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Yoon SZ, Park JJ, Jung JS, Kim JE, Lee SH, Lee J, Kim EH. Effects of intravenous inflammasome inhibitor (NuSepin) on suppression of proinflammatory cytokines release induced by cardiopulmonary bypass in swine model: a pilot study. Sci Rep 2024; 14:12797. [PMID: 38834773 DOI: 10.1038/s41598-024-62944-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 05/22/2024] [Indexed: 06/06/2024] Open
Abstract
The systemic inflammatory response syndrome can occur due to an inflammatory reaction to the release of cytokines, and it has been linked to the circulation of pro- and anti-inflammatory cytokines. The cardiopulmonary bypass (CPB) system is known to activate numerous inflammatory pathways. Applying CPB in large animals for an extended period may be useful as a controlled experimental model for systemic inflammatory responses. The authors hypothesized that 0.2 mg/kg NuSepin® would inhibit CBP-induced proinflammatory cytokine release, and attenuate CPB-induced vasoplegia. CPB was maintained for 2 h in 8 male Yorkshire pigs. Ten ml of saline was administered intravenously to the control group, while the study group received 10 ml of NuSepin® (0.2 mg/kg), before start of CPB. Blood samples were collected at four different time points to evaluating the level of cytokine (TNF-α, IL-1β, IL-6, IL-8) release during and after CBP. All vital signals were recorded as continuous waveforms using the vital recorder®. Our study demonstrated that IL-6 increased in both groups during CPB remained unchanged. However, in the Nusepin group, IL-6 levels rapidly decreased when CPB was stopped and the proinflammatory reaction subsided. Furthermore, the dose of norepinephrine required to maintain a mean pressure of 60 mmHg was also lower in the Nusepin group.
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Affiliation(s)
- Seung Zhoo Yoon
- Department of Anesthesiology and Pain Medicine, Korea University College of Medicine, Seoul, Korea.
| | - Jeong Jun Park
- Department of Anesthesiology and Pain Medicine, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea
| | - Jae Seung Jung
- Department of Thoracic and Cardiovascular Surgery, Korea University College of Medicine, Seoul, Korea
| | - Ji Eon Kim
- Department of Thoracic and Cardiovascular Surgery, Korea University College of Medicine, Seoul, Korea
| | - Seung Hyong Lee
- Department of Thoracic and Cardiovascular Surgery, Korea University College of Medicine, Seoul, Korea
| | - Jeonghoon Lee
- Department of Anesthesiology and Pain Medicine, Korea University College of Medicine, Seoul, Korea
| | - Eung Hwi Kim
- Institute for Healthcare Innovation, Korea University College of Medicine, Seoul, Korea
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Nteliopoulos G, Nikolakopoulou Z, Chow BHN, Corless R, Nguyen B, Dimarakis I. Lung injury following cardiopulmonary bypass: a clinical update. Expert Rev Cardiovasc Ther 2022; 20:871-880. [PMID: 36408601 DOI: 10.1080/14779072.2022.2149492] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Cardiopulmonary bypass (CPB) is an integral component of cardiac surgery; however, one of its most critical complications is acute lung injury induced by multiple factors including systemic inflammatory response. AREAS COVERED The objective of this review is to investigate the multiple factors that can lead to CPB-induced lung injury. These include contact of blood components with the artificial surface of the CPB circuit, local and systemic inflammatory response syndrome (SIRS), lung ischemia/re-perfusion injury, arrest of ventilation, and circulating endotoxins. We also focus on possible interventions to curtail the negative impact of CPB, such as off-pump surgery, impregnation of the circuit with less biologically active substances, leukocyte depletion filters and ultrafiltration, and pharmacological agents such as steroids and aprotinin. EXPERT OPINION Although many aspects of CPB are proposed to contribute to lung injury, its overall role is still not clear. Multiple interventions have been introduced to reduce the risk of pulmonary dysfunction, with many of these interventions having shown promising results, significantly attenuating inflammatory mediators and improving post-operative outcome. However, since lung injury is multifactorial and affected by inextricably linked components, multiple interventions tackling each of them is required.
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Affiliation(s)
| | - Zacharoula Nikolakopoulou
- Department of Department of Immunology and Inflammation, Centre for Haematology, Imperial College London, London, UK
| | - Bobby Hiu Nam Chow
- Division of Cardiovascular Sciences, University of Manchester, Manchester, UK
| | | | - Bao Nguyen
- Department of Cardiothoracic Surgery, Derriford Hospital, Plymouth, UK
| | - Ioannis Dimarakis
- Division of Cardiovascular Sciences, University of Manchester, Manchester, UK.,Department of Cardiothoracic Transplantation and Mechanical Circulatory Support, Wythenshawe Hospital, Manchester, UK
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Romiti S, Totaro M, Laderchi A, Peruzzi M, Vinciguerra M, Greco E. Case Report: Emergency CABG Following Failure of PTCA in a COVID-19 Patient. Front Cardiovasc Med 2021; 7:620610. [PMID: 33505996 PMCID: PMC7829248 DOI: 10.3389/fcvm.2020.620610] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 12/14/2020] [Indexed: 12/15/2022] Open
Abstract
The coronavirus disease 2019 (COVID-19) pandemic outbreak, caused by severe acute respiratory syndrome coronavirus-2 (SARS-Cov-2) is affecting people worldwide representing a public health emergency. The effect of concomitant COVID-19 on patients who underwent cardiac surgery using cardiopulmonary bypass (CPB) is still undefined. Both SARS-Cov-2 infection and CPB can develop a cytokines storm and haemostatic disarrangements leading to acute respiratory distress syndrome (ARDS) and post-perfusion lung syndrome, respectively. SARS-Cov-2 infection may trigger and exacerbate post-inflammatory state after CPB resulting in higher risk of post-surgical adverse outcomes. International guidelines lack to provide standard management protocols for pre-operative COVID-19 patients requiring non-deferrable cardiac surgery intervention. We present a report of a successful coronary artery bypass grafting (CABG) emergency operation in a COVID-19 patient, who presented unstable angina and coronary artery dissection during cardiac catheterization and percutaneous transluminal coronary angioplasty (PTCA).
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Affiliation(s)
- Silvia Romiti
- Department of Clinical, Internal Medicine, Anaesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | - Marco Totaro
- Department of Clinical, Internal Medicine, Anaesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | - Amalia Laderchi
- Department of Anaesthesiology, Sant'Andrea Hospital, Rome, Italy
| | - Mariangela Peruzzi
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy.,Mediterranea Cardiocentro, Naples, Italy
| | - Mattia Vinciguerra
- Department of Clinical, Internal Medicine, Anaesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | - Ernesto Greco
- Department of Clinical, Internal Medicine, Anaesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
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Cheng ZB, Chen H. Higher incidence of acute respiratory distress syndrome in cardiac surgical patients with elevated serum procalcitonin concentration: a prospective cohort study. Eur J Med Res 2020; 25:11. [PMID: 32228702 PMCID: PMC7106626 DOI: 10.1186/s40001-020-00409-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 03/23/2020] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Inflammatory response is activated during cardiopulmonary bypass (CPB), which may lead to acute respiratory distress syndrome (ARDS) and procalcitonin (PCT) increases during this inflammatory response. The objective of the study was to validate whether patients with higher serum PCT concentrations have a higher incidence of ARDS. METHODS The study was a prospective, single-center, observational cohort study. All patients who received cardiac surgery with CPB were screened for study eligibility. Patients were assigned to the PCT-elevated cohort or the control cohort according to serum PCT concentration on the first postoperative day with a cut-off value of 7.0 ng/mL. Patients were followed up until the 7th postoperative day. The primary endpoint was the incidence of ARDS, which was diagnosed according to the Berlin definition. RESULTS A total of 296 patients were enrolled, 64 patients were assigned to the PCT-elevated cohort and 232 patients were assigned to the control cohort. PCT concentration was 16.23 ± 5.9 ng/mL in the PCT-elevated cohort, and 2.70 ± 1.43 ng/mL in the control cohort (p < 0.001). The incidence of ARDS was significantly higher in the PCT-elevated cohort than in the control cohort (21.9% versus 5.6%, p < 0.001). The incidence of moderate-to-severe ARDS was also significantly higher in the PCT-elevated cohort than in the control cohort (10.9% versus 0.4%, p < 0.001). The hazard ratio of ARDS at 7 days in the PCT-elevated cohort, as compared with the control cohort, was 6.8 (95% confidence interval 2.7 to 17.4). The hazard ratio of moderate-to-severe ARDS in the PCT-elevated cohort was 57.3 (95% confidence interval 10.4 to 316.3). The positive predictive value of PCT for ARDS and moderate-to-severe ARDS were 0.242 and 0.121, respectively; the negative predictive value of PCT for ARDS and moderate-to-severe ARDS were 0.952 and 1.0, respectively. CONCLUSION Cardiac surgical patients with elevated PCT concentration have a higher incidence of ARDS. Elevated PCT may serve as a warning signal of postoperative ARDS in patients undergoing cardiac surgery with CPB. Study registration Chinese Clinical Trial Registry (ChiCTR-OCH-14005076).
