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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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Wang L, Xiao L, Hu L, Chen X, Wang X. Development and validation of a nomogram for predicting intraoperative hypotension in cardiac valve replacement. Biomark Med 2023; 17:849-858. [PMID: 38214145 DOI: 10.2217/bmm-2023-0548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2024] Open
Abstract
Background: Cardiac valve replacement risks include intraoperative hypotension, endangering organ perfusion. Our nomogram predicted hypotension risk in valve surgery, guiding early intervention. Methods: Analyzing 561 patients from July to November 2022, we developed a nomogram to predict hypotension in valve replacement patients, validated using data from December 2022 to January 2023 on 241 patients, with robust statistical confirmation. Results: Our study identified age, hypertension, left ventricular ejection fraction and serum creatinine as hypotension predictors. The resulting nomogram, validated with high concordance index and area under the curve scores, provided a clinically useful tool for managing intraoperative risk. Conclusion: For valve replacement patients, factors like age, hypertension, low left ventricular ejection fraction and high serum creatinine predicted hypotension risk. Our nomogram enabled clinicians to quantify this risk and proactively manage it.
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Affiliation(s)
- Lei Wang
- Department of Thoracic & Cardiovascular Surgery, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Liqiong Xiao
- Department of Thoracic & Cardiovascular Surgery, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Lanyue Hu
- Department of Thoracic & Cardiovascular Surgery, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Xin Chen
- Department of Thoracic & Cardiovascular Surgery, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Xiaoliang Wang
- Department of Thoracic & Cardiovascular Surgery, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
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Tagaya M, Murataka T, Okano S, Handa H, Takahashi S. Comparison of complement consumption and platelet accumulation between membrane oxygenators coated with a polymer or heparin. Perfusion 2023:2676591231177912. [PMID: 37216953 DOI: 10.1177/02676591231177912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
INTRODUCTION The membrane oxygenator in extracorporeal circulation circuits is coated with acrylate-copolymer (ACP) or immobilized heparin (IHP) to enhance hemocompatibility. To evaluate the relative features of both coatings, we compared blood components circulated in the circuits with ACP-and IHP-coated membranes in vitro using whole human blood. METHODS Whole human blood was heparinized and circulated in two experimental circuits with an ACP-coated reservoir, tubes, and an ACP- or IHP-coated membrane. Platelet (PLT) counts and the amount of total protein (TP), complement component 3 (C3), and complement component 4 (C4) were measured at 0, 8, 16, 24, and 32 h in each experiment (n = 5). RESULTS The PLT count at 0-h circulation was lower in the IHP-coated than in the ACP-coated circuits (p = 0.034); however, no significant difference was observed at other time points. Reduction in TP at 8-h and 16-h circulation and in C3 at 32-h circulation was lesser in the ACP-coated than in the IHP-coated circuits (p = 0.004, 0.034, and 0.027, respectively); reduction in TP and C3 at other time points and C4 at each time point was not significantly different. There were significant interactions between coating type and circulation duration in the PLT, TP, and C3 transitions (p = 0.008, 0.020, and 0.043, respectively). CONCLUSIONS Our findings suggest that ACP-coated membranes can prevent the initial drop in PLT count and C3 consumption over 32 h, whereas IHP-coated membranes could not prevent this drop in extracorporeal circulation. Therefore, ACP-coated membranes are suitable for short- and long-term extracorporeal life support.
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Affiliation(s)
- Masashi Tagaya
- Department of Medical Engineering, National Hospital Organization Kure Medical Center and Chugoku Cancer Center, Hiroshima, Japan
| | - Takuo Murataka
- Department of Medical Engineering, National Hospital Organization Kure Medical Center and Chugoku Cancer Center, Hiroshima, Japan
| | - Shinya Okano
- Department of Medical Engineering, National Hospital Organization Kure Medical Center and Chugoku Cancer Center, Hiroshima, Japan
| | - Hiroki Handa
- Department of Medical Engineering, National Hospital Organization Kure Medical Center and Chugoku Cancer Center, Hiroshima, Japan
| | - Shunsuke Takahashi
- Department of Nephrology, National Hospital Organization Kure Medical Center and Chugoku Cancer Center, Hiroshima, Japan
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Gao S, Ma G, Zhou L, Guan S, Zhang J. Effects of Dexmedetomidine Pretreatment, Posttreatment, and Whole-Course Pumping on Myocardial Damage during Cardiac Valve Replacement. Int Heart J 2022; 63:837-842. [DOI: 10.1536/ihj.22-008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Shenqiang Gao
- Department of Anesthesia, Tai'an City Central Hospital
| | - Guifen Ma
- Department of Anesthesia, Tai'an City Central Hospital
| | - Lina Zhou
- Department of Anesthesia, Tai'an City Central Hospital
| | - Shanhui Guan
- Department of Anesthesia, Tai'an City Central Hospital
| | - Jinjun Zhang
