Complement (C3, C4) consumption in cardiopulmonary bypass, cardioplegia, and protamine administration

Complement activation during cardiopulmonary bypass and association with clinical outcomes

In this prospective, single-centre observational study of 30 patients undergoing cardiopulmonary bypass (CPB), the effect of unfractionated heparin (UFH), CPB surgery and protamine sulphate on complement and on post-operative blood loss were assessed. Although C3 and C4 levels decreased significantly immediately following the administration of UFH, C3a, C5a, Bb fragment and SC5b-9 remained unchanged. During CPB, C3 and C4 continued to fall whilst both alternative and classical pathways activation markers, Bb, C3a, C5a and SC5b-9 increased significantly. Protamine sulphate had no effect on classical pathway components or activation markers but decreased alternative pathway activation marker Bb. Over the 12-24 h post-surgery, both classical and alternative pathway activation markers returned to baseline, whilst C3 and C4 levels increased significantly but not to baseline values. Total drain volume 24 h after the surgery showed a moderate inverse correlation with post-protamine C3 (r = -0.46, p = 0.01) and C4 (r = -0.57, p = 0.0009) levels, whilst a moderate positive correlation was observed with post-protamine C3a (r = 0.46, p = 0.009), C5a (r = 0.37, p = 0.04) and SC5b-9 (r = 0.56, p = 0.001) levels but not with Bb fragment (r = 0.25, p = 0.17). Thus, inhibition of complement activation may be a therapeutic intervention to reduce post-operative blood in patients undergoing CPB.

Blood - Artificial Surface Interactions during Cardiopulmonary Bypass

Evaluation of the biocompatibility of four different types of oxygenator (bubble, membrane, hollow fibre and ‘hybrid’) was performed on 26 patients undergoing cardiopulmonary bypass during elective coronary surgery. More platelet derangement and an increased degree of hemolysis, revealed by higher plasmatic concentration of beta-thromboglobulin, platelet factor 4 and plasmatic free hemoglobin (p < 0.05), was seen when using the bubble oxygenator. Damage to blood cells was minimal with the membrane oxygenator while the ‘hybrid’ and the hollow fibre oxygenators proved to rank at an intermediate level. Complement activation at the beginning of the cardiopulmonary bypass occurred via the alternative pathway as demonstrated by C3adesarg increase (up to nine times) without a concomitant elevation of C4adesarg. Cardiopulmonary bypass complement activation was quantitatively similar with all the oxygenators. A further activation via the classical pathway occured in all the patients after protamine injection. Consistent differences as far as clinical and biological effects exist among the various commercially available cardiopulmonary bypass apparatus; our study provides guidelines for the evaluation and selection of devices which might reduce postoperative sequelae.

Complement consumption during cardiopulmonary bypass: bubble versus membrane oxygenators

The purpose of this study was to compare levels of C3 and C4 during cardiopulmonary bypass, using bubble and membrane oxygenators. In vitro studies were performed using human blood in a simple circuit involving an oxygenator, roller pump and connector tubing. In vivo studies were carried out in two separate institutions using a variety of bubble and membrane oxygenators. Samples were taken throughout the pump run (30-1 20 minutes). Complement levels were corrected for haemodilution. All oxygenators tested caused a rapid decrease in C3 and C4 complement levels on institution of bypass. The magnitude and timing of these decreases were similar in the membrane and bubble groups. Thereafter, complement levels were stable throughout the pump run. These data do not suggest that there is any difference in complement activation during relatively short pump runs using bubble and membrane oxygenators.

Prostacyclin, cardiopulmonary bypass and the alveolar capillary membrane

In a double blind controlled study of 24 patients undergoing coronary artery bypass grafting, 12 received an infusion of prostacyclin at 20 ng/kg/min during cardiopulmonary bypass in an attempt to reduce the previously reported increased alveolar capillary membrane permeability that occurs postoperatively. Prostacyclin significantly reduced platelet activation but had no effect in reducing complement activation or transpulmonary neutrophil sequestration. Alveolar epithelial permeability as assessed by measuring the clearance of inhaled 99mTc-DTPA from lung to blood did not change postoperatively in either group.

In order to fully evaluate pulmonary damage following cardiopulmonary bypass a marker for pulmonary endothelial damage may need to be used.