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Affiliation(s)
- Zhang-Bo Cheng
- Department of Cardiosurgery, Fujian Provincial Hospital, 134 Dongjie Street, Fuzhou, Fujian, China.,Fujian Provincial Clinical College, Fujian Medical University, Fuzhou, Fujian, China
| | - Han Chen
- Surgical Intensive Care Unit, Fujian Provincial Hospital, 134 Dongjie Street, Fuzhou, Fujian, China. .,Fujian Provincial Clinical College, Fujian Medical University, Fuzhou, Fujian, China.
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Dryer C, Tolpin D, Anton J. Con: Mechanical Ventilation During Cardiopulmonary Bypass Does Not Improve Outcomes After Cardiac Surgery. J Cardiothorac Vasc Anesth 2018; 32:2001-2004. [PMID: 29680491 DOI: 10.1053/j.jvca.2018.02.030] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2018] [Indexed: 01/22/2023]
Affiliation(s)
- Chinwe Dryer
- Division of Cardiovascular Anesthesiology, Texas Heart Institute, Baylor St. Luke's Medical Center, Houston, TX; Department of Anesthesiology, Baylor College of Medicine, Houston, TX.
| | - Daniel Tolpin
- Division of Cardiovascular Anesthesiology, Texas Heart Institute, Baylor St. Luke's Medical Center, Houston, TX; Department of Anesthesiology, Baylor College of Medicine, Houston, TX
| | - James Anton
- Division of Cardiovascular Anesthesiology, Texas Heart Institute, Baylor St. Luke's Medical Center, Houston, TX; Department of Anesthesiology, Baylor College of Medicine, Houston, TX
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Rhee KY, Sung TY, Kim JD, Kang H, Mohamad N, Kim TY. High-dose ulinastatin improves postoperative oxygenation in patients undergoing aortic valve surgery with cardiopulmonary bypass: A retrospective study. J Int Med Res 2018; 46:1238-1248. [PMID: 29332409 PMCID: PMC5972268 DOI: 10.1177/0300060517746841] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Objective To determine whether pre-treatment with high-dose ulinastatin provides enhanced postoperative oxygenation in patients who have undergone aortic valve surgery with moderate hypothermic cardiopulmonary bypass (CPB). Methods Patients who underwent aortic valve surgery with moderate hypothermic CPB were retrospectively evaluated. In total, 94 of 146 patients were included. The patients were classified into one of two groups: patients in whom ulinastatin (10,000 U/kg followed by 5,000 U/kg/h) was administered during CPB (Group U, n = 38) and patients in whom ulinastatin was not administered (Group C, n = 56). The PaO2/FiO2 ratio was calculated at the following time points: before CPB (pre-CPB), 2 h after weaning from CPB (post-CPB), and 6 h after arrival to the intensive care unit (ICU-6). The incidence of a low PaO2/FiO2 ratio was also compared among the time points. Results Group U showed a significantly higher PaO2/FiO2 ratio (F(4, 89.0) = 657.339) and a lower incidence of lung injury (PaO2/FiO2 ratio < 300) than Group C at the post-CPB and ICU-6 time points. Conclusion High-dose ulinastatin improved pulmonary oxygenation after CPB and in the early stages of the ICU stay in patients undergoing aortic valve surgery with CPB.
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Affiliation(s)
- Ka-Young Rhee
- 1 Department Anaesthesiology, Konkuk University School of Medicine, Seoul, Korea
| | - Tae-Yun Sung
- 2 Department of Anaesthesiology and Pain Medicine, Konkuk University School of Medicine Konyang University College of Medicine, Daejeon, Korea
| | - Ju Deok Kim
- 3 Department of Anaesthesiology and Pain Medicine, 89482 Kosin University College of Medicine 384997 Konyang University College of Medicine 58933 Konkuk University School of Medicine 37985 Chung-Ang University College of Medicine and Graduate School of Medicine 58933 Konkuk University School of Medicine Kosin University School of Medicine, Busan, Korea
| | - Hyun Kang
- 4 Department of Anaesthesiology and Pain Medicine, 89482 Kosin University College of Medicine 384997 Konyang University College of Medicine 58933 Konkuk University School of Medicine 37985 Chung-Ang University College of Medicine and Graduate School of Medicine 58933 Konkuk University School of Medicine Chung-Ang University School of Medicine, Seoul, Korea
| | - Nazri Mohamad
- 5 Department of Anaesthesiology and Perfusion, 65187 Hospital Tengku Ampuan Afzan Hospital Tengku Ampuan Afzan, Kuantan, Malaysia
| | - Tae-Yop Kim
- 1 Department Anaesthesiology, Konkuk University School of Medicine, Seoul, Korea.,6 Department of Anaesthesiology, Konkuk University Medical Center, Seoul, Korea
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Tang M, Gu YJ, Wang WJ, Xu YP, Chen CZ. Effect of cardiopulmonary bypass on leukocyte activation: changes in membrane-bound elastase on neutrophils. Perfusion 2016; 19:93-9. [PMID: 15162923 DOI: 10.1191/0267659104pf727oa] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Background: Neutrophil elastase is known to be released from the activated leukocytes as a result of cardiopulmonary bypass (CPB). However, its biological effect on organ injury is questionable because it is quickly bound by natural proteinase inhibitors (PIs). Recently, membrane-bound elastase (MBE) was found to be able to resist the PIs’ process and, thus, is biologically more active. This paper studies the effect of CPB on the kinetic change of MBE and its possible link to postoperative inflammation and organ function.Method: Ten consecutive patients undergoing elective coronary artery bypass grafting (CABG) surgery with CPB were recruited into the study. Blood samples were taken before sternotomy, after aortic declamping, at the end of CPB, three and six hours after CPB and on the first postoperative day. MBE was determined by substrate assay from isolated neutrophils. Inflammation and organ function markers were determined according to routine laboratory methods.Results: MBE slightly increased after aortic declamping, while it significantly increased and reached its peak at the end of CPB; it returned to its preoperative level on the first postoperative day. In contrast to lung sequestration of neutrophils, there was no transpulmonary gradient of MBE between left and right atria after aortic declamping. Neither MBE nor total MBE activity was positively correlated with postoperative inflammation markers such as blood lactate and C-reactive protein and organ function markers such as creatine phosphokinase and alanine aminotransferase.Conclusions: CPB induces increased MBE expression on neutrophils with its peak at the end of CPB. Lack of association between neutrophil MBE and clinical markers suggests that multiple systems might be involved in the post-CPB inflammatory reaction and organ dysfunction.
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Affiliation(s)
- M Tang
- Department of Cardiothoracic Surgery, Ren Ji Hospital affiliated to Shanghai Second Medical University, Pudong district, Shanghai, PR China
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Su ZK, Sun Y, Yang YM, Zhang HB, Xu ZW. Lung Function after Deep Hypothermic Cardiopulmonary Bypass in Infants. Asian Cardiovasc Thorac Ann 2016; 11:328-31. [PMID: 14681094 DOI: 10.1177/021849230301100412] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
There is increasing concern about neurologic injury due to deep hypothermia with low flow during repair of complex congenital heart defects in neonates and infants. Twenty infants with ventricular septal defect and pulmonary hypertension were randomly assigned to cardiac repair under deep hypothermia with circulatory arrest or deep hypothermia with low flow. Measurements of static pulmonary compliance, airway resistance, and respiratory index were performed before institution of cardiopulmonary bypass and at 5 minutes and 2 hours after cessation of cardiopulmonary bypass. Both groups had significant pulmonary dysfunction in terms of static pulmonary compliance, airway resistance, and respiratory index. There was greater impairment of pulmonary compliance and respiratory index after deep hypothermia with low flow, and this group required longer intensive care unit stay.
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Affiliation(s)
- Zhao Kang Su
- Department of Cardiothoracic Surgery, Shanghai Children's Medical Center, Xinua Hospital, Shanghai Second Medical University, Shanghai 200127, People's Republic of China.
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Coronary Artery Bypass Surgery and Percutaneous Coronary Revascularization: Impact on Morbidity and Mortality in Patients with Coronary Artery Disease. Coron Artery Dis 2015. [DOI: 10.1007/978-1-4471-2828-1_26] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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10
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Esper SA, Subramaniam K, Tanaka KA. Pathophysiology of Cardiopulmonary Bypass. Semin Cardiothorac Vasc Anesth 2014; 18:161-76. [DOI: 10.1177/1089253214532375] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
The techniques and equipment of cardiopulmonary bypass (CPB) have evolved over the past 60 years, and numerous numbers of cardiac surgical procedures are conducted around the world using CPB. Despite more widespread applications of percutaneous coronary and valvular interventions, the need for cardiac surgery using CPB remains the standard approach for certain cardiac pathologies because some patients are ineligible for percutaneous procedures, or such procedures are unsuccessful in some. The ageing patient population for cardiac surgery poses a number of clinical challenges, including anemia, decreased cardiopulmonary reserve, chronic antithrombotic therapy, neurocognitive dysfunction, and renal insufficiency. The use of CPB is associated with inductions of systemic inflammatory responses involving both cellular and humoral interactions. Inflammatory pathways are complex and redundant, and thus, the reactions can be profoundly amplified to produce a multiorgan dysfunction that can manifest as capillary leak syndrome, coagulopathy, respiratory failure, myocardial dysfunction, renal insufficiency, and neurocognitive decline. In this review, pathophysiological aspects of CPB are considered from a practical point of view, and preventive strategies for hemodilutional anemia, coagulopathy, inflammation, metabolic derangement, and neurocognitive and renal dysfunction are discussed.