- Taishan Sanatorium and Hospital of Shandong Province
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Liu T, Amos SH, Ganga AL, Bullins CM, Jennings CD, Arnold WS, Joseph M. Evaluation of cytokine response to extracorporeal membrane oxygenation. Artif Organs 2021; 46:146-154. [PMID: 34606116 DOI: 10.1111/aor.14079] [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: 04/15/2021] [Revised: 09/22/2021] [Accepted: 09/24/2021] [Indexed: 11/26/2022]
Abstract
RATIONALE Increased cytokine response is common in patients receiving extracorporeal life support and is often a poor prognostic indicator. There is interest in using adjunctive cytokine adsorption technologies to reduce inflammatory burden, However, it is debated whether extracorporeal membrane oxygenation (ECMO) itself provides therapeutic benefit beyond gas exchange. Thus, we sought to characterize the inflammatory profile of ECMO in the first 72-96 h of and quantify its effect on cytokine levels in a case series of patients undergoing ECMO. METHODS Eight patients initiating ECMO were studied. Of these, we measured cytokines pre- and post-oxygenator over 96 h. Comparisons of cytokine levels were made across the oxygenator and over time. RESULTS The average age of patients was 64.3 years with 62% being male. Centrally cannulated patients had higher IL-6 levels (820.43 vs. 6907.53 pg/ml, p < 0.03), whereas peripherally cannulated patients had higher IL-12p70 levels (7.73 vs. 2.59 pg/ml, p < 0.05). Cytokine levels on day one included IL-12p70 (4.17 ± 2.56), IL-6 (4971.23 ± 8569.88), TNF (undetected), IL-8 (346.68 ± 670.18), IL-1B (undetected), and IL-10 (72.27 ± 87.9). Cytokine levels increased over 96 h; however, no significant differences were appreciated despite blood product transfusion. On day 3, IL-12p70 levels were significantly lower post-oxygenator (p < 0.05). CONCLUSION The inflammatory profile of ECMO does not change significantly over the early course of illness when accounting for transfusion. However, the decrease in IL-12p70 specifically at day 3 of ECMO may indicate adsorption of specific inflammatory markers by the oxygenator although the clinical significance of this is still unknown. Further investigation of the oxygenator on cytokine response is warranted.
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Affiliation(s)
- Tom Liu
- Department of Surgery, Rutgers - New Jersey Medical School, Newark, New Jersey, USA.,Virginia Tech Carilion School of Medicine and Research Institute, Roanoke, Virginia, USA.,Fralin Biomedical Research Institute, Roanoke, Virginia, USA.,Department of Cardiothoracic Surgery, Carilion Clinic, Roanoke, Virginia, USA
| | - Shayna H Amos
- Department of Cardiothoracic Surgery, Carilion Clinic, Roanoke, Virginia, USA
| | - Anil L Ganga
- Department of Cardiothoracic Surgery, Carilion Clinic, Roanoke, Virginia, USA
| | - Charles M Bullins
- Department of Cardiothoracic Surgery, Carilion Clinic, Roanoke, Virginia, USA
| | - Cathy D Jennings
- Department of Cardiothoracic Surgery, Carilion Clinic, Roanoke, Virginia, USA
| | - W Scott Arnold
- Department of Cardiothoracic Surgery, Carilion Clinic, Roanoke, Virginia, USA.,Department of Cardiothoracic Surgery, Banner University Medical Center at University of Arizona, Tucson, Arizona, USA
| | - Mark Joseph
- Virginia Tech Carilion School of Medicine and Research Institute, Roanoke, Virginia, USA.,Fralin Biomedical Research Institute, Roanoke, Virginia, USA.,Department of Cardiothoracic Surgery, Carilion Clinic, Roanoke, Virginia, USA
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Al-Fares A, Pettenuzzo T, Del Sorbo L. Extracorporeal life support and systemic inflammation. Intensive Care Med Exp 2019; 7:46. [PMID: 31346840 PMCID: PMC6658641 DOI: 10.1186/s40635-019-0249-y] [Citation(s) in RCA: 66] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 04/22/2019] [Indexed: 01/10/2023] Open
Abstract
Extracorporeal life support (ECLS) encompasses a wide range of extracorporeal modalities that offer short- and intermediate-term mechanical support to the failing heart or lung. Apart from the daily use of cardiopulmonary bypass (CPB) in the operating room, there has been a resurgence of interest and utilization of veno-arterial and veno-venous extracorporeal membrane oxygenation (VA- and VV-ECMO, respectively) and extracorporeal carbon dioxide removal (ECCO2R) in recent years. This might be attributed to the advancement in technology, nonetheless the morbidity and mortality associated with the clinical application of this technology is still significant. The initiation of ECLS triggers a systemic inflammatory response, which involves the activation of the coagulation cascade, complement systems, endothelial cells, leukocytes, and platelets, thus potentially contributing to morbidity and mortality. This is due to the release of cytokines and other biomarkers of inflammation, which have been associated with multiorgan dysfunction. On the other hand, ECLS can be utilized as a therapy to halt the inflammatory response associated with critical illness and ICU therapeutic intervention, such as facilitating ultra-protective mechanical ventilation. In addition to addressing the impact on outcome of the relationship between inflammation and ECLS, two different but complementary pathophysiological perspectives will be developed in this review: ECLS as the cause of inflammation and ECLS as the treatment of inflammation. This framework may be useful in guiding the development of novel therapeutic strategies to improve the outcome of critical illness.