Serious anaphylactic reactions due to protamine sulfate: a systematic literature review

Anaphylactic reactions caused by injection of protamine sulfate during cardiac surgery are a well-known complication. A systematic literature review was therefore conducted to gather evidence of the knowledge concerning these side effects, and to see if any prospective randomized studies supported this. Studies investigating the effect of protamine sulfate in human beings were extracted from MEDLINE, Embase and the Cochrane Library, retrieving 487 articles. Abstracts were evaluated by both authors, and referred articles not found in the primary search were furthermore extracted from reviews and case reports, resulting in a total of 272 relevant articles. Of these, 9 retrospective studies and 16 prospective studies were performed in an evidence-based manner. However, only 3 of the 16 prospective articles had an optimal design as far as inclusion criteria, randomization, and description of symptoms were concerned. Incidence of anaphylactic reactions in the prospective studies was 0.69% compared to 0.19% in the retrospective studies, but caution should be taken due to a pronounced heterogeneity of those studies. One study found heparinase I unsuitable as replacement for protamine sulfate. Overall, our findings support the low incidence of anaphylactic reactions reported in previous studies, but of note only few prospective investigations was conducted on the subject. Our study also emphasizes the need for critical appraisal of many routine procedures: in all aspects of medical care, systematic literature review conducted in a well-structured, repeated manner should be given high priority.

Does off-pump coronary surgery reduce morbidity and mortality?

OBJECTIVE

To compare hospital outcomes of on-pump and off-pump coronary artery bypass surgery.

METHODS

From 1997 to 2000, primary coronary artery bypass grafting was performed in 481 patients off pump and in 3231 patients on pump. Hospital outcomes were compared between propensity-matched pairs of 406 on-pump and 406 off-pump patients. The 2 groups were similar in age (P =.9), left ventricular function (P =.7), extent of coronary artery disease (P =.5), carotid artery disease (P =.4), and chronic obstructive pulmonary disease (P =.5). However, off-pump patients had more previous strokes (P =.05) and peripheral vascular disease (P =.02); on-pump patients had a higher preoperative New York Heart Association class (P =.01).

RESULTS

In the matched pairs the mean number of bypass grafts was 2.8 +/- 1.0 in off-pump patients and 3.5 +/- 1.1 in on-pump patients (P <.001). Fewer grafts were performed to the circumflex (P <.001) and right coronary (P =.006) artery systems in the off-pump patients. Postoperative mortality, stroke, myocardial infarction, and reoperation for bleeding were similar in the 2 groups. There was more encephalopathy (P =.02), sternal wound infection (P =.04), red blood cell use (P =.002), and renal failure requiring dialysis (P =.03) in the on-pump patients.

CONCLUSIONS

Both off- and on-pump procedures produced excellent early clinical results with low mortality. An advantage of an off-pump operation was less postoperative morbidity; however, less complete revascularization introduced uncertainty about late results. A disadvantage of on-pump bypass was higher morbidity that seemed attributable to cardiopulmonary bypass.

Reperfusion injury after focal myocardial ischaemia: polymorphonuclear leukocyte activation and its clinical implications

The only way to rescue ischaemic tissue is to re-instate the oxygen supply to the tissue. However reperfusion of the ischaemic area not only oxygenates the tissue but also initiates a cascade of processes, which may in some cases result in temporary dysfunction of the myocardium. In order to devise protective measures, it is essential to understand the mechanisms and the triggers of this reperfusion phenomenon. In this review we will mainly focus on the inflammatory response caused by reperfusion. We will cover the different steps of polymorphonuclear leukocyte activation and will briefly discuss the molecular biology of the receptors involved. The currently used pharmacological medications in acute cardiology will be reviewed and in particular their actions on polymorphonuclear leukocyte activation, adhesion and degranulation. This review is a compilation of the current knowledge in the field and the therapeutic progress in the prevention of reperfusion injury made today.

The effects of methylprednisolone on complement, immunoglobulins and pulmonary neutrophil sequestration during cardiopulmonary bypass

In this study, the authors administered high dose (30 mg/kg body weight i.v.) methylprednisolone before cardiopulmonary bypass to observe the effects on complement, immunoglobulins and pulmonary neutrophil sequestration. Fifty patients undergoing valve replacements were included in this study. Patients were divided into two groups: group I (20 patients) served as control and did not receive methylprednisolone, group II (30 patients) received methylprednisolone. Blood samples for complements (C3c and C4) were taken, before cardiopulmonary bypass, at 5, 10 and 30 min intervals from the end of cardiopulmonary bypass, after reversal of heparin with protamine infusion, and after skin closure. Blood samples for immunoglobulins were taken before cardiopulmonary bypass, 30 min after onset of cardiopulmonary bypass and after skin closure. After onset of cardiopulmonary bypass, all C3c and C4 levels decreased in both groups. There was a significant decrease in C4 levels at end of cardiopulmonary bypass and after protamine infusion in group I compared with group II (P < 0.05). C3c levels in group I decreased significantly compared with group II after 30 min of cardiopulmonary bypass and after protamine infusion (P < 0.05). All immunoglobulin (IgG, IgM, IgA) levels were decreased in both groups, but the decrease in IgG was statistically significant after skin closure in group I compared with group II (P < 0.05). Pulmonary neutrophil sequestration was higher in the control group compared with the methyl-prednisolone group (P < 0.05). In conclusion, methylprednisolone administration before cardiopulmonary bypass may prevent the harmful effects of complement activation, immunoglobulin denaturation and neutrophil sequestration in the pulmonary capillary system.

