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Bertini P, Guarracino F. Pro: Pulsatile Flow During Cardiopulmonary Bypass. J Cardiothorac Vasc Anesth 2023; 37:2370-2373. [PMID: 37258366 DOI: 10.1053/j.jvca.2023.04.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 04/11/2023] [Accepted: 04/25/2023] [Indexed: 06/02/2023]
Affiliation(s)
- Pietro Bertini
- Department of Anesthesia and Critical Care Medicine, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy.
| | - Fabio Guarracino
- Department of Anesthesia and Critical Care Medicine, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
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2
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Kant S, Banerjee D, Sabe SA, Sellke F, Feng J. Microvascular dysfunction following cardiopulmonary bypass plays a central role in postoperative organ dysfunction. Front Med (Lausanne) 2023; 10:1110532. [PMID: 36865056 PMCID: PMC9971232 DOI: 10.3389/fmed.2023.1110532] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 01/30/2023] [Indexed: 02/17/2023] Open
Abstract
Despite significant advances in surgical technique and strategies for tissue/organ protection, cardiac surgery involving cardiopulmonary bypass is a profound stressor on the human body and is associated with numerous intraoperative and postoperative collateral effects across different tissues and organ systems. Of note, cardiopulmonary bypass has been shown to induce significant alterations in microvascular reactivity. This involves altered myogenic tone, altered microvascular responsiveness to many endogenous vasoactive agonists, and generalized endothelial dysfunction across multiple vascular beds. This review begins with a survey of in vitro studies that examine the cellular mechanisms of microvascular dysfunction following cardiac surgery involving cardiopulmonary bypass, with a focus on endothelial activation, weakened barrier integrity, altered cell surface receptor expression, and changes in the balance between vasoconstrictive and vasodilatory mediators. Microvascular dysfunction in turn influences postoperative organ dysfunction in complex, poorly understood ways. Hence the second part of this review will highlight in vivo studies examining the effects of cardiac surgery on critical organ systems, notably the heart, brain, renal system, and skin/peripheral tissue vasculature. Clinical implications and possible areas for intervention will be discussed throughout the review.
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Affiliation(s)
| | | | | | | | - Jun Feng
- Cardiothoracic Surgery Research Laboratory, Department of Cardiothoracic Surgery, Rhode Island Hospital, Lifespan, Providence, RI, United States
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3
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Hughes C, Djaiani G, Pungsornruk K, Agarwal S. Renal failure in cardiac surgery: in search of the magic bullet. Anaesthesia 2022; 77:1197-1201. [PMID: 36059270 DOI: 10.1111/anae.15857] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/09/2022] [Indexed: 01/11/2023]
Affiliation(s)
- C Hughes
- Unit of Academic Anaesthesia, Critical Care and Peri-operative Medicine, University of Glasgow, Glasgow, UK
| | - G Djaiani
- Department of Anaesthesia and Pain Management, University Health Network, Toronto, ON, Canada.,University of Toronto, ON, Canada
| | - K Pungsornruk
- Department of Anaesthesia and Pain Management, University Health Network, Toronto, ON, Canada
| | - S Agarwal
- Department of Cardiothoracic Anaesthesia, Manchester University Hospitals, Manchester, UK.,Manchester University, Manchester, UK
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4
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Hall JD, Farzaneh S, Babakhani Galangashi R, Pujari A, Sweet DT, Kahn ML, Jiménez JM. Lymphoedema conditions disrupt endothelial barrier function in vitro. J R Soc Interface 2022; 19:20220223. [PMID: 36000230 PMCID: PMC9399713 DOI: 10.1098/rsif.2022.0223] [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: 03/19/2022] [Accepted: 07/27/2022] [Indexed: 11/12/2022] Open
Abstract
Lymphatic vessel contractions generate net antegrade pulsatile lymph flow. By contrast, impaired lymphatic vessels are often associated with lymphoedema and altered lymph flow. The effect of lymphoedema on the lymph flow field and endothelium is not completely known. Here, we characterized the lymphatic flow field of a platelet-specific receptor C-type lectin-like receptor 2 (CLEC2) deficient lymphoedema mouse model. In regions of lymphoedema, collecting vessels were significantly distended, vessel contractility was greatly diminished and pulsatile lymph flow was replaced by quasi-steady flow. In vitro exposure of human dermal lymphatic endothelial cells (LECs) to lymphoedema-like quasi-steady flow conditions increased intercellular gap formation and permeability in comparison to normal pulsatile lymph flow. In the absence of flow, LECs exposed to steady pressure (SP) increased intercellular gap formation in contrast with pulsatile pressure (PP). The absence of pulsatility in steady fluid flow and SP conditions without flow-induced upregulation of myosin light chain (MLCs) regulatory subunits 9 and 12B mRNA expression and phosphorylation of MLCs, in contrast with pulsatile flow and PP without flow. These studies reveal that the loss of pulsatility, which can occur with lymphoedema, causes LEC contraction and an increase in intercellular gap formation mediated by MLC phosphorylation.