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Affiliation(s)
- Abdulrahman Al-Fares
- Adult Critical Care Medicine Fellowship Program, University of Toronto, Toronto, Canada.,Al-Amiri Hospital, Ministry of Health, Kuwait City, Kuwait.,Interdepartmental Division of Critical Care Medicine, Toronto General Hospital, University of Toronto, Toronto, Canada
| | - Tommaso Pettenuzzo
- Adult Critical Care Medicine Fellowship Program, University of Toronto, Toronto, Canada.,Interdepartmental Division of Critical Care Medicine, Toronto General Hospital, University of Toronto, Toronto, Canada
| | - Lorenzo Del Sorbo
- Interdepartmental Division of Critical Care Medicine, Toronto General Hospital, University of Toronto, Toronto, Canada. .,Toronto General Hospital, 585 University Avenue, PMB 11-122, Toronto, Ontario, M5G 2 N2, Canada.
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Itoh H, Ichiba S, Ujike Y, Douguchi T, Kasahara S, Arai S, Sano S. A prospective randomized trial comparing the clinical effectiveness and biocompatibility of heparin-coated circuits and PMEA-coated circuits in pediatric cardiopulmonary bypass. Perfusion 2015; 31:247-54. [PMID: 26228276 DOI: 10.1177/0267659115598217] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECT We compared the clinical effectiveness and biocompatibility of poly-2-methoxyethyl acrylate (PMEA)-coated and heparin-coated cardiopulmonary bypass (CPB) circuits in a prospective pediatric trial. METHODS Infants randomly received heparin-coated (n=7) or PMEA-coated (n=7) circuits in elective pediatric cardiac surgery with CPB for ventricular septum defects. Clinical and hematologic variables, respiratory indices and hemodynamic changes were analyzed perioperatively. RESULTS Demographic and clinical variables were similar in both groups. Leukocyte counts were significantly lower 5 minutes after CPB in the PMEA group than the heparin group. Hemodynamic data showed that PMEA caused hypotension within 5 minutes of CPB. The respiratory index was significantly higher immediately after CPB and 1 hour after transfer to the intensive care unit (ICU) in the PMEA group, as were levels of C-reactive protein 24 hours after transfer to the ICU. CONCLUSION Our study shows that PMEA-coated circuits, unlike heparin-coated circuits, cause transient leukopenia during pediatric CPB and, perhaps, systemic inflammatory respiratory syndrome after pediatric CPB.
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Affiliation(s)
- Hideshi Itoh
- Department of Medical Engineering, Faculty of Health Sciences, Junshin Gakuen University, Fukuoka, Japan Department of Emergency and Critical Care Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Shingo Ichiba
- Department of Community and Emergency Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Yoshihito Ujike
- Department of Emergency and Critical Care Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Takuma Douguchi
- Department of Cardiovascular Surgery, Okayama University Hospital, Okayama, Japan
| | - Shingo Kasahara
- Department of Cardiovascular Surgery, Okayama University Hospital, Okayama, Japan
| | - Sadahiko Arai
- Department of Cardiovascular Surgery, Okayama University Hospital, Okayama, Japan
| | - Shunji Sano
- Department of Cardiovascular Surgery, Okayama University Hospital, Okayama, Japan
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Cohn WE, Frazier OH, Mallidi HR, Cooley DA. Surgical Treatment of Coronary Artery Disease. Coron Artery Dis 2015. [DOI: 10.1007/978-1-4471-2828-1_25] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Morita S, Tanaka M. Effect of sodium chloride on hydration structures of PMEA and P(MPC-r-BMA). LANGMUIR : THE ACS JOURNAL OF SURFACES AND COLLOIDS 2014; 30:10698-10703. [PMID: 25133748 DOI: 10.1021/la502550d] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
The hydration structures of two different types of biomaterials, i.e., poly(2-methoxyethyl acrylate) (PMEA) and a random copolymer of 2-methacryloyloxyethyl phosphorylcholine and n-butyl methacrylate (P(MPC-r-BMA)), were investigated by means of attenuated total reflection infrared (ATR-IR) spectroscopy. The effects of the addition of sodium chloride to liquid water in contact with the surfaces of the polymer films were examined. The neutral polymer of PMEA was easily dehydrated by NaCl addition, whereas the zwitterionic polymer of P(MPC-r-BMA) was hardly dehydrated. More specifically, nonfreezing water having a strong interaction with the PMEA chain and freezing bound water having an intermediate interaction were hardly dehydrated by contacting with normal saline solution, whereas freezing water having a weak interaction with the PMEA chain was readily dehydrated. In contrast, freezing water in P(MPC-r-BMA) is exchanged for the saline solution contacting with the material surface without dehydration.
