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VanZalen JJ, Nakashima T, Phillips A, Hill JE, Westover AJ, Lou L, Liao J, Mergos J, Fogo G, Sanderson TH, Stacey WC, Tiba MH, Humes DH, Bartlett RH, Rojas-Peña A, Neumar RW. Leukocyte filtration and leukocyte modulation therapy during extracorporeal cardiopulmonary resuscitation in a porcine model of prolonged cardiac arrest. Sci Rep 2024; 14:13081. [PMID: 38844477 PMCID: PMC11156900 DOI: 10.1038/s41598-024-63522-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Accepted: 05/29/2024] [Indexed: 06/09/2024] Open
Abstract
Extracorporeal cardiopulmonary resuscitation (ECPR) is emerging as a feasible and effective rescue strategy for prolonged cardiac arrest (CA). However, prolonged total body ischemia and reperfusion can cause microvascular occlusion that prevents organ reperfusion and recovery of function. One hypothesized mechanism of microvascular "no-reflow" is leukocyte adhesion and formation of neutrophil extracellular traps. In this study we tested the hypothesis that a leukocyte filter (LF) or leukocyte modulation device (L-MOD) could reduce NETosis and improve recovery of heart and brain function in a swine model of prolonged cardiac arrest treated with ECPR. Thirty-six swine (45.5 ± 2.5 kg, evenly distributed sex) underwent 8 min of untreated ventricular fibrillation CA followed by 30 min of mechanical CPR with subsequent 8 h of ECPR. Two females were later excluded from analysis due to CPR complications. Swine were randomized to standard care (Control group), LF, or L-MOD at the onset of CPR. NET formation was quantified by serum dsDNA and citrullinated histone as well as immunofluorescence staining of the heart and brain for citrullinated histone in the microvasculature. Primary outcomes included recovery of cardiac function based on cardiac resuscitability score (CRS) and recovery of neurologic function based on the somatosensory evoked potential (SSEP) N20 cortical response. In this model of prolonged CA treated with ECPR we observed significant increases in serum biomarkers of NETosis and immunohistochemical evidence of microvascular NET formation in the heart and brain that were not reduced by LF or L-MOD therapy. Correspondingly, there were no significant differences in CRS and SSEP recovery between Control, LF, and L-MOD groups 8 h after ECPR onset (CRS = 3.1 ± 2.7, 3.7 ± 2.6, and 2.6 ± 2.6 respectively; p = 0.606; and SSEP = 27.9 ± 13.0%, 36.7 ± 10.5%, and 31.2 ± 9.8% respectively, p = 0.194). In this model of prolonged CA treated with ECPR, the use of LF or L-MOD therapy during ECPR did not reduce microvascular NETosis or improve recovery of myocardial or brain function. The causal relationship between microvascular NETosis, no-reflow, and recovery of organ function after prolonged cardiac arrest treated with ECPR requires further investigation.
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Affiliation(s)
- Jensyn J VanZalen
- Department of Surgery and ECLS Laboratory, University of Michigan Medical School, Ann Arbor, MI, 48109, USA
| | - Takahiro Nakashima
- Department of Surgery and ECLS Laboratory, University of Michigan Medical School, Ann Arbor, MI, 48109, USA
- The Max Harry Weil Institute for Critical Care Research and Innovation, University of Michigan, Ann Arbor, MI, 48109, USA
| | - Annie Phillips
- Department of Surgery and ECLS Laboratory, University of Michigan Medical School, Ann Arbor, MI, 48109, USA
| | - Joseph E Hill
- Department of Surgery and ECLS Laboratory, University of Michigan Medical School, Ann Arbor, MI, 48109, USA
| | - Angela J Westover
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, 48109, USA
| | - Liandi Lou
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, 48109, USA
| | - Jinhui Liao
- The Max Harry Weil Institute for Critical Care Research and Innovation, University of Michigan, Ann Arbor, MI, 48109, USA
- Department of Emergency Medicine, University of Michigan Medical School, 1500 E Medical Center Drive, Ann Arbor, MI, 48109-5303, USA
| | - Joshua Mergos
- Movement Science, University of Michigan School of Kinesiology, Ann Arbor, MI, 48109, USA
- Department of Neurology, University of Michigan Medical School, Ann Arbor, MI, 48109, USA
| | - Garrett Fogo
- The Max Harry Weil Institute for Critical Care Research and Innovation, University of Michigan, Ann Arbor, MI, 48109, USA
| | - Thomas H Sanderson
- The Max Harry Weil Institute for Critical Care Research and Innovation, University of Michigan, Ann Arbor, MI, 48109, USA
- Department of Emergency Medicine, University of Michigan Medical School, 1500 E Medical Center Drive, Ann Arbor, MI, 48109-5303, USA
- Neuroscience Graduate Program, University of Michigan Medical School, Ann Arbor, MI, 48109, USA
- Department of Molecular and Integrative Physiology, University of Michigan Medical School, Ann Arbor, MI, 48109, USA
| | - William C Stacey
- Movement Science, University of Michigan School of Kinesiology, Ann Arbor, MI, 48109, USA
- Department of Neurology, University of Michigan Medical School, Ann Arbor, MI, 48109, USA
| | - Mohamad Hakam Tiba
- The Max Harry Weil Institute for Critical Care Research and Innovation, University of Michigan, Ann Arbor, MI, 48109, USA
- Department of Emergency Medicine, University of Michigan Medical School, 1500 E Medical Center Drive, Ann Arbor, MI, 48109-5303, USA
| | - David H Humes
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, 48109, USA
| | - Robert H Bartlett
- Department of Surgery and ECLS Laboratory, University of Michigan Medical School, Ann Arbor, MI, 48109, USA
| | - Alvaro Rojas-Peña
- Department of Surgery and ECLS Laboratory, University of Michigan Medical School, Ann Arbor, MI, 48109, USA
- The Max Harry Weil Institute for Critical Care Research and Innovation, University of Michigan, Ann Arbor, MI, 48109, USA
- Department of Surgery Section of Transplantation, University of Michigan Medical School, Ann Arbor, MI, 48109, USA
| | - Robert W Neumar
- The Max Harry Weil Institute for Critical Care Research and Innovation, University of Michigan, Ann Arbor, MI, 48109, USA.