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Ultrasound monitoring of RBC aggregation as a real-time marker of the inflammatory response in a cardiopulmonary bypass swine model. Crit Care Med 2013; 41:e171-8. [PMID: 23648566 DOI: 10.1097/ccm.0b013e31828a2354] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES In many pathological conditions, including high-risk surgery, the severity of the inflammatory response is related to the patient outcome. However, determining the patient inflammatory state presents difficulties, as markers are obtained intermittently through blood testing with long delay. RBC aggregation is a surrogate marker of inflammation that can be quantified with the ultrasound Structure Factor Size and Attenuation Estimator. The latter is proposed as a real-time inflammation monitoring technique for patient care. DESIGN Ten swine underwent a 90-minute cardiopulmonary bypass, and surveillance was maintained during 120 minutes in the postbypass period. To promote the inflammatory reaction, lipopolysaccharide was administrated two times prior to surgery in six of those swine (lipopolysaccharide group). During the whole procedure, the Structure Factor Size and Attenuation Estimator cellular imaging method displayed a RBC aggregation index (W) computed from images acquired within the pump circuit and the femoral vein. Interleukin-6, interleukin-10, C-reactive protein, haptoglobin, immunoglobulin G, and fibrinogen concentrations were measured at specific periods. MAIN RESULTS Compared with controls, the lipopolysaccharide group exhibited higher W within the pump circuit (p < 0.05). In the femoral vein, W was gradually amplified in the lipopolysaccharide group during cardiopulmonary bypass and the postbypass period (p < 0.05), whereas interleukin levels were higher in the lipopolysaccharide group but only at the end of cardiopulmonary bypass and beginning of postbypass (p < 0.05). CONCLUSIONS Continuous RBC aggregation monitoring can characterize the evolving inflammatory response during and after cardiopulmonary bypass. The Structure Factor Size and Attenuation Estimator is proposed as a real-time noninvasive monitoring technique to anticipate inflammation-related complications during high-risk surgery or critical care situations. Because RBC aggregation promotes vascular resistance and thrombosis, W could also provide early information on vascular disorders in those clinical situations.
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12
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ZHANG ZHIWEI, WU YUAN, ZHAO YUAN, XIAO XIANZHONG, LIU JUNWEN, ZHOU XINMIN. Dynamic changes in HMGB1 levels correlate with inflammatory responses during cardiopulmonary bypass. Exp Ther Med 2013; 5:1523-1527. [PMID: 23737912 PMCID: PMC3671828 DOI: 10.3892/etm.2013.1026] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2012] [Accepted: 03/06/2013] [Indexed: 12/03/2022] Open
Abstract
High mobility group box 1 (HMGB1), which is released by activated immune cells and necrotic cells, has properties similar to those of pro-inflammatory cytokines. Cardiopulmonary bypass (CPB) induces systemic inflammation and aortic cross-clamping induces myocardial ischemia. This study was conducted to observe the dynamic changes of HMGB1 and tumor necrosis factor (TNF)-α levels during CPB and to analyze their clinical significance. A total of 78 cases of American Society of Anesthesiologists (ASA) grade II-IV undergoing elective valve replacement under CPB were included in this study. Blood and urine samples were collected after anesthesia prior to surgery (T1), before aortic cross-clamping (T2), after CPB (T3) and on the first day after surgery (T4), as well as the second (T5) and third (T6) day after surgery for determination of the levels of HMGB1, TNF-α, alanine aminotransferase (ALT), creatinine (Cr), blood urea nitrogen (BUN), N-acetyl-β-D-glucosamidase (NAG) and β2-microglobulin (β2-MG). Results revealed that: i) the serum levels of HMGB1 elevated as early as T1, increased until reaching a peak at T3, then decreased to a lower level at T4; ii) the serum level of TNF-α was low at T1, gradually increased in a similar manner to HMGB1, then decreased following CPB and reached the lowest point at T5; and iii) the levels of HMGB1 were positively correlated with serum TNF-α and serum ALT at T3. In conclusion, HMGB1 levels may be used as an indicator of inflammation and may be a novel target for controlling inflammation during CPB. The optimal treatment time is T3 (after CPB).
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Affiliation(s)
- ZHIWEI ZHANG
- Department of Cardiothoracic Surgery, The Second Xiang-Ya Hospital, Central South University, Changsha, Hunan 410011
| | - YUAN WU
- Department of Cardiothoracic Surgery, The Second Xiang-Ya Hospital, Central South University, Changsha, Hunan 410011
| | - YUAN ZHAO
- Department of Cardiothoracic Surgery, The Second Xiang-Ya Hospital, Central South University, Changsha, Hunan 410011
| | - XIANZHONG XIAO
- Department of Pathophysiology, School of Basic Medical Sciences, Central South University, Changsha, Hunan 410078,
P.R. China
| | - JUNWEN LIU
- Department of Pathophysiology, School of Basic Medical Sciences, Central South University, Changsha, Hunan 410078,
P.R. China
| | - XINMIN ZHOU
- Department of Cardiothoracic Surgery, The Second Xiang-Ya Hospital, Central South University, Changsha, Hunan 410011
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13
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Song J, Park J, Kim JY, Kim JD, Kang WS, Muhammad HB, Kwon MY, Kim SH, Yoon TG, Kim TY, Chung JW. Effect of ulinastatin on perioperative organ function and systemic inflammatory reaction during cardiac surgery: a randomized double-blinded study. Korean J Anesthesiol 2013; 64:334-40. [PMID: 23646243 PMCID: PMC3640166 DOI: 10.4097/kjae.2013.64.4.334] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2012] [Revised: 10/08/2012] [Accepted: 10/09/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND This study evaluated the efficacy of ulinastatin for attenuating organ injury and the release of proinflammatory cytokines due to cardiopulmonary bypass (CPB) during cardiac surgery. METHODS Patients undergoing valvular heart surgery employing CPB were assigned to receive either ulinastatin (group U, n = 13) or a placebo (group C, n = 11) before the commencement of CPB. Hemodynamic data, parameters of major organ injury and function, and proinflammatory cytokines were measured after the induction of anesthesia (T1), after CPB (T2), at the end of anesthesia (T3), and at 24 hours after surgery (POD). RESULTS The demographic data, CPB duration, and perioperative transfusions were not different between the groups. PaO2/FiO2 in group U was significantly higher than that in group C at T3 (3.8 ± 0.8 vs. 2.8 ± 0.7, P = 0.005) and at POD (4.0 ± 0.7 vs. 2.8 ± 0.7, P < 0.001). Creatine kinase-MB at POD in group U was significantly lower than that in group C (17.7 ± 8.3 vs. 33.7 ± 22.1, P = 0.03), whereas troponin I at POD was not different between the groups. Creatinine clearance and the extubation time were not different between the groups at POD. The dopamine infusion rate during the post-CPB period in group U was significantly lower than that in group C (1.6 ± 1.6 vs. 5.5 ± 3.3 µg/kg/min, P = 0.003). The interleukin-6 and tumor necrosis factor-α concentrations at T1, T2, and T3 as well as the incidences of postoperative cardiac, pulmonary and kidney injuries were not different between the groups. CONCLUSIONS Ulinastatin pretreatment resulted in an improved oxygenation profile and reduced inotropic support, probably by attenuating the degree of cardiopulmonary injury; however, it did not reduce the levels of proinflammatory cytokines.
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Affiliation(s)
- Jieun Song
- Department of Anesthesiology, CHA Bundang Medical Center, CHA University, Seongnam, Korea
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14
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Muedra V. [Acquired antithrombin III deficiency in cardiac surgery: an update]. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2012; 59:347-349. [PMID: 22749326 DOI: 10.1016/j.redar.2012.05.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/13/2012] [Revised: 05/03/2012] [Accepted: 05/08/2012] [Indexed: 06/01/2023]
Affiliation(s)
- V Muedra
- Grupo de Investigación Multidisciplinar de la Antitrombina y Cirugía Cardiaca, Hospital Universitario La Ribera, Alzira, Valencia, España
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15
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Pino CJ, Lou L, Smith PL, Ding F, Pagani FD, Buffington DA, Humes HD. A selective cytopheretic inhibitory device for use during cardiopulmonary bypass surgery. Perfusion 2012; 27:311-9. [PMID: 22508804 DOI: 10.1177/0267659112444944] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Systemic inflammatory response syndrome (SIRS) can occur in association with cardiopulmonary bypass (CPB) surgery, resulting in multiple organ dysfunction (MOD). Activated neutrophils have been implicated as major inciting factors in this process. Neutrophil-depleting filters incorporated within the extracorporeal blood circuit during CPB have been developed and evaluated, with inconsistent clinical results. METHODS A novel, biomimetic, selective cytopheretic device (SCD) was tested in vitro within a blood circuit to assess safety and interactions with blood components and further evaluated ex vivo in a bovine model of CPB surgery during ventricular assist device implantation. RESULTS In vitro blood circuit studies demonstrated that the SCD reduces circulating neutrophils while maintaining low rates of hemolysis compared to current leukocyte-reduction filters. In the bovine CPB model, animals without SCD treatment (No SCD) demonstrated an increase in circulating white blood cell (WBC) and neutrophil counts, steadily increasing throughout CPB. SCD with only systemic heparin anticoagulation (SCD-H) acutely reduced neutrophils for the first 2 hrs of CPB, but followed with a greater than 6-fold increase in neutrophil counts. SCD treatment with regional citrate anticoagulation along the SCD circuit (SCD-C) reduced systemic neutrophil counts throughout 4 hrs of CPB despite lower amounts of eluted cells from the SCD. When analyzed for immature neutrophils, the control and SCD-H showed increasing counts at later time-points, not seen in the SCD-C group, suggesting a more complex mechanism of action than simple leukoreduction. CONCLUSIONS These results suggest that SCD-C therapy may disrupt the systemic leukocyte response during CPB, leading to improved outcomes for CPB-mediated MOD.