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Affiliation(s)
- Shigeaki Morita
- Department of Engineering Science, Osaka Electro-Communication University , 18-8 Hatsucho, Neyagawa 572-8530, Japan
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Belway D, Rubens FD. Currently available biomaterials for use in cardiopulmonary bypass. Expert Rev Med Devices 2014; 3:345-55. [PMID: 16681456 DOI: 10.1586/17434440.3.3.345] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Cardiopulmonary bypass (CPB) represents one of the most important technical innovations in healthcare history, yet the systemic responses to CPB remain a fundamentally unresolved problem. Study of the blood-biomaterial interaction and development of biocompatible materials is intimately related to efforts to optimize patient outcome following CPB. This article reviews the design innovations in biomaterial surfaces that have been introduced into clinical practice in an attempt to ameliorate the detrimental consequences of CPB, contrasting the actual clinical improvements and patient benefits achieved against those predicted on the basis of theory and in vitro testing. Some discussion of the underlying mechanisms of action as presently understood is provided and the current limitations of biomaterial-dependent strategies to improve outcome following CPB are addressed.
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Affiliation(s)
- Dean Belway
- University of Ottawa Heart Institute, Department of Cardiovascular Perfusion, 40 Ruskin St., Ottawa, Ontario K1Y 4W7, Canada
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Hall R. Identification of Inflammatory Mediators and Their Modulation by Strategies for the Management of the Systemic Inflammatory Response During Cardiac Surgery. J Cardiothorac Vasc Anesth 2013; 27:983-1033. [DOI: 10.1053/j.jvca.2012.09.013] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2012] [Indexed: 12/21/2022]
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Inoue N, Oka N, Kitamura T, Shibata K, Itatani K, Tomoyasu T, Miyaji K. Neutrophil elastase inhibitor sivelestat attenuates perioperative inflammatory response in pediatric heart surgery with cardiopulmonary bypass. Int Heart J 2013; 54:149-53. [PMID: 23774238 DOI: 10.1536/ihj.54.149] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Cardiopulmonary bypass (CPB) evokes activation of a systemic inflammatory response. Sivelestat has been used clinically to treat acute lung injury associated with systemic inflammatory response syndrome. This prospective, doubleblind, randomized study was designed to evaluate the effects of sivelestat in the perioperative period of elective pediatric open-heart surgery with CPB. Twenty-six consecutive pediatric patients weighing between 5 and 10 kg and undergoing open-heart surgery with CPB were divided into a sivelestat group (n = 13) and a control group (n = 13). The patients in the sivelestat group were administered a continuous intravenous infusion of 0.2 mg/kg/hour of sivelestat, and the patients in the control group were administered the same volume of 0.9% saline from the initiation of CPB to 24 hours after surgery. Blood samples were drawn for the measurement of cytokines, polymorphonuclear elastase (PMN-E), white blood cell count (WBC), neutrophil count (NC), and C-reactive protein (CRP). There were no significant differences in cytokine data between the two groups. The peak PMN-E and WBC levels were significantly increased in the control group (P = 0.049, P = 0.039). The WBC and NC levels immediately after surgery in the control group were significantly greater than those in the sivelestat group (P = 0.049, P = 0.044). The peak CRP level in the control group was significantly greater than the sivelestat group (P = 0.04), and the CRP level on postoperative day 4 in the control group was significantly greater than in the sivelestat group (P = 0.014). This study showed that sivelestat attenuates the perioperative inflammatory response in pediatric heart surgery with CPB.
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Affiliation(s)
- Nobuyuki Inoue
- Department of Cardiovascular Surgery, Kitasato University School of Medicine, Japan
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Abstract
This paper reviews the basic fluid dynamics underlying extracorporeal membrane oxygenation (ECMO) cannula design. General cannula features and their effect on flow are discussed and the specific requirements of different ECMO circuits are explained. The current commercially available cannula options for veno-arterial and veno-venous circuits are reviewed and the main characteristics presented.