- Department of Emergency Medicine, University of Michigan Medical School, 1500 E Medical Center Drive, Ann Arbor, MI, 48109-5303, USA.
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Abbasciano RG, Tomassini S, Roman MA, Rizzello A, Pathak S, Ramzi J, Lucarelli C, Layton G, Butt A, Lai F, Kumar T, Wozniak MJ, Murphy GJ. Effects of interventions targeting the systemic inflammatory response to cardiac surgery on clinical outcomes in adults. Cochrane Database Syst Rev 2023; 10:CD013584. [PMID: 37873947 PMCID: PMC10594589 DOI: 10.1002/14651858.cd013584.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2023]
Abstract
BACKGROUND Organ injury is a common and severe complication of cardiac surgery that contributes to the majority of deaths. There are no effective treatment or prevention strategies. It has been suggested that innate immune system activation may have a causal role in organ injury. A wide range of organ protection interventions targeting the innate immune response have been evaluated in randomised controlled trials (RCTs) in adult cardiac surgery patients, with inconsistent results in terms of effectiveness. OBJECTIVES The aim of the review was to summarise the results of RCTs of organ protection interventions targeting the innate immune response in adult cardiac surgery. The review considered whether the interventions had a treatment effect on inflammation, important clinical outcomes, or both. SEARCH METHODS CENTRAL, MEDLINE, Embase, conference proceedings and two trial registers were searched on October 2022 together with reference checking to identify additional studies. SELECTION CRITERIA RCTs comparing organ protection interventions targeting the innate immune response versus placebo or no treatment in adult patients undergoing cardiac surgery where the treatment effect on innate immune activation and on clinical outcomes of interest were reported. DATA COLLECTION AND ANALYSIS Searches, study selection, quality assessment, and data extractions were performed independently by pairs of authors. The primary inflammation outcomes were peak IL-6 and IL-8 concentrations in blood post-surgery. The primary clinical outcome was in-hospital or 30-day mortality. Treatment effects were expressed as risk ratios (RR) and standardised mean difference (SMD) with 95% confidence intervals (CI). Meta-analyses were performed using random effects models, and heterogeneity was assessed using I2. MAIN RESULTS A total of 40,255 participants from 328 RCTs were included in the synthesis. The effects of treatments on IL-6 (SMD -0.77, 95% CI -0.97 to -0.58, I2 = 92%) and IL-8 (SMD -0.92, 95% CI -1.20 to -0.65, I2 = 91%) were unclear due to heterogeneity. Heterogeneity for inflammation outcomes persisted across multiple sensitivity and moderator analyses. The pooled treatment effect for in-hospital or 30-day mortality was RR 0.78, 95% CI 0.68 to 0.91, I2 = 0%, suggesting a significant clinical benefit. There was little or no treatment effect on mortality when analyses were restricted to studies at low risk of bias. Post hoc analyses failed to demonstrate consistent treatment effects on inflammation and clinical outcomes. Levels of certainty for pooled treatment effects on the primary outcomes were very low. AUTHORS' CONCLUSIONS A systematic review of RCTs of organ protection interventions targeting innate immune system activation did not resolve uncertainty as to the effectiveness of these treatments, or the role of innate immunity in organ injury following cardiac surgery.
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Affiliation(s)
| | | | - Marius A Roman
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Angelica Rizzello
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Suraj Pathak
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Joussi Ramzi
- Leicester Medical School, University of Leicester, Leicester, UK
| | - Carla Lucarelli
- Department of Cardiac Surgery, University of Verona, Verona, Italy
| | - Georgia Layton
- University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Ayesha Butt
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Florence Lai
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Tracy Kumar
- Leicester Clinical Trials Unit, University of Leicester, Leicester, UK
| | - Marcin J Wozniak
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Gavin J Murphy
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
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3
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Milojevic M, Milosevic G, Nikolic A, Petrovic M, Petrovic I, Bojic M, Jagodic S. Mastering the Best Practices: A Comprehensive Look at the European Guidelines for Cardiopulmonary Bypass in Adult Cardiac Surgery. J Cardiovasc Dev Dis 2023; 10:296. [PMID: 37504552 PMCID: PMC10380276 DOI: 10.3390/jcdd10070296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Revised: 07/05/2023] [Accepted: 07/06/2023] [Indexed: 07/29/2023] Open
Abstract
The successful outcome of a cardiac surgery procedure is significantly dependent on the management of cardiopulmonary bypass (CPB). Even if a cardiac operation is technically well-conducted, a patient may suffer CPB-related complications that could result in severe comorbidities, reduced quality of life, or even death. However, the role of clinical perfusionists in perioperative patient care, which is critical, is often overlooked. Therefore, the European Association for Cardio-Thoracic Surgery (EACTS), the European Association of Cardiothoracic Anaesthesiology (EACTA), and the European Board of Cardiovascular Perfusion (EBCP) have agreed to develop joint clinical practice guidelines (CPGs) for CPB due to its significant impact on patient care and significant variations in practice patterns between countries. The European guidelines, based on the EACTS standardized framework for the development of CPGs, cover the entire spectrum of CPB management in adult cardiac surgery. This includes training and education of clinical perfusionists, machine hardware, disposables, preparation for initiation of CPB, a complete set of procedures during CPB to help maintain end-organ function and anticoagulation, weaning from CPB, and the gaps in evidence and future research directions. This comprehensive coverage ensures that all aspects of CPB management are addressed, providing clinicians with a standardized approach to CPB management based on the latest evidence and best practices. To ensure better integration of these evidence-based recommendations into daily practice, this review aims to provide a general understanding of guideline development and an overview of essential treatment recommendations for CPB management.