[Acute ventricular septal perforation in a patient with autoimmune hemolytic anemia]

A 71-year-old woman with autoimmune hemolytic anemia underwent an emergency endocardial patch repair for ventricular septal perforation after acute myocardial infarction. Use of washed red blood cells was effective in averting hemolytic crisis throughout perioperative period. In spite of improvement of her hemodynamics, liver dysfunction which had been present preoperatively deteriorated after the operation. Finally she died of hepatic failure on the 21st postoperative day. Deterioration of liver function could not be associated with autoimmune hemolytic anemia. To date, little information is available concerning the influence of cardiopulmonary bypass on hemolysis in patients with autoimmune hemolytic anemia. Therefore, prudent management and use of washed red blood cells transfusion would prevent hemolytic aggravation even in open heart surgery.

Complement consumption during cardiopulmonary bypass: comparison of Duraflo II heparin-coated and uncoated circuits in fully heparinized patients

Heparin attachment to synthetic surfaces is one means of improving the biocompatibility of clinically used cardiopulmonary bypass (CPB) circuits. To assess the effect of heparin-coated circuits on complement consumption during CPB, 40 patients undergoing elective myocardial revascularization were prospectively randomized either to a group in which a completely Duraflo II heparin-coated circuit was used for perfusion (heparin-coated Group, n = 20 patients) or to a control group (n = 20 patients) in which an uncoated, but otherwise standard circuit was used. Full systemic heparinization was induced (activated clotting time, 480 seconds) in all the patients included in the study, regardless of which perfusion circuit was used. The two groups did not differ significantly in terms of bodyweight, aortic crossclamp and extracorporeal circulation times. No patient had difficulty in weaning from bypass and the postoperative period was uneventful in all patients. Concentrations of C3 and C4 were found to be within the "normal' range in the prebypass period in both groups. There were no significant intergroup differences with regard to C3 and C4 consumption during CPB. We conclude that Duraflo II heparin-coated circuits have no effect in reducing complement consumption during CPB in fully heparinized patients.

Purpurogallin, a scavenger of polymorphonuclear leukocyte-derived oxyradicals

Purpurogallin (PPG) is a phenolic compound extracted from nutgalls formed on oak trees. It has been used as an additive to edible or nonedible oils or fats, and to hydrocarbon fuels or lubricants to retard their oxidation. We investigated by luminol-dependent chemiluminescence (PMNL-CL), the ability of PPG to scavenge oxygen free radicals (OFRs) generated by zymosan-activated polympophonuclear leukocytes (PMNLs). Its OFR-scavenging ability was also investigated by the use of nitro blue tetrazolium (NBT). We also investigated by the dye-exclusion method, if PPG affects the viability of PMNLs. PPG in the concentrations of 0.005-0.4 mM was used in this study. PPG scavenged OFRs produced by zymosan-activated PMNLs in a concentration-dependent manner. Almost complete scavenging was observed at a concentration of 0.2 mM. The NBT test indicated that PPG (0.2 mM) did not completely prevent the activation of PMNLs by zymosan. Viability of PMNLs in the absence or presence of PPG (0.4 mM) were 95.77 +/- 0.56% and 96.78 +/- 0.60% respectively. The results suggest that PPG scavenges OFRs produced from activated PMNLs in a concentration-dependent manner and that the cell viability is not affected by PPG. PPG is a potent scavenger of OFRs and should be of value in the prevention and treatment of diseases in the pathophysiology of which OFRs are invovled.

