of Anesthesiology, University ofThessaly, Faculty of Medicine, Larisa, Greece
| | - Eleni Arnaoutoglou
- Department of Anesthesiology, University ofThessaly, Faculty of Medicine, Larisa, Greece
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22
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Arterial blood flow waveform shapes – their original quantification and importance in chosen aspects of physiology and psychology: A review. Biocybern Biomed Eng 2021. [DOI: 10.1016/j.bbe.2021.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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23
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Microcirculatory Changes in Pediatric Patients During Congenital Heart Defect Corrective Surgery. J Cardiovasc Transl Res 2021; 14:1173-1185. [PMID: 33948868 DOI: 10.1007/s12265-021-10132-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Accepted: 04/26/2021] [Indexed: 10/21/2022]
Abstract
A prospective, observational single-center study was carried out. Pediatric patients undergoing congenital heart defect surgery were evaluated before, during, and after surgery. At each time point, sublingual microcirculation and clinical parameters were assessed, along with analytical variables. Twenty-four patients were included. All microcirculatory parameters worsened during cardiopulmonary bypass and returned to baseline values after surgery (p ≤ 0.001). In the intraoperative evaluation, body temperature correlated with perfused small vessel density (p = 0.014), proportion of perfused small vessels (p < 0.001), small vessel microvascular flow index (p = 0.003), and small vessel heterogeneity index (p < 0.002). Patients with cyanotic disease exhibited higher small vessel density (p < 0.008) and higher density of perfused small vessels (p < 0.022) at baseline, and a lower microvascular flow index (p = 0.022) and higher heterogeneity (p = 0.026) in the intraoperative phase. Children with congenital heart disease exhibited decreased vascular density and microvascular blood flow and increased heterogeneity during cardiopulmonary bypass. All these parameters returned to baseline values after surgery.
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24
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Mizunoya K, Yagi Y, Morimoto Y, Hirano S. Altered microvascular reactivity assessed by near-infrared spectroscopy after hepato-pancreato-biliary surgery. J Clin Monit Comput 2021; 36:703-712. [PMID: 33829357 DOI: 10.1007/s10877-021-00697-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 03/23/2021] [Indexed: 11/25/2022]
Abstract
Little is known about microcirculatory dysfunction following abdominal surgeries. This study aimed to evaluate changes in microvascular reactivity (MVR) before and after major abdominal surgery, assessed by near-infrared spectroscopy in conjunction with a vascular occlusion test. This prospective observational study included 50 adult patients who underwent hepato-pancreato-biliary surgery lasting ≥ 8 h. MVR was assessed by tissue oxygen saturation (StO2) changes in the plantar region of the foot during 3 min of vascular occlusion and subsequent release under general anesthesia before and after surgery. The primary outcome was alteration in the recovery slope of StO2 (RecStO2) and recovery time (tM) between the preoperative and postoperative values. Postoperative short-term outcome was represented by the Post-operative Morbidity Survey (POMS) score on the morning of postoperative day 2. After surgery, RecStO2 was reduced (0.74% [0.58-1.06]/s vs. 0.89% [0.62-1.41]/s, P = 0.001), and tM was longer (57.0 [42.9-71.0] s vs. 41.3 [35.5-56.5] s, P < 0.001), compared to the preoperative values. Macrohemodynamic variables such as cardiac index, arterial pressure, and stroke volume during postoperative measurement did not differ with or without relative MVR decline. In addition, the POMS score was not associated with postoperative alterations in microcirculatory responsiveness. MVR in the plantar region of the foot was reduced after major hepato-pancreato-biliary surgery regardless of macrocirculatory adequacy. Impaired MVR was not associated with short-term outcomes as long as macrocirculatory indices were well maintained. The impact of relative microcirculatory changes, especially combined with inadequate macrocirculation, on postoperative complications remains to be elucidated.Clinical Trial Registrations UMIN-CTR trial ID: 000033461.
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Affiliation(s)
- Kazuyuki Mizunoya
- Department of Anesthesiology, Hokkaido University Hospital, Kita-ku, Sapporo, N14, W5060-8648, Japan.
