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Zhang H, Wang J, Wang T, Ji B. How to Design a Study Comparing Pulsatile and Nonpulsatile Perfusion During Cardiopulmonary Bypass? ASAIO J 2024:00002480-990000000-00498. [PMID: 38815247 DOI: 10.1097/mat.0000000000002247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2024] Open
Affiliation(s)
- Han Zhang
- Department of Cardiopulmonary Bypass National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Cardiovascular Diseases, Fuwai Hospital, Beijing, China
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Li ZQ, Zhang W, Guo Z, Du XW, Wang W. Risk factors of gastrointestinal bleeding after cardiopulmonary bypass in children: a retrospective study. Front Cardiovasc Med 2023; 10:1224872. [PMID: 37795489 PMCID: PMC10545956 DOI: 10.3389/fcvm.2023.1224872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 09/08/2023] [Indexed: 10/06/2023] Open
Abstract
Background During cardiac surgery that involved cardiopulmonary bypass (CPB) procedure, gastrointestinal (GI) system was known to be vulnerable to complications such as GI bleeding. Our study aimed to determine the incidence and risk factors associated with GI bleeding in children who received CPB as part of cardiac surgery. Methods This retrospective study enrolled patients aged <18 years who underwent cardiac surgery with CPB from 2013 to 2019 at Shanghai Children's Medical Center. The primary outcome was the incidence of postoperative GI bleeding in children, and the associated risk factors with postoperative GI bleeding episodes were evaluated. Results A total of 21,893 children who underwent cardiac surgery with CPB from 2013 to 2019 were included in this study. For age distribution, 636 (2.9%) were neonates, 10,984 (50.2%) were infants, and 10,273 (46.9%) were children. Among the 410 (1.9%) patients with GI bleeding, 345 (84.2%) survived to hospital discharge. Incidence of GI bleeding in neonates, infants and children were 22.6% (144/636), 2.0% (217/10,984) and 0.5% (49/10,273), respectively. The neonates (22.6%) group was associated with highest risk of GI bleeding. Patients with GI bleeding showed longer length of hospital stays (25.8 ± 15.9 vs. 12.5 ± 8.9, P < 0.001) and higher mortality (15.9% vs. 1.8%, P < 0.001). Multivariate logistic regression analysis showed that age, weight, complicated surgery, operation time, use of extracorporeal membrane oxygenation (ECMO), low cardiac output syndrome (LCOS), hepatic injury, artery lactate level, and postoperative platelet counts were significantly associated with increased risk of GI bleeding in children with congenital heart disease (CHD) pediatric patients that underwent CPB procedure during cardiac surgery. Conclusion The study results suggest that young age, low weight, long operation time, complicated surgery, use of ECMO, LCOS, hepatic injury, high arterial lactate level, and low postoperative platelet counts are independently associated with GI bleeding after CPB in children.
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Affiliation(s)
| | | | | | | | - Wei Wang
- Department of Cardiothoracic Surgery, Shanghai Children’s Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
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Weymann A, Foroughi J, Vardanyan R, Punjabi PP, Schmack B, Aloko S, Spinks GM, Wang CH, Arjomandi Rad A, Ruhparwar A. Artificial Muscles and Soft Robotic Devices for Treatment of End-Stage Heart Failure. ADVANCED MATERIALS (DEERFIELD BEACH, FLA.) 2023; 35:e2207390. [PMID: 36269015 DOI: 10.1002/adma.202207390] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/13/2022] [Revised: 09/19/2022] [Indexed: 05/12/2023]
Abstract
Medical soft robotics constitutes a rapidly developing field in the treatment of cardiovascular diseases, with a promising future for millions of patients suffering from heart failure worldwide. Herein, the present state and future direction of artificial muscle-based soft robotic biomedical devices in supporting the inotropic function of the heart are reviewed, focusing on the emerging electrothermally artificial heart muscles (AHMs). Artificial muscle powered soft robotic devices can mimic the action of complex biological systems such as heart compression and twisting. These artificial muscles possess the ability to undergo complex deformations, aiding cardiac function while maintaining a limited weight and use of space. Two very promising candidates for artificial muscles are electrothermally actuated AHMs and biohybrid actuators using living cells or tissue embedded with artificial structures. Electrothermally actuated AHMs have demonstrated superior force generation while creating the prospect for fully soft robotic actuated ventricular assist devices. This review will critically analyze the limitations of currently available devices and discuss opportunities and directions for future research. Last, the properties of the cardiac muscle are reviewed and compared with those of different materials suitable for mechanical cardiac compression.
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Affiliation(s)
- Alexander Weymann
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center, University of Duisburg-Essen, Hufelandstraße 55, 45122, Essen, Germany
| | - Javad Foroughi
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center, University of Duisburg-Essen, Hufelandstraße 55, 45122, Essen, Germany
- Faculty of Engineering and Information Sciences, University of Wollongong, Northfields Ave, Wollongong, NSW, 2522, Australia
- School of Mechanical and Manufacturing Engineering, University of New South Wales, Library Rd, Kensington, NSW, 2052, Australia
| | - Robert Vardanyan
- Department of Medicine, Faculty of Medicine, Imperial College London, Imperial College Road, London, SW7 2AZ, UK
| | - Prakash P Punjabi
- Department of Cardiothoracic Surgery, Hammersmith Hospital, National Heart and Lung Institute, Imperial College London, 72 Du Cane Rd, London, W12 0HS, UK
| | - Bastian Schmack
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center, University of Duisburg-Essen, Hufelandstraße 55, 45122, Essen, Germany
| | - Sinmisola Aloko
- Faculty of Engineering and Information Sciences, University of Wollongong, Northfields Ave, Wollongong, NSW, 2522, Australia
| | - Geoffrey M Spinks
- Faculty of Engineering and Information Sciences, University of Wollongong, Northfields Ave, Wollongong, NSW, 2522, Australia
| | - Chun H Wang
- School of Mechanical and Manufacturing Engineering, University of New South Wales, Library Rd, Kensington, NSW, 2052, Australia
| | - Arian Arjomandi Rad
- Department of Medicine, Faculty of Medicine, Imperial College London, Imperial College Road, London, SW7 2AZ, UK
| | - Arjang Ruhparwar
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center, University of Duisburg-Essen, Hufelandstraße 55, 45122, Essen, Germany
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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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Jufar AH, Lankadeva YR, May CN, Cochrane AD, Marino B, Bellomo R, Evans RG. Renal and Cerebral Hypoxia and Inflammation During Cardiopulmonary Bypass. Compr Physiol 2021; 12:2799-2834. [PMID: 34964119 DOI: 10.1002/cphy.c210019] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Cardiac surgery-associated acute kidney injury and brain injury remain common despite ongoing efforts to improve both the equipment and procedures deployed during cardiopulmonary bypass (CPB). The pathophysiology of injury of the kidney and brain during CPB is not completely understood. Nevertheless, renal (particularly in the medulla) and cerebral hypoxia and inflammation likely play critical roles. Multiple practical factors, including depth and mode of anesthesia, hemodilution, pump flow, and arterial pressure can influence oxygenation of the brain and kidney during CPB. Critically, these factors may have differential effects on these two vital organs. Systemic inflammatory pathways are activated during CPB through activation of the complement system, coagulation pathways, leukocytes, and the release of inflammatory cytokines. Local inflammation in the brain and kidney may be aggravated by ischemia (and thus hypoxia) and reperfusion (and thus oxidative stress) and activation of resident and infiltrating inflammatory cells. Various strategies, including manipulating perfusion conditions and administration of pharmacotherapies, could potentially be deployed to avoid or attenuate hypoxia and inflammation during CPB. Regarding manipulating perfusion conditions, based on experimental and clinical data, increasing standard pump flow and arterial pressure during CPB appears to offer the best hope to avoid hypoxia and injury, at least in the kidney. Pharmacological approaches, including use of anti-inflammatory agents such as dexmedetomidine and erythropoietin, have shown promise in preclinical models but have not been adequately tested in human trials. However, evidence for beneficial effects of corticosteroids on renal and neurological outcomes is lacking. © 2021 American Physiological Society. Compr Physiol 11:1-36, 2021.