Brain natriuretic peptide and fluid volume homeostasis--studies during cardiopulmonary bypass surgery

Brain natriuretic peptide (BNP) is a recently identified cardiac ventricular hormone with diuretic, natriuretic and vasorelaxant properties. The aim of our study was to examine whether serial changes in endogenous levels of BNP were associated with fluid volume homeostasis following cardiopulmonary bypass. We studied nine patients undergoing elective cardiac surgery for the repair of cardiac abnormalities requiring cardiopulmonary bypass. Urinary levels of cyclic guanosine monophosphate (cGMP), sodium, urine output, fluid balance, and plasma levels of BNP, aldosterone, plasma renin activity (PRA) and central venous pressure (CVP) were measured before, during and after cardiopulmonary bypass. Basal pre-operative plasma BNP levels were highly elevated in all nine patients with cardiac abnormalities. During bypass, pre-operative levels of BNP, urinary cGMP and plasma aldosterone decreased significantly (p < 0.05), whereas pre-operative levels of urinary sodium and PRA were slightly reduced. During recovery following bypass levels of urinary cGMP, sodium, PRA and aldosterone returned to basal pre-operative values, whereas post-operative levels of plasma BNP were found to be three-fold below basal pre-operative levels. CVP (4.3 +/- 0.2 mmHg) during the onset of bypass increased significantly (p < 0.05) at the end of bypass (9 +/- 0.3 mmHg) followed by a modest increase post-operatively (10 +/- 0.4 mmHg). After operation only BNP had a significant correlation with urine output (r = -0.82, p < 0.02) and net fluid balance (r = -0.84, p < 0.01), whereas urinary cGMP, PRA and aldosterone all exhibited a non-significant correlation with urine output.(ABSTRACT TRUNCATED AT 250 WORDS)

Complement (C3, C4) and C-reactive protein responses to cardiopulmonary bypass and protamine administration

Complement activation has been deemed responsible for the damaging effects of cardiopulmonary bypass (CPB) in patients undergoing open heart surgery. We studied C3, C4 and C-reactive protein (CRP) in 22 patients undergoing CPB. In Group 1 (11 patients), protamine was given intravenously and in Group 2 (11 patients), via the aortic root after CPB. Significant decreases were observed in C3 and C4 during CPB in both groups indicating complement activation primarily by the classic pathway. Protamine did not lead to further activation of the complement system. In both groups, C3 levels gradually returned toward baseline within 24 hours but C4 levels were still lower than baseline 24 hours postoperatively. CPB and protamine administration did not cause any significant changes in CRP levels, but CRP increased abruptly 24 hours after operation. Although activation of complement system during CPB is expected to invoke an acute phase response, we conclude that this period is not long enough to induce an increased production of CRP in response to tissue injury or inflammation.

Influence of cardiopulmonary bypass on water balance hormones in children

OBJECTIVE

To determine the changes in the endocrine mechanisms of fluid balance after cardiopulmonary bypass in children.

DESIGN

Prospective study; analysis of numbered plasma samples performed blind with respect to clinical data.

SETTING

Regional paediatric cardiothoracic unit.

PATIENTS

Nine patients, median age 4, range 2 to 9 years, five males. Patients under the age of 1 year were excluded because of the frequent blood sampling involved.

MAIN OUTCOME MEASURES

Plasma concentrations of atrial natriuretic peptide (ANP), arginine vasopressin, plasma renin activity, aldosterone, noradrenaline and adrenaline, and urinary concentrations of cyclic guanosine monophosphate (cGMP) as measured by radioimmunoassay.

RESULTS

After 30 minutes of cardiopulmonary bypass plasma atrial natriuretic peptide (ANP) decreased from (mean (SEM)) 151 (71) pg/ml to 52 (44) pg/ml (NS), and urinary production of its second messenger cyclic guanosine monophosphate (cGMP) decreased from 1286 (600) pmol/ml to 151 (414) pmol (p < 0.05). Other plasma concentrations of hormones studied did not change significantly although arginine vasopressin, adrenaline, and noradrenaline increased whereas aldosterone and plasma renin activity decreased. After cardiopulmonary bypass stopped there was an immediate and significant rise in plasma ANP, but within the next 24 hours plasma ANP declined significantly (p < 0.05), decreasing from 294 (49) pg/ml to 64 (29) pg/ml at 22 hours. In the postoperative period there was a significant correlation between plasma ANP and both mean fluid balance (r = 0.96, p < 0.001) and mean urine output (r = 0.97, p < 0.001). Plasma aldosterone peaked (p < 0.05) at 22 hours after operation, and argine vasopressin peaked (p < 0.05) at two hours and then declined (p < 0.05) to a trough at 24 hours. Plasma renin activity, adrenaline, noradrenaline, and urinary cGMP concentrations, and mean central venous pressure did not change significantly in the postoperative period.