| | - Yasunori Yagi
- Department of Anesthesiology, Hokkaido University Hospital, Kita-ku, Sapporo, N14, W5060-8648, Japan
| | - Yuji Morimoto
- Department of Anesthesiology, Hokkaido University Hospital, Kita-ku, Sapporo, N14, W5060-8648, Japan
| | - Satoshi Hirano
- Department of Gastroenterological Surgery II, Hokkaido University Hospital, Sapporo, Japan
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Drochon A, Fouquet O, Baufreton C. Extracorporeal circulation during on-pump cardiac surgery: An evaluation of the energy equivalent pressure index based on waveforms decomposition in harmonics. Artif Organs 2021; 45:861-865. [PMID: 33529368 DOI: 10.1111/aor.13928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 01/14/2021] [Accepted: 01/26/2021] [Indexed: 11/29/2022]
Abstract
The use of pulsatile perfusion instead of nonpulsatile perfusion during cardiopulmonary bypass continues to be a source of debate. The disagreements among the conclusions of the published studies may be due to different factors: differences in the type of patients included in the studies, differences in the protocol of the studies, and difficulty to quantify the pulsatility of the flow. In the present paper, we propose a quantitative evaluation of Shepard's energy equivalent pressure index, based on the harmonic decomposition of the physiological aortic pressure and flow rate signal. It is thus demonstrated that the surplus energy provided by pulsatile flow remains moderate (of order 10 mm Hg), but that it can be improved by changing the relative shapes of the pressure and flow waves.
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Affiliation(s)
- Agnès Drochon
- Arts et Metiers Institute of Technology, Bordeaux INP, INRAE, I2M Bordeaux, CNRS, University of Bordeaux, Talence, France
| | - Olivier Fouquet
- Department of Cardio -Thoracic Surgery, University-Hospital Angers, Angers, France
| | - Christophe Baufreton
- Department of Cardio -Thoracic Surgery, University-Hospital Angers, Angers, France
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26
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Nguyen KT, Donoghue L, Giridharan GA, Naber JP, Vincent D, Fukamachi K, Kotru A, Sethu P. Acute Response of Human Aortic Endothelial Cells to Loss of Pulsatility as Seen during Cardiopulmonary Bypass. Cells Tissues Organs 2021; 211:324-334. [PMID: 33631743 DOI: 10.1159/000512558] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 10/25/2020] [Indexed: 11/19/2022] Open
Abstract
Cardiopulmonary bypass (CPB) results in short-term (3-5 h) exposure to flow with diminished pulsatility often referred to as "continuous flow". It is unclear if short-term exposure to continuous flow influences endothelial function, particularly, changes in levels of pro-inflammatory and pro-angiogenic cytokines. In this study, we used the endothelial cell culture model (ECCM) to evaluate if short-term (≤5 h) reduction in pulsatility alters levels of pro-inflammatory/pro-angiogenic cytokine levels. Human aortic endothelial cells (HAECs) cultured within the ECCM provide a simple model to evaluate endothelial cell function in the absence of confounding factors. HAECs were maintained under normal pulsatile flow for 24 h and then subjected to continuous flow (diminished pulsatile pressure and flow) as observed during CPB for 5 h. The ECCM replicated pulsatility and flow morphologies associated with normal hemodynamic status and CPB as seen with clinically used roller pumps. Levels of angiopoietin-2 (ANG-2), vascular endothelial growth factor-A (VEGF-A), and hepatocyte growth factor were lower in the continuous flow group in comparison to the pulsatile flow group whereas the levels of endothelin-1 (ET-1), granulocyte colony stimulating factor, interleukin-8 (IL-8) and placental growth factor were higher in the continuous flow group in comparison to the pulsatile flow group. Immunolabelling of HAECs subjected to continuous flow showed a decrease in expression of ANG-2 and VEGF-A surface receptors, tyrosine protein kinase-2 and Fms-related receptor tyrosine kinase-1, respectively. Given that the 5 h exposure to continuous flow is insufficient for transcriptional regulation, it is likely that pro-inflammatory/pro-angiogenic signaling observed was due to signaling molecules stored in Weible-Palade bodies (ET-1, IL-8, ANG-2) and via HAEC binding/uptake of soluble factors in media. These results suggest that even short-term exposure to continuous flow can potentially activate pro-inflammatory/pro-angiogenic signaling in cultured HAECs and pulsatile flow may be a successful strategy in reducing the undesirable sequalae following continuous flow CPB.