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Affiliation(s)
- K Kohler
- Department of Anaesthesia, West Suffolk Hospital, Bury St Edmunds, UK
| | - K Valchanov
- Department of Anaesthesia and Intensive Care, Papworth Hospital, Papworth Everard, Cambridgeshire, UK
| | - G Nias
- Department of Anaesthesia and Intensive Care, Papworth Hospital, Papworth Everard, Cambridgeshire, UK
| | - A Vuylsteke
- Department of Anaesthesia and Intensive Care, Papworth Hospital, Papworth Everard, Cambridgeshire, UK
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Tanaka M, Mochizuki A. Clarification of the Blood Compatibility Mechanism by Controlling the Water Structure at the Blood–Poly(meth)acrylate Interface. JOURNAL OF BIOMATERIALS SCIENCE-POLYMER EDITION 2012; 21:1849-63. [DOI: 10.1163/092050610x517220] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Masaru Tanaka
- a Department of Biochemical Engineering, Graduate School of Science and Technology, Yamagata University, Yonezawa 992-8510, Japan
| | - Akira Mochizuki
- b Department of Bio-Medical Engineering, School of High-Technology for Human Welfare, Tokai University, 317 Nishino, Numazu, Shizuoka 410-03, Japan
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Bergsland J. Safe introduction and quality control of new methods in coronary surgery. Acta Inform Med 2011; 19:203-15. [PMID: 23408734 PMCID: PMC3564183 DOI: 10.5455/aim.2011.19.203-215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2011] [Accepted: 12/25/2011] [Indexed: 11/04/2022] Open
Abstract
Introduction: The first part of the paper analyses off pump coronary bypass surgery (OPCAB), which is compared with traditional on-pump procedures (ONCAB). Furthermore ,the paper evaluates the use of a new automatic device for performance of the proximal anastomosis and finally the effect of intracoronary shunt on myocardial ischemia during OPCAB. The main goal of the paper is to demonstrate the importance of careful clinical studies during introduction of the new techniques in cardiac surgery. Methods: Statistical analysis was performed on a large clinical database from Buffalo, NY, USA comparing OPCAB and ONCAB. Subsequently, a sequential controlled clinical study compared patients operated with a new automatic connector device to patients operated with classic suture technique. Finally a randomized study was performed to evaluate the effect of the use of an intracoronary shunt during construction of distal anastomosis. Results: The studies from Buffalo demonstrated reduced complications rates in high risk patients when OPCAB techniques were used. The use of connector devices in saphenous venous anastomosis was clearly inferior to standard technique. Intracoronary shunt was found to be beneficial by preventing ischemia. Discussion: Numerous studies have studied the results of OPCAB vs ONCAB and although results are variable it seems that OPCAB is advantageous in high risk patients, while in low risk patients there are much less if any benefit. The results of the studies of connector devices caused the product to be taken off the market. The value of shunt in OPCAB was clearly demonstrated by the randomized studies. Conclusion: The investigations presented in this paper clearly demonstrates the importance of well-designed studies when new surgical methods are introduced. In the present period of rapid technological development, carefully controlled, un-biased clinical trials are crucial to preserve patient safety and avoid unjustified societal cost.
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Affiliation(s)
- Jacob Bergsland
- The Interventional Centre, Oslo University Hospital, Oslo, Norway ; BH Heart Centre, Tuzla, Bosnia and Herzegovina
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Pediatric cardiopulmonary bypass and the inflammatory response: years of investigation, only incremental progress. Pediatr Crit Care Med 2011; 12:594-6. [PMID: 21897161 DOI: 10.1097/pcc.0b013e3181fe3b48] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Rimmelé T, Bishop J, Simon P, Carter M, Kong L, Lee M, Singbartl K, Kellum JA. What blood temperature for an ex vivo extracorporeal circuit? Artif Organs 2011; 35:593-601. [PMID: 21314837 DOI: 10.1111/j.1525-1594.2010.01147.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Ex vivo circuits are commonly used to evaluate biomaterials or devices used for extracorporeal blood purification. However, various aspects of the ex vivo circuit, apart from the circuit materials, may affect inflammation and coagulation. One such aspect is temperature. The aim of this study was to evaluate the influence of different blood temperature conditions on inflammation parameters in an ex vivo circuit. Blood was collected from 20 healthy volunteers and run through three different experimental conditions for 4 h: a miniaturized ex vivo extracorporeal circuit equipped with a blood warmer set to 37°C, the same circuit without the warmer (23°C), and a tube placed in an incubator at 37°C (no circuit). We measured the granulocyte macrophage colony-stimulating factor, the tumor necrosis factor, and the interleukin (IL)-1β, IL-6, IL-8, and IL-10 concentrations at baseline, 15, 60, 120, and 240 min. Human leukocyte antigen (HLA)-DR, CD11b, CD11a, CD62L, tumor necrosis factor alpha converting enzyme, annexin V expression, and NFkB DNA binding were measured in monocytes and polymorphonuclear neutrophils (PMNs) using flow cytometry at baseline, 120 min, and 240 min. While cytokine production over time was very slight at room temperature, levels increased by more than 100-fold in the two heated conditions. Differences in the expression of some surface markers were also observed between the room temperature circuit and the two heated conditions (CD11b PMN, P < 0.0001; HLA-DR Mono, P=0.0019; and CD11a PMN, P<0.0001). Evolution of annexin V expression was also different over time between the three groups (P=0.0178 for monocytes and P=0.0011 for PMNs). A trend for a greater NFkB DNA binding was observed in the heated conditions. Thus, for ex vivo studies using extracorporeal circuits, heating blood to maintain body temperature results in significant activation of inflammatory cells while hypothermia (room temperature) seems to suppress the leukocyte response. Both strategies may lead to erroneous conclusions, possibly masking some specific effects of the device being studied. Investigators in this field must be aware of the fact that blood temperature is a crucial confounding parameter and the type of "background noise" they will face depending on the strategy adopted.