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Affiliation(s)
- Milan Milojevic
- Department of Cardiac Surgery and Cardiovascular Research, Dedinje Cardiovascular Institute, 11000 Belgrade, Serbia
- Erasmus University Medical Center, Department of Cardiothoracic Surgery, 3015 GD Rotterdam, The Netherlands
| | - Goran Milosevic
- Department of Perfusion Technology, Dedinje Cardiovascular Institute, 11000 Belgrade, Serbia
| | - Aleksandar Nikolic
- Department of Cardiac Surgery, Acibadem-Sistina Hospital, 1000 Skopje, North Macedonia
| | - Masa Petrovic
- Center of Excellence, Dedinje Cardiovascular Institute, 11000 Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia
| | - Ivana Petrovic
- Center of Excellence, Dedinje Cardiovascular Institute, 11000 Belgrade, Serbia
| | - Milovan Bojic
- Center of Excellence, Dedinje Cardiovascular Institute, 11000 Belgrade, Serbia
| | - Sinisa Jagodic
- Department of Perfusion Technology, Dedinje Cardiovascular Institute, 11000 Belgrade, Serbia
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Wahba A, Milojevic M, Boer C, De Somer FMJJ, Gudbjartsson T, van den Goor J, Jones TJ, Lomivorotov V, Merkle F, Ranucci M, Kunst G, Puis L. 2019 EACTS/EACTA/EBCP guidelines on cardiopulmonary bypass in adult cardiac surgery. Eur J Cardiothorac Surg 2021; 57:210-251. [PMID: 31576396 DOI: 10.1093/ejcts/ezz267] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Affiliation(s)
- Alexander Wahba
- Department of Cardio-Thoracic Surgery, St Olav's University Hospital, Trondheim, Norway.,Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
| | - Milan Milojevic
- Department of Cardiovascular Anaesthesia and Intensive Care Unit, Dedinje Cardiovascular Institute, Belgrade, Serbia.,Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Christa Boer
- Department of Anaesthesiology, Amsterdam UMC, VU University, Amsterdam Cardiovascular Sciences, Amsterdam, Netherlands
| | | | - Tomas Gudbjartsson
- Department of Cardiothoracic Surgery, Faculty of Medicine, Landspitali University Hospital, University of Iceland, Reykjavik, Iceland
| | - Jenny van den Goor
- Department of Cardiothoracic Surgery, Academic Medical Centre of the University of Amsterdam, Amsterdam, Netherlands
| | - Timothy J Jones
- Department of Paediatric Cardiac Surgery, Birmingham Women's and Children's Hospital, Birmingham, UK
| | - Vladimir Lomivorotov
- Department of Anesthesiology and Intensive Care, E. Meshalkin National Medical Research Center, Novosibirsk State University, Novosibirsk, Russia
| | - Frank Merkle
- Academy for Perfusion, Deutsches Herzzentrum, Berlin, Germany
| | - Marco Ranucci
- Department of Cardiovascular Anaesthesia and Intensive Care Unit, IRCCS Policlinico San Donato, Milan, Italy
| | - Gudrun Kunst
- Department of Anaesthetics and Pain Medicine, King's College Hospital NHS Foundation Trust and School of Cardiovascular Medicine & Sciences, King's College London British Heart Foundation Centre of Excellence, London, UK
| | - Luc Puis
- Department of Perfusion, University Hospital Brussels, Jette, Belgium
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5
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Puis L, Milojevic M, Boer C, De Somer FMJJ, Gudbjartsson T, van den Goor J, Jones TJ, Lomivorotov V, Merkle F, Ranucci M, Kunst G, Wahba A. 2019 EACTS/EACTA/EBCP guidelines on cardiopulmonary bypass in adult cardiac surgery. Interact Cardiovasc Thorac Surg 2020; 30:161-202. [PMID: 31576402 PMCID: PMC10634377 DOI: 10.1093/icvts/ivz251] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Luc Puis
- Department of Perfusion, University Hospital Brussels, Jette, Belgium
| | - Milan Milojevic
- Department of Cardiovascular Anaesthesia and Intensive Care Unit, Dedinje Cardiovascular Institute, Belgrade, Serbia
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Christa Boer
- Department of Anaesthesiology, Amsterdam UMC, VU University, Amsterdam Cardiovascular Sciences, Amsterdam, Netherlands
| | | | - Tomas Gudbjartsson
- Department of Cardiothoracic Surgery, Faculty of Medicine, Landspitali University Hospital, University of Iceland, Reykjavik, Iceland
| | - Jenny van den Goor
- Department of Cardiothoracic Surgery, Academic Medical Centre of the University of Amsterdam, Amsterdam, Netherlands
| | - Timothy J Jones
- Department of Paediatric Cardiac Surgery, Birmingham Women’s and Children’s Hospital, Birmingham, UK
| | - Vladimir Lomivorotov
- Department of Anesthesiology and Intensive Care, E. Meshalkin National Medical Research Center, Novosibirsk State University, Novosibirsk, Russia
| | - Frank Merkle
- Academy for Perfusion, Deutsches Herzzentrum, Berlin, Germany
| | - Marco Ranucci
- Department of Cardiovascular Anaesthesia and Intensive Care Unit, IRCCS Policlinico San Donato, Milan, Italy
| | - Gudrun Kunst
- Department of Anaesthetics and Pain Medicine, King's College Hospital NHS Foundation Trust and School of Cardiovascular Medicine & Sciences, King's College London British Heart Foundation Centre of Excellence, London, UK
| | - Alexander Wahba
- Department of Cardio-Thoracic Surgery, St Olav s University Hospital, Trondheim, Norway
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
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6