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Affiliation(s)
- Alemayehu H Jufar
- Cardiovascular Disease Program, Biomedicine Discovery Institute and Department of Physiology, Monash University, Melbourne, Victoria, Australia.,Pre-Clinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Yugeesh R Lankadeva
- Pre-Clinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Victoria, Australia.,Department of Critical Care, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Victoria, Australia
| | - Clive N May
- Pre-Clinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Victoria, Australia.,Department of Critical Care, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Victoria, Australia
| | - Andrew D Cochrane
- Department of Cardiothoracic Surgery, Monash Health and Department of Surgery (School of Clinical Sciences at Monash Health), Monash University, Melbourne, Victoria, Australia
| | - Bruno Marino
- Cellsaving and Perfusion Resources, Melbourne, Victoria, Australia
| | - Rinaldo Bellomo
- Department of Critical Care, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Victoria, Australia.,Department of Intensive Care, Austin Health, Heidelberg, Victoria, Australia
| | - Roger G Evans
- Cardiovascular Disease Program, Biomedicine Discovery Institute and Department of Physiology, Monash University, Melbourne, Victoria, Australia.,Pre-Clinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Victoria, Australia
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Moosaeifar S, Mousavizadeh M, Najafi Ghezeljeh T, Hosseinian A, Babaee T, Hosseini S, Mestres CA. The effect of pulsatile versus non-pulsatile flow during cardiopulmonary bypass on cerebral oxygenation: A randomized trial. Asian Cardiovasc Thorac Ann 2021; 30:441-448. [PMID: 34904903 DOI: 10.1177/02184923211045915] [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: 11/16/2022]
Abstract
BACKGROUND The present study aims to compare regional oxygen supply determined by Near-Infrared Spectroscopy in the course of pulsatile perfusion with non-pulsatile perfusion during cardiopulmonary bypass in patients undergoing valvular heart surgery. METHODS In this prospective randomized single-blinded trial, we enrolled adult subjects aged 18-65 years scheduled for elective valvular heart repair/replacement surgery with non-stenotic carotid arteries, employing a consecutive sampling method. Eligible patients were then randomly assigned in a 1:1 ratio to pulsatile or non-pulsatile perfusion during aortic cross-clamp. The primary outcome was regional cerebral oxygenation monitored by Near-Infrared Spectroscopy in each group. RESULTS Seventy patients were randomly assigned, and each group comprised 35 patients. Mean age was 46.8 and 46.5 years in pulsatile and non-pulsatile groups, respectively. There were no significant between-group differences in regional cerebral oxygen saturation at different time points of cardiopulmonary bypass (p-value for analysis of variance repeated measures: 0.923 and 0.223 for left and right hemispheres, respectively). Moreover, no significant differences in regional cerebral oxygen saturation levels from baseline between pulsatile and non-pulsatile groups at all desired time points for the left (p = 0.51) and right (p = 0.22) hemispheres of the brain were detected. CONCLUSION Pulsatile perfusion during cardiopulmonary bypass does not offer superior regional cerebral oxygenation measured by Near-Infrared Spectroscopy than non-pulsatile perfusion during cardiopulmonary bypass. Nonetheless, the efficacy of pulsatile flow in the subgroup of patients in whom cerebral blood flow is impaired due to carotid artery stenosis needs to be explored and evaluated by this method in future studies.
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Affiliation(s)
- Samira Moosaeifar
- Department of Critical Care Nursing and Midwifery, 440827Iran University of Medical Sciences, Tehran, Iran
| | - Mostafa Mousavizadeh
- Heart Valve disease Research Center, Rajaie Cardiovascular, Medical and Research Center, 158776Iran University of Medical Sciences, Tehran, Iran
| | - Tahereh Najafi Ghezeljeh
- Center for Nursing Care Research, Department of Critical Care Nursing and Midwifery, 440827Iran University of Medical Sciences, Tehran, Iran
| | - Afshin Hosseinian
- Heart Valve disease Research Center, Rajaie Cardiovascular, Medical and Research Center, 158776Iran University of Medical Sciences, Tehran, Iran
| | - Touraj Babaee
- Heart Valve disease Research Center, Rajaie Cardiovascular, Medical and Research Center, 158776Iran University of Medical Sciences, Tehran, Iran
| | - Saeid Hosseini
- Heart Valve disease Research Center, Rajaie Cardiovascular, Medical and Research Center, 158776Iran University of Medical Sciences, Tehran, Iran
| | - Carlos-A Mestres
- Department of Cardiac Surgery, University Hospital Zürich, Zürich, Switzerland
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Renal Recovery in Critically Ill Adult Patients Treated with Veno-Venous Or Veno-Arterial Extra Corporeal Membrane Oxygenation: a Retrospective Cohort Analysis. J Crit Care Med (Targu Mures) 2021; 7:104-112. [PMID: 34722911 PMCID: PMC8519359 DOI: 10.2478/jccm-2021-0006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 01/27/2021] [Indexed: 11/20/2022] Open
Abstract
Introduction Patients on extracorporeal membrane oxygenator (ECMO) therapy are critically ill and often develop acute kidney injury (AKI) during hospitalisation. Little is known about the association of exposure to and the effect of the type of ECMO and extent of renal recovery after AKI development. Aim of the study In patients who developed AKI, renal recovery was characterised as complete, partial or dialysis-dependent at the time of hospital discharge in both the Veno-Arterial (VA) and Veno-Venous (VV) ECMO treatment groups. Material and methods The study consisted of a single-centre retrospective cohort that includes all adult patients (n=125) who received ECMO treatment at a tertiary academic medical centre between 2015 to 2019. Data on demographics, type of ECMO circuit, comorbidities, exposure to nephrotoxic factors and receipt of renal replacement therapy (RRT) were collected as a part of the analysis. Acute Kidney Injury Network (AKIN) criteria were used for the diagnosis and classification of AKI. Group differences were assessed using Fisher’s exact tests for categorical data and independent t-tests for continuous outcomes. Results Sixty-four patients received VA ECMO, and 58 received VV ECMO. AKI developed in 58(91%) in the VA ECMO group and 51 (88%) in the VV ECMO group (p=0.77). RRT was prescribed in significantly higher numbers in the VV group 38 (75%) compared to the VA group 27 (47%) (p=0.0035). At the time of discharge, AKI recovery rate in the VA group consisted of 15 (26%) complete recovery and 5 (9%) partial recovery; 1 (2%) remained dialysis-dependent. In the VV group, 22 (43%) had complete recovery (p=0.07), 3(6%) had partial recovery (p=0.72), and 1 (2%) was dialysis-dependent (p>0.99). In-hospital mortality was 64% in the VA group and 49% in the VV group (p=0.13). Conclusions Renal outcomes in critically ill patients who develop AKI are not associated with the type of ECMO used. This serves as preliminary data for future studies in the area.