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Affiliation(s)
- C J Pino
- Innovative BioTherapies Inc., Ann Arbor, MI 48108, USA
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Tetik S, Ak K, Sahin Y, Gulsoy O, Isbir S, Arsan S, Yardimci T. Postoperative Statin Therapy Attenuates the Intensity of Systemic Inflammation and Increases Fibrinolysis After Coronary Artery Bypass Grafting. Clin Appl Thromb Hemost 2010; 17:526-31. [DOI: 10.1177/1076029610379398] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
A total of 25 patients undergoing coronary artery bypass grafting (CABG) were included in the study. Patients received statin (20 mg daily) postoperatively for 2 weeks. All analyses were performed at 2 different time points: preoperatively (group 1) and 2 weeks after operation (group 2). Interleukin (IL)-6, IL-8, plasminogen activator inhibitor 1 (PAI-1), tumor necrosis factor α (TNF-α), tissue plasminogen activator (t-PA) levels, and tissue factor pathway inhibitor (TFPI) were evaluated. Statin treatment caused a significant reduction in the plasma level of PAI-1 (preop: 15.04 ± 0.13 ng/mL vs postop: 13.89 ± 2.14 ng/mL; P < .05) and increased t-PA levels (preop: 109.74 ± 0.13 vs postop: 231.40 ± 1.22 ng/mL; P < .001). Plasma TNF-α and IL-6 levels did not change with treatment. Statin treatment caused a significant reduction in plasma IL-8 level (279.70 ± 3.42 ng/mL vs postop: 207.18 ± 3.63 ng/mL, P < .05), and TFPI (4.87 ± 2.05 ng/mL vs postop: 6.27 ± 1.25 ng/mL; P < .05). The results demonstrate that atorvastatin attenuates systemic inflammatory reaction after cardiac surgery.
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Affiliation(s)
- Sermin Tetik
- Department of Biochemistry, Faculty of Pharmacy, Marmara University, Istanbul, Turkey
| | - Koray Ak
- School of Medicine, Department of Cardiovascular Surgery, Marmara University, Istanbul, Turkey
| | - Yucel Sahin
- Department of Biochemistry, Faculty of Pharmacy, Marmara University, Istanbul, Turkey
| | | | - Selim Isbir
- School of Medicine, Department of Cardiovascular Surgery, Marmara University, Istanbul, Turkey
| | - Sinan Arsan
- School of Medicine, Department of Cardiovascular Surgery, Marmara University, Istanbul, Turkey
| | - Turay Yardimci
- Department of Biochemistry, Faculty of Pharmacy, Marmara University, Istanbul, Turkey
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Luciani R, Goracci M, Simon C, Principe F, Fazzari L, Punzo G, Menè P. Reduction of Early Postoperative Morbidity in Cardiac Surgery Patients Treated With Continuous Veno-Venous Hemofiltration During Cardiopulmonary Bypass. Artif Organs 2009; 33:654-7. [DOI: 10.1111/j.1525-1594.2009.00777.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Goebel U, Mecklenburg A, Siepe M, Roesslein M, Schwer CI, Pahl HL, Priebe HJ, Schlensak C, Loop T. Protective effects of inhaled carbon monoxide in pig lungs during cardiopulmonary bypass are mediated via an induction of the heat shock response. Br J Anaesth 2009; 103:173-84. [PMID: 19403594 DOI: 10.1093/bja/aep087] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Cardiopulmonary bypass (CPB) may cause acute lung injury leading to increased morbidity and mortality after cardiac surgery. Preconditioning by inhaled carbon monoxide reduces pulmonary inflammation during CPB. We hypothesized that inhaled carbon monoxide mediates its anti-inflammatory and cytoprotective effects during CPB via induction of pulmonary heat shock proteins (Hsps). METHODS Pigs were randomized either to a control group, to standard CPB, to carbon monoxide+CPB, or to quercetin (a flavonoid and unspecific inhibitor of the heat shock response)+control, to quercetin+CPB, and to quercetin+carbon monoxide+CPB. In the carbon monoxide groups, lungs were ventilated with 250 ppm carbon monoxide in addition to standard ventilation before CPB. At various time points, lung biopsies were obtained and pulmonary Hsp and cytokine concentrations determined. RESULTS Haemodynamic parameters were largely unaffected by CPB, carbon monoxide inhalation, or administration of quercetin. Compared with standard CPB, carbon monoxide inhalation significantly increased the pulmonary expression of the Hsps 70 [27 (SD 3) vs 69 (10) ng ml(-1) at 120 min post-CPB, P<0.05] and 90 [0.3 (0.03) vs 0.52 (0.05) after 120 min CPB, P<0.05], induced the DNA binding of heat shock factor-1, reduced interleukin-6 protein expression [936 (75) vs 320 (138) at 120 min post-CPB, P<0.001], and decreased CPB-associated lung injury (assessed by lung biopsy). These carbon monoxide-mediated effects were inhibited by quercetin. CONCLUSIONS As quercetin, a Hsp inhibitor, reversed carbon monoxide-mediated pulmonary effects, we conclude that the anti-inflammatory and protective effects of preconditioning by inhaled carbon monoxide during CPB in pigs are mediated by an activation of the heat shock response.
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Affiliation(s)
- U Goebel
- Department of Anaesthesia and Critical Care Medicine, University Medical Center, Hugstetterstrasse 55, D-79106 Freiburg im Breisgau, Germany
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Shaw DM, Sutherland AM, Russell JA, Lichtenstein SV, Walley KR. Novel polymorphism of interleukin-18 associated with greater inflammation after cardiac surgery. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2009; 13:R9. [PMID: 19178691 PMCID: PMC2688121 DOI: 10.1186/cc7698] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/03/2008] [Revised: 12/01/2008] [Accepted: 01/29/2009] [Indexed: 02/06/2023]
Abstract
Introduction Interleukin (IL)-18 is a key modulator of the cytokine response that leads to organ dysfunction and prolonged intensive care unit (ICU) stay after cardiopulmonary bypass surgery. We hypothesised that variation in the pro-inflammatory gene IL-18 is associated with adverse clinical outcome because of a more intense inflammatory response. Methods Haplotypes of the IL-18 gene were inferred from genotypes of 23 Coriell Registry subjects. Four haplotype tag single nucleotide polymorphisms (-607 C/A, -137 G/C, 8148 C/T and 9545 T/G) identified four major haplotype clades. These polymorphisms were genotyped in 658 Caucasian patients undergoing cardiopulmonary bypass surgery. Clinical phenotypes were collected by retrospective chart review. Results Patients homozygous for the T allele of the 9545 T/G polymorphism had an increased occurrence of prolonged ICU stay (6.8% for TT genotype versus 2.7% for GG or GT genotype; p = 0.015). Patients homozygous for the T allele also had increased occurrence of low systemic vascular resistance index (62%) compared with the GG and GT genotypes (53%; p = 0.045). Patients homozygous for the T allele had increased serum IL-18 concentrations 24 hours post-surgery (p = 0.018), increased pro-inflammatory tumour necrosis factor alpha concentrations (p = 0.014) and decreased anti-inflammatory serum IL-10 concentrations (p = 0.018) 24 hours post-surgery. Conclusions The TT genotype of the IL-18 9545 T/G polymorphism is associated with an increased occurrence of prolonged ICU stay post-surgery and greater post-surgical inflammation. These results may be explained by greater serum IL-18, leading to greater pro-versus anti-inflammatory cytokine expression.
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Affiliation(s)
- David M Shaw
- Critical Care Research Laboratories, Heart + Lung Institute, University of British Columbia, Vancouver, BC, Canada
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Carvalho EMF, Gabriel EA, Salerno TA. Pulmonary protection during cardiac surgery: systematic literature review. Asian Cardiovasc Thorac Ann 2009; 16:503-7. [PMID: 18984765 DOI: 10.1177/021849230801600617] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Ischemia-reperfusion injury occurs during heart surgery in which cardiopulmonary bypass is used. Current knowledge of the factors contributing to postoperative pulmonary dysfunction and the measures to avoid it are reviewed.
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Affiliation(s)
- Enisa M F Carvalho
- Division of Cardiothoracic Surgery, University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami, Florida 33136, USA
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Sauvée M, Poignet P, Dombre E. Ultrasound Image-Based Visual Servoing of a Surgical Instrument Through Nonlinear Model Predictive Control. Int J Rob Res 2008. [DOI: 10.1177/0278364907082269] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Ultrasound image-guided interventions are widespread in surgery because of the non-invasive character of the procedures. However, hand/eye synchronization is relatively difficult for a surgeon. Ultrasound image-based visual servoing is one way to perform this kind of surgery. In this work, the control of instrument motion based on ultrasound images through nonlinear model predictive control is investigated. This new scheme ensures the convergence of the instrument to the desired position and also offers the possibility of satisfying constraints such as joint limits, actuator saturation and visibility preserving. This paper describes the proposed controller. The efficiency and the robustness of the proposed solution to control a six degree-of-freedom mechanical system is first illustrated by simulation. Experiments on a Mitsubishi PA10 robot highlight the efficiency of the vision control scheme to handle constraints of ultrasound image-based visual servoing.