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Kunst G, Milojevic M, Boer C, De Somer FM, Gudbjartsson T, van den Goor J, Jones TJ, Lomivorotov V, Merkle F, Ranucci M, Puis L, Wahba A, Alston P, Fitzgerald D, Nikolic A, Onorati F, Rasmussen BS, Svenmarker S. 2019 EACTS/EACTA/EBCP guidelines on cardiopulmonary bypass in adult cardiac surgery. Br J Anaesth 2019; 123:713-757. [DOI: 10.1016/j.bja.2019.09.012] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
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7
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Zhang X, Zhou C, Zhuang J, Xiao X, Zheng S, Xiong W, Wang W, Wu R. Effects of Leukocyte Depletion on Cardiopulmonary Protection and Inflammation after Valve Surgery. Int J Artif Organs 2018. [DOI: 10.1177/039139881003301106] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background To evaluate the effects of leukocyte-depleting filtration on myocardial and pulmonary protection and the inflammatory response in patients undergoing valve surgery. Methods Fifty-two patients who underwent mitral valve or mitral and aortic valve replacement were randomized into two groups with or without a leukocyte-depleting filter during surgery. The filter was used from 10 minutes before the release of the aortic cross-clamp to the end of cardiopulmonary bypass. Results Total leukocyte and neutrophil counts showed a short-term reduction in patients undergoing leukocyte filtration, but there was no significant difference between the two groups during the study. Serum levels of cardiac troponin I were lower than that of the control group (p=0.030). Leukocyte depletion resulted in a significantly higher oxygenation index (p=0.002) and a lower respiratory index (p=0.003) compared with the control group. Serum levels of interleukin-8 were significantly elevated in patients undergoing leukocyte filtration compared with patients without leukocyte filtration (p=0.001). There were no statistically significant differences between the two groups with regards to the concentration of interleukin-6 and TNFα, or the duration of intensive care and hospital stay. Conclusions Leukocyte depletion is associated with improved myocardial and lung protection but does not appear to attenuate the inflammatory response in valve surgery.
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Affiliation(s)
- Xiaohua Zhang
- Department of Cardiac Surgery and Anesthesiology, Guangdong Cardiovascular Institute, Guangdong General Hospital, Guangdong Academy of Medical Science, Guangzhou - China
| | - Chengbin Zhou
- Department of Cardiac Surgery and Anesthesiology, Guangdong Cardiovascular Institute, Guangdong General Hospital, Guangdong Academy of Medical Science, Guangzhou - China
| | - Jian Zhuang
- Department of Cardiac Surgery and Anesthesiology, Guangdong Cardiovascular Institute, Guangdong General Hospital, Guangdong Academy of Medical Science, Guangzhou - China
| | - Xuejun Xiao
- Department of Cardiac Surgery and Anesthesiology, Guangdong Cardiovascular Institute, Guangdong General Hospital, Guangdong Academy of Medical Science, Guangzhou - China
| | - Shaoyi Zheng
- Department of Cardiac Surgery and Anesthesiology, Guangdong Cardiovascular Institute, Guangdong General Hospital, Guangdong Academy of Medical Science, Guangzhou - China
| | - Weiping Xiong
- Department of Cardiac Surgery and Anesthesiology, Guangdong Cardiovascular Institute, Guangdong General Hospital, Guangdong Academy of Medical Science, Guangzhou - China
| | - Wenxian Wang
- Department of Cardiac Surgery and Anesthesiology, Guangdong Cardiovascular Institute, Guangdong General Hospital, Guangdong Academy of Medical Science, Guangzhou - China
| | - Ruobin Wu
- Department of Cardiac Surgery and Anesthesiology, Guangdong Cardiovascular Institute, Guangdong General Hospital, Guangdong Academy of Medical Science, Guangzhou - China
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Gunaydin S, Ayrancioglu K, Dikmen E, Mccusker K, Vijay V, Sari T, Tezcaner T, Zorlutuna Y. Clinical effects of leukofiltration and surface modification on post-cardiopulmonary bypass atrial fibrillation in different risk cohorts. Perfusion 2016; 22:279-88. [DOI: 10.1177/0267659107084146] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective. A manifestation of inflammatory injury to the heart, atrial fibrillation (AF), ranks among the most frequent and potentially life-threatening post-operative complications. Methods. In a prospective randomized study, 120 patients undergoing CABG were allocated into two groups (N = 60): Group 1- Polymethoxyethylacry late-coated circuits + Leukocyte filters (Terumo,USA); Group 2: Control:Uncoated circuits (Terumo,USA). Each group was further divided into three subgroups (N = 20) with respect to low (Euroscore 0—2), medium (3—5) and high (6+) risk patients. Results. Serum IL-2 levels were significantly lower in the study group at T4 and T5 (p < 0.01). C3a levels showed significant differences in the leukofiltrated group at T4 and T5 (p < 0.05). CPKMB levels demonstrated well-preserved myocardium in the leukofiltration group, post-operatively. AF incidence was 10% (2 patients) in the study and 35% (7 patients) in the control cohorts (p < 0.05). Phagocytic capacity on fibers in filtered patients was significantly lower. Conclusion: Leukofiltration and coating significantly reduce the incidence, ventricular rate, and duration of AF after CABG via modulation of systemic inflammatory response and platelet preservation in high risk groups. Perfusion (2007) 22, 279—288.