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Torres DS, Mazzetto M, Cestari IA. A novel automated simulator of pediatric systemic circulation: Design and applications. Biomed Signal Process Control 2021. [DOI: 10.1016/j.bspc.2021.102926] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Lee SI, Lim YS, Park CH, Choi WS, Choi CH. Importance of pulse pressure after extracorporeal cardiopulmonary resuscitation. J Card Surg 2021; 36:2743-2750. [PMID: 33993537 DOI: 10.1111/jocs.15614] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 02/01/2021] [Accepted: 04/03/2021] [Indexed: 01/27/2023]
Abstract
BACKGROUND Recent reports have revealed better clinical outcomes for extracorporeal cardiopulmonary resuscitation (ECPR) than conventional cardiopulmonary resuscitation (CPR). In this retrospective study, we attempted to identify predictors associated with successful weaning off extracorporeal membrane oxygenation (ECMO) support after ECPR. METHODS The demographic and clinical data of 30 ECPR patients aged over 18 years treated between August 2016 and January 2019 were analyzed. All clinical data were retrospectively collected. The primary endpoint was successful weaning off ECMO support after ECPR. Patients were divided into two groups based on successful or unsuccessful weaning off ECMO support (Weaned (n = 14) vs. Failed (n = 16)). RESULTS Univariate logistic regression analysis showed that age, CPR duration, ECMO complications, and loss of pulse pressure significantly predicted the results of weaning off ECMO support. However, multivariate logistic regression analysis showed that only CPR duration and loss of pulse pressure independently predicted unsuccessful weaning from ECMO support. CONCLUSION We conclude that long CPR duration and loss of pulse pressure after ECPR predict unsuccessful weaning from ECMO. However, unlike CPR duration, loss of pulse pressure during post-ECPR was related to subsequent management. In patients with reduced pulse pressure after ECPR, careful management is warranted because this reduction is closely associated with unsuccessful weaning off ECMO support after ECPR.
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Affiliation(s)
- Seok In Lee
- Department of Thoracic and Cardiovascular Surgery, Gachon University Gil Medical Center, Gachon University School of Medicine, Incheon, South Korea
| | - Yong Su Lim
- Department of Emergency Medicine, Gachon University Gil Medical Center, Gachon University School of Medicine, Incheon, South Korea
| | - Chul-Hyun Park
- Department of Thoracic and Cardiovascular Surgery, Gachon University Gil Medical Center, Gachon University School of Medicine, Incheon, South Korea
| | - Woo Sung Choi
- Department of Emergency Medicine, Gachon University Gil Medical Center, Gachon University School of Medicine, Incheon, South Korea
| | - Chang Hyu Choi
- Department of Thoracic and Cardiovascular Surgery, Gachon University Gil Medical Center, Gachon University School of Medicine, Incheon, South Korea
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Jiang Q, Sun J, Xu L, Chang X, Sun L, Zhen Y, Guo Z. Frequency domain analysis and clinical outcomes of pulsatile and non-pulsatile blood flow energy during cardiopulmonary bypass. Perfusion 2021; 36:788-797. [PMID: 33926331 DOI: 10.1177/02676591211012216] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
INTRODUCTION The superiority of pulsatile perfusion during cardiopulmonary bypass remains controversial. We analyzed the frequency-domain characteristics and organ protection of pulsatile and nonpulsatile flow in adult patients with valvular disease. METHODS EEP and SHE were used to calculate blood flow energy in 60 patients. The Fast Fourier Transform was employed to analyze the power spectral density and power density ratio (Rvpd) of flow energy. Changes in endothelin-1, nitric oxide, interleukin-6,10, tumor necrotic factor, S100β, NSE, blood and urinary β2-microglobulin levels were investigated to assess the endothelial function, inflammatory reaction, kidney and brain injury during CPB. RESULTS EEP and SHE in PP group at each time point were 1.52-1.62 times and 2.03-2.22 times higher respectively compared with NP group. Power spectral density analysis demonstrated that the blood flow energy frequencies in each group were all within 40 Hz and the low frequency energy (0-5 Hz) was dominant in physiological perfusion (>90%). The energy ratio of 0-5 Hz at radial artery was significantly decreased compared with that of post arterial filter in PP (81% vs 64%) and NP (63% vs 37%) group. The power density ratio (Rvpd) was higher than that of NP in all frequency ranges at the radial artery (9.51 vs 4.68 vs 3.59) and arterial filter (3.87 vs 2.69 vs 2.38). The S100β, NSE Urinary and plasma β2-microglobulin level were significantly increased at 6 and 24 hours after surgery in two group, and significantly higher in group NP. CONCLUSION PP provided more energy than NP. The proportion of low frequency energy in the pulsatile or nonpulsatile flow is significantly reduced. The low-frequency energy is significantly attenuated during conduction to peripheral tissues in nonpulsatile flow. The surplus pulsatile energy influences the secretion of endothelial and inflammatory factors, and demonstrate better cerebral and kidney protective effect at the biological marker level.
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Affiliation(s)
- Qiliang Jiang
- Department of Anesthesiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Jian Sun
- Department of Anesthesiology, Feicheng Hospital Affiliated to Shandong First Medical University, Feicheng, China
| | - Lingfeng Xu
- Department of Cardiac Surgery and Cardiopulmonary Bypass, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Xin Chang
- Department of Cardiac Surgery and Cardiopulmonary Bypass, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Lin Sun
- Department of Cardiac Surgery and Cardiopulmonary Bypass, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Yue Zhen
- Department of Cardiac Surgery, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Zhen Guo
- Department of Cardiac Surgery and Cardiopulmonary Bypass, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
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Drochon A, Fouquet O, Baufreton C. Extracorporeal circulation during on-pump cardiac surgery: An evaluation of the energy equivalent pressure index based on waveforms decomposition in harmonics. Artif Organs 2021; 45:861-865. [PMID: 33529368 DOI: 10.1111/aor.13928] [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: 10/27/2020] [Revised: 01/14/2021] [Accepted: 01/26/2021] [Indexed: 11/29/2022]
Abstract
The use of pulsatile perfusion instead of nonpulsatile perfusion during cardiopulmonary bypass continues to be a source of debate. The disagreements among the conclusions of the published studies may be due to different factors: differences in the type of patients included in the studies, differences in the protocol of the studies, and difficulty to quantify the pulsatility of the flow. In the present paper, we propose a quantitative evaluation of Shepard's energy equivalent pressure index, based on the harmonic decomposition of the physiological aortic pressure and flow rate signal. It is thus demonstrated that the surplus energy provided by pulsatile flow remains moderate (of order 10 mm Hg), but that it can be improved by changing the relative shapes of the pressure and flow waves.