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Affiliation(s)
- Mickaël Sauvée
- LIRMM (Laboratoire d'informatique, de Robotique et de Microélectronique de Montpellier), UMR 5506 CNRS Université de Montpellier 2 161 rue Ada, 34392 Montpellier Cedex 5, France, sauvee, @lirmm.fr
| | - Philippe Poignet
- LIRMM (Laboratoire d'informatique, de Robotique et de Microélectronique de Montpellier) UMR 5506 CNRS Université de Montpellier 2 161 rue Ada, 34392 Montpellier Cedex 5, France, poignet, @lirmm.fr
| | - Etienne Dombre
- LIRMM (Laboratoire d'informatique, de Robotique et de Microélectronique de Montpellier) UMR 5506 CNRS Université de Montpellier 2 161 rue Ada, 34392 Montpellier Cedex 5, France,
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Three-dimensional heart motion estimation using endoscopic monocular vision system: From artificial landmarks to texture analysis. Biomed Signal Process Control 2007. [DOI: 10.1016/j.bspc.2007.07.006] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Novitzky D, Shroyer AL, Collins JF, McDonald GO, Lucke J, Hattler B, Kozora E, Bradham DD, Baltz J, Grover FL. A study design to assess the safety and efficacy of on-pump versus off-pump coronary bypass grafting: the ROOBY trial. Clin Trials 2007; 4:81-91. [PMID: 17327248 DOI: 10.1177/1740774506075859] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Since the late 1960s, coronary artery bypass graft (CABG-only) procedures were traditionally performed using a heart-lung machine on an arrested heart (on-pump). Over the past decade, an increasing number CABG-only procedures were performed on a beating heart (off-pump). Advocates of the off-pump approach expect to reduce many of the adverse side effects related to using the heart-lung machine, while advocates for the on-pump procedure raise concerns related to graft patency rates and long-term event-free survival for the off-pump technique. Purpose The U.S. Department of Veteran Affairs (VA) Cooperative Studies Program funded a randomized, multicenter clinical trial comparing the clinical and resourcerelated outcomes following on-pump versus off-pump techniques for veterans undergoing a non-emergent CABG-only procedure. The planning committee was faced with several critically important challenges to assure feasibility of study costs and required sample size; generalizability to non-VA surgical practices; and comparability of clinically meaningful results. These challenges are discussed. Methods This study is a prospective, randomized, multicenter, single blinded (patient) clinical trial that compares on-pump and off-pump techniques for veterans requiring non-emergent CABG-only procedures. There will be 2200 patients randomized at 17 VA Medical Centers when the five-year recruitment period ends on 15 April 2007. There are two primary objectives: a short-term objective to assess the immediate impact of the two techniques on 30-day mortality/morbidity and a long-term objective to assess one-year mortality/morbidity. Major secondary outcomes are one-year graft patency rates and change in neuropsychological assessments from baseline to one year. All patients are assessed at 30 days post-surgery or discharge from the hospital, whichever is latest, and at one-year post-surgery. Results During planning, several key issues had to be decided. These included 1) choosing primary objectives: a short-term (30-day) and a long-term (one-year) objective were chosen; 2) choosing primary outcome measures: composite measures were selected to ensure sufficient end-points; 3) standardization of surgical techniques: minimal standardization required but guidelines and continuing discussions on both techniques provided; 4) establishing criteria for surgeons and residents for participation: surgeons required to have completed 20 off-pump procedures prior to doing study procedures and residents, in presence of study surgeon, capable of doing either procedure; 5) identifying metrics of cognitive dysfunction sensitive to treatment: a neuropshychologist hired who centrally monitors cognitive functioning testing; and 6) blinding participants of surgical procedure: attempt to blind participants. Limitations Areas of concern are whether all surgeons sufficiently experienced on the off-pump procedure, should residents have been allowed to do study surgeries, should techniques have been standardized more and were the best neurocognitive tests selected. Conclusion The study design presented allows for a balanced and fair assessment of the on-pump and off-pump CABG procedures across a diversity of clinical outcomes and resource use metrics. Its results have the potential to influence clinical cardiac surgical practice in the future.
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Wilson JM, Ferguson JJ, Hall RJ. Coronary Artery Bypass Surgery and Percutaneous Coronary Revascularization: Impact on Morbidity and Mortality in Patients with Coronary Artery Disease. CARDIOVASCULAR MEDICINE 2007. [DOI: 10.1007/978-1-84628-715-2_50] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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Wakayama F, Fukuda I, Suzuki Y, Kondo N. Neutrophil Elastase Inhibitor, Sivelestat, Attenuates Acute Lung Injury After Cardiopulmonary Bypass in the Rabbit Endotoxemia Model. Ann Thorac Surg 2007; 83:153-60. [PMID: 17184651 DOI: 10.1016/j.athoracsur.2006.08.023] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2006] [Revised: 08/03/2006] [Accepted: 08/08/2006] [Indexed: 11/30/2022]
Abstract
BACKGROUND Neutrophil elastase probably contributes to the development of acute lung injury after cardiopulmonary bypass (CPB) in patients with infection or shock. We evaluated whether pretreatment with sivelestat sodium hydrate, a neutrophil elastase inhibitor (EI), can prevent acute lung injury caused by CPB. METHODS Rabbits were assigned four groups: CPB for 60 minutes, control CPB group; low-dose lipopolysaccharide (LPS) administration without CPB, LPS group; CPB after lipopolysaccharide administration, LPS+CPB group; or preparation with continuous infusion of sivelestat and CPBs after lipopolysaccharide administration, EI group. Blood samples to determine blood gas concentration, plasma elastase activity, and plasma interleukin-8 levels were obtained. Histopathologic examinations of the lung were performed. RESULTS The decreased arterial oxygen pressure at the end of CPB was observed in the LPS+CPB group only, but was suppressed in the EI group (p < 0.01). Elastase activity was markedly elevated at 120 minutes after CPB, and interleukin-8 levels were markedly elevated at 180 minutes in the LPS+CPB group but were much lower (p < 0.05) in the EI group. Histopathology demonstrated accumulation of polymorphonuclear neutrophils in bronchoalveolar areas in the LPS+CPB group (p < 0.01). Pulmonary myeloperoxidase activity was significantly lower in the LPS+CPB group than in the other groups (p < 0.01). These changes were minimal in the EI group. CONCLUSIONS The combination of low dose LPS+60 minutes of CPB, but neither intervention alone, produced evidence of acute lung injury in a rabbit model. This did not occur when the animals were pretreated with sivelestat.
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Affiliation(s)
- Fuminori Wakayama
- First Department of Surgery, Hirosaki University School of Medicine, Aomori, Japan
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Kotani T, Kotake Y, Morisaki H, Takeda J, Shimizu H, Ueda T, Ishizaka A. Activation of a Neutrophil-Derived Inflammatory Response in the Airways During Cardiopulmonary Bypass. Anesth Analg 2006; 103:1394-9. [PMID: 17122209 DOI: 10.1213/01.ane.0000243391.05091.bb] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Cardiopulmonary bypass (CPB) is believed to cause postoperative lung dysfunction. To more closely examine the inflammatory processes occurring in the airways during CPB, we serially measured inflammatory mediators, with the assistance of a new bronchoscopic microsample probe, in 11 patients undergoing repair of aortic arch aneurysms. Epithelial lining fluid (ELF) and arterial blood were sampled simultaneously after induction of anesthesia, at the time of pulmonary reperfusion, and at the end of surgery. A decrease in the PaO2/FiO2 ratio was observed at the end of surgery (P = 0.029). Although the ELF concentrations of interleukin (IL)-8, IL-6, and neutrophil elastase had increased significantly at the end of surgery (median = 23,200, 1818, and 12,900 microg/mL, respectively), they did not correlate with the degree of hypoxemia. Neutrophil elastase increased significantly at the time of pulmonary reperfusion, before IL-8 and IL-6, and independently of blood transfusions. At the end of surgery, IL-6 in ELF correlated with total blood transfusion volume (rho = 0.731, P = 0.011). These results indicate that a neutrophil-derived inflammatory response is activated in the airway in the early phase of CPB.