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Ferraris VA, Brown JR, Despotis GJ, Hammon JW, Reece TB, Saha SP, Song HK, Clough ER, Shore-Lesserson LJ, Goodnough LT, Mazer CD, Shander A, Stafford-Smith M, Waters J, Baker RA, Dickinson TA, FitzGerald DJ, Likosky DS, Shann KG. 2011 update to the Society of Thoracic Surgeons and the Society of Cardiovascular Anesthesiologists blood conservation clinical practice guidelines. Ann Thorac Surg 2011; 91:944-82. [PMID: 21353044 DOI: 10.1016/j.athoracsur.2010.11.078] [Citation(s) in RCA: 874] [Impact Index Per Article: 67.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2010] [Revised: 11/20/2010] [Accepted: 11/29/2010] [Indexed: 12/16/2022]
Abstract
BACKGROUND Practice guidelines reflect published literature. Because of the ever changing literature base, it is necessary to update and revise guideline recommendations from time to time. The Society of Thoracic Surgeons recommends review and possible update of previously published guidelines at least every three years. This summary is an update of the blood conservation guideline published in 2007. METHODS The search methods used in the current version differ compared to the previously published guideline. Literature searches were conducted using standardized MeSH terms from the National Library of Medicine PUBMED database list of search terms. The following terms comprised the standard baseline search terms for all topics and were connected with the logical 'OR' connector--Extracorporeal circulation (MeSH number E04.292), cardiovascular surgical procedures (MeSH number E04.100), and vascular diseases (MeSH number C14.907). Use of these broad search terms allowed specific topics to be added to the search with the logical 'AND' connector. RESULTS In this 2011 guideline update, areas of major revision include: 1) management of dual anti-platelet therapy before operation, 2) use of drugs that augment red blood cell volume or limit blood loss, 3) use of blood derivatives including fresh frozen plasma, Factor XIII, leukoreduced red blood cells, platelet plasmapheresis, recombinant Factor VII, antithrombin III, and Factor IX concentrates, 4) changes in management of blood salvage, 5) use of minimally invasive procedures to limit perioperative bleeding and blood transfusion, 6) recommendations for blood conservation related to extracorporeal membrane oxygenation and cardiopulmonary perfusion, 7) use of topical hemostatic agents, and 8) new insights into the value of team interventions in blood management. CONCLUSIONS Much has changed since the previously published 2007 STS blood management guidelines and this document contains new and revised recommendations.
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Loberg AG, Stallard J, Dunning J, Dark J. Can leucocyte depletion reduce reperfusion injury following cardiopulmonary bypass? Interact Cardiovasc Thorac Surg 2011; 12:232-7. [DOI: 10.1510/icvts.2010.257568] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
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11
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Systemic Leukofiltration Does Not Attenuate Pulmonary Injury after Cardiopulmonary Bypass. ASAIO J 2008; 54:78-88. [DOI: 10.1097/mat.0b013e3181618e9b] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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12
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Lim HK, Anderson J, Leong JY, Pepe S, Salamonsen RF, Rosenfeldt FL. What is the Role of Leukocyte Depletion in Cardiac Surgery? Heart Lung Circ 2007; 16:243-53. [PMID: 17360235 DOI: 10.1016/j.hlc.2007.01.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2006] [Revised: 12/07/2006] [Accepted: 01/07/2007] [Indexed: 11/30/2022]
Abstract
Leukocytes play an important pathogenic role in ischaemia-reperfusion injury. During cardiopulmonary bypass, leukocyte filters have the potential to remove leukocytes, thereby reducing contact of activated leukocytes with the endothelium of target organs. Improvement in the safety and efficacy of commercially available leukocyte filters in recent years has led to their increasing use in cardiac surgery. However, the benefits have been inconsistent. Current evidence suggests that leukocyte depletion may not have a significant impact in low risk elective coronary artery bypass grafting but may be beneficial in valve surgery and high-risk cardiac surgery. High-risk surgical groups that may benefit from leukocyte filtration are those with left ventricular hypertrophy (LV mass>300 g), poor ejection fraction (EF<40%), chronic obstructive airways disease (predicted FEV1<75%), prolonged ischaemia (cross clamp time>120 min or cardiac transplantation), paediatric cardiac surgery and patients in cardiogenic shock requiring emergency coronary artery bypass grafting. Future trials should be powered to detect important clinical end points and be designed to avoid premature exhaustion of the filter.
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Affiliation(s)
- Hou-Kiat Lim
- Cardiac Surgical Research Unit, Alfred Hospital, Melbourne, Australia
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13
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Warren O, Wallace S, Massey R, Tunnicliffe C, Alexiou C, Powell J, Meisuria N, Darzi A, Athanasiou T. Does Systemic Leukocyte Filtration Affect Perioperative Hemorrhage in Cardiac Surgery? A Systematic Review and Meta-Analysis. ASAIO J 2007; 53:514-21. [PMID: 17667241 DOI: 10.1097/mat.0b013e31805c15f9] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Cardiopulmonary bypass causes a systemic inflammatory reaction. Activation of leukocytes is an important part of this process, and is known to directly contribute to the development of postoperative coagulopathy, and thus hemorrhage. The removal of leukocytes from the cardiopulmonary bypass circulation, using specialized filters, has been proposed as one method for attenuating this inflammatory response. However, there is no consensus on its effectiveness. We used meta-analytical techniques to systematically assess the literature reporting on the potential effect of systemic leukofiltration on perioperative hemorrhage. Random effects modeling was used to calculate overall estimate, and heterogeneity was assessed. Systemic leukofiltration made no significant impact on chest tube drainage in the first 24 hours (weighted mean difference [WMD], x23.9 ml; 95% confidence interval [CI], x95.48-47.61; p = 0.51) or on the total packed red cell transfusion requirements of each patient (WMD, 7.84 ml; 95% CI, x80.13-95.81; p = 0.86). The studies performed in this area thus far are highly heterogeneous, due in part to relatively poor-quality design and inadequate matching of their study groups. Although further high-quality trials on systemic leukofiltration may be appropriate, other strategies to reduce the coagulopathy associated with cardiopulmonary bypass should be sought and evaluated.