CONCLUSION

The changes documented show the differing pattern of release of water balance hormones invoked by cardiopulmonary bypass. The central role of ANP is shown by its strong correlation with urinary output and its similarly strong relation to fluid balance.

Increased oxygen free radical activity in patients on cardiopulmonary bypass undergoing aortocoronary bypass surgery

Cardiac dysfunction after cardiopulmonary bypass (CPB) has been reported by various investigators. Oxygen free radicals have been shown to depress cardiac function and contractility. To evaluate the possible role of oxygen free radicals (OFR) in post-pump cardiac dysfunction, measurements of cardiac function, OFR producing activity of polymorphonuclear (PMN) leukocytes (PMN chemiluminescence) and malondialdehyde (MDA), a lipid peroxidation product, in blood were made at induction of anesthesia (T1), before cross clamping of the aorta (T2), after closure of the chest (T3), and 24 hours postoperatively (T4) in 21 patients undergoing aortocoronary bypass surgery. The total OFR-derived chemiluminescence at T1, T2, T3, and T4 was 1590 +/- 156, 3169 +/- 338, 1972 +/- 214, and 2614 +/- 366 mv.min.10(6) PMN-1, respectively. Superoxide dismutase (SOD)-inhibitable chemiluminescence at T1, T2, T3, and T4 was 1214 +/- 129, 2674 +/- 328, 1752 +/- 215, and 2139 +/- 292 mv.min.10(6) PMN-1, respectively. Superoxide anion at T1, T2, T3, and T4 was 0.99 +/- 0.14, 1.30 +/- 0.17, 1.07 +/- 0.14, and 1.19 +/- 0.12 nmol.10(6) PMN-1.30 min-1, respectively. Blood MDA at T1, T2, T3, and T4 was 0.17 +/- 0.02, 0.25 +/- 0.03, 0.20 +/- 0.03, and 0.23 +/- 0.02 nmol/ml, respectively. OFR-derived and SOD inhibitable chemiluminescence, superoxide anion, and blood MDA increased significantly during CPB and postoperatively. There were decreases in the blood pressure and stroke volume, and increases in the central venous pressure, capillary wedge pressure, and heart rate during CPB and postoperatively. Cardiac output remained unchanged during this procedure. There was leukopenia during CPB.(ABSTRACT TRUNCATED AT 250 WORDS)

Absence of complement-mediated events after protamine reversal of heparin anticoagulation

Protamine reversal of heparin anticoagulation is associated with adverse hemodynamic effects that may be attenuated with protamine pretreatment (PP). This study assesses the role of complement activation during these phenomena in adult cardiac surgery patients. Sixteen individuals undergoing cardiopulmonary bypass were given intravenous normal saline or protamine (2 mg/kg) as a randomized pretreatment prior to undergoing heparin anticoagulation (400 IU/kg), coronary artery revascularization, and subsequent reversal of the anticoagulated state with protamine (4 mg/kg). Blood pressure, pulmonary artery diastolic pressure (PAD), heart rate, and cardiac output (CO) were measured during and after pretreatment, prior to heparin reversal by protamine, and for 10 min after reversal. Total hemolytic complement (CH50), C3 conversion to C3b, C3a/C5a, platelet count, and white blood cell count (WBC) were also measured at the same time periods. No significant correlation existed between complement activation and hemodynamic events, as might have been evident by decreased CH50, increased C3 conversion to C3b, or elevations in C3a/C5a levels. PP significantly prevented the CO decrease occurring at 1 and 3 min following heparin reversal by protamine (-0.8 and -1.4 liters/min vs 0.1 and -0.2 liters/min, P less than 0.05 and P less than 0.01, respectively). Reversal hypotension was less with PP, although PAD fell equally in both groups. WBC decreases after heparin reversal were less after PP (-25% vs -7%, P = 0.06). These data support the conclusion that, contrary to earlier reports, adverse hemodynamic and hematologic responses accompanying protamine reversal of heparin anticoagulation do not appear to be correlated with activation of complement. In fact, those patients having the greatest C3a generation exhibited the least hemodynamic changes.

Complement activation and depletion during LDL-apheresis by heparin-induced extracorporeal LDL-precipitation (HELP)

The heparin-induced extracorporeal elimination of low density lipoproteins (LDL) is a well-established clinical procedure to markedly reduce cholesterol levels. The biocompatibility of this artificial filter system (HELP) was investigated by quantitation of representative complement proteins within the extracorporeal circuit using established ELISA procedures, based on monoclonal antibodies recognizing exclusively either native (C6, C7) or activated proteins (act.C3, C5a, TCC). HELP was found to be a self-limiting extracorporeal system with respect to complement activation, since act.C3 and TCC, generated mainly at the plasma filter, were partially adsorbed to the following HELP specific filters to concentrations which were lower than those obtained before the plasma filter. C5a, which increased 14.5-fold at the plasma filter was not eliminated by the following filters; however, elevated levels were not found in the patients at the end of apheresis and no leucocytopenia was observed.