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Affiliation(s)
- Thomas Rimmelé
- The CRISMA (Clinical Research, Investigation, and Systems Modeling of Acute Illness) Laboratory, Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Abstract
Since 2005, we have used a novel technique based on the closed cardiopulmonary bypass system without cardiotomy suction (minimal cardiopulmonary bypass [mini-CPB]) for aortic valve replacement (AVR). In this study, we investigated the clinical advantages of this approach. We prospectively studied 32 patients who underwent isolated AVR using the mini-CPB (group M, n = 13) or conventional CPB (group C, n = 19). We compared the hemodilution ratio, serum interleukin (IL)-6 and IL-8 levels, and blood transfusion volume between the two groups. The characteristics, duration of CPB, and aortic cross-clamping time did not differ between the two groups. The hemodilution ratio was significantly lower in group M just after starting CPB (M vs. C: 14% +/- 2% vs. 25% +/- 3%, p = 0.0009). IL-6 levels increased significantly after surgery in both groups, but the postoperative levels were significantly lower in group M at 6 (84.9 +/- 24.9 pg/ml vs. 152 +/- 78 pg/ml, p = 0.042) and 12 (72.7 +/- 36.1 pg/ml vs. 123 +/- 49.6 pg/ml, p = 0.029) hours after CPB. There were no differences in IL-8 or blood transfusion volume after CPB. Mini-CPB offers an alternative to conventional CPB for AVR and has some advantages regarding hemodilution and serum IL-6 levels. However, it is unlikely to become the standard approach for AVR because there are no marked clinical advantages of mini-CPB.
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Rimmelé T, Venkataraman R, Madden NJ, Elder MM, Wei LM, Pellegrini RV, Kellum JA. Comparison of inflammatory response during on-pump and off-pump coronary artery bypass surgery. Int J Artif Organs 2010; 33:131-8. [PMID: 20383854 DOI: 10.1177/039139881003300301] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/18/2010] [Indexed: 11/15/2022]
Abstract
PURPOSE On-pump coronary artery bypass graft (CABG) surgery has been traditionally associated with a higher magnitude of inflammatory response than off-pump CABG. However with the development of polymer-coated biocompatible extracorporeal circuits, we wanted to see if cardiopulmonary bypass still played an important role in triggering this inflammatory response. METHODS In this prospective observational study, 33 patients undergoing CABG surgeries (25 on-pump and 8 off-pump patients) were studied. Serial plasma cytokine (TNF IL-6, IL-10) and procalcitonin concentrations were measured at different time-points during and after the surgery. Demographic and baseline clinical data, intra-operative management details and post-operative complications were also collected from the patients' charts. RESULTS Plasma levels of all 4 mediators increased during surgery and returned towards normal postoperatively. There were no differences between groups for any mediator at any time-point. CONCLUSIONS We conclude that with the use of recent polymer-coated biocompatible extracorporeal circuits, the inflammatory response triggered by on-pump CABG becomes very similar in magnitude and pattern to that triggered by off-pump CABG. Thus, the surgical procedure contributes to most of the inflammatory response, with the extra-corporeal circuit having minimal to no effect on this response.
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Affiliation(s)
- Thomas Rimmelé
- The CRISMA (Clinical Research, Investigation, and Systems Modeling of Acute Illness) Laboratory, Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA 1526, USA
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Marcoux J, Sohn N, McNair E, Rosin M, Smith G, Lim H, Mycyk T, Meng Q. Outcomes comparison of 5 coated cardiopulmonary bypass circuits versus an uncoated control group of patients undergoing cardiac surgery. Perfusion 2009; 24:307-15. [DOI: 10.1177/0267659109352114] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Attenuated inflammatory response and decreased platelet activation have been claimed repeatedly when biocompatible circuits are used for cardiopulmonary bypass. We evaluated five Health Canada approved biocompatible circuit coatings (BCC) against an un-coated control group to determine their effectiveness in improving post-operative outcomes. Patients were assigned to the Control group or one of the 5 coated circuit groups: 40 Control; 33 Trillium; 32 Phisio; 34 Bioline; 33 X; and 11 GBS. Measured outcomes included: ventilator time; ICU time; post-operative chest tube drainage and transfusion volume; high sensitivity C-reactive protein (hsCRP); tau protein; and pre- and 72-hour post-operative anti-saccadic eye movement test comparisons. Results: 183 patients were enlisted into the study. One arm of the study (GBS) was abandoned after 11 patients on account of inconsistent pressure excursions within the oxygenator and the excessive consumption of platelets necessitating transfusion. Patients in the X-coated group had significantly longer ventilator and intensive care unit (ICU) time compared to the three remaining coated circuit study groups. Though not significant, patients in the X group also demonstrated the highest post-operative chest tube losses, the most platelet transfusions, the highest tau protein levels and the lowest post-operative anti-saccadic eye movement test (ASEMT) results compared to the three remaining coated groups. The patients in the Trillium, Bioline and Phisio groups showed an improvement in ventilator and ICU time relative to the Control group. The diabetic patients in the Trillium, Bioline and Phisio groups showed an improvement in bleeding relative to the diabetic patients in the Control group. Conclusion: We compared all 5 coated circuits approved for clinical use in Canada against an uncoated control circuit. Three of the 5 coated circuits (Trillium, Phisio and Bioline BCC) were found to improve ventilator and ICU time compared to Control. Further studies are indicated to validate these results and their impact upon approval criteria, purchasing choices and safe clinical practice, especially as applied to higher risk diabetic patients.