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Affiliation(s)
- Joshua D. Hall
- Department of Mechanical and Industrial Engineering, University of Massachusetts Amherst, Amherst, MA, USA
| | - Sina Farzaneh
- Department of Mechanical and Industrial Engineering, University of Massachusetts Amherst, Amherst, MA, USA
| | - Reza Babakhani Galangashi
- Department of Mechanical and Industrial Engineering, University of Massachusetts Amherst, Amherst, MA, USA
| | - Akshay Pujari
- Department of Mechanical and Industrial Engineering, University of Massachusetts Amherst, Amherst, MA, USA
| | - Daniel T. Sweet
- Department of Medicine and Division of Cardiology, University of Pennsylvania, Philadelphia, PA, USA
| | - Mark L. Kahn
- Department of Medicine and Division of Cardiology, University of Pennsylvania, Philadelphia, PA, USA
| | - Juan M. Jiménez
- Department of Mechanical and Industrial Engineering, University of Massachusetts Amherst, Amherst, MA, USA
- Department of Biomedical Engineering, University of Massachusetts Amherst, Amherst, MA, USA
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5
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Efficacy of Pulsatile Flow Perfusion in Adult Cardiac Surgery: Hemodynamic Energy and Vascular Reactivity. J Clin Med 2021; 10:jcm10245934. [PMID: 34945230 PMCID: PMC8703987 DOI: 10.3390/jcm10245934] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2021] [Revised: 12/08/2021] [Accepted: 12/13/2021] [Indexed: 11/17/2022] Open
Abstract
Background: The role of pulsatile (PP) versus non-pulsatile (NP) flow during a cardiopulmonary bypass (CPB) is still debated. This study’s aim was to analyze hemodynamic effects, endothelial reactivity and erythrocytes response during a CPB with PP or NP. Methods: Fifty-two patients undergoing an aortic valve replacement were prospectively randomized for surgery with either PP or NP flow. Pulsatility was evaluated in terms of energy equivalent pressure (EEP) and surplus hemodynamic energy (SHE). Systemic (SVRi) and pulmonary (PVRi) vascular resistances, endothelial markers levels and erythrocyte nitric-oxide synthase (eNOS) activity were collected at different perioperative time-points. Results: In the PP group, the resultant EEP was 7.3% higher than the mean arterial pressure (MAP), which corresponded to 5150 ± 2291 ergs/cm3 of SHE. In the NP group, the EEP and MAP were equal; no SHE was produced. The PP group showed lower SVRi during clamp-time (p = 0.06) and lower PVRi after protamine administration and during first postoperative hours (p = 0.02). Lower SVRi required a higher dosage of norepinephrine in the PP group (p = 0.02). Erythrocyte eNOS activity results were higher in the PP patients (p = 0.04). Renal function was better preserved in the PP group (p = 0.001), whereas other perioperative variables were comparable between the groups. Conclusions: A PP flow during a CPB results in significantly lower SVRi, PVRi and increased eNOS production. The clinical impact of increased perioperative vasopressor requirements in the PP group deserves further evaluation.