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Affiliation(s)
- Agnès Drochon
- Arts et Metiers Institute of Technology, Bordeaux INP, INRAE, I2M Bordeaux, CNRS, University of Bordeaux, Talence, France
| | - Olivier Fouquet
- Department of Cardio -Thoracic Surgery, University-Hospital Angers, Angers, France
| | - Christophe Baufreton
- Department of Cardio -Thoracic Surgery, University-Hospital Angers, Angers, France
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Luciano MG, Dombrowski SM, El-Khoury S, Yang J, Thyagaraj S, Qvarlander S, Khalid S, Suk I, Manbachi A, Loth F. Epidural Oscillating Cardiac-Gated Intracranial Implant Modulates Cerebral Blood Flow. Neurosurgery 2020; 87:1299-1310. [PMID: 32533835 PMCID: PMC7666905 DOI: 10.1093/neuros/nyaa188] [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: 06/25/2019] [Accepted: 03/16/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND We have previously reported a method and device capable of manipulating ICP pulsatility while minimally effecting mean ICP. OBJECTIVE To test the hypothesis that different modulations of the intracranial pressure (ICP) pulse waveform will have a differential effect on cerebral blood flow (CBF). METHODS Using an epidural balloon catheter attached to a cardiac-gated oscillating pump, 13 canine subjects underwent ICP waveform manipulation comparing different sequences of oscillation in successive animals. The epidural balloon was implanted unilaterally superior to the Sylvian sulcus. Subjects underwent ICP pulse augmentation, reduction and inversion protocols, directly comparing time segments of system activation and deactivation. ICP and CBF were measured bilaterally along with systemic pressure and heart rate. CBF was measured using both thermal diffusion, and laser doppler probes. RESULTS The activation of the cardiac-gate balloon implant resulted in an ipsilateral/contralateral ICP pulse amplitude increase with augmentation (217%/202% respectively, P < .0005) and inversion (139%/120%, P < .0005). The observed changes associated with the ICP mean values were smaller, increasing with augmentation (23%/31%, P < .0001) while decreasing with inversion (7%/11%, P = .006/.0003) and reduction (4%/5%, P < .0005). CBF increase was observed for both inversion and reduction protocols (28%/7.4%, P < .0001/P = .006 and 2.4%/1.3%, P < .0001/P = .003), but not the augmentation protocol. The change in CBF was correlated with ICP pulse amplitude and systolic peak changes and not with change in mean ICP or systemic variables (heart rate, arterial blood pressure). CONCLUSION Cardiac-gated manipulation of ICP pulsatility allows the study of intracranial pulsatile dynamics and provides a potential means of altering CBF.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Amir Manbachi
- Correspondence: Mark G. Luciano, MD, PhD, Departments of Neurosurgery and Biomedical Engineering, Johns Hopkins University, 600 North Wolfe Street, Phipps 126, Baltimore, MD 20287, USA.
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Sun P, Bozkurt S, Sorguven E. Computational analyses of aortic blood flow under varying speed CF-LVAD support. Comput Biol Med 2020; 127:104058. [PMID: 33091606 DOI: 10.1016/j.compbiomed.2020.104058] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 09/21/2020] [Accepted: 10/11/2020] [Indexed: 11/17/2022]
Abstract
Continuous Flow Left Ventricular Assist Devices (CF-LVADs) generally operate at a constant speed whilst supporting a failing heart. However, constant speed CF-LVAD support may cause complications and increase the morbidity rates in the patients. Therefore, different varying speed operating modes for CF-LVADs have been proposed to generate more physiological blood flow, which may reduce complication rates under constant speed CF-LVAD support. The proposed varying speed CF-LVAD algorithms simulate time-dependant dynamics and three dimensional blood flow patterns in aorta under varying speed CF-LVAD support remain unclear. The aim of this study is to evaluate three dimensional blood flow patterns in a patient-specific aorta model under co-pulsating and counter-pulsating CF-LVAD support modes driven by speed and flow rate control algorithms using numerical simulations. Aortic blood flow was evaluated for 10,000 rpm constant speed CF-LVAD support generating 4.71 L/min mean flow rate over a cardiac cycle. Co-pulsating and counter-pulsating CF-LVAD speed control operated the pump at the same average speed over a cardiac cycle and co-pulsating and counter-pulsating CF-LVAD flow rate control generated the same average flow rate over cardiac cycle as in the constant speed pump support. Simulation results show that the utilised counter-pulsating pump flow rate control may decrease the haemolysis to a third compared to the most commonly employed constant speed pump operating mode. Moreover, CF-LVAD support utilising counter-pulsating pump flow rate control generated the most favourable hemodynamic characteristics, i.e. low Dean number, least wall shear stress and least haemolysis values among the investigated cases.
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Affiliation(s)
- Peiying Sun
- Thermo Fluid Mechanics Research Centre (TFMRC), University of Sussex, Falmer, BN1 9RS, UK
| | - Selim Bozkurt
- Institute of Cardiovascular Science, University College London, London, WC1E 6BT, UK
| | - Esra Sorguven
- Thermo Fluid Mechanics Research Centre (TFMRC), University of Sussex, Falmer, BN1 9RS, UK.
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14
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Dort DIM, Thannhauser J, Gommans FDH, Ten Cate TJ, Duncker DJ, Suryapranata H, Morshuis WJ, Geuzebroek GSC. Proof of principle of a novel co‐pulsating intra‐ventricular membrane pump. Artif Organs 2020; 44:1267-1275. [DOI: 10.1111/aor.13757] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 06/04/2020] [Accepted: 06/08/2020] [Indexed: 12/15/2022]
Affiliation(s)
- Daniël I. M. Dort
- Department of Cardiothoracic Surgery Radboudumc Nijmegen The Netherlands
| | - Jos Thannhauser
- Department of Cardiology Radboudumc Nijmegen The Netherlands
| | | | - Tim J. Ten Cate
- Department of Cardiology Radboudumc Nijmegen The Netherlands
| | - Dirk J. Duncker
- Department of Experimental Cardiology Erasmus MC Rotterdam The Netherlands
| | | | - Wim J. Morshuis
- Department of Cardiothoracic Surgery Radboudumc Nijmegen The Netherlands
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15
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Advances in Hemodynamic Analysis in Cardiovascular Diseases Investigation of Energetic Characteristics of Adult and Pediatric Sputnik Left Ventricular Assist Devices during Mock Circulation Support. Cardiol Res Pract 2019; 2019:4593174. [PMID: 31885902 PMCID: PMC6925692 DOI: 10.1155/2019/4593174] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Revised: 09/11/2019] [Accepted: 10/17/2019] [Indexed: 11/17/2022] Open
Abstract
The need to simulate the operating conditions of the human body is a key factor in every study and engineering process of a bioengineering device developed for implantation. In the present paper, we describe in detail the interaction between the left ventricle (LV) and our Sputnik left ventricular assist devices (LVADs). This research aims to evaluate the influence of different rotary blood pumps (RBPs) on the LV depending on the degree of heart failure (HF), in order to investigate energetic characteristics of the LV-LVAD interaction and to estimate main parameters of left ventricular unloading. We investigate energetic characteristics of adult Sputnik 1 and Sputnik 2 LVADs connected to a hybrid adult mock circulation (HAMC) and also for the Sputnik pediatric rotary blood pump (PRBP) connected to a pediatric mock circulation (PMC). A major improvement of the LV unloading is observed during all simulations for each particular heart failure state when connected to the LVAD, with sequential pump speed increased within 5000–10000 rpm for adult LVADs and 6000–13000 rpm for PRBP with 200 rpm step. Additionally, it was found that depending on the degree of heart failure, LVADs influence the LV in different ways and a significant support level cannot be achieved without the aortic valve closure. Furthermore, this study expands the information on LV-LVAD interaction, which leads to the optimization of the RBP speed rate control in clinics for adult and pediatric patients suffering from heart failure. Finally, we show that the implementation of control algorithms using the modulation of the RBP speed in order to open the aortic valve and unload the LV more efficiently is necessary and will be content of further research.