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Affiliation(s)
- Khanh T Nguyen
- Division of Cardiovascular Disease, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
- Department of Biomedical Engineering, School of Engineering, University of Alabama at Birmingham, Birmingham, Alabama, USA
- Comprehensive Cardiovascular Center, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Leslie Donoghue
- Division of Cardiovascular Disease, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
- Department of Biomedical Engineering, School of Engineering, University of Alabama at Birmingham, Birmingham, Alabama, USA
- Comprehensive Cardiovascular Center, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Guruprasad A Giridharan
- Department of Bioengineering, J. B. Speed School of Engineering, University of Louisville, Louisville, Kentucky, USA
| | | | | | - Kiyotaka Fukamachi
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Arushi Kotru
- Division of Cardiovascular Disease, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
- Department of Biomedical Engineering, School of Engineering, University of Alabama at Birmingham, Birmingham, Alabama, USA
- Comprehensive Cardiovascular Center, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Palaniappan Sethu
- Division of Cardiovascular Disease, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA,
- Department of Biomedical Engineering, School of Engineering, University of Alabama at Birmingham, Birmingham, Alabama, USA,
- Comprehensive Cardiovascular Center, University of Alabama at Birmingham, Birmingham, Alabama, USA,
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27
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Rajaram A, Milej D, Suwalski M, Yip LCM, Guo LR, Chu MWA, Chui J, Diop M, Murkin JM, St. Lawrence K. Optical monitoring of cerebral perfusion and metabolism in adults during cardiac surgery with cardiopulmonary bypass. BIOMEDICAL OPTICS EXPRESS 2020; 11:5967-5981. [PMID: 33149999 PMCID: PMC7587277 DOI: 10.1364/boe.404101] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 09/03/2020] [Accepted: 09/03/2020] [Indexed: 05/23/2023]
Abstract
During cardiac surgery with cardiopulmonary bypass (CPB), adequate maintenance of cerebral blood flow (CBF) is vital in preventing postoperative neurological injury - i.e. stroke, delirium, cognitive impairment. Reductions in CBF large enough to impact cerebral energy metabolism can lead to tissue damage and subsequent brain injury. Current methods for neuromonitoring during surgery are limited. This study presents the clinical translation of a hybrid optical neuromonitor for continuous intraoperative monitoring of cerebral perfusion and metabolism in ten patients undergoing non-emergent cardiac surgery with non-pulsatile CPB. The optical system combines broadband near-infrared spectroscopy (B-NIRS) to measure changes in the oxidation state of cytochrome c oxidase (oxCCO) - a direct marker of cellular energy metabolism - and diffuse correlation spectroscopy (DCS) to provide an index of cerebral blood flow (CBFi). As the heart was arrested and the CPB-pump started, increases in CBFi (88.5 ± 125.7%) and significant decreases in oxCCO (-0.5 ± 0.2 µM) were observed; no changes were noted during transitions off CPB. Fifteen hypoperfusion events, defined as large and sustained reductions in CPB-pump flow rate, were identified across all patients and resulted in significant decreases in perfusion and metabolism when mean arterial pressure dropped to 30 mmHg or below. The maximum reduction in cerebral blood flow preceded the corresponding metabolic reduction by 18.2 ± 15.0 s. Optical neuromonitoring provides a safe and non-invasive approach for assessing intraoperative perfusion and metabolism and has potential in guiding patient management to prevent adverse clinical outcomes.
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Affiliation(s)
- Ajay Rajaram
- Imaging Program, Lawson Health Research Institute, 268 Grosvenor St., London, ON, N6A 4V2, Canada
- Department of Medical Biophysics, Western University, 1151 Richmond St., London, ON, N6A 3K7, Canada
| | - Daniel Milej
- Imaging Program, Lawson Health Research Institute, 268 Grosvenor St., London, ON, N6A 4V2, Canada
| | - Marianne Suwalski
- Imaging Program, Lawson Health Research Institute, 268 Grosvenor St., London, ON, N6A 4V2, Canada
- Department of Medical Biophysics, Western University, 1151 Richmond St., London, ON, N6A 3K7, Canada
| | - Lawrence C. M. Yip
- Imaging Program, Lawson Health Research Institute, 268 Grosvenor St., London, ON, N6A 4V2, Canada
- Department of Medical Biophysics, Western University, 1151 Richmond St., London, ON, N6A 3K7, Canada
| | - Linrui R. Guo
- Division of Cardiac Surgery, London Health Science Centre, 339 Windermere Rd, London, ON, N6A 5A5, Canada