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Affiliation(s)
- Oliver Warren
- Department of BioSurgery and Surgical Technology, Imperial College, St. Mary's Hospital, London, United Kingdom
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Warren O, Alexiou C, Massey R, Leff D, Purkayastha S, Kinross J, Darzi A, Athanasiou T. The effects of various leukocyte filtration strategies in cardiac surgery. Eur J Cardiothorac Surg 2007; 31:665-76. [PMID: 17240156 DOI: 10.1016/j.ejcts.2006.12.034] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2006] [Revised: 11/16/2006] [Accepted: 12/23/2006] [Indexed: 11/16/2022] Open
Abstract
It is known that cardiopulmonary bypass causes an inflammatory reaction with an associated morbidity and mortality. Several anti-inflammatory strategies have been implemented to reduce this response, including leukocyte removal from the circulation using specialised filters. The aim of this study is to systematically review the available evidence on leukocyte filtration in cardiac surgery, focusing on its effect on systemic inflammation and whether this has influenced clinical outcomes. Five electronic databases were systematically searched for studies reporting the effect of leukocyte filtration at any point within the cardiopulmonary bypass circuit in humans. Reference lists of all identified studies were checked for any missing publications. Two authors independently extracted the data from the included studies. Whilst systemic leukodepleting filters do not appear to consistently lower leukocyte counts, they may preferentially remove activated leukocytes. Small improvements in early post-operative lung function in patients receiving systemic leukodepletion have been reported, but this does not lead to reduced hospital stay or decreased mortality. There is substantial evidence that cardioplegic leukocyte filtration attenuates the reperfusion injury at a cellular level, but this has not been translated into clinical improvements. Finally, whilst various strategies involving multiple leukocyte filters, or the incorporation of pharmacological agents into leukocyte-depleting protocols have been evaluated, the current available results are not conclusive. Our study suggests that there is not enough high quality or consistent evidence to draw guidelines regarding the use of leukocyte-depleting filters within routine cardiac surgical practice.
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Affiliation(s)
- Oliver Warren
- Department of BioSurgery and Surgical Technology, Imperial College, St Mary's Hospital, Praed Street, London, UK.
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Gunaydin S, McCusker K, Vijay V, Isbir S, Sari T, Onur MA, Gurpinar A, Sezgin A, Sargon MF, Tezcaner T, Zorlutuna Y. Comparison of polymethoxyethylacrylate-coated circuits with leukocyte filtration and reduced heparinization protocol on heparin-bonded circuits in different risk cohorts. Perfusion 2007; 21:329-42. [PMID: 17312857 DOI: 10.1177/0267659106070507] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objectives: The relative benefits of strategic leukofiltration on polymer-coated and low-dose heparin protocol on heparin-coated circuits were studied across EuroSCORE patient risk strata for three different cohorts. Methods: In a prospective, randomized study, 270 patients undergoing coronary artery bypass grafting were allocated into three groups (n = 90): Group 1 -polymethoxyethylacrylate-coated circuits+leukocyte filters; Group 2 -polypeptide-based heparin-bonded circuits with reduced heparinization; and Group 3 -Control: uncoated circuits. Each group was further divided into three subgroups (n = 30), with respect to low- (EuroSCORE 0-2), medium- (3-5), and high- (6+) risk patients. Blood samples were collected at T1: following induction of anesthesia; T2: following heparin administration; T3: 15 min after CPB; T4: before cessation of CPB; T5: 15 min after protamine reversal; and T6: ICU. Results: In high-risk cohorts, leukocyte counts demonstrated significant differences at T4 and T5 in Group 1, and at T4 in Group 2. Platelet counts were preserved significantly better at T4 and T5 in both groups (p <0.05 versus control). Serum IL-2 and C3a levels were significantly lower at T3, T4 and T5 in Group 1, and T4 and T5 in Group 2 (p <0.05). Postoperative bleeding, respiratory support time and incidence of atrial fibrillation were lower in the study groups versus control. Cell counts on filter mesh and heparin-coated fibers/circuits were significantly higher in the high-risk cohorts versus uncoated fibers. Phagocytic capacity increased on filter mesh, especially in high-risk specimens. SEM evaluation demonstrated better preserved coated circuits. Conclusion: Leukofiltration and coating reduced platelet adhesion, protein adsorption, atrial fibrillation and reduced heparinization acted via modulation of systemic inflammatory response in high-risk groups.