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16
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Medikonda R, Ong CS, Wadia R, Goswami D, Schwartz J, Wolff L, Hibino N, Vricella L, Barodka V, Steppan J. A Review of Goal-Directed Cardiopulmonary Bypass Management in Pediatric Cardiac Surgery. World J Pediatr Congenit Heart Surg 2018; 9:565-572. [PMID: 30157729 DOI: 10.1177/2150135118775964] [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] [Indexed: 12/22/2022]
Abstract
Cardiopulmonary bypass perfusion management significantly affects postoperative outcomes. In recent years, the principles of goal-directed therapy have been applied to the field of cardiothoracic surgery to improve patient outcomes. Goal-directed therapy involves continuous peri- and postoperative monitoring of vital clinical parameters to tailor perfusion to each patient's specific needs. Closely measured parameters include fibrinogen, platelet count, lactate, venous oxygen saturation, central venous oxygen saturation, mean arterial pressure, perfusion flow rate, and perfusion pulsatility. These parameters have been shown to influence postoperative fresh frozen plasma transfusion rate, coagulation state, end-organ perfusion, and mortality. In this review, we discuss the recent paradigm shift in pediatric perfusion management toward goal-directed perfusion.
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Affiliation(s)
| | - Chin Siang Ong
- 2 Department of Surgery, Johns Hopkins University, Baltimore, MD, USA
| | - Rajeev Wadia
- 3 Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Dheeraj Goswami
- 3 Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Jamie Schwartz
- 3 Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Larry Wolff
- 2 Department of Surgery, Johns Hopkins University, Baltimore, MD, USA
| | - Narutoshi Hibino
- 2 Department of Surgery, Johns Hopkins University, Baltimore, MD, USA
| | - Luca Vricella
- 2 Department of Surgery, Johns Hopkins University, Baltimore, MD, USA
| | - Viachaslau Barodka
- 3 Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Jochen Steppan
- 3 Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA
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17
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Walski T, Drohomirecka A, Bujok J, Czerski A, Wąż G, Trochanowska-Pauk N, Gorczykowski M, Cichoń R, Komorowska M. Low-Level Light Therapy Protects Red Blood Cells Against Oxidative Stress and Hemolysis During Extracorporeal Circulation. Front Physiol 2018; 9:647. [PMID: 29904353 PMCID: PMC5991292 DOI: 10.3389/fphys.2018.00647] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Accepted: 05/11/2018] [Indexed: 12/21/2022] Open
Abstract
Aim: An activation of non-specific inflammatory response, coagulation disorder, and blood morphotic elements damage are the main side effects of the extracorporeal circulation (ECC). Red-to-near-infrared radiation (R/NIR) is thought to be capable of stabilizing red blood cell (RBC) membrane through increasing its resistance to destructive factors. We focused on the development of a method using low-level light therapy (LLLT) in the spectral range of R/NIR which could reduce blood trauma caused by the heart-lung machine during surgery. Methods: R/NIR emitter was adjusted in terms of geometry and optics to ECC circuit. The method of extracorporeal blood photobiomodulation was tested during in vivo experiments in an animal, porcine model (1 h of ECC plus 23 h of animal observation). A total of 24 sows weighing 90-100 kg were divided into two equal groups: control one and LLLT. Blood samples were taken during the experiment to determine changes in blood morphology [RBC and white blood cell (WBC) counts, hemoglobin (Hgb)], indicators of hemolysis [plasma-free hemoglobin (PFHgb), serum bilirubin concentration, serum lactate dehydrogenase (LDH) activity], and oxidative stress markers [thiobarbituric acid reactive substances (TBARS) concentration, total antioxidant capacity (TAC)]. Results: In the control group, a rapid systemic decrease in WBC count during ECC was accompanied by a significant increase in RBC membrane lipids peroxidation, while in the LLLT group the number of WBC and TBARS concentration both remained relatively constant, indicating limitation of the inflammatory process. These results were consistent with the change in the hemolysis markers like PFHgb, LDH, and serum bilirubin concentration, which were significantly reduced in LLLT group. No differences in TAC, RBC count, and Hgb concentration were detected. Conclusion: We presented the applicability of the LLLT with R/NIR radiation to blood trauma reduction during ECC.
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Affiliation(s)
- Tomasz Walski
- Department of Biomedical Engineering, Faculty of Fundamental Problems of Technology, Wrocław University of Science and Technology, Wrocław, Poland
- Regional Specialist Hospital in Wrocław, Research and Development Centre, Wrocław, Poland
| | - Anna Drohomirecka
- Regional Specialist Hospital in Wrocław, Research and Development Centre, Wrocław, Poland
- Institute of Cardiology, Warsaw, Poland
| | - Jolanta Bujok
- Regional Specialist Hospital in Wrocław, Research and Development Centre, Wrocław, Poland
- Department of Animal Physiology and Biostructure, Faculty of Veterinary Medicine, Wrocław University of Environmental and Life Sciences, Wrocław, Poland
| | - Albert Czerski
- Regional Specialist Hospital in Wrocław, Research and Development Centre, Wrocław, Poland
- Department of Animal Physiology and Biostructure, Faculty of Veterinary Medicine, Wrocław University of Environmental and Life Sciences, Wrocław, Poland
| | - Grzegorz Wąż
- Regional Specialist Hospital in Wrocław, Research and Development Centre, Wrocław, Poland
- Medinet Heart Center Ltd., Wrocław, Poland
| | - Natalia Trochanowska-Pauk
- Department of Biomedical Engineering, Faculty of Fundamental Problems of Technology, Wrocław University of Science and Technology, Wrocław, Poland
- Regional Specialist Hospital in Wrocław, Research and Development Centre, Wrocław, Poland
| | - Michał Gorczykowski
- Department of Internal Medicine and Clinic of Diseases of Horses, Dogs and Cats, Faculty of Veterinary Medicine, Wrocław University of Environmental and Life Sciences, Wrocław, Poland
| | | | - Małgorzata Komorowska
- Department of Biomedical Engineering, Faculty of Fundamental Problems of Technology, Wrocław University of Science and Technology, Wrocław, Poland
- Regional Specialist Hospital in Wrocław, Research and Development Centre, Wrocław, Poland
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18
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Zeilmaker GA, Pokorna P, Mian P, Wildschut ED, Knibbe CAJ, Krekels EHJ, Allegaert K, Tibboel D. Pharmacokinetic considerations for pediatric patients receiving analgesia in the intensive care unit; targeting postoperative, ECMO and hypothermia patients. Expert Opin Drug Metab Toxicol 2018; 14:417-428. [PMID: 29623729 DOI: 10.1080/17425255.2018.1461836] [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: 12/26/2022]
Abstract
INTRODUCTION Adequate postoperative analgesia in pediatric patients in the intensive care unit (ICU) matters, since untreated pain is associated with negative outcomes. Compared to routine postoperative patients, children undergoing hypothermia (HT) or extracorporeal membrane oxygenation (ECMO), or recovering after cardiac surgery likely display non-maturational differences in pharmacokinetics (PK) and pharmacodynamics (PD). These differences warrant additional dosing recommendations to optimize pain treatment. Areas covered: Specific populations within the ICU will be discussed with respect to expected variations in PK and PD for various analgesics. We hereby move beyond maturational changes and focus on why PK/PD may be different in children undergoing HT, ECMO or cardiac surgery. We provide a stepwise manner to develop PK-based dosing regimens using population PK approaches in these populations. Expert opinion: A one-dose to size-fits-all for analgesia is suboptimal, but for several commonly used analgesics the impact of HT, ECMO or cardiac surgery on average PK parameters in children is not yet sufficiently known. Parameters considering both maturational and non-maturational covariates are important to develop population PK-based dosing advices as part of a strategy to optimize pain treatment.