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Miyamoto T, Sunagawa G, Dessoffy R, Karimov JH, Grady P, Naber JP, Vincent D, Sale SM, Kvernebo K, Tran VNP, Moazami N, Fukamachi K. Hemodynamic evaluation of a new pulsatile blood pump during low flow cardiopulmonary bypass support. Artif Organs 2021; 46:643-652. [PMID: 34780074 DOI: 10.1111/aor.14119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 10/05/2021] [Accepted: 11/11/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND The VentriFlo® True Pulse Pump (VentriFlo, Inc, Pelham, NH, USA) is a new pulsatile blood pump intended for use during short-term circulatory support. The purpose of this study was to evaluate the feasibility of the VentriFlo and compare it to a conventional centrifugal pump (ROTAFLOW, Getinge, Gothenberg, Sweden) in acute pig experiments. METHODS Pigs (40-45 kg) were supported by cardiopulmonary bypass (CPB) with the VentriFlo (n = 9) or ROTAFLOW (n = 5) for 6 h. Both VentriFlo and ROTAFLOW circuits utilized standard CPB components. We evaluated hemodynamics, blood chemistry, gas analysis, plasma hemoglobin, and microcirculation at the groin skin with computer-assisted video microscopy (Optilia, Sollentuna, Sweden). RESULTS Pigs were successfully supported by CPB for 6 h without any pump-related complications in either group. The VentriFlo delivered an average stroke volume of 29.2 ± 4.8 ml. VentriFlo delivered significantly higher pulse pressure (29.1 ± 7.2 mm Hg vs. 4.4 ± 7.0 mm Hg, p < 0.01) as measured in the carotid artery, with mean aortic pressure and pump flow comparable with those in ROTAFLOW. In blood gas analysis, arterial pH was significantly lower after five hours support in the VentriFlo group (7.30 ± 0.07 vs. 7.43 ± 0.03, p = 0.001). There was no significant difference in plasma hemoglobin level in both groups after six hours of CPB support. In microcirculatory assessment, VentriFlo tended to keep normal capillary flow, but it was not statistically significant. CONCLUSIONS VentriFlo-supported pigs showed comparable hemodynamic parameters with significantly higher pulse pressure compared to ROTAFLOW without hemolysis.
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Affiliation(s)
- Takuma Miyamoto
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Gengo Sunagawa
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Raymond Dessoffy
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Jamshid H Karimov
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Patrick Grady
- Department of Thoracic and Cardiovascular Surgery, Miller Family Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | | | | | - Shiva M Sale
- Department of Cardiothoracic Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Knut Kvernebo
- Department of Cardio-thoracic Surgery, Oslo University Hospital, Ullevaal, Oslo, Norway
| | - Van N P Tran
- Department of Cardio-thoracic Surgery, Oslo University Hospital, Ullevaal, Oslo, Norway
| | - Nader Moazami
- Department of Cardiothoracic surgery, New York University's Langone Health, New York, New York, USA
| | - Kiyotaka Fukamachi
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
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Sun J, Yuan J, Li B. SBP Is Superior to MAP to Reflect Tissue Perfusion and Hemodynamic Abnormality Perioperatively. Front Physiol 2021; 12:705558. [PMID: 34594235 PMCID: PMC8476970 DOI: 10.3389/fphys.2021.705558] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 08/11/2021] [Indexed: 11/15/2022] Open
Abstract
Many articles have reported that intraoperative low mean artery pressure (MAP) or low systolic blood pressure (SBP) impacts on organs’ function and patients’ outcomes perioperatively. On the contrary, what type of blood pressure should be obtained still needs to be clarified. In our paper, we compared the influencing factors of MAP and SBP, and mathematical formula, arterial pulse contour calculation, and cardiovascular physiological knowledge were adopted to discuss how blood pressure can effectively reflect tissue perfusion and hemodynamic abnormality perioperatively. We concluded that MAP can reflect cardiac output change sensitively and SBP can reflect stroke volume change sensitively. Moreover, SBP can reflect the early hemodynamic changes, organs’ perfusion, and heart systolic function. Compared with MAP, perioperative monitoring of SBP and timely detection and treatment of abnormal SBP are very important for the early detection of hemodynamic abnormalities.
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Affiliation(s)
- Jie Sun
- Department of Anesthesiology, Zhongda Hospital, Southeast University, Nanjing, China
| | - Jing Yuan
- Department of Anesthesiology, Zhongda Hospital, Southeast University, Nanjing, China
| | - Bin Li
- Department of Anesthesiology, Zhongda Hospital, Southeast University, Nanjing, China
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8
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Pulsatile Versus Nonpulsatile Flow During Cardiopulmonary Bypass: Extent of Hemolysis and Clinical Significance. ASAIO J 2020; 66:1025-1030. [PMID: 32224786 DOI: 10.1097/mat.0000000000001154] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Pulsatile flow has been used during cardiopulmonary bypass (CPB) for decades and its use is increasing with advancing extracorporeal technology. Pulsatile flow generates higher circuit pressures and shear forces than nonpulsatile flow at comparable pump flow and patient mean arterial pressure. Very little is known about the effect this has on erythrocytes. We included 62 adult patients (32 in the pulsatile group and 30 in the nonpulsatile group) undergoing elective coronary artery bypass grafting in this prospective observational study. Blood samples were collected at routine sampling times throughout surgery and were analyzed for the presence of free heme and globin using mass spectroscopy. Patient characteristics, CPB, and aortic cross-clamp times, pump flow as well as patient mean arterial pressure were similar in both groups. Maximum circuit pressure in the pulsatile flow group was statistically significantly higher than that in the nonpulsatile flow group (257.12 vs. 190.64 mmHg, p < 0.0001). Both heme and globin levels were higher in the pulsatile flow group. This reached statistical significance with globin at 30 minutes of CPB and with heme after aortic unclamping. We conclude that pulsatile CPB using roller pumps results in a greater extent of hemolysis. The clinical significance, however, is not yet known.