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Leal-Noval SR, Amaya R, Herruzo A, Hernández A, Ordóñez A, Marín-Niebla A, Camacho P. Effects of a leukocyte depleting arterial line filter on perioperative morbidity in patients undergoing cardiac surgery: a controlled randomized trial. Ann Thorac Surg 2006; 80:1394-400. [PMID: 16181877 DOI: 10.1016/j.athoracsur.2005.04.021] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2005] [Revised: 04/07/2005] [Accepted: 04/14/2005] [Indexed: 11/19/2022]
Abstract
BACKGROUND Activated leukocytes may increase morbidity in cardiac surgery. The objective of this study is to investigate the influence on morbidity of leukocyte-depleting blood filters placed into the arterial line of cardiopulmonary bypass circuits. METHODS Simple, blind, prospective, randomized and controlled clinical trial carried out in a cardiac surgery ICU at a university center. We included 159 consecutive low-risk patients (ie, Parsonnet score < 10) undergoing cardiac surgery who were initially stratified in three risk levels according to the Parsonnet score at admission into the hospital (ie, low, < 4; middle, 4 to 7; and high, 8 to 10). Once stratified, all patients were randomized to undergo cardiopulmonary bypass either with a conventional blood filter or with a leukocyte filter (randomization ratio, 2:1). The outcome variable was morbidity. Patients were considered to have a high morbidity if any of the following clinical situations were present (ie, pulmonary dysfunction, cardiac dysfunction, perioperative infections, postoperative hyperthermia, and hyperdynamic states). RESULTS The leukocyte filter was used in 52 patients and the conventional filter in 107 patients. The morbidity rate was similar in both groups, but patients with leukocyte filter had a lower incidence of perioperative infections, fever, and hyperdynamic states as compared with patients with the conventional filter. CONCLUSIONS Leukocyte filtration in patients undergoing cardiac surgery with extracorporeal perfusion showed no measurable effects on postoperative morbidity. However, although not statistically significant, a decrease was observed in the rates of perioperative infection, fever, and hyperdynamic states.
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Koskenkari JK, Rimpiläinen J, Ohman H, Surcel HM, Vainionpää V, Biancari F, Ala-Kokko T, Juvonen T. Leukocyte Filter Enhances Neutrophil Activation during Combined Aortic Valve and Coronary Artery Bypass Surgery. Heart Surg Forum 2006; 9:E693-9. [PMID: 16844623 DOI: 10.1532/hsf98.20061008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE Cardiopulmonary bypass-induced systemic inflammatory reaction involving the expression of neutrophil surface adhesion molecules is the main mechanism leading to myocardial ischemia-reperfusion injury as well as multiorgan dysfunction. Patients undergoing prolonged cardiopulmonary bypass are especially at risk in this regard. The aim of this prospective, randomized study was to evaluate the impact of continuous leukocyte filtration on the perioperative expression of neutrophil adhesion molecules along with the markers of systemic inflammation during combined coronary artery revascularization and aortic valve surgery due to aortic stenosis. PATIENT AND METHODS Twenty patients scheduled for combined coronary artery revascularization and aortic valve surgery due to aortic stenosis were randomized to undergo cardiopulmonary bypass with or without a leukocyte filter (LeukoGuard LG6). The expression of neutrophil adhesion molecules and proinflammatory cytokine response were measured. RESULTS The use of the leukocyte filter significantly increased neutrophil CD11b expression (Pg = .003) compared to the control group, which was followed by a faster rise in interleukin-6 levels 5 minutes (median, 125 versus 34 pg/mL) and 2 hours after cardiopulmonary bypass (median, 158 versus 92 pg/mL, Pt x g < .001), respectively. No marked differences in terms of levels of CD11a, CD62L, cardiac troponin-I, or oxyhemodynamics were observed. CONCLUSIONS The observed increased neutrophil activation and enhanced inflammatory response do not support the use of continuous leukofiltration in patients undergoing prolonged cardiopulmonary bypass.
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Affiliation(s)
- Juha K Koskenkari
- Division of Intensive Care, Department of Anesthesiology, Oulu University Hospital, Oulu, Finland
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Koskenkari J, Rimpiläinen J, Biancari F, Surcel HM, Kaukoranta P, Kiviluoma K, Ala-Kokko T, Juvonen T. Leukocyte depleting filter attenuates myocardial injury during elective coronary artery bypass surgery. SCAND CARDIOVASC J 2006; 39:358-68. [PMID: 16352489 DOI: 10.1080/14017430510035943] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND Ischemia-reperfusion injury secondary to leukocyte activation has been widely recognized as one of the most relevant mechanism leading to postoperative organ dysfunction occurring after a period of ischemia. The aim of the present study was to evaluate in a prospective, randomized study, the value of leukocyte depleting filter in patients undergoing elective coronary artery bypass surgery. METHODS Twenty patients scheduled for elective on-pump coronary artery bypass surgery were randomized to undergo cardiopulmonary bypass either with a leukocyte depleting filter incorporated in the extracorporeal circulation arterial line or without a filter. RESULTS The main finding of this study was the significantly lower postoperative concentrations of cardiac troponin I in the leukocyte filter group (Tests of between-subjects effects: p = 0.024). There were also slightly better cardiac indices in the leukocyte filter group. A larger amount of blood units was infused intra- and postoperatively in patients undergoing cardiopulmonary bypass with leukocyte filtration (median, 600 [IQR, 0-1200] vs. 0 [IQR, 0-600], p = 0.08). Two patients in the leukocyte filter group underwent reoperation for bleeding but none in the control group (p = 0.48). Intra-and postoperative platelet count was lower in the leukocyte filter group (Tests of between-subjects effects: p = 0.08). Despite a significant increased concentration of C-reactive protein on the first postoperative day in the control group (p = 0.029), repeated-measures analysis failed to show any significant increase during the study period (p = 0.33). CONCLUSIONS The results of this study suggest a myocardial protective effect of leukocyte filter in the setting of elective coronary artery bypass surgery.
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Affiliation(s)
- Juha Koskenkari
- Division of Intensive Care, Department of Anesthesiology, Oulu University Hospital, Oulu, Finland.