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Affiliation(s)
- Gerdien A Zeilmaker
- a Intensive Care and Department of Pediatric Surgery , Erasmus MC-Sophia Children's Hospital , Rotterdam , The Netherlands
| | - Paula Pokorna
- a Intensive Care and Department of Pediatric Surgery , Erasmus MC-Sophia Children's Hospital , Rotterdam , The Netherlands.,b Department of Pediatrics, General Faculty Hospital Prague, First Faculty of Medicine , Charles University and General University Hospital in Prague , Prague , Czech Republic.,c Institute of Pharmacology, First Faculty of Medicine , Charles University and General University Hospital in Prague , Prague , Czech Republic
| | - Paola Mian
- a Intensive Care and Department of Pediatric Surgery , Erasmus MC-Sophia Children's Hospital , Rotterdam , The Netherlands
| | - Enno D Wildschut
- a Intensive Care and Department of Pediatric Surgery , Erasmus MC-Sophia Children's Hospital , Rotterdam , The Netherlands
| | - Catherijne A J Knibbe
- d Division of Pharmacology , LACDR, Leiden University , Leiden , The Netherlands.,e Department of Clinical Pharmacy , St. Antonius Hospital , Nieuwegein , The Netherlands
| | - Elke H J Krekels
- d Division of Pharmacology , LACDR, Leiden University , Leiden , The Netherlands
| | - Karel Allegaert
- a Intensive Care and Department of Pediatric Surgery , Erasmus MC-Sophia Children's Hospital , Rotterdam , The Netherlands.,f Department of Development and Regeneration , KU Leuven , Leuven , Belgium
| | - Dick Tibboel
- a Intensive Care and Department of Pediatric Surgery , Erasmus MC-Sophia Children's Hospital , Rotterdam , The Netherlands
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19
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Park SM, Yang S, Rye SM, Choi SW. Effect of pulsatile flow perfusion on decellularization. Biomed Eng Online 2018; 17:15. [PMID: 29391037 PMCID: PMC5796601 DOI: 10.1186/s12938-018-0445-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Accepted: 01/16/2018] [Indexed: 11/20/2022] Open
Abstract
Background Decellularized animal organs have been used as scaffolds for tissue engineering. To make a properly functioning scaffolds, the extracellular matrix (ECM) components must be preserved after decellularization. Because pulsatile flow is known to be beneficial for tissue perfusion, pulsatile perfusion of a detergent might decrease the exposure time of the tissues to the detergent used for decellularization. Using Energy Equivalent Pressure (EEP) as a pulsatility parameter, the effect of pulsatile flow in decellularization process is studied. Results Twelve rat hearts were decellularization with 1% sodium dodecyl sulfate (SDS) solution for 2 h. They are divided into two groups, one with pulsatile perfusion (n = 6), the other with non-pulsatile perfusion (n = 6) of SDS. The initial mean perfusion pressures were same in both group. The result indicated that the EEP and the perfusion flow were increased significantly in the pulsatile group compared to the non-pulsatile group. Photographs taken during the decellularization showed more profound decellularization in the pulsatile group. The residual DNA content in the scaffolds was significantly lower in the pulsatile group. However, the level of ECM components, collagen and GAG showed no significant differences between the groups. Conclusions Decellularization is more efficient in pulsatile flow than in non-pulsatile flow but still preserves the ECM molecules.
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Affiliation(s)
- Sung Min Park
- School of Medicine, Kangwon National University, Chuncheon-si, Republic of Korea
| | - Seran Yang
- School of Medicine, Kangwon National University, Chuncheon-si, Republic of Korea
| | - Se-Min Rye
- School of Medicine, Kangwon National University, Chuncheon-si, Republic of Korea
| | - Seong Wook Choi
- Program of Mechanical and Biomedical Engineering, College of Engineering, Kangwon National University, Chuncheon-si, Republic of Korea.
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20
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O'Neil MP, Alie R, Guo LR, Myers ML, Murkin JM, Ellis CG. Microvascular Responsiveness to Pulsatile and Nonpulsatile Flow During Cardiopulmonary Bypass. Ann Thorac Surg 2018; 105:1745-1753. [PMID: 29391150 DOI: 10.1016/j.athoracsur.2018.01.007] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Revised: 11/17/2017] [Accepted: 01/03/2018] [Indexed: 11/15/2022]
Abstract
BACKGROUND Pulsatile perfusion may offer microcirculatory advantages over conventional nonpulsatile perfusion during cardiopulmonary bypass (CPB). Here, we present direct visual evidence of microvascular perfusion and vasoreactivity between perfusion modalities. METHODS A prospective, randomized cohort study of 20 high-risk cardiac surgical patients undergoing pulsatile (n = 10) or nonpulsatile (n = 10) flow during CPB was conducted. Changes in sublingual mucosal microcirculation were assessed with orthogonal polarization spectral imaging along with near-infrared spectroscopic indices of thenar muscle tissue oxygen saturation (StO2) and its recovery during a vascular occlusion test at the following time points: baseline (T0), 30 minutes on CPB (T1), 90 minutes on CPB (T2), 1 hour after CPB (T3), and 24 hours after CPB (T4). RESULTS On the basis of our scoring scale, a shift in microcirculatory blood flow occurred over time. The pulsatile group maintained normal perfusion characteristics, whereas the nonpulsatile group exhibited deterioration in perfusion during CPB (T2: 74.0% ± 5.6% versus 57.6% ± 5.0%) and after CPB (T3: 76.2% ± 2.7% versus 58.9% ± 5.2%, T4: 85.7% ± 2.6% versus 69.8% ± 5.9%). Concurrently, no important differences were found between groups in baseline StO2 and consumption slope at all time points. Reperfusion slope was substantially different between groups 24 hours after CPB (T4: 6.1% ± 0.6% versus 3.7% ± 0.5%), indicating improved microvascular responsiveness in the pulsatile group versus the nonpulsatile group. CONCLUSIONS Pulsatility generated by the roller pump during CPB improves microcirculatory blood flow and tissue oxygen saturation compared with nonpulsatile flow in high-risk cardiac surgical patients, which may reflect attenuation of the systemic inflammatory response and ischemia-reperfusion injury.