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9
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Coulson TG, McPhilimey E, Falter F, Abu-Omar Y, Klein AA. The Association Between Pulsatile Cardiopulmonary Bypass and Acute Kidney Injury After Cardiac Surgery: A Before-and-After Study. J Cardiothorac Vasc Anesth 2020; 34:108-113. [DOI: 10.1053/j.jvca.2019.05.021] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Revised: 05/13/2019] [Accepted: 05/15/2019] [Indexed: 01/22/2023]
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10
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Hendrix RHJ, Ganushchak YM, Weerwind PW. Oxygen delivery, oxygen consumption and decreased kidney function after cardiopulmonary bypass. PLoS One 2019; 14:e0225541. [PMID: 31756180 PMCID: PMC6874338 DOI: 10.1371/journal.pone.0225541] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Accepted: 11/05/2019] [Indexed: 11/29/2022] Open
Abstract
Introduction Low oxygen delivery during cardiopulmonary bypass is related to a range of adverse outcomes. Previous research specified certain critical oxygen delivery levels associated with acute kidney injury. However, a single universal critical oxygen delivery value is not sensible, as oxygen consumption has to be considered when determining critical delivery values. This study examined the associations between oxygen delivery and oxygen consumption and between oxygen delivery and kidney function in patients undergoing cardiopulmonary bypass. Methods Oxygen delivery, oxygen consumption and kidney function decrease were retrospectively studied in 65 adult patients. Results Mean oxygen consumption was 56 ± 8 ml/min/m2, mean oxygen delivery was 281 ± 39 ml/min/m2. Twenty-seven patients (42%) had an oxygen delivery lower than the previously mentioned critical value of 272 ml/min/m2. None of the patients developed acute kidney injury according to RIFLE criteria. However, in 10 patients (15%) a decrease in the estimated glomerular filtration rate of more than 10% was noted, which was not associated with oxygen delivery lower than 272 ml/min/m2. Eighteen patients had a strong correlation (r >0.500) between DO2 and VO2, but this was not related to low oxygen delivery. Central venous oxygen saturation (77 ± 3%), oxygen extraction ratio (21 ± 3%) and blood lactate levels at the end of surgery (1.2 ± 0.3 mmol/l) showed not to be indicative of insufficient oxygen delivery either. Conclusions This study could not confirm an evident correlation between O2 delivery and O2 consumption or kidney function decrease, even at values below previously specified critical levels. The variability in O2 consumption however, is an indication that every patient has individual O2 needs, advocating for an individualized O2 delivery goal.
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Affiliation(s)
- Rik H J Hendrix
- Department of Extra-Corporeal Circulation, Maastricht University Medical Centre+, Maastricht, the Netherlands
| | - Yuri M Ganushchak
- Department of Extra-Corporeal Circulation, Maastricht University Medical Centre+, Maastricht, the Netherlands
| | - Patrick W Weerwind
- Department of Extra-Corporeal Circulation, Maastricht University Medical Centre+, Maastricht, the Netherlands.,Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, the Netherlands
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Abstract
In this review the impact of cardiopulmonary bypass (CPB) on the microcirculation is discussed. The impact of conventional non-pulsatile perfusion is contrasted with the microcirculatory impact of pulsatile CPB which is associated with better preservation of microcirculatory function. Evidence that alterations in microcirculatory function that persist following cardiac surgery are associated with adverse clinical outcomes is reviewed. Recent studies using novel techniques employing near infrared reflectance spectroscopy (NIRS) and sublingual microscopy to explore alterations in microcirculatory function during CPB are reviewed and the implications of these observations for studies investigating minimally invasive extracorporeal circulation (MiECC) are discussed.