Effects of diltiazem on the functional recovery of the myocardium at organ and cellular level during prolonged hypothermic ischemic cardiac arrest

The effectiveness of diltiazem on the functional recovery of the heart, calcium (Ca++) uptake and binding, Ca++ ATPase of cardiac sarcoplasmic reticulum (SR), and MB fraction of creatine kinase (MBCK) of coronary sinus blood was investigated after one and a half hours of reperfusion following three hours of ischemic cardiac arrest. The dogs were divided into three groups: group I, sham bypass; group II, cold crystalloid cardioplegia; and group III, cold crystalloid cardioplegia with diltiazem. There was a decrease in aortic pressures left ventricular pressure development (dp/dt), left ventricular work index (LVWI), total systemic vascular resistance (TSVR), and left ventricular systolic pressure (LVSP) in the sham bypass group. There was a decrease in cardiac index (CI), LVWI, and mean right atrial pressure (mRAP) and an increase in TSVR and pulmonary vascular resistance (PVR) in group II as compared with group I. Although there was a tendency for a decrease in the indices of myocardial contractility in group II, they were not significantly different from those in group I. The indices of myocardial contractility, CI, and LVWI in group III were slightly higher than in group II, but they were not significantly different from each other. The values for calcium uptake by SR in groups II and III were similar but significantly lower than those in group I. Calcium binding in group III was significantly lower than that in group I. Calcium ATPase of SR in the three groups were similar. Although MBCK increased in all the groups, the increases were not significantly different among the three groups. The results of this study indicate that cold crystalloid cardioplegia with diltiazem was not better than cold crystalloid alone in preserving the cardiac contractility and cellular function during prolonged ischemic cardiac arrest. However, the cardiac function in terms of cardiac index was better preserved with diltiazem.

Effect of polymorphonuclear leukocyte-derived oxygen free radicals and hypochlorous acid on cardiac function and some biochemical parameters

Polymorphonuclear (PMN) leukocyte activation is known to result in the production and release of oxygen free radicals and hypochlorous acid. Various clinical conditions are associated with PMN leukocyte stimulation. The present investigation deals with the effects of stimulated PMN leukocytes in the absence and in the presence of scavengers of oxygen free radicals (superoxide dismutase, catalase), hypochlorous acid quencher (methionine), and myeloperoxidase inhibitor (azide) on cardiac function and contractility; blood lactate, gases, and pH levels, blood and cardiac tissue malondialdehyde; and PMN leukocyte chemiluminescence activity in anesthetized dogs. Opsonised zymosan was used for stimulation of PMN leukocytes, and the effects were observed for 2 hours. The dogs were divided into four groups: group I, zymosan; group II, superoxide dismutase + catalase + zymosan; group III, methionine + zymosan; group IV, azide + methionine + zymosan. Zymosan produced a decrease in cardiac function and in indices of myocardial contractility and an increase in systemic and pulmonary vascular resistance. There was a decrease in blood pH and in PMN leukocyte chemiluminescense and an increase in the blood lactate and malondialdehyde. Superoxide dismutase plus catalase and methionine reduced the effect of zymosan on cardiac function and contractility and on blood malondialdehyde, lactate, and pH. The combination of azide and methionine did not prevent the deleterious effects of zymosan on cardiac function and contractility. Cardiac tissue malondialdehyde levels were lower in groups III and IV than in groups I and II which had values similar to each other. Methionine was superior to superoxide dismutase plus catalase in the prevention of the deleterious effects of PMN leukocyte stimulation on the various measured parameters. These results suggest that oxygen free radicals and hypochlorous acid are cardiac depressants and increase systemic and pulmonary vascular resistance in addition to causing tissue damage. Clinical situations with PMN stimulation may result in cardiac depression. The oxygen free radical scavenger and hypochlorous acid quencher may be beneficial in the counteraction of the deleterious effects of PMN leukocyte stimulation on the hemodynamic parameters and cellular integrity.