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Affiliation(s)
- Michael P O'Neil
- Department of Clinical Perfusion Services, Division of Cardiac Surgery, London Health Sciences Centre, London, Ontario, Canada; Department of Medical Biophysics, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada.
| | - Rene Alie
- Department of Clinical Perfusion Services, Division of Cardiac Surgery, London Health Sciences Centre, London, Ontario, Canada
| | - Linrui Ray Guo
- Department of Surgery, Division of Cardiac Surgery, London Health Sciences Centre, London, Ontario, Canada
| | - Mary-Lee Myers
- Department of Surgery, Division of Cardiac Surgery, London Health Sciences Centre, London, Ontario, Canada
| | - John M Murkin
- Department of Anesthesiology, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada
| | - Christopher G Ellis
- Department of Medical Biophysics, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada
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21
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Schetz M, Bove T, Morelli A, Mankad S, Ronco C, Kellum J. Prevention of Cardiac Surgery-Associated Acute Kidney Injury. Int J Artif Organs 2018; 31:179-89. [DOI: 10.1177/039139880803100211] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Numerous strategies have been evaluated to prevent early CSA-AKI. Although correction of hemodynamic problems is paramount, there are no clinical studies that compare different hemodynamic management or monitoring strategies with regard to their effect on kidney function. Pharmacologic strategies including diuretics, different classes of vasodilators and drugs with anti-inflammatory effects such as N-acetyl-cysteine, do not appear to be effective. Most of the studies are underpowered and use physiological rather than clinical endpoints. Further trials are warranted with fenoldopam and nesiritide (rhBNP). Observational and underpowered randomized studies show beneficial renal effects of off-pump technique and avoidance of aortic manipulation. There is very limited evidence for preoperative fluid loading and preemptive RRT. Potentially nephrotoxic agents should be used with caution in patients at risk of CSA-AKI. Tranexamic acid or aminocaproic acid should be preferred over aprotinin. No pharmacologic intervention has been adequately tested in the prevention of late CSA-AKI. A single-center study, including a predominance of patients after cardiac surgery, showed a decrease of kidney injury with tight glycemic control.
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Affiliation(s)
- M. Schetz
- Department of Intensive Care Medicine, University of Leuven, Leuven - Belgium
| | - T. Bove
- Department of Cardiothoracic Anesthesia and Intensive Care, Vita-Salute San Raffaele University, Milan - Italy
| | - A. Morelli
- Department of Anesthesiology and Intensive Care, University of Rome, La Sapienza, Rome - Italy
| | - S. Mankad
- Division of Cardiology, The Mayo Clinic, Rochester, Minnesota - USA
| | - C. Ronco
- Department of Nephrology, Dialysis and Transplantation, St. Bortolo Hospital - International Renal Research Institute Vicenza (IRRIV), Vicenza - Italy
| | - J.A. Kellum
- Department of Critical Care Medicine. University of Pittsburgh, Pittsburgh, Pennsylvania - USA
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22
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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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23
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Sunagawa G, Koprivanac M, Karimov JH, Moazami N, Fukamachi K. Is a pulse absolutely necessary during cardiopulmonary bypass? Expert Rev Med Devices 2016; 14:27-35. [DOI: 10.1080/17434440.2017.1265445] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Gengo Sunagawa
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Marijan Koprivanac
- Department of Thoracic and Cardiovascular Surgery, Kaufman Center for Heart Failure, Cardiac Transplantation and Mechanical Circulatory Support, Miller Family Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Jamshid H. Karimov
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Nader Moazami
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
- Department of Thoracic and Cardiovascular Surgery, Kaufman Center for Heart Failure, Cardiac Transplantation and Mechanical Circulatory Support, Miller Family Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Kiyotaka Fukamachi
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
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24
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Millar JE, Fanning JP, McDonald CI, McAuley DF, Fraser JF. The inflammatory response to extracorporeal membrane oxygenation (ECMO): a review of the pathophysiology. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:387. [PMID: 27890016 PMCID: PMC5125043 DOI: 10.1186/s13054-016-1570-4] [Citation(s) in RCA: 403] [Impact Index Per Article: 50.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Extracorporeal membrane oxygenation (ECMO) is a technology capable of providing short-term mechanical support to the heart, lungs or both. Over the last decade, the number of centres offering ECMO has grown rapidly. At the same time, the indications for its use have also been broadened. In part, this trend has been supported by advances in circuit design and in cannulation techniques. Despite the widespread adoption of extracorporeal life support techniques, the use of ECMO remains associated with significant morbidity and mortality. A complication witnessed during ECMO is the inflammatory response to extracorporeal circulation. This reaction shares similarities with the systemic inflammatory response syndrome (SIRS) and has been well-documented in relation to cardiopulmonary bypass. The exposure of a patient’s blood to the non-endothelialised surface of the ECMO circuit results in the widespread activation of the innate immune system; if unchecked this may result in inflammation and organ injury. Here, we review the pathophysiology of the inflammatory response to ECMO, highlighting the complex interactions between arms of the innate immune response, the endothelium and coagulation. An understanding of the processes involved may guide the design of therapies and strategies aimed at ameliorating inflammation during ECMO. Likewise, an appreciation of the potentially deleterious inflammatory effects of ECMO may assist those weighing the risks and benefits of therapy.
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Affiliation(s)
- Jonathan E Millar
- Critical Care Research Group, University of Queensland, Brisbane, Australia. .,Critical Care Research Group, The Prince Charles Hospital, Rode Road, Chermside, Queensland, 4032, Australia.
| | - Jonathon P Fanning
- Critical Care Research Group, University of Queensland, Brisbane, Australia
| | - Charles I McDonald
- Critical Care Research Group, University of Queensland, Brisbane, Australia
| | - Daniel F McAuley
- Wellcome-Wolfson Centre for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - John F Fraser
- Critical Care Research Group, University of Queensland, Brisbane, Australia
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25
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Temporary extracorporeal bypass modalities during aortic surgery. Best Pract Res Clin Anaesthesiol 2016; 30:341-57. [DOI: 10.1016/j.bpa.2016.08.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Accepted: 08/08/2016] [Indexed: 11/21/2022]
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26
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Luciano MG, Dombrowski SM, Qvarlander S, El-Khoury S, Yang J, Thyagaraj S, Loth F. Novel method for dynamic control of intracranial pressure. J Neurosurg 2016; 126:1629-1640. [PMID: 27419825 DOI: 10.3171/2016.4.jns152457] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Intracranial pressure (ICP) pulsations are generally considered a passive result of the pulsatility of blood flow. Active experimental modification of ICP pulsations would allow investigation of potential active effects on blood and CSF flow and potentially create a new platform for the treatment of acute and chronic low blood flow states as well as a method of CSF substance clearance and delivery. This study presents a novel method and device for altering the ICP waveform via cardiac-gated volume changes. METHODS The novel device used in this experiment (named Cadence) consists of a small air-filled inelastic balloon (approximately 1.0 ml) implanted into the intracranial space and connected to an external programmable pump, triggered by an R-wave detector. Balloons were implanted into the epidural space above 1 of the hemispheres of 19 canines for up to 10 hours. When activated, the balloons were programed to cyclically inflate with the cardiac cycle with variable delay, phase, and volume. The ICP response was measured in both hemispheres. Additionally, cerebral blood flow (heat diffusion and laser Doppler) was studied in 16 canines. RESULTS This system, depending on the inflation pattern of the balloon, allowed a flattening of the ICP waveform, increase in the ICP waveform amplitude, or phase shift of the wave. This occurred with small mean ICP changes, typically around ± 2 mm Hg (15%). Bilateral ICP effects were observed with activation of the device: balloon inflation at each systole increased the systolic ICP pulse (up to 16 mm Hg, 1200%) and deflation at systole decreased or even inverted the systolic ICP pulse (-0.5 to -19 mm Hg, -5% to -1600%) in a dose-(balloon volume) dependent fashion. No aphysiological or deleterious effects on systemic pressure (≤ ±10 mm Hg; 13% change in mean pressure) or cardiac rate (≤ ± 17 beats per minute; 16% change) were observed during up to 4 hours of balloon activity. CONCLUSIONS The results of these initial studies using an intracranially implanted, cardiac-gated, volume-oscillating balloon suggest the Cadence device can be used to modify ICP pulsations, without physiologically deleterious effects on mean ICP, systemic vascular effects, or brain injury. This device and technique may be used to study the role of ICP pulsatility in intracranial hemo- and hydrodynamic processes and introduces the creation of a potential platform of a cardiac-gated system for treatment of acute and chronic low blood flow states, and diseases requiring augmentation of CSF substance clearance or delivery.