| | - Michael W. A. Chu
- Division of Cardiac Surgery, London Health Science Centre, 339 Windermere Rd, London, ON, N6A 5A5, Canada
| | - Jason Chui
- Department of Anesthesiology and Perioperative Medicine, London Health Science Centre, 339 Windermere Rd, London, ON, N6A 5A5, Canada
| | - Mamadou Diop
- Imaging Program, Lawson Health Research Institute, 268 Grosvenor St., London, ON, N6A 4V2, Canada
- Department of Medical Biophysics, Western University, 1151 Richmond St., London, ON, N6A 3K7, Canada
| | - John M. Murkin
- Department of Anesthesiology and Perioperative Medicine, London Health Science Centre, 339 Windermere Rd, London, ON, N6A 5A5, Canada
| | - Keith St. Lawrence
- Imaging Program, Lawson Health Research Institute, 268 Grosvenor St., London, ON, N6A 4V2, Canada
- Department of Medical Biophysics, Western University, 1151 Richmond St., London, ON, N6A 3K7, Canada
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Flick M, Duranteau J, Scheeren TW, Saugel B. Monitoring of the Sublingual Microcirculation During Cardiac Surgery: Current Knowledge and Future Directions. J Cardiothorac Vasc Anesth 2020; 34:2754-2765. [DOI: 10.1053/j.jvca.2019.10.038] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Revised: 09/29/2019] [Accepted: 10/21/2019] [Indexed: 11/11/2022]
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29
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Primed Left Ventricle Heart Perfusion Creates Physiological Aortic Pressure in Porcine Hearts. ASAIO J 2020; 66:55-63. [PMID: 30893130 DOI: 10.1097/mat.0000000000000947] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
This article presents a primed left ventricle heart perfusion method to generate physiologic aortic pressure (AoP) and perform functional assessment. Isolated hearts of male Yorkshire pigs were used to study the hemodynamic behaviors of AoPs generated in the primed left ventricle heart perfusion (n = 6) and conventional (zero-loaded left ventricle) Langendorff perfusion (n = 6). The measurement results show that left ventricular pressure generated in the primed left ventricle heart perfusion is a determinant of physiologic AoP (i.e. systolic and diastolic pressures within physiologic range). The aortic pulse pressure (systolic pressure = 124.5 ± 1.7 mm Hg, diastolic pressure = 87.8 ± 0.9 mm Hg, aortic pulse pressure = 36.7 ± 2.6 mm Hg) from the primed left ventricle heart perfusion represents close match with the in vivo physiologic data. The volume in the left ventricle remains constant throughout the primed left ventricle heart perfusion, which allows us to perform isovolumetric left ventricular pressure measurement in ex vivo heart perfusion (EVHP). Left ventricular contractility measurements (maximum and minimum rates of left ventricular pressure change) were derived for cardiac assessment. In summary, the proposed primed left ventricle heart perfusion method is able to create physiologic AoP and enables left ventricular functional assessment in EVHP in porcine hearts.
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30
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Poredos P, Jezovnik MK, Radovancevic R, Gregoric ID. Endothelial Function in Patients With Continuous-Flow Left Ventricular Assist Devices. Angiology 2020; 72:9-15. [PMID: 32757767 DOI: 10.1177/0003319720946977] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
The endothelium plays a crucial role in maintaining cardiovascular homeostasis. Shear stress generated by flowing blood regulates the release of substances that provide adequate tissue perfusion. The extent of damage to endothelial cells depends on locally disturbed shear stress caused by the deteriorated flow. Patients with heart failure have reduced cardiac output, which results in reduced blood flow and negative shear stress. Reduced shear stress also affects microcirculation and reduces tissue perfusion. Consequently, the production of free oxygen radicals is increased and bioavailability of nitric oxide is additionally decreased. Therefore, endothelial dysfunction is involved in the progression of heart failure and cardiovascular events. Left ventricular assist devices (LVAD) are used for the treatment of patients with advanced heart failure. Older pulsatile flow LVADs were mostly substituted by continuous-flow LVADs (cf-LVADs). Despite the advantages of the cf-LVADs, the loss of pulsatility leads to different complications on the micro- and macrovascular levels. One of the pathogenetic mechanisms of cardiovascular complications with cf-LVADs may be endothelial dysfunction, which after the implantation of the device does not improve and may even deteriorate. In contrast, the pulsatile pattern of LVADs on blood flow could preserve endothelial function.