Lack of cross-reactivity between IgE to salmon and protamine sulfate

Immediate type-generalized reactions to protamine sulfate are uncommon but may be fatal. The mechanisms of severe or fatal reactions are unknown in most cases. One theory is that contaminating fish (salmon) proteins present in protamine solutions induce anaphylaxis in salmon-sensitive subjects. A second hypothesis is that protamine interacts with anti-salmon IgE to cause anaphylaxis. We assessed these hypotheses by establishing an indirect amplified enzyme-linked immunosorbent assay (ELISA) for IgE to salmon. Sera obtained from two subjects anaphylactically sensitive to salmon demonstrated high binding to salmon that was not inhibited by preincubation of sera with 500 or 1000 micrograms of protamine or Aspergillus fumigatus. Serum from a patient who experienced anaphylactic shock from protamine was indistinguishable from control sera in the ELISA for IgE to salmon. Anti-protamine IgE could not be demonstrated in separate experiments. The assays prove that 1) serum IgE to salmon is not inhibited by protamine and 2) serum from a patient experiencing a severe reaction to protamine did not contain IgE to salmon or protamine. The experiments do not support the notion that there is cross-reactivity between IgE to salmon and protamine sulfate in the cases evaluated.

Deleterious effects of complement activation on the lungs during extracorporeal circulation and its inhibition by FUT-175

The purpose of this paper is to review the deleterious effects of complement activation during extracorporeal circulation on the lungs and to discuss the feasibility of FUT-175, a new synthetic protease inhibitor, as a complement activation inhibitor. Complement activation causes leukocyte aggregation and aggregated leukocytes behave as microemboli in the pulmonary vessels. Anaphylatoxins produced by complement activation have potent vasoactive properties and many chemical mediators are also released from leukocytes. FUT-175 might be effective to inhibit complement activation during cardiopulmonary bypass (CPB). Although deleterious effects of CPB on the lungs are multifactorial, we hypothesize that complement activation may play a major role in lung injury during CPB.

Complement activation from protamine sulfate administration after coronary angiography

The cause of hypotension after reversal of heparin by protamine has not been well defined. In this study we evaluated complement activation (C3a and C4a) by the heparin-protamine complex in 46 consecutive patients (40 received protamine sulfate to reverse heparin, and six did not) during and after coronary angiography. In patients receiving protamine sulfate, there was a significant increase in C3a over the value before protamine sulfate administration (P less than .001) or in patients who did not receive protamine sulfate (P less than .05): 807 +/- 100 ng/ml vs. 274 +/- 75 ng/ml. There were no significant changes in C4a after protamine sulfate administration. These results indicate that the alternate complement pathway is activated when protamine sulfate is administered after coronary angiography. This may induce hypotension as well as platelet aggregation and thrombus formation and may contribute to coronary instability. Therefore, in unstable patients, heparin reversal by protamine should not be done routinely.

Complement depletion and persistent hemodynamic-hematologic responses in protamine-heparin reactions

Hypotension, bradycardia, pulmonary artery hypertension, neutropenia, and thrombocytopenia have been suspected to be due to complement activation following protamine reversal of heparin. This investigation examined these phenomena in complement-depleted animals. Eight dogs received intraperitoneal naja n. naja cobra venom factor (CVF), 20 U/kg, 48 and 24 hr prior to anticoagulation with sodium heparin, 150 IU/kg, and reversal 30 min later with protamine sulfate, 1.5 mg/kg. Decomplementation was confirmed in all dogs. Systemic blood pressure (BP), pulse (HR), pulmonary artery systolic and diastolic pressures, (PAS, PAD), cardiac output (CO), platelet count (PTC), and white blood count (WBC) with differential were monitored. The maximal mean changes for the entire group were BP, -43 mm Hg; HR, -16; PAS, +6 mm Hg; PAD, +3 mm Hg; CO, -27%; PTC, -49%; and WBC, -48%. These hemodynamic and hematologic responses, occurring in the face of CVF-induced decomplementation, support the conclusion that complement components C3 and C5-C9 are not influential factors contributing to these protamine-heparin-induced events.

Complement conversion and leukocyte kinetics in open heart surgery

Complement conversions and a pulmonary leukocyte sequestration were observed during cardiopulmonary bypass (CPB) in all of twenty patients who received open heart surgery. A systemic neutropenia was initially observed in the early phase of CPB, and it subsequently turned into a systemic neutrocytosis during the late phase of it. A significant leukocyte sequestration was found in the pulmonary circulation during CPB coincidently with the systemic neutropenia. The contribution of the transpulmonary sequestration to the leukopenia was major, being as high as 80 per cent. Plasma C3, C4, and CH50 levels rapidly decreased following the commencement of CPB. Alterations of the C3 molecule in the patients' plasma were demonstrated using the immunoblotting method. The appearances of C3a and C3b with the apparent molecular weights of 10,000 and 170,000 respectively, might be evidence of the complement activation during CPB. Another type of alteration in the C3 molecule was observed in the generation of a new fragment with the apparent molecular weight of 14,000. The appearance of this fragment, which did not share common epitopes with C3a, might suggest the consumption of complement components during CPB, unrelated to the activation of the complement systems.