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Affiliation(s)
- John M Murkin
- Department of Anesthesia & Perioperative Medicine, London Health Sciences Centre, University Hospital, London, ON, Canada
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12
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Miyamoto T, Karimov JH, Fukamachi K. Acute and chronic effects of continuous‐flow support and pulsatile‐flow support. Artif Organs 2019; 43:618-623. [DOI: 10.1111/aor.13446] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Accepted: 02/21/2019] [Indexed: 01/03/2023]
Affiliation(s)
- Takuma Miyamoto
- Department of Biomedical Engineering Lerner Research Institute, Cleveland Clinic Cleveland Ohio
| | - Jamshid H. Karimov
- Department of Biomedical Engineering Lerner Research Institute, Cleveland Clinic Cleveland Ohio
| | - Kiyotaka Fukamachi
- Department of Biomedical Engineering Lerner Research Institute, Cleveland Clinic Cleveland Ohio
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13
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Leow EH, Chan YH, Ng YH, Lim JKB, Nakao M, Lee JH. Prevention of Acute Kidney Injury in Children Undergoing Cardiac Surgery: A Narrative Review. World J Pediatr Congenit Heart Surg 2018; 9:79-90. [PMID: 29310552 DOI: 10.1177/2150135117743211] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Children undergoing cardiac surgery are at risk of developing acute kidney injury (AKI). Preventing cardiac surgery-associated AKI (CS-AKI) is important as it is associated with increased early- and long-term mortality and morbidity. Targeting modifiable risk factors (eg, avoiding poor renal perfusion, nephrotoxic drugs, and fluid overload) reduces the risk of CS-AKI. There is currently no strong evidence for the routine use of pharmacological approaches (eg, aminophylline, dexmedetomidine, fenoldopam, and steroids) to prevent CS-AKI. There is robust evidence to support the role of early peritoneal dialysis as a nonpharmacologic approach to prevent CS-AKI.
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Affiliation(s)
- Esther Huimin Leow
- 1 Department of Paediatrics, KK Women's and Children's Hospital, Singapore, Singapore
| | - Yoke Hwee Chan
- 2 Children's Intensive Care Unit, KK Women's and Children's Hospital, Singapore, Singapore.,3 Duke-NUS School of Medicine, Singapore, Singapore
| | - Yong Hong Ng
- 1 Department of Paediatrics, KK Women's and Children's Hospital, Singapore, Singapore
| | - Joel Kian Boon Lim
- 1 Department of Paediatrics, KK Women's and Children's Hospital, Singapore, Singapore
| | - Masakazu Nakao
- 4 Department of Paediatric Cardiothoracic Surgery, KK Women's and Children's Hospital, Singapore, Singapore
| | - Jan Hau Lee
- 2 Children's Intensive Care Unit, KK Women's and Children's Hospital, Singapore, Singapore.,3 Duke-NUS School of Medicine, Singapore, Singapore
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Kreibich M, Trummer G, Beyersdorf F, Scherer C, Förster K, Taunyane I, Benk C. Improved Outcome in an Animal Model of Prolonged Cardiac Arrest Through Pulsatile High Pressure Controlled Automated Reperfusion of the Whole Body. Artif Organs 2018; 42:992-1000. [PMID: 30015357 DOI: 10.1111/aor.13147] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Revised: 01/09/2018] [Accepted: 02/23/2018] [Indexed: 12/22/2022]
Abstract
The reperfusion period after extracorporeal cardiopulmonary resuscitation has been recognized as a key player in improving the outcome after cardiac arrest (CA). Our aim was to evaluate the effects of high mean arterial pressure (MAP) and pulsatile flow during controlled automated reperfusion of the whole body. Following 20 min of normothermic CA, high MAP, and pulsatile blood flow (pulsatile group, n = 10) or low MAP and nonpulsatile flow (nonpulsatile group, n = 6) controlled automated reperfusion of the whole body was commenced through the femoral vessels of German landrace pigs for 60 min. Afterwards, animals were observed for eight days. Blood samples were analyzed throughout the experiment and a species-specific neurologic disability score (NDS) was used for neurologic evaluation. In the pulsatile group, nine animals finished the study protocol, while no animal survived postoperative day four in the nonpulsatile group. NDS were significantly better at any given time in the pulsatile group and reached overall satisfactory outcome values. In addition, blood analyses revealed lower levels of lactate in the pulsatile group compared to the nonpulsatile group. This study demonstrates superior survival and neurologic outcome when using pulsatile high pressure automated reperfusion following 20 min of normothermic CA compared to nonpulsatile flow and low MAP. This study strongly supports regulating the reperfusion period after prolonged periods of CA.