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Affiliation(s)
- Pavel Poredos
- Department of Advanced Cardiopulmonary Therapies and Transplantation, Center for Advanced Heart Failure, 12340The University of Texas Health Science Center at Houston, Houston, TX, USA.,Department of Vascular Disease, 37663University Medical Center, Ljubljana, Slovenia
| | - Mateja K Jezovnik
- Department of Advanced Cardiopulmonary Therapies and Transplantation, Center for Advanced Heart Failure, 12340The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Rajko Radovancevic
- Department of Advanced Cardiopulmonary Therapies and Transplantation, Center for Advanced Heart Failure, 12340The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Igor D Gregoric
- Department of Advanced Cardiopulmonary Therapies and Transplantation, Center for Advanced Heart Failure, 12340The University of Texas Health Science Center at Houston, Houston, TX, USA
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31
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Risk Factors for Delayed Neurocognitive Recovery According to Brain Biomarkers and Cerebral Blood Flow Velocity. ACTA ACUST UNITED AC 2020; 56:medicina56060288. [PMID: 32545416 PMCID: PMC7353900 DOI: 10.3390/medicina56060288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 06/09/2020] [Accepted: 06/09/2020] [Indexed: 11/16/2022]
Abstract
Background and Objectives: The aim of this study is to identify risk factors for the development of delayed neurocognitive recovery (dNCR). Methods: 140 patients underwent neurocognitive evaluations (Adenbrooke, MoCa, trial making, and CAM test) and middle cerebral artery (MCA) blood flow velocity (BFV) measurements, one day before cardiac surgery. BFV was re-evaluated after anesthesia induction, before the beginning, middle, end, and after cardiopulmonary bypass (CPB) and postsurgery. To measure glial fibrillary acidic protein (GFAP) and neurofilament heavy chain (Nf-H), blood samples were collected after anesthesia induction, 24 and 48 h after the surgery. Neurocognitive evaluation was repeated 7-10 days after surgery. According to the results, patients were divided into two groups: with dNCR (dNCR group) and without dNCR (non-dNCR group). Results: 101 patients completed participation in this research. GFAP increased in both the non-dNCR group (p < 0.01) and in the dNCR group (p < 0.01), but there was no difference between the groups (after 24 h, p 0.342; after 48 h, p 0.273). Nf-H increased in both groups (p < 0.01), but there was no difference between them (after 24 h, p = 0.240; after 48 h, p = 0.597). MCA BFV was significantly lower in the dNCR group during the bypass (37.13 cm/s SD 7.70 versus 43.40 cm/s SD 9.56; p = 0.001) and after surgery (40.54 cm/s SD 11.21 versus 47.6 cm/s SD 12.01; p = 0.003). Results of neurocognitive tests correlated with CO2 concentration (Pearson's r 0.40, p < 0.01), hematocrit (r 0.42, p < 0.01), MCA BFV during bypass (r 0.41, p < 0.01), and age (r -0.533, p < 0.01). The probability of developing dNCR increases 1.21 times with every one year of increased age (p < 0.01). The probability of developing dNCR increases 1.07 times with a decrease of BFV within 1 cm/s during bypass (p = 0.02). Conclusion: Risk factors contributing to dNCR among the tested patients were older age and middle cerebral artery blood flow velocity decrease during bypass.
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32
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den Os MM, van den Brom CE, van Leeuwen ALI, Dekker NAM. Microcirculatory perfusion disturbances following cardiopulmonary bypass: a systematic review. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:218. [PMID: 32404120 PMCID: PMC7222340 DOI: 10.1186/s13054-020-02948-w] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/08/2019] [Accepted: 05/05/2020] [Indexed: 12/11/2022]
Abstract
Background Microcirculatory perfusion disturbances are associated with increased morbidity and mortality in patients undergoing cardiac surgery with cardiopulmonary bypass (CPB). Technological advancements made it possible to monitor sublingual microcirculatory perfusion over time. The goal of this review is to provide an overview of the course of alterations in sublingual microcirculatory perfusion following CPB. The secondary goal is to identify which parameter of sublingual microcirculatory perfusion is most profoundly affected by CPB. Methods PubMed and Embase databases were systematically searched according to PRISMA guidelines and as registered in PROSPERO. Studies that reported sublingual microcirculatory perfusion measurements before and after onset of CPB in adult patients undergoing cardiac surgery were included. The primary outcome was sublingual microcirculatory perfusion, represented by functional capillary density (FCD), perfused vessel density (PVD), total vessel density (TVD), proportion of perfused vessels (PPV), and microvascular flow index (MFI). Results The search identified 277 studies, of which 19 fulfilled all eligibility criteria. Initiation of CPB had a profound effect on FCD, PVD, or PPV. Seventeen studies (89%) reported one or more of these parameters, and in 11 of those studies (65%), there was a significant decrease in these parameters during cardiac surgery; the other 6 studies (35%) reported no effect. In 29% of the studies, FCD, PVD, or PPV normalized by the end of cardiac surgery, and in 24% percent of the studies, this effect lasted at least 24 h. There was no clear effect of CPB on TVD and a mixed effect on MFI. Conclusion CPB during cardiac surgery impaired sublingual microcirculatory perfusion as reflected by reduced FCD, PVD, and PPV. Four studies reported this effect at least 24 h after surgery. Further research is warranted to conclude on the duration of CPB-induced microcirculatory perfusion disturbances and the relationship with clinical outcome. Trial registration PROSPERO, CRD42019127798
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Affiliation(s)
- Matthijs M den Os
- Department of Anesthesiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - Charissa E van den Brom
- Department of Anesthesiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands.,Department of Physiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Anoek L I van Leeuwen
- Department of Anesthesiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands.,Department of Physiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands.,Department of Cardiothoracic surgery, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Nicole A M Dekker
- Department of Anesthesiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands. .,Department of Physiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands.