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Fan X, Liu Y, Wang Q, Yu C, Wei B, Ruan Y. Lung perfusion with clarithromycin ameliorates lung function after cardiopulmonary bypass. Ann Thorac Surg 2006; 81:896-901. [PMID: 16488691 DOI: 10.1016/j.athoracsur.2005.09.032] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2005] [Revised: 09/12/2005] [Accepted: 09/15/2005] [Indexed: 11/19/2022]
Abstract
BACKGROUND Macrolides antibiotics may affect neutrophil functions that correlate with the inflammation induced by cardiopulmonary bypass. Our study observed the protective effect of clarithromycin on inflammatory lung injury after cardiopulmonary bypass. METHODS Twelve adult sheep were randomly divided into two groups. After cardiopulmonary bypass was established, the lung was perfused through the pulmonary artery with either dextran solution (30 mL/kg) in the control group (n = 6) or dextran solution added to clarithromycin (10 mg/kg) in the experimental group (n = 6). Bypass was withdrawn after 90 minutes. Pulmonary function was determined and inflammatory factors were analyzed. Apoptotic neutrophils in the lung were assayed and lung biopsies were also performed. RESULTS Pulmonary vascular resistance (102.2 +/- 14.0 dyne.s.cm(-5)) was lower in the experimental group compared with the control group (202.6 +/- 47.3 dyne.s.cm(-5), p < 0.01) whereas the oxygen index was higher in the experimental group (p < 0.05). Plasma myeloperoxidase in the experimental group (0.015 +/- 0.006 U/L) was lower than that in the control group (0.029 +/- 0.007 U/L, p < 0.01). Plasma interlukin-8 (0.18 +/- 0.04 ug/L) and tumor necrosis factor (1.00 +/- 0.13 ug/L) in the experimental group were lower than in the control group (0.39 +/- 0.09 ug/L, 1.55 +/- 0.35 ug/L, p < 0.01). Histologic analyses showed intra-alveolar hemorrhage and neutrophil accumulation in the control group, whereas there were no significant changes in the experimental group. The apoptosis rate of accumulated neutrophils was significantly lower in the control group (p < 0.01). CONCLUSIONS Lung perfusion with hypothermic protective solution containing clarithromycin distinctly inhibits inflammatory responses caused by cardiopulmonary bypass and ameliorates lung function.
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Affiliation(s)
- Xiangming Fan
- Department of Surgery, FuWai Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China.
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Hubert B, Troncy E, Gauvin D, Taha R, Pang D, Beauchamp G, Radomski A, Radomski MW, Blaise GA. Increased Alveolar and Plasma Gelatinases Activity during Postpump Syndrome: Inhibition by Inhaled Nitric Oxide. J Cardiovasc Pharmacol 2006; 48:71-8. [PMID: 17031259 DOI: 10.1097/01.fjc.0000242054.66031.5c] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Postpump syndrome is associated with systemic inflammation. Matrix metalloproteinases (MMP)-2 and -9 contribute to proinflammatory and platelet-activator reactions. Nitric oxide (NO) is involved in the regulation of MMPs. The objectives of our study were to investigate the intensity of inflammation induced by 3 different surgical procedures, the effects of inflammation on the activity of MMPs, and the regulation of inflammation by inhaled NO (20 ppm). Inhaled NO was initiated immediately after tracheal intubation and maintained for the total duration of the experiments. Thirty pigs were equally randomized into 6 groups [sham; sham + NO; cardiopulmonary bypass; bypass + NO; bypass + lipopolysaccharide (1 microg/kg for 50 min); bypass + lipopolysaccharide + NO] and animals were subjected to anesthesia and mechanical ventilation up to 24 h. The levels of MMP-2 and MMP-9 in plasma and bronchoalveolar lavage were measured using zymography. Bypass resulted in a time-dependent rise in MMP activity, an effect potentiated by lipopolysaccharide. Inhaled NO attenuated the effects of bypass + lipopolysaccharide. These results confirm that MMP-2 and MMP-9 are associated with the inflammatory process causing the postpump syndrome. Preemptive and continuous administration of inhaled NO helps to prevent increased MMP-2 and MMP-9 activity.
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Affiliation(s)
- Bernard Hubert
- Department of Anesthesia, Centre Hospitalier de l'Université de Montréal, Montréal, Canada
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Troncy E, Hubert B, Pang D, Taha R, Gauvin D, Beauchamp G, Veldhuizen RAW, Blaise GA. Pre-emptive and continuous inhaled NO counteracts the cardiopulmonary consequences of extracorporeal circulation in a pig model. Nitric Oxide 2006; 14:261-71. [PMID: 16545587 DOI: 10.1016/j.niox.2006.01.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2005] [Revised: 01/05/2006] [Accepted: 01/16/2006] [Indexed: 11/15/2022]
Abstract
Cardiopulmonary bypass (CPB) activates a systemic inflammatory response characterized clinically by alterations in cardiovascular and pulmonary function. The aim of this study was to measure the cardiopulmonary consequences in sham-operated pigs, and in animals subjected to CPB in the presence or absence of lipopolysaccharide (LPS). We also investigated, if the perioperative administration of inhaled NO exerts significant cardiopulmonary effects in an anaesthetized and mechanically ventilated pig model of extracorporeal circulation. Thirty pigs were randomized into six equal groups (sham; sham+INO; CPB; CPB+INO; CPB+LPS; CPB+LPS+INO) and subjected to anaesthesia with mechanical ventilation for up to 24h. We found that CPB+LPS group has the highest degree of lung injury. We also demonstrated that there was a significant difference on the cardiovascular parameters (heart rate, central venous pressure, stroke volume index, and mean systemic arterial blood pressure) between the CPB groups and the sham groups. The deteriorated lung mechanics was associated with a decrease in active subfraction of surfactant (LA) with time during the procedure (P=0.0003), on which inhaled NO had only an initial beneficial effect. In our model, inhaled NO had no long-term beneficial effect on lung mechanics and surfactant homeostasis despite improving lung haemodynamics, inflammation, and oxygenation. We conclude from this study that the use of pre-emptive and continuous inhaled NO therapy has protective and safe effects against lung ischemia/reperfusion associated with CPB.
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Affiliation(s)
- Eric Troncy
- Unit of Anaesthesiology/Pharmacology, Department of Veterinary Biomedicine, Faculty of Veterinary Medicine, Université de Montréal, St-Hyacinthe, Que., Canada
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Baufreton C, Corbeau JJ, Pinaud F. [Inflammatory response and haematological disorders in cardiac surgery: toward a more physiological cardiopulmonary bypass]. ACTA ACUST UNITED AC 2006; 25:510-20. [PMID: 16488106 DOI: 10.1016/j.annfar.2005.12.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2005] [Accepted: 12/23/2005] [Indexed: 10/25/2022]
Abstract
The systemic inflammatory response in cardiac surgery is closely related to the haemostasis disturbances. It is responsible of a significant morbidity and mortality that was previously suspected to be caused by cardiopulmonary bypass alone. However, it is time now to clearly identify the factors that are material-dependent from that material-independent. From this point of view, off-pump surgery allowed for better comprehension of the multiple sources of the inflammatory response. Numerous pathways are activated, involving complement, platelets, neutrophiles and monocytes. The tissue pathway of the coagulation system, through tissue factor, is of major importance and has to be surgically considered in order to reduce the whole body inflammatory response postoperatively. The quality of the extracorporeal perfusion through its consequences on organ perfusion, particularly in the splanchnic area, also participates to this pathophysiological process. Beyond the progress of technology provided by the industry, particularly the minimally extracorporeal circulation derived from off-pump surgery evolution, the surgical approach is of major importance in the control of the systemic inflammatory response and must not be ignored yet.
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Affiliation(s)
- C Baufreton
- Service de Chirurgie Cardiaque et Département d'Anesthésie-Réanimation, CHU d'Angers, 4, rue Larrey, 49933 Angers cedex 09, France.
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Sauvée M, Poignet P, Triboulet J, Dombre E, Malis E, Demaria R. 3D HEART MOTION ESTIMATION USING ENDOSCOPIC MONOCULAR VISION SYSTEM. ACTA ACUST UNITED AC 2006. [DOI: 10.3182/20060920-3-fr-2912.00029] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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El Kebir D, Taha R, Hubert B, Gauvin D, Gangal M, Blaise G. The anti-inflammatory effect of inhaled nitric oxide on pulmonary inflammation in a swine model. Can J Physiol Pharmacol 2005; 83:252-8. [PMID: 15870839 DOI: 10.1139/y05-008] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Cardiopulmonary bypass (CPB) is associated with an inflammatory process that leads to lung injury. In this study, we hypothesized that inhaled nitric oxide (INO) possesses the ability to modulate CPB-induced inflammation. Fifteen male pigs were randomly divided into 3 groups: Sham, CPB+LPS (CPB and lipopolysaccharide), and CPB+LPS+INO. INO (20 parts per million) was administered for 24 h after anesthesia. CPB was performed for 90 min, and LPS was infused (1 µg/kg) after CPB. Bronchoalveolar lavage (BAL) fluid and blood were collected at T0(before CPB), at 4 h, and at 24 h. At 24 h, BAL interleukin-8 (IL-8) levels were not increased as expected in the CPB+LPS group compared with the Sham group, but they were reduced significantly in the CPB+LPS+INO group. Cell hypo reactivity observed in the groups receiving LPS also seemed to downregulate endothelial nitric oxide synthase NOS protein expression relative to the Sham group. Nitrite and nitrate (NOx) concentrations were decreased significantly in the groups without INO. Moreover, animals treated with INO showed higher rates of pulmonary apoptosis compared with their respective controls. These results demonstrate that NOx production is reduced after CPB and that INO acts on the inflammatory process by diminishing neutrophils and their major chemoattractant, IL-8. INO also increases cell apoptosis in the lungs under inflammatory conditions, which may explain, in part, how it resolves pulmonary inflammation.Key words: CPB, nitric oxide, apoptosis, LPS, IL-8.