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Affiliation(s)
- Maximilian Kreibich
- Faculty of Medicine, Department of Cardiovascular Surgery, Heart Centre Freiburg University, University of Freiburg, Freiburg, Germany
| | - Georg Trummer
- Faculty of Medicine, Department of Cardiovascular Surgery, Heart Centre Freiburg University, University of Freiburg, Freiburg, Germany
| | - Friedhelm Beyersdorf
- Faculty of Medicine, Department of Cardiovascular Surgery, Heart Centre Freiburg University, University of Freiburg, Freiburg, Germany
| | - Christian Scherer
- Faculty of Medicine, Department of Cardiovascular Surgery, Heart Centre Freiburg University, University of Freiburg, Freiburg, Germany
| | - Katharina Förster
- Faculty of Medicine, Department of Cardiovascular Surgery, Heart Centre Freiburg University, University of Freiburg, Freiburg, Germany
| | - Itumeleng Taunyane
- Faculty of Medicine, Department of Cardiovascular Surgery, Heart Centre Freiburg University, University of Freiburg, Freiburg, Germany
| | - Christoph Benk
- Faculty of Medicine, Department of Cardiovascular Surgery, Heart Centre Freiburg University, University of Freiburg, Freiburg, Germany
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15
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An Assessment of Renal Function with Pulsatile Perfusion During Proximal Graft Using Cardiac Contraction in Coronary Artery Bypass Graft Surgery. Nephrourol Mon 2017. [DOI: 10.5812/numonthly.14324] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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16
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Cardiac Surgery-Associated Acute Kidney Injury. CURRENT ANESTHESIOLOGY REPORTS 2017. [DOI: 10.1007/s40140-017-0224-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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17
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Crosina J, Lerner J, Ho J, Tangri N, Komenda P, Hiebert B, Choi N, Arora RC, Rigatto C. Improving the Prediction of Cardiac Surgery-Associated Acute Kidney Injury. Kidney Int Rep 2017; 2:172-179. [PMID: 29142955 PMCID: PMC5678656 DOI: 10.1016/j.ekir.2016.10.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Revised: 10/11/2016] [Accepted: 10/11/2016] [Indexed: 12/27/2022] Open
Abstract
INTRODUCTION Acute kidney injury (AKI) is a potentially fatal complication of cardiac surgery. The inability to predict cardiac surgery-associated AKI is a major barrier to prevention and early treatment. Current clinical risk models for the prediction of cardiac surgery-associated AKI are insufficient, particularly in patients with preexisting kidney dysfunction. METHODS To identify intraoperative variables that might improve the performance of a validated clinical risk score (Cleveland Clinic Score, CCS) for the prediction of cardiac surgery-associated AKI, we conducted a prospective cohort study in 289 consecutive elective cardiac surgery patients at a tertiary care center. We compared the area under the receiver operator characteristic curve (AUC) of a base model including only the CCS with models containing additional selected intraoperative variables including mean arterial pressure, hematocrit, duration of procedure, blood transfusions, and fluid balance. AKI was defined by the Kidney Disease Improving Global Outcomes 2012 criteria. RESULTS The CCS alone gave an AUC of 0.72 (95% confidence interval, 0.62-0.82) for postoperative AKI. Nadir intraoperative hematocrit was the only variable that improved AUC for postoperative AKI when added to the CCS (AUC = 0.78; 95% confidence interval, 0.70-0.87; P = 0.002). In the subcohort of patients without preexisting chronic kidney disease (n = 214), where the CCS underperformed (AUC, 0.60 [0.43-0.76]), the improvement with the addition of nadir hematocrit was more marked (AUC, 0.74 [0.62-0.86]). Other variables did not improve discrimination. DISCUSSION Nadir intraoperative hematocrit is useful in improving discrimination of clinical risk scores for AKI, and may provide a target for intervention.