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Sutton SW, Patel AN, Chase VA, Schmidt LA, Hunley EK, Yancey LW, Hebeler RF, Cheung EH, Henry AC, Meyers TP, Wood RE. Clinical benefits of continuous leukocyte filtration during cardiopulmonary bypass in patients undergoing valvular repair or replacement. Perfusion 2005; 20:21-9. [PMID: 15751667 DOI: 10.1191/0267659105pf781oa] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Valve operations in the form of repair or replacement make up a significant population of patients undergoing surgical procedures in the USA annually with the use of cardiopulmonary bypass. These patients experience a wide range of complications that are considered to be mediated by activation of complement and leukocytes. The extracorporeal perfusion circuit consists of multiple synthetic artificial surfaces. The biocompatibility of the blood contact surfaces is a variable that predisposes patients to an increased risk of complement mediation and activation. This can result in an inflammatory process, causing leukocytes to proliferate and sequester in the major organ systems. The purpose of this study was to determine whether filtration of activated leukocytes improved clinical outcomes following surgical intervention for valve repair or replacement. In this paper, we report a retrospective matched cohort study of 700 patients who underwent valve procedures from June 1999 to December 2002. The control group (CG) consisted of patients who had a conventional arterial line filter. In the study group (SG), patients had a conventional arterial line filter and a leukocyte arterial line filter (Pall Medical, NY). In the SG, blood diverted to the cardioplegia system was also leukocyte depleted to enhance myocardial preservation by adapting this device to the outflow port on the filter. Patient characteristics were similar for the SG and the CG, including 228 males and 122 females, mean age (62.4 versus 64.2 years), cardiopulmonary bypass time (127+/-64 versus 116+/-53 min), and aortic crossclamp time (84+/-23 versus 81+/-23 min). Our results demonstrate that the SG achieved statistically significant reduction in the time to extubation (p =0.03) and the number of patients with prolonged intubation in excess of 24 hours (p <0.04), in addition to improved postoperative oxygenation (p=0.01), and decreased length of hospital stay (p =0.03). We believe that leukocyte filters are clinically beneficial, as demonstrated by the results presented in this study.
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Affiliation(s)
- S W Sutton
- Baylor University Medical Center, Dallas, TX, USA.
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Karaiskos TE, Palatianos GM, Triantafillou CD, Kantidakis GH, Astras GM, Papadakis EG, Vassili MI. Clinical Effectiveness of Leukocyte Filtration During Cardiopulmonary Bypass in Patients with Chronic Obstructive Pulmonary Disease. Ann Thorac Surg 2004; 78:1339-44. [PMID: 15464496 DOI: 10.1016/j.athoracsur.2004.04.040] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/12/2004] [Indexed: 11/16/2022]
Abstract
BACKGROUND We tested the hypothesis that leukocyte filtration during pulmonary reperfusion preserves pulmonary function and results in improved oxygenation after cardiopulmonary bypass (CPB) in patients with chronic obstructive pulmonary disease (COPD). METHODS In a prospective, randomized study, the treatment group consisted of 20 patients with COPD from consecutive open-heart procedures. A primed leukocyte filter was connected to the arterial line downstream of the standard arterial filter but was excluded from circulation. Circulated blood was directed through the leukocyte filter approximately 10 minutes before aortic cross-clamp removal and at early reperfusion for up to 30 minutes. These patients were compared to 20 additional COPD patients (controls) on whom systemic leukocyte filtration was not used during open-heart surgery. RESULTS There was no significant difference in gender, age, left ventricular ejection fraction, type of procedure, aortic cross-clamp time, perfusion time, preoperative FEV1 and preoperative respiratory index (Pao2/FiO2 ratio) between treatment and control groups. The respiratory index changed in the treatment group by +9.8% of baseline after completion of CPB, by -14.2% upon arrival in the intensive care unit (ICU), and by -19.6% 12 hours later, whereas in the control group, it changed by -14.5% (p < 0.05), -27.7%, and -24%, respectively. Leukocyte-depleted patients required shorter intubation time (20.4 +/- 16.1 hours), ICU stay (46.2 +/- 40.1 hours) and length of hospitalization (8.3 +/- 2.8 days) than controls (29.5 +/- 21.9 hours, p < 0.05; 75.5 +/- 34.9 hours, p < 0.005; and 10.4 +/- 3.5 days, p < 0.05, respectively). Surgical (30-day) mortality was zero in both groups. CONCLUSIONS In COPD patients having CPB, systemic leukocyte depletion at early reperfusion was associated with better oxygenation, shorter intubation time, and shorter ICU and hospital stays. Leukocyte filtration during CPB most likely preserves pulmonary function by ameliorating pulmonary reperfusion injury.
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Abstract
During the past year, blood component therapy witnessed two quite contradictory trends in the area of leukoreduction. On the one hand, the year saw widespread forced implementation of leukoreduction by several national blood suppliers, including the American Red Cross, who refused to sell hospitals nonleukoreduced blood. The forced implementation came at high cost to hospitals and with the strong endorsement of the US Food and Drug Administration, which stopped short of mandating universal leukoreduction in the United States. On the other hand, the year saw the publication of several pivotal clinical trials that failed to demonstrate significant patient benefit from the use of leukoreduced blood components. The emerging scientific and clinical evidence reviewed in this article demonstrates that leukoreduction technology is an effective means to reduce the risk of three complications of transfusion: HLA alloimmunization, cytomegalovirus transmission, and recurrent febrile nonhemolytic transfusion reactions. The application of the technology to all blood components does not appear to be warranted.
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Affiliation(s)
- Walter H Dzik
- Blood Transfusion Service, Massachusetts General Hospital, Boston, 02114, USA.
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