Deposition of terminal C5b-9 complement complexes on erythrocytes and leukocytes during cardiopulmonary bypass

Hemolysis, leukopenia, a hemostatic deficit, and nonspecific systemic reactions collectively known as the postperfusion syndrome develop in patients who undergo cardiopulmonary bypass. We now report that terminal C5b-9 complement complexes are deposited on erythrocytes and polymorphonuclear neutrophilic leukocytes during cardiopulmonary bypass. Plasma samples taken from 48 unselected patients during and at the end of cardiopulmonary bypass contained raised levels of fluid-phase SC5b-9 complement complexes, indicating that the complement sequence had been activated to completion. Various degrees of overt intravascular hemolysis were observed in all the patients, and lysed erythrocyte membranes were recovered from the blood samples. Immunoassays performed with use of antibodies to C5b-9 neoantigens demonstrated the presence of C5b-9 on red-cell ghosts but not on intact erythrocytes. The appearance of ghosts carrying C5b-9 always coincided with hemolysis. Furthermore, granulocytes isolated from 20 patients during bypass were all found to carry C5b-9 complexes, whereas cells isolated before or 24 hours after surgery carried no C5b-9. The neoantigen-positive material present in detergent extracts of granulocytes sedimented in a broad peak (25 to 40 sedimentation coefficient [S]) in sucrose-density gradients, exactly as did pore-forming C5b-9 complexes. Deposition of C5b-9 on blood cells during cardiopulmonary bypass may be partly responsible for the hemolysis and may augment granulocyte activation by the stimulation of arachidonate metabolism in those cells.

The myocardial contractile responses to protamine sulfate and heparin

The administration of protamine sulfate for the reversal of heparin anticoagulation has been associated with adverse hemodynamic changes including hypotension and decreased cardiac output. The possible direct toxic effect of protamine on human right atrial trabeculae contracting isometrically in vitro was studied. Muscles were stimulated to contract at 1 Hz in Tyrode's solution (maintained at 34 degrees C, pH 7.4) into which protamine was continuously added. Following a polynomial regression analysis, a parabolic dose-response curve resulted. The equation was: y = 95.13 + 38.76x - 278.71x2 where y = relative developed force and x = concentration of protamine (milligrams per milliliters) (r = 0.82). The estimated concentration of protamine resulting in 50% developed force was 0.48 mg/ml. In a second series of experiments, protamine was added to the bath along with a neutralizing amount of heparin. This resulted in a limited reduction in the fall of relative developed force. Thus, protamine in high concentrations alone or in complex with heparin has a direct toxic effect on human myocardial muscle mechanics, and care is warranted in its clinical use.

Pituitary apoplexy: a complication of cardiac surgery

Pituitary apoplexy occurred in 3 patients in the immediate postoperative period following cardiac operation with cardiopulmonary bypass. In this setting, this complication is extremely rare and not widely recognized. Precipitating factors may be related to the extracorporeal bypass apparatus, anticoagulation, low cerebral blood flow, and even anesthetic agents. Neurosurgical decompression can be safely performed in the early postoperative period following open-heart operations.

Effects of protamine administration after cardiopulmonary bypass on complement, blood elements, and the hemodynamic state

Nineteen patients were prospectively selected and studied before and after the administration of protamine sulfate following cardiopulmonary bypass (CPB). After protamine administration, C3a, C4a, and C4d were elevated; the peak levels of C3a and C4a were in samples taken 10 minutes after protamine administration while those of C4d were in those obtained at 5 hours. Only C3a was elevated after CPB and before protamine administration. In vitro, only the combination of protamine sulfate and heparin, and neither alone, resulted in increased C3a and C4a. Administration of protamine was associated with small and transient decreases in total white blood cells, granulocytes, and platelets, and with small and transient reductions in systemic and pulmonary arterial and left and right atrial pressures. Systemic vascular resistance fell (p = 0.07), and pulmonary vascular resistance rose but the change could be due to chance (p = 0.29). These data and those reported by others support the inference that complement activation occurs during CPB by the alternative pathway and again during protamine administration by the classic pathway; and that this accompanies a whole-body inflammatory reaction with blood cell and hemodynamic changes which, when extreme, could result in a severe hemodynamic derangement.