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33
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Kado Y, Smith WA, Miyamoto T, Adams J, Polakowski AR, Dessoffy R, Horvath DJ, Fukamachi K, Karimov JH. Use of a Virtual Mock Loop model to evaluate a new left ventricular assist device for transapical insertion. Int J Artif Organs 2020; 43:677-683. [PMID: 32089074 DOI: 10.1177/0391398820907104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
We are developing a novel type of miniaturized left ventricular assist device that is configured for transapical insertion. The aim of this study was to assess the performance and function of a new pump by using a Virtual Mock Loop system for device characterization and mapping. The results, such as pressure-flow performance curves, from pump testing in a physical mock circulatory loop were used to analyze its function as a left ventricular assist device. The Virtual Mock Loop system was programmed to mimic the normal heart condition, systolic heart failure, diastolic heart failure, and both systolic and diastolic heart failure, and to provide hemodynamic pressure values before and after the activation of several left ventricular assist device pump speeds (12,000, 14,000, and 16,000 r/min). With pump support, systemic flow and mean aortic pressure increased, and mean left atrial pressure and pulmonary artery pressure decreased for all heart conditions. Regarding high pump-speed support, the systemic flow, aortic pressure, left atrial pressure, and pulmonary artery pressure returned to the level of the normal heart condition. Based on the test results from the Virtual Mock Loop system, the new left ventricular assist device for transapical insertion may be able to ease the symptoms of patients with various types of heart failure. The Virtual Mock Loop system could be helpful to assess pump performance before in vitro bench testing.
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Affiliation(s)
- Yuichiro Kado
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | | | - Takuma Miyamoto
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Joseph Adams
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Anthony R Polakowski
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Raymond Dessoffy
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | | | - Kiyotaka Fukamachi
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Jamshid H Karimov
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
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34
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Bukauskienė R, Širvinskas E, Lenkutis T, Benetis R, Steponavičiūtė R. The influence of blood flow velocity changes to postoperative cognitive dysfunction development in patients undergoing heart surgery with cardiopulmonary bypass. Perfusion 2020; 35:672-679. [PMID: 32072860 DOI: 10.1177/0267659120906045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND The aim of this study was to compare blood flow velocity changes in the middle cerebral artery before, during and after heart surgery with cardiopulmonary bypass for patients with and without postoperative cognitive dysfunction. MATERIALS AND METHODS A total of 100 patients, undergoing elective coronary artery bypass grafting or/and valve surgery enrolled in the study. A neurocognitive test evaluation included Adenbrooke, Mini-Mental State Examination and Trial Making test before and 7-10 days after surgery. Middle cerebral artery mean blood flow velocity was evaluated 1 day before the surgery, after anaesthesia induction, before cardiopulmonary bypass, at the beginning, ending and after cardiopulmonary bypass, and post surgery in intensive care unit. Blood samples for glial fibrillary acidic protein were measured after anaesthesia induction, 24 hours and 48 hours after surgery. According to neurocognitive tests results patients were divided in to two groups: patients with and without postoperative cognitive dysfunction. RESULTS Of the 100, 86 patients completed investigation. After induction, blood flow velocity of the middle cerebral artery was lower in postoperative cognitive dysfunction group (41.2; min 27.91, max 49.47) than in the H group (41.2, min 21.9, max 84.3) p = 0.034, and during cardiopulmonary bypass, blood flow velocity of the middle cerebral artery was lower in the postoperative cognitive dysfunction group (37.35, min 26.6, max 44.02) than the H group (42.3, min 20.1, max 86.5), p = 0.001. After the surgery, blood flow velocity of the middle cerebral artery was lower in the postoperative cognitive dysfunction group (40.7, min 29.7, max 50.4) than in the H group (45.3, min 34.12, max 59.88), p = 0.05. Results of cognitive tests had weak correlation (rho, 0.391) with middle cerebral artery's blood flow velocity after anaesthesia induction (p = 0.001) and during bypass (p = 0.018). The receiver operating characteristic analysis showed that the blood flow velocity of the middle cerebral artery during bypass (area under the curve = 0.735) was a fair predictor for postoperative cognitive dysfunction (p = 0.001). No significant correlations were found among glial fibrillary acidic protein, middle cerebral artery blood flow velocity, and cognitive tests results. CONCLUSION Middle cerebral artery's blood flow velocity was decreased after anaesthesia induction and during cardiopulmonary bypass for patients with postoperative cognitive dysfunction comparing with their blood flow velocity preoperatively. Blood flow velocity during bypass has diagnostic value for postoperative cognitive dysfunction. Brain biomarker glial fibrillary acidic protein is not helpful in diagnosing postoperative cognitive dysfunction.