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Affiliation(s)
- J. Marcoux
- Department of Clinical Perfusion, Cardiovascular Surgery and Clinical Chemistry, Royal University Hospital, Saskatoon, Saskatchewan, Canada,
| | - N. Sohn
- Department of Clinical Perfusion, Cardiovascular Surgery and Clinical Chemistry, Royal University Hospital, Saskatoon, Saskatchewan, Canada
| | - E. McNair
- Department of Clinical Perfusion, Cardiovascular Surgery and Clinical Chemistry, Royal University Hospital, Saskatoon, Saskatchewan, Canada
| | - M. Rosin
- Department of Clinical Perfusion, Cardiovascular Surgery and Clinical Chemistry, Royal University Hospital, Saskatoon, Saskatchewan, Canada
| | - G. Smith
- Department of Clinical Perfusion, Cardiovascular Surgery and Clinical Chemistry, Royal University Hospital, Saskatoon, Saskatchewan, Canada
| | - H. Lim
- Department of Clinical Perfusion, Cardiovascular Surgery and Clinical Chemistry, Royal University Hospital, Saskatoon, Saskatchewan, Canada
| | - T. Mycyk
- Department of Clinical Perfusion, Cardiovascular Surgery and Clinical Chemistry, Royal University Hospital, Saskatoon, Saskatchewan, Canada
| | - Q. Meng
- Department of Clinical Perfusion, Cardiovascular Surgery and Clinical Chemistry, Royal University Hospital, Saskatoon, Saskatchewan, Canada
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Skrabal CA, Khosravi A, Westphal B, Steinhoff G, Liebold A. Effects of poly-2-methoxyethylacrylate (PMEA)-coating on CPB circuits. SCAND CARDIOVASC J 2009; 40:224-9. [PMID: 16914413 DOI: 10.1080/14017430600833124] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
OBJECTIVES In this study, the immuno- and neuroprotective effect of a novel cardiopulmonary bypass coating was investigated. DESIGN Thirty nine patients scheduled for elective coronary artery bypass grafting were randomly assigned to either PMEA-coated (n = 19) or non-coated CPB circuits (n = 20). Pericardial suction blood was separated and retransfused only if needed at the end of operation. Neurocognitive functions were examined preoperatively and 7-10 days postoperatively using a standard neuropsychological test battery. Assuming an inflammatory etiology, the most cogent inflammatory markers were perioperatively analyzed. RESULTS Postoperatively, patients of the PMEA-coated group performed better in Go/NoGo and Mini-Mental-test than patients of the non-coated group (p < 0.04). Other neurocognitive testing did not reveal significant differences between the groups. Although most inflammatory parameters showed a significant intraindividual increase during or shortly after CPB, there was no difference in inflammatory alteration between the groups. CONCLUSIONS PMEA-coating of cardiopulmonary bypass surfaces revealed some minor benefits in preservation of neurocognitive functions after surgery. The immediate inflammatory response remained mostly unaffected. Suction blood separation may additionally contribute to proper postoperative outcome.