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Affiliation(s)
- D El Kebir
- Laboratory of Anesthesia, Department of Anesthesia, Centre hospitalier de l'Université de Montréal-Hôpital Notre-Dame, QC, Canada
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Koner O, Celebi S, Balci H, Cetin G, Karaoglu K, Cakar N. Effects of protective and conventional mechanical ventilation on pulmonary function and systemic cytokine release after cardiopulmonary bypass. Intensive Care Med 2004; 30:620-6. [PMID: 14722635 DOI: 10.1007/s00134-003-2104-5] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2003] [Accepted: 11/14/2003] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To evaluate the effects of protective and conventional ventilation with or without positive end-expiratory pressure (PEEP), on systemic tumor necrosis factor-alpha, interleukin-6 levels and pulmonary function during open heart surgery. DESIGN Prospective, randomized clinical study. SETTING Single university hospital. PATIENTS AND PARTICIPANTS Forty-four patients undergoing elective coronary artery bypass grafting surgery with cardiopulmonary bypass. INTERVENTIONS Patients ventilated with (1) protective tidal volumes (6 ml/kg, respiratory rate: 15 breaths/min, PEEP 5 cmH(2)O, n=15) group PV; (2) conventional tidal volumes (10 ml/kg, respiratory rate: 9 breaths/min, PEEP 5 cmH(2)O, n=14) group CV+PEEP and (3) conventional tidal volumes (10 ml/kg, respiratory rate: 9 breaths/min, n=15) without PEEP, group CV+ZEEP. Various pulmonary parameters, systemic TNF-alpha and IL-6 levels were determined throughout the study. MEASUREMENTS AND RESULTS There were no differences among the groups regarding the systemic TNF- alpha and IL-6 levels. The plateau airway pressures of group PV were lower than those of groups CV+PEEP ( p=0.02) and CV+ZEEP ( p=0.001) after cardiopulmonary bypass. The shunt fraction of group PV was significantly lower than that of group CV+ZEEP 24 h after surgery ( p<0.05). Oxygenation and the alveolar-arterial oxygen difference were better in both PEEP groups than in group CV+ZEEP 24 h after the operation. CONCLUSIONS We could not find any evidence that protective mechanical ventilation prevents some of the adverse effects of cardiopulmonary bypass on the lung, nor systemic cytokine levels, postoperative pulmonary function or length of hospitalization.
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Affiliation(s)
- Ozge Koner
- Anesthesiology Department, Cardiology Institute, Istanbul University, Haseki caddesi, 34303, Aksaray-Istanbul, Turkey,
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Dixon B, Santamaria JD, Campbell DJ. Plasminogen activator inhibitor activity is associated with raised lactate levels after cardiac surgery with cardiopulmonary bypass. Crit Care Med 2003; 31:1053-9. [PMID: 12682472 DOI: 10.1097/01.ccm.0000055390.97331.db] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To investigate the pathophysiology underlying raised lactate levels after cardiac surgery with cardiopulmonary bypass (CPB). DESIGN Prospective observational study. SETTING Medical and surgical intensive care unit of a tertiary hospital. PATIENTS A total of 40 patients undergoing first-time coronary artery bypass grafting with CPB. INTERVENTIONS The prothrombotic response to cardiac surgery with CPB was assessed by measuring plasma levels of prothrombin fragment 1 + 2 and plasminogen activator inhibitor (PAI) activity. The hemodynamic responses to cardiac surgery with CPB were also measured using standard techniques. MEASUREMENTS AND MAIN RESULTS After cardiac surgery, prothrombin fragment 1 + 2 levels increased 6-fold and PAI activity increase 2- to 3-fold (p <.0001). Lactate levels were not associated with prothrombin fragment 1 + 2 and PAI activity levels after CPB. Lactate levels were associated with baseline PAI activity (p =.006), a history of hypertension (p =.02), raised baseline lactate levels (p =.02), an early increase in body temperature after CPB (p =.05), a late increase in oxygen consumption after CPB (p =.03), and a raised white cell count after CPB (p =.06). Lactate levels were inversely associated with the maximum activated clotting time level reached during CPB (p =.02). Multivariate linear regression demonstrated lactate levels were independently associated with baseline PAI activity. CONCLUSION We found cardiac surgery with CPB was associated with a marked prothrombotic response. Lactate levels were associated with elevated baseline PAI activity and evidence of an amplified inflammatory response to cardiac surgery with CPB. Our findings implicate aspects of the inflammatory response, including microvascular thrombosis, in the development of raised lactate levels after cardiac surgery with CPB.
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Affiliation(s)
- Barry Dixon
- Intensive Care Centre, St. Vincent's Hospital, St. Vincent's Institute of Medical Research, Fitzroy, Australia
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Gu YJ, Schoen P, Tigchelaar I, Loef BG, Ebels T, Rankin AJ, van Oeveren W. Increased neutrophil priming and sensitization before commencing cardiopulmonary bypass in cardiac surgical patients. Ann Thorac Surg 2002; 74:1173-9. [PMID: 12400764 DOI: 10.1016/s0003-4975(02)03822-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND Neutrophil activation is implicated in postoperative complications in patients having cardiac surgery with cardiopulmonary bypass (CPB). This study was designed to determine the temporal fluctuations in the primability of neutrophils in the preoperative, intraoperative, and postoperative periods of CPB, and specifically whether CPB was a primary cause leading to increased neutrophil priming and elastase release. METHODS Twenty patients undergoing multiple coronary bypass grafting, valve replacement, or both of these procedures were included in this study. Blood samples were taken 1 day before the operation and at several time points during and after the operation. For each sample, blood was divided in vitro into four subgroups: control without priming, priming alone with cytochalasin B (CytoB), priming plus stimulation with platelet-activating factor (PAF), and priming plus stimulation with N-formyl-methionyl-leucyl-phenylalanine (fMLP). The elastase concentration of all these samples was determined using the enzyme immunoassay. RESULTS Compared with the controls, CytoB priming increased release of elastase more than 10-fold before CPB, 1.6-fold during CPB, and 1.5-fold at the end of CPB. Further stimulation with PAF or fMLP showed greater increase of elastase than priming alone, with peak values in both found before CPB. This increased neutrophil primability prior to CPB did not differ significantly among patients who had different preoperative disease profiles. CONCLUSIONS Our data suggest that neutrophil priming occurs early before commencing CPB in cardiac surgical patients, and that CPB is not the primary primer. Anesthesia, surgical trauma, and other events may have been involved in neutrophil priming and sensitization before CPB, which warrants further investigation.
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Affiliation(s)
- Y John Gu
- Department of Cardiothoracic Surgery, University of Groningen, The Netherlands.
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Abstract
Postoperative lung injury is one of the most frequent complications of cardiac surgery that impacts significantly on health-care expenditures and largely has been believed to result from the use of cardiopulmonary bypass (CPB). However, recent comparative studies between conventional and off-pump coronary artery bypass grafting have indicated that CPB itself may not be the major contributor to the development of postoperative pulmonary dysfunction. In our study, we review the associated physiologic, biochemical, and histologic changes, with particular reference to the current understanding of underlying mechanisms. Intraoperative modifications aiming at limiting lung injury are discussed. The potential benefits of maintaining ventilation and pulmonary artery perfusion during CPB warrant further investigation.
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Affiliation(s)
- Calvin S H Ng
- Division of Cardiothoracic Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, China
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Bocsi J, Hambsch J, Osmancik P, Schneider P, Valet G, Tárnok A. Preoperative prediction of pediatric patients with effusions and edema following cardiopulmonary bypass surgery by serological and routine laboratory data. Crit Care 2002; 6:226-33. [PMID: 12133183 PMCID: PMC125311 DOI: 10.1186/cc1494] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2002] [Accepted: 02/22/2002] [Indexed: 11/21/2022] Open
Abstract
AIM Postoperative effusions and edema and capillary leak syndrome in children after cardiac surgery with cardiopulmonary bypass constitute considerable clinical problems. Overshooting immune response is held to be the cause. In a prospective study we investigated whether preoperative immune status differences exist in patients at risk for postsurgical effusions and edema, and to what extent these differences permit prediction of the postoperative outcome. METHODS One-day preoperative serum levels of immunoglobulins, complement, cytokines and chemokines, soluble adhesion molecules and receptors as well as clinical chemistry parameters such as differential counts, creatinine, blood coagulation status (altogether 56 parameters) were analyzed in peripheral blood samples of 75 children (aged 3-18 years) undergoing cardiopulmonary bypass surgery (29 with postoperative effusions and edema within the first postoperative week). RESULTS Preoperative elevation of the serum level of C3 and C5 complement components, tumor necrosis factor-alpha, percentage of leukocytes that are neutrophils, body weight and decreased percentage of lymphocytes (all P < 0.03) occurred in children developing postoperative effusions and edema. While single parameters did not predict individual outcome, >86% of the patients with postoperative effusions and oedema were correctly predicted using two different classification algorithms. Data mining by both methods selected nine partially overlapping parameters. The prediction quality was independent of the congenital heart defect. CONCLUSION Indicators of inflammation were selected as risk indicators by explorative data analysis. This suggests that preoperative differences in the immune system and capillary permeability status exist in patients at risk for postoperative effusions. These differences are suitable for preoperative risk assessment and may be used for the benefit of the patient and to improve cost effectiveness.