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Affiliation(s)
- Rasa Bukauskienė
- Department of Cardiothoracic and Vascular Surgery, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Edmundas Širvinskas
- Department of Cardiothoracic and Vascular Surgery, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Tadas Lenkutis
- Department of Cardiothoracic and Vascular Surgery, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Rimantas Benetis
- Department of Cardiothoracic and Vascular Surgery, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Rasa Steponavičiūtė
- Department of Laboratory Medicine, Lithuanian University of Health Sciences, Kaunas, Lithuania
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35
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Veraar CM, Rinösl H, Kühn K, Skhirtladze-Dworschak K, Felli A, Mouhieddine M, Menger J, Pataraia E, Ankersmit HJ, Dworschak M. Non-pulsatile blood flow is associated with enhanced cerebrovascular carbon dioxide reactivity and an attenuated relationship between cerebral blood flow and regional brain oxygenation. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:426. [PMID: 31888721 PMCID: PMC6937980 DOI: 10.1186/s13054-019-2671-7] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Accepted: 11/13/2019] [Indexed: 12/16/2022]
Abstract
BACKGROUND Systemic blood flow in patients on extracorporeal assist devices is frequently not or only minimally pulsatile. Loss of pulsatile brain perfusion, however, has been implicated in neurological complications. Furthermore, the adverse effects of absent pulsatility on the cerebral microcirculation are modulated similarly as CO2 vasoreactivity in resistance vessels. During support with an extracorporeal assist device swings in arterial carbon dioxide partial pressures (PaCO2) that determine cerebral oxygen delivery are not uncommon-especially when CO2 is eliminated by the respirator as well as via the gas exchanger of an extracorporeal membrane oxygenation machine. We, therefore, investigated whether non-pulsatile flow affects cerebrovascular CO2 reactivity (CVR) and regional brain oxygenation (rSO2). METHODS In this prospective, single-centre case-control trial, we studied 32 patients undergoing elective cardiac surgery. Blood flow velocity in the middle cerebral artery (MCAv) as well as rSO2 was determined during step changes of PaCO2 between 30, 40, and 50 mmHg. Measurements were conducted on cardiopulmonary bypass during non-pulsatile and postoperatively under pulsatile blood flow at comparable test conditions. Corresponding changes of CVR and concomitant rSO2 alterations were determined for each flow mode. Each patient served as her own control. RESULTS MCAv was generally lower during hypocapnia than during normocapnia and hypercapnia (p < 0.0001). However, the MCAv/PaCO2 slope during non-pulsatile flow was 14.4 cm/s/mmHg [CI 11.8-16.9] and 10.4 cm/s/mmHg [CI 7.9-13.0] after return of pulsatility (p = 0.03). During hypocapnia, non-pulsatile CVR (4.3 ± 1.7%/mmHg) was higher than pulsatile CVR (3.1 ± 1.3%/mmHg, p = 0.01). Independent of the flow mode, we observed a decline in rSO2 during hypocapnia and a corresponding rise during hypercapnia (p < 0.0001). However, the relationship between ΔrSO2 and ΔMCAv was less pronounced during non-pulsatile flow. CONCLUSIONS Non-pulsatile perfusion is associated with enhanced cerebrovascular CVR resulting in greater relative decreases of cerebral blood flow during hypocapnia. Heterogenic microvascular perfusion may account for the attenuated ΔrSO2/ΔMCAv slope. Potential hazards related to this altered regulation of cerebral perfusion still need to be assessed. TRIAL REGISTRATION The study was retrospectively registered on October 30, 2018, with Clinical Trial.gov (NCT03732651).
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Affiliation(s)
- Cecilia Maria Veraar
- Division of Cardiothoracic and Vascular Anaesthesia and Intensive Care Medicine, Department of Anaesthesia, Intensive Care Medicine, and Pain Medicine, Vienna General Hospital, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Harald Rinösl
- Department of Anaesthesia and Intensive Care Medicine, LKH Feldkirch, Feldkirch, Austria
| | - Karina Kühn
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Klinikum Traunstein, Traunstein, Germany
| | - Keso Skhirtladze-Dworschak
- Division of Cardiothoracic and Vascular Anaesthesia and Intensive Care Medicine, Department of Anaesthesia, Intensive Care Medicine, and Pain Medicine, Vienna General Hospital, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Alessia Felli
- Division of Cardiothoracic and Vascular Anaesthesia and Intensive Care Medicine, Department of Anaesthesia, Intensive Care Medicine, and Pain Medicine, Vienna General Hospital, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Mohamed Mouhieddine
- Division of Cardiothoracic and Vascular Anaesthesia and Intensive Care Medicine, Department of Anaesthesia, Intensive Care Medicine, and Pain Medicine, Vienna General Hospital, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Johannes Menger
- Division of Cardiothoracic and Vascular Anaesthesia and Intensive Care Medicine, Department of Anaesthesia, Intensive Care Medicine, and Pain Medicine, Vienna General Hospital, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Ekaterina Pataraia
- Department of Neurology, Vienna General Hospital, Medical University of Vienna, Vienna, Austria
| | - Hendrik Jan Ankersmit
- Division of Thoracic Surgery, Department of Surgery, Vienna General Hospital, Medical University of Vienna, Vienna, Austria
| | - Martin Dworschak
- Division of Cardiothoracic and Vascular Anaesthesia and Intensive Care Medicine, Department of Anaesthesia, Intensive Care Medicine, and Pain Medicine, Vienna General Hospital, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria.