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Affiliation(s)
- Jordan Crosina
- Department of Medicine, University of Manitoba, Winnipeg, Canada
| | - Jordyn Lerner
- Department of Medicine, University of Manitoba, Winnipeg, Canada
| | - Julie Ho
- Department of Medicine, University of Manitoba, Winnipeg, Canada
- Department of Immunology, University of Manitoba, Winnipeg, Canada
| | - Navdeep Tangri
- Department of Medicine, University of Manitoba, Winnipeg, Canada
- Department of Community Health Sciences, University of Manitoba, Winnipeg, Canada
- Chronic Disease Innovation Centre, Seven Oaks Hospital, Winnipeg, Canada
| | - Paul Komenda
- Department of Medicine, University of Manitoba, Winnipeg, Canada
- Department of Community Health Sciences, University of Manitoba, Winnipeg, Canada
- Chronic Disease Innovation Centre, Seven Oaks Hospital, Winnipeg, Canada
| | - Brett Hiebert
- Cardiac Sciences Program, St. Boniface Hospital Research Centre, Winnipeg, Canada
| | - Nora Choi
- Department of Immunology, University of Manitoba, Winnipeg, Canada
| | - Rakesh C. Arora
- Cardiac Sciences Program, St. Boniface Hospital Research Centre, Winnipeg, Canada
- Department of Surgery, University of Manitoba, Winnipeg, Canada
| | - Claudio Rigatto
- Department of Medicine, University of Manitoba, Winnipeg, Canada
- Department of Community Health Sciences, University of Manitoba, Winnipeg, Canada
- Chronic Disease Innovation Centre, Seven Oaks Hospital, Winnipeg, Canada
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Griep LM, van Barneveld LJ, Simons AP, Boer C, Weerwind PW. Impact of Distinct Oxygenators on Pulsatile Energy Indicators in an Adult Cardiopulmonary Bypass Model. Artif Organs 2017; 41:E15-E25. [DOI: 10.1111/aor.12889] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Revised: 09/23/2016] [Accepted: 10/12/2016] [Indexed: 12/12/2022]
Affiliation(s)
- Lonneke M. Griep
- Department of Cardiothoracic Surgery; Institute for Cardiovascular Research, VU University Medical Center; Amsterdam
| | - Laurentius J.M. van Barneveld
- Department of Cardiothoracic Surgery; Institute for Cardiovascular Research, VU University Medical Center; Amsterdam
| | - Antoine P. Simons
- Department of Cardiothoracic Surgery; Cardiovascular Research Institute Maastricht, Maastricht University Medical Center; Maastricht
| | - Christa Boer
- Department of Anesthesiology; Institute for Cardiovascular Research, VU University Medical Center; Amsterdam The Netherlands
| | - Patrick W. Weerwind
- Department of Cardiothoracic Surgery; Cardiovascular Research Institute Maastricht, Maastricht University Medical Center; Maastricht
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19
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Raignault A, Bolduc V, Lesage F, Thorin E. Pulse pressure-dependent cerebrovascular eNOS regulation in mice. J Cereb Blood Flow Metab 2017; 37:413-424. [PMID: 26823473 PMCID: PMC5381440 DOI: 10.1177/0271678x16629155] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Arterial blood pressure is oscillatory; whether pulse pressure (PP) regulates cerebral artery myogenic tone (MT) and endothelial function is currently unknown. To test the impact of PP on MT and dilation to flow (FMD) or to acetylcholine (Ach), isolated pressurized mouse posterior cerebral arteries were subjected to either static pressure (SP) or a physiological PP (amplitude: 30 mm Hg; frequency: 550 bpm). Under PP, MT was significantly higher than in SP conditions ( p < 0.05) and was not affected by eNOS inhibition. In contrast, under SP, eNOS inhibition increased ( p < 0.05) MT to levels observed under PP, suggesting that PP may inhibit eNOS. At a shear stress of 20 dyn/cm2, FMD was lower ( p < 0.05) under SP than PP. Under SP, eNOS-dependent [Formula: see text] production contributed to FMD, while under PP, eNOS-dependent NO was responsible for FMD, indicating that PP favours eNOS coupling. Differences in FMD between pressure conditions were abolished after NOX2 inhibition. In contrast to FMD, Ach-induced dilations were higher ( p < 0.05) under SP than PP. Reactive oxygen species scavenging reduced ( p < 0.05) Ach-dependent dilations under SP, but increased ( p < 0.05) them under PP; hence, under PP, Ach promotes ROS production and limits eNOS-derived NO activity. In conclusion, PP finely regulates eNOS, controlling cerebral artery reactivity.