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Affiliation(s)
- Christian A Skrabal
- Department of Cardiac Surgery, University of Rostock, Schillingallee 35, 18057, Rostock, Germany
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Benk C, Klemm R, Schaller S, Brehm K, Schlensak C, Beyersdorf F. Was der Herzchirurg schon immer über die Herz-Lungen-Maschine wissen wollte. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2008. [DOI: 10.1007/s00398-008-0644-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Beneficial Effects of Mini-Cardiopulmonary Bypass on Hemostasis in Coronary Artery Bypass Grafting: Analysis of Inflammatory Response and Hemodilution. ASAIO J 2008; 54:207-9. [DOI: 10.1097/mat.0b013e3181648dbc] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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An Y, Xiao YB. Growth hormone prevents acute liver injury induced by cardiopulmonary bypass in a rat model. J Thorac Cardiovasc Surg 2007; 134:342-50. [PMID: 17662771 DOI: 10.1016/j.jtcvs.2007.02.036] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2006] [Revised: 02/07/2007] [Accepted: 02/14/2007] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Cardiopulmonary bypass-induced acute liver injury is a life-threatening complication thought to be associated with the inflammatory response and the acute-phase response. Recombinant human growth hormone can modulate the acute-phase response and inflammatory response. We tested the protective effect of growth hormone on cardiopulmonary bypass-induced liver injury in the rat. METHODS Adult male Sprague-Dawley rats (group G received 2.5 mg/kg recombinant human growth hormone intramuscularly at 8 am every 24 hours for 3 days and just before the initiation of cardiopulmonary bypass; group C served as a control group) underwent cardiopulmonary bypass (120 minutes, 120 mL x kg(-1) x min(-1), 34 degrees C) and were killed 3 hours after the termination of cardiopulmonary bypass. RESULTS Administration of recombinant human growth hormone markedly increased serum insulin-like growth factor and insulin-like growth factor-binding protein 3 levels compared with those seen in group C. Group G showed significantly lower serum concentrations of alanine aminotransferase and total bilirubin after cardiopulmonary bypass termination. Those receiving recombinant human growth hormone demonstrated a significant increase in serum prealbumin and transferrin levels and a marked decrease in serum amyloid A and C-reactive protein levels. Recombinant human growth hormone significantly decreased serum tumor necrosis factor alpha and interleukin 1beta levels, whereas no changes were found for serum interleukin 6 and interleukin 10 levels. Recombinant human growth hormone significantly increased total liver protein content and hepatocyte proliferation and decreased hepatocyte apoptosis versus values seen in group C. CONCLUSIONS These results suggest that growth hormone prevents cardiopulmonary bypass-induced acute liver injury in a rat model through decreases in acute-phase proteins, proinflammatory cytokines tumor necrosis factor alpha and interleukin 1beta, and hepatocyte apoptosis, which is associated with increases in constitutive hepatic proteins, total liver protein content, and hepatocyte proliferation. This strategy of pretreatment with growth hormone might be a prospective management for preventing acute liver injury when major cardiac surgery with cardiopulmonary bypass is performed.
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Affiliation(s)
- Yong An
- Department of Cardiovascular Surgery, Xin-Qiao Hospital, Third Military Medical University, Chongqing, China
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Surgical Treatment of Coronary Artery Disease. CARDIOVASCULAR MEDICINE 2007. [DOI: 10.1007/978-1-84628-715-2_49] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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Taneja R, Cheng DCH. Con: Heparin-Bonded Cardiopulmonary Bypass Circuits Should Be Routine for All Cardiac Surgical Procedures. Anesth Analg 2006; 103:1370-2. [PMID: 17122205 DOI: 10.1213/01.ane.0000223781.83906.1b] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Kozik DJ, Tweddell JS. Characterizing the Inflammatory Response to Cardiopulmonary Bypass in Children. Ann Thorac Surg 2006; 81:S2347-54. [PMID: 16731102 DOI: 10.1016/j.athoracsur.2006.02.073] [Citation(s) in RCA: 152] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2005] [Revised: 01/07/2006] [Accepted: 02/04/2006] [Indexed: 11/29/2022]
Abstract
Cardiopulmonary bypass is known to trigger a global inflammatory response. Age-dependent differences in the inflammatory response, the increased susceptibility to injury of immature organ systems, and the larger extracorporeal circuit to patient size ratio results in greater susceptibility of younger and smaller patients to the damaging effects of cardiopulmonary bypass. In this review the components of the inflammatory response to cardiopulmonary bypass are reviewed with special reference to the pediatric age group, including the age-specific impact on organ systems. In addition the current and evolving strategies to prevent, limit, and treat the inflammatory response to cardiopulmonary bypass in children are examined.
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Affiliation(s)
- Deborah J Kozik
- The Herma Heart Center, Children's Hospital of Wisconsin, Milwaukee, Wisconsin 53226, USA
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Karamlou T, Hickey E, Silliman CC, Shen I, Ungerleider RM. Reducing risk in infant cardiopulmonary bypass: the use of a miniaturized circuit and a crystalloid prime improves cardiopulmonary function and increases cerebral blood flow. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2005:3-11. [PMID: 15818352 DOI: 10.1053/j.pcsu.2005.01.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
Advances in perfusion strategies have played an important role in improving outcomes following repair of complex congenital heart defects. The influence of cooling strategy, temperature, duration of circulatory arrest, and specific method of cerebral perfusion on neurologic morbidity have been extensively characterized. Similarly, the ability of pharmacologic agents to modulate the post-cardiopulmonary bypass (CPB) inflammatory response has been previously elucidated in both the laboratory and clinical arena. However, modification of the circuit and priming components have received comparably less attention. We recently showed that employment of a miniaturized circuit and a bloodless prime reduce inflammation and have salutary effects on cardiopulmonary function following hypothermic low-flow perfusion (HLF), and that this circuit may also improve cerebral protection following both deep hypothermic circulatory arrest and HLF. The current report, therefore, reviews current strategies utilized to minimize post-CPB inflammation and highlights the empirical evidence from our laboratory demonstrating the beneficial role of a miniaturized extracorporeal circuit in this context.
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Affiliation(s)
- Tara Karamlou
- Division of Cardiovascular Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada
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