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36
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Pollak U, Ruderman T, Borik-Chiger S, Mishaly D, Serraf A, Vardi A. Transfusion-related acute hepatic injury following postoperative platelets administration in pediatric patients undergoing the Fontan procedure. CONGENIT HEART DIS 2019; 14:968-977. [PMID: 31343842 DOI: 10.1111/chd.12825] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2019] [Revised: 05/11/2019] [Accepted: 07/08/2019] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The final common pathway of single ventricle patients is the Fontan procedure. Among the immediate postoperative complications is acute hepatic injury presented by marked elevation of liver enzymes (alanine transaminase [ALT] and aspartate transaminase [AST]). We aimed to determine the contribution of blood products transfusion to acute hepatic injury. DESIGN Single center retrospective cohort study. SETTING Pediatric Cardiac Intensive Care Unit at a tertiary medical center. PATIENTS Ninety-nine pediatric patients undergoing the Fontan procedure between January 2009 and December 2016. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Out of the four types of blood products, transfusion of platelets was found to significantly affect postoperative levels of ALT and AST. Additional factors included postoperative administration of sodium bicarbonate, decreased flow through the Fontan canal and decreased urine output. Preoperative pulmonary artery pressure and pulmonary vascular resistance, cardiopulmonary bypass time, aortic cross-clamp time, amount of postoperative bleeding, and vasoactive-inotropic score did not influence liver enzymes levels CONCLUSIONS: In pediatric Fontan patients, platelets transfusions contribute to an acute hepatic injury. The relation between platelets and transfusion-related acute lung injury (TRALI) has been well described, but this is the first time it is being described in regard to acute hepatic injury (TRAHI). Changing platelet transfusion strategy could decrease morbidity in Fontan patients but further research is needed.
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Affiliation(s)
- Uri Pollak
- Pediatric Cardiac Critical Care Unit, Hadassah University Medical Center, Jerusalem, Israel.,Pediatric Cardiology, Hadassah University Medical Center, Jerusalem, Israel.,Pediatric Extracorporeal Support Program, Hadassah University Medical Center, Jerusalem, Israel.,The Hebrew University Hadassah Medical School, Jerusalem, Israel
| | - Tatyana Ruderman
- The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Sharon Borik-Chiger
- The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Pediatric Cardiology, Edmond J Safra International Congenital Heart Center, The Edmond and Lily Safra Children's Hospital, Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - David Mishaly
- The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Pediatric and Congenital Cardiac Surgery, Edmond J Safra International Congenital Heart Center, The Edmond and Lily Safra Children's Hospital, Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - Alain Serraf
- The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Pediatric and Congenital Cardiac Surgery, Edmond J Safra International Congenital Heart Center, The Edmond and Lily Safra Children's Hospital, Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - Amir Vardi
- The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Pediatric Cardiac Intensive Care Unit, Edmond J Safra International Congenital Heart Center, The Edmond and Lily Safra Children's Hospital, Chaim Sheba Medical Center, Tel Hashomer, Israel
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37
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Abstract
In this review the impact of cardiopulmonary bypass (CPB) on the microcirculation is discussed. The impact of conventional non-pulsatile perfusion is contrasted with the microcirculatory impact of pulsatile CPB which is associated with better preservation of microcirculatory function. Evidence that alterations in microcirculatory function that persist following cardiac surgery are associated with adverse clinical outcomes is reviewed. Recent studies using novel techniques employing near infrared reflectance spectroscopy (NIRS) and sublingual microscopy to explore alterations in microcirculatory function during CPB are reviewed and the implications of these observations for studies investigating minimally invasive extracorporeal circulation (MiECC) are discussed.
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Affiliation(s)
- John M Murkin
- Department of Anesthesia & Perioperative Medicine, London Health Sciences Centre, University Hospital, London, ON, Canada
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