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Affiliation(s)
- Adeline Raignault
- 1 Faculty of Medicine, Department of Pharmacology, Université de Montréal, Montreal, Quebec, Canada.,2 Montreal Heart Institute Research Center, Montreal, Quebec, Canada
| | - Virginie Bolduc
- 1 Faculty of Medicine, Department of Pharmacology, Université de Montréal, Montreal, Quebec, Canada.,2 Montreal Heart Institute Research Center, Montreal, Quebec, Canada
| | - Frédéric Lesage
- 2 Montreal Heart Institute Research Center, Montreal, Quebec, Canada.,3 Ecole Polytechnique de Montréal, Montreal, Quebec, Canada
| | - Eric Thorin
- 1 Faculty of Medicine, Department of Pharmacology, Université de Montréal, Montreal, Quebec, Canada.,2 Montreal Heart Institute Research Center, Montreal, Quebec, Canada.,4 Faculty of Medicine, Department of Surgery, Université de Montréal, Montreal, Quebec, Canada
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20
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Prediction and Prevention of Acute Kidney Injury after Cardiac Surgery. BIOMED RESEARCH INTERNATIONAL 2016; 2016:2985148. [PMID: 27419130 PMCID: PMC4935903 DOI: 10.1155/2016/2985148] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Revised: 05/25/2016] [Accepted: 05/29/2016] [Indexed: 12/17/2022]
Abstract
The incidence of acute kidney injury after cardiac surgery (CS-AKI) ranges from 33% to 94% and is associated with a high incidence of morbidity and mortality. The etiology is suggested to be multifactorial and related to almost all aspects of perioperative management. Numerous studies have reported the risk factors and risk scores and novel biomarkers of AKI have been investigated to facilitate the subclinical diagnosis of AKI. Based on the known independent risk factors, many preventive interventions to reduce the risk of CS-AKI have been tested. However, any single preventive intervention did not show a definite and persistent benefit to reduce the incidence of CS-AKI. Goal-directed therapy has been considered to be a preventive strategy with a substantial level of efficacy. Many pharmacologic agents were tested for any benefit to treat or prevent CS-AKI but the results were conflicting and evidences are still lacking. The present review will summarize the current updated evidences about the risk factors and preventive strategies for CS-AKI.
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Thorin-Trescases N, Thorin E. Lifelong Cyclic Mechanical Strain Promotes Large Elastic Artery Stiffening: Increased Pulse Pressure and Old Age-Related Organ Failure. Can J Cardiol 2015; 32:624-33. [PMID: 26961664 DOI: 10.1016/j.cjca.2015.12.022] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2015] [Revised: 12/02/2015] [Accepted: 12/14/2015] [Indexed: 01/08/2023] Open
Abstract
The arterial wall is under a huge mechanical constraint imposed by the cardiac cycle that is bound to generate damage with time. Each heartbeat indeed imposes a pulsatile pressure that generates a vascular stretch. Lifetime accumulation of pulsatile stretches will eventually induce fatigue of the elastic large arterial walls, such as aortic and carotid artery walls, promoting their stiffening that will gradually perturb the normal blood flow and local pressure within the organs, and lead to organ failure. The augmented pulse pressure induced by arterial stiffening favours left ventricular hypertrophy because of the repeated extra work against stiff high-pressure arteries, and tissue damage as a result of excessive pulsatile pressure transmitted into the microcirculation, especially in low resistance/high-flow organs such as the brain and kidneys. Vascular aging is therefore characterized by the stiffening of large elastic arteries leading to a gradual increase in pulse pressure with age. In this review we focus on the effect of age-related stiffening of large elastic arteries. We report the clinical evidence linking arterial stiffness and organ failure and discuss the molecular pathways that are activated by the increase of mechanical stress in the wall. We also discuss the possible interventions that could limit arterial stiffening with age, such as regular aerobic exercise training, and some pharmacological approaches.
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Affiliation(s)
| | - Eric Thorin
- Montreal Heart Institute, Research Center, Montreal, Quebéc, Canada; Department of Surgery, Faculty of Medicine, Université de Montréal, Montreal, Quebéc, Canada.
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Wolfe R, Strother A, Wang S, Kunselman AR, Ündar A. Impact of Pulsatility and Flow Rates on Hemodynamic Energy Transmission in an Adult Extracorporeal Life Support System. Artif Organs 2015; 39:E127-37. [DOI: 10.1111/aor.12484] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Affiliation(s)
- Rachel Wolfe
- Penn State Hershey Pediatric Cardiovascular Research Center; Department of Pediatrics; Penn State Hershey Children's Hospital; Hershey PA USA
| | - Ashton Strother
- Penn State Hershey Pediatric Cardiovascular Research Center; Department of Pediatrics; Penn State Hershey Children's Hospital; Hershey PA USA
| | - Shigang Wang
- Penn State Hershey Pediatric Cardiovascular Research Center; Department of Pediatrics; Penn State Hershey Children's Hospital; Hershey PA USA
| | - Allen R. Kunselman
- Public Health and Sciences; Penn State Hershey Children's Hospital; Hershey PA USA
| | - Akif Ündar
- Penn State Hershey Pediatric Cardiovascular Research Center; Department of Pediatrics; Penn State Hershey Children's Hospital; Hershey PA USA
- Surgery and Bioengineering; Penn State Milton S. Hershey Medical Center; Penn State Hershey College of Medicine; Penn State Hershey Children's Hospital; Hershey PA USA
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