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Affiliation(s)
- József Bocsi
- Director, Flow Cytometry Unit, 1st Department of Pathology, Semmelweis University, Budapest, Hungary
| | - Jörg Hambsch
- Assistant Medical Director, Pediatric Cardiology, Heart Center Leipzig GmbH, University of Leipzig, Germany
| | - Pavel Osmancik
- Assistant Cardiologist, Cardiac Center, University Hospital Kralovske Vinohrady, Charles University, Prague, Czech Republic
| | - Peter Schneider
- Director, Pediatric Cardiology, Heart Center Leipzig GmbH, University of Leipzig, Germany
| | - Günter Valet
- Head, Cell Biochemistry Group, Max-Planck-Institute for Biochemistry, Martinsried, Munich, Germany
| | - Attila Tárnok
- Head, Research Facility, Pediatric Cardiology, Heart Center Leipzig GmbH, University of Leipzig, Germany
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Kilo J, Baumer H, Czerny M, Fasching* P, Wolner E, Grimm M. Der geriatrische Patient aus chirurgischer Sicht - Koronar- und Herzklappenchirurgie. Eur Surg 2001. [DOI: 10.1046/j.1563-2563.2001.01177.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Tárnok A, Bocsi J, Pipek M, Osmancik P, Valet G, Schneider P, Hambsch J. Preoperative prediction of postoperative edema and effusion in pediatric cardiac surgery by altered antigen expression patterns on granulocytes and monocytes. CYTOMETRY 2001; 46:247-53. [PMID: 11514959 DOI: 10.1002/cyto.1135] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Postoperative edema and effusion (POEE) following cardiopulmonary bypass (CPB) surgery in children retards recovery and may aggravate postpericardiotomy (PPS), capillary leak syndrome (CLS), or multiorgan failure (MOF). Compared with complication-free children, POEE affected children have different preoperative serum levels of circulating cytokines and adhesion molecules. These levels may be used preoperatively to assess POEE, but their determination is time consuming, costly, and a substantial blood volume is required. Altered serum levels of cytokines and adhesion molecules also may be reflected in altered antigen expression on circulating blood leukocytes. The predictive potential of flow cytometric (FCM) leukocyte immunophenotyping was explored as a sensitive and fast method that required small blood samples. Blood samples taken 24 h preoperatively from 49 patients (3-18 years old) were stained with monoclonal antibodies for adhesion molecules (ICAM-1, LFA-1, Mac-1) or constitutive/activation markers (CD4, CD14, CD16, CD25, CD54, CD69, HLA-DR) and measured on a microbead calibrated FCM. Neutrophils, monocytes, and eosinophils from POEE patients express higher preoperative levels of LFA-1, monocytes, HLA-DR, and other activation markers (all P < 0.03). Over 89% of the patients were classified correctly by using two discriminant analysis methods (sensitivity, >76%; specificity, >86%; positive prediction, >80%; negative prediction, >83%). Granulocytes and monocytes of postoperative POEE patients exhibit significant preoperative immune activation, suggesting an increased risk for patients with atopic/allergic predisposition. Surgical trauma and CPB cause additional immune activation, leading to POEE by a summative response. Most patients at risk for POEE can be identified preoperatively by using data pattern analysis on FCM-derived parameters.
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Affiliation(s)
- A Tárnok
- Pediatric Cardiology, Heart Center Leipzig GmbH, University Hospital, Russenstrasse 19, D-04289 Leipzig, Germany.
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Carney DE, McCann UG, Schiller HJ, Gatto LA, Steinberg J, Picone AL, Nieman GF. Metalloproteinase inhibition prevents acute respiratory distress syndrome. J Surg Res 2001; 99:245-52. [PMID: 11469893 DOI: 10.1006/jsre.2001.6180] [Citation(s) in RCA: 72] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND The acute respiratory distress syndrome (ARDS) occurs in patients with clearly identifiable risk factors, and its treatment remains merely supportive. We postulated that patients at risk for ARDS can be protected against lung injury by a prophylactic treatment strategy that targets neutrophil-derived proteases. We hypothesized that a chemically modified tetracycline 3 (COL-3), a potent inhibitor of neutrophil matrix metalloproteinases (MMPs) and neutrophil elastase (NE) with minimal toxicity, would prevent ARDS in our porcine endotoxin-induced ARDS model. METHODS Yorkshire pigs were anesthetized, intubated, surgically instrumented for hemodynamic monitoring, and randomized into three groups: (1) control (n = 4), surgical instrumentation only; (2) lipopolysaccharide (LPS) (n = 4), infusion of Escherichia coli lipopolysaccharide at 100 microg/kg; and (3) COL-3 + LPS (n = 5), ingestion of COL-3 (100 mg/kg) 12 h before LPS infusion. All animals were monitored for 6 h following LPS or sham LPS infusion. Serial bronchoalveolar lavage (BAL) samples were analyzed for MMP concentration by gelatin zymography. Lung tissue was fixed for morphometric assessment at necropsy. RESULTS LPS infusion was marked by significant (P < 0.05) physiological deterioration as compared with the control group, including increased plateau airway pressure (P(plat)) (control = 15.7 +/- 0.4 mm Hg, LPS = 23.0 +/- 1.5 mm Hg) and a decrement in arterial oxygen partial pressure (P(a)O(2)) (LPS = 66 +/- 15 mm Hg, Control = 263 +/- 25 mm Hg) 6 h following LPS or sham LPS infusion, respectively. Pretreatment with COL-3 reduced the above pathophysiological changes 6 h following LPS infusion (P(plat) = 18.5 +/- 1.7 mm Hg, P(a)O(2) = 199 +/- 35 mm Hg; P = NS vs control). MMP-9 and MMP-2 concentration in BAL fluid was significantly increased between 2 and 4 h post-LPS infusion; COL-3 reduced the increase in MMP-9 and MMP-2 concentration at all time periods. Morphometrically LPS caused a significant sequestration of neutrophils and monocytes into pulmonary tissue. Pretreatment with COL-3 ameliorated this response. The wet/dry lung weight ratio was significantly greater (P < 0.05) in the LPS group (10.1 +/- 1.0 ratio) than in either the control (6.4 +/- 0.5 ratio) or LPS+COL-3 (7.4 +/- 0.6 ratio) group. CONCLUSIONS A single prophylactic treatment with COL-3 prevented lung injury in our model of endotoxin-induced ARDS. The proposed mechanism of COL-3 is a synergistic inhibition of the terminal neutrophil effectors MMPs and NE. Similar to the universal practice of prophylaxis against gastric stress ulceration and deep venous thromboses in trauma patients, chemically modified tetracyclines may likewise be administered to prevent acute lung injury in critically injured patients at risk of developing ARDS.
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Affiliation(s)
- D E Carney
- State University of New York Upstate Medical University, 750 East Adams Street, Syracuse, NY 13210, USA
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Tárnok A, Schneider P. Induction of transient immune suppression and Th1/Th2 disbalance by pediatric cardiac surgery with cardiopulmonary bypass. ACTA ACUST UNITED AC 2001. [DOI: 10.1016/s1529-1049(01)00033-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Carney DE, Lutz CJ, Picone AL, Gatto LA, Ramamurthy NS, Golub LM, Simon SR, Searles B, Paskanik A, Snyder K, Finck C, Schiller HJ, Nieman GF. Matrix metalloproteinase inhibitor prevents acute lung injury after cardiopulmonary bypass. Circulation 1999; 100:400-6. [PMID: 10421601 DOI: 10.1161/01.cir.100.4.400] [Citation(s) in RCA: 100] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Acute lung injury (ALI) after cardiopulmonary bypass (CPB) results from sequential priming and activation of neutrophils. Activated neutrophils release neutral serine, elastase, and matrix metalloproteinases (MMPs) and oxygen radical species, which damage alveolar-capillary basement membranes and the extracellular matrix, resulting in an ALI clinically defined as adult respiratory distress syndrome (ARDS). We hypothesized that treatment with a potent MMP and elastase inhibitor, a chemically modified tetracycline (CMT-3), would prevent ALI in our sequential insult model of ALI after CPB. METHODS AND RESULTS Anesthetized Yorkshire pigs were randomized to 1 of 5 groups: control (n=3); CPB (n=5), femoral-femoral hypothermic bypass for 1 hour; LPS (n=7), sham bypass followed by infusion of low-dose Escherichia coli lipopolysaccharide (LPS; 1 microgram/kg); CPB+LPS (n=6), both insults; and CPB+LPS+CMT-3 (n=5), both insults plus intravenous CMT-3 dosed to obtain a 25-micromol/L blood concentration. CPB+LPS caused severe lung injury, as demonstrated by a significant fall in PaO(2) and an increase in intrapulmonary shunt compared with all groups (P<0.05). These changes were associated with significant pulmonary infiltration of neutrophils and an increase in elastase and MMP-9 activity. CONCLUSIONS All pathological changes typical of ALI after CPB were prevented by CMT-3. Prevention of lung dysfunction followed an attenuation of both elastase and MMP-2 activity. This study suggests that strategies to combat ARDS should target terminal neutrophil effectors.
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Affiliation(s)
- D E Carney
- Departments of Surgery and Cardiovascular Perfusion, SUNY Health Science Center at Syracuse, NY, 13210, USA
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