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Affiliation(s)
- Mark G Luciano
- Department of Neurosurgery, Section of Pediatric Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio.,Department of Neurosurgery, Johns Hopkins University, Baltimore, Maryland; and
| | - Stephen M Dombrowski
- Department of Neurosurgery, Section of Pediatric Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | - Sara Qvarlander
- Department of Neurosurgery, Section of Pediatric Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio.,Department of Radiation Sciences-Biomedical Engineering, Umeå University, Umeå, Sweden
| | - Serge El-Khoury
- Department of Neurosurgery, Section of Pediatric Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | - Jun Yang
- Department of Neurosurgery, Section of Pediatric Neurosurgery, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | - Suraj Thyagaraj
- Department of Mechanical Engineering.,Conquer Chiari Research Center, Department of Mechanical Engineering, The University of Akron, Ohio
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Ji B, Undar A. Review Article: Comparison of perfusion modes on microcirculation during acute and chronic cardiac support: is there a difference? Perfusion 2016; 22:115-9. [PMID: 17708160 DOI: 10.1177/0267659107080115] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Although heart-lung machines and cardiac assist devices have been used successfully for acute and chronic cardiac support for decades, controversies still remain concerning the benefits of pulsatile and non-pulsatile perfusion. The core of the debate is whether enough energy is generated by the artificial pulse to keep capillary beds open and cell metabolism stabilized during acute or chronic cardiac support. In other words, does artificial pulsatility exist in the microcirculation: small vessels of less than 100 μm in diameter? Many investigators have tried to use different tools and biomarkers to reflect directly or indirectly the state of the microcirculation when comparing the two different perfusion modes during acute and chronic cardiac support. However, the results are controversial. First, direct observation of the state of the microcirculation during acute and chronic cardiac support is limited; and reports concerning direct observation of the microcirculation with different perfusion modes in contemporary literature are rare. Secondly, different investigators have used their own criteria to define pulsatile flow. Therefore, it is necessary to develop more efficient methodologies, enabling direct observation of the microcirculation during acute and chronic cardiac support and also establish common criteria that will precisely quantify the pulsatile flow in terms of energy equivalent pressure (EEP) and surplus hemodynamic energy (SHE) levels. Using these critical parameters may explain how excess energy is created by pulsatile flow and maintains perfusion through the microcirculation by ensuring capillary patency. Perfusion (2007) 22, 115—119.
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Affiliation(s)
- Bingyang Ji
- Department of Pediatrics, Penn State Children's Hospital, Penn State College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania 17033-0850, USA
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Faravan A, Mohammadi N, Alizadeh Ghavidel A, Toutounchi MZ, Ghanbari A, Mazloomi M. Comparison of current practices of cardiopulmonary perfusion technology in Iran with American Society of Extracorporeal Technology's standards. J Cardiovasc Thorac Res 2016; 8:72-6. [PMID: 27489600 PMCID: PMC4970574 DOI: 10.15171/jcvtr.2016.14] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2016] [Accepted: 05/29/2016] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Standards have a significant role in showing the minimum level of optimal optimum and the expected performance. Since the perfusion technology staffs play an the leading role in providing the quality services to the patients undergoing open heart surgery with cardiopulmonary bypass machine, this study aimed to assess the standards on how Iranian perfusion technology staffs evaluate and manage the patients during the cardiopulmonary bypass process and compare their practice with the recommended standards by American Society of Extracorporeal Technology. METHODS In this descriptive study, data was collected from 48 Iranian public hospitals and educational health centers through a researcher-created questionnaire. The data collection questionnaire assessed the standards which are recommended by American Society of Extracorporeal Technology. RESULTS Findings showed that appropriate measurements were carried out by the perfusion technology staffs to prevent the hemodilution and avoid the blood transfusion and unnecessary blood products, determine the initial dose of heparin based on one of the proposed methods, monitor the anticoagulants based on ACT measurement, and determine the additional doses of heparin during the cardiopulmonary bypass based on ACT or protamine titration. It was done only in 4.2% of hospitals and health centers. CONCLUSION Current practices of cardiopulmonary perfusion technology in Iran are inappropriate based on the standards of American Society of Cardiovascular Perfusion. This represents the necessity of authorities' attention to the validation programs and development of the caring standards on one hand and continuous assessment of using these standards on the other hand.
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Affiliation(s)
- Amir Faravan
- Department of Critical Care Nursing, Center for Nursing Care Research, Nursing and Midwifery Faculty, Iran University of Medical Sciences, Tehran, Iran
| | - Nooredin Mohammadi
- Department of Critical Care Nursing, Nursing and Midwifery Faculty, Iran University of Medical Sciences, School of Nursing and Midwifery, Flinders University, Australia
| | - Alireza Alizadeh Ghavidel
- Heart Valve Disease Research Center, Rajaie Cardiovascular Medical & Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Mohammad Zia Toutounchi
- Heart Valve Disease Research Center, Rajaie Cardiovascular Medical & Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Ameneh Ghanbari
- Rajaie Cardiovascular Medical & Research Center, Cardiac Surgery Department, Iran University of Medical Sciences, Tehran, Iran
| | - Mehran Mazloomi
- Department of Critical Care Nursing, Center for Nursing Care Research, Nursing and Midwifery Faculty, Iran University of Medical Sciences, Tehran, Iran
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Elvevoll B, Lundemoen S, Svendsen ØS, Mongstad A, Grong K, Kvalheim VL, Husby P. Does Roller Pump-Induced Pulsatile CPB Perfusion Affect Microvascular Fluid Shifts and Tissue Perfusion? Ann Thorac Surg 2016; 102:564-72. [PMID: 27139370 DOI: 10.1016/j.athoracsur.2016.02.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2015] [Revised: 12/15/2015] [Accepted: 02/01/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Pulsatile versus nonpulsatile cardiopulmonary bypass (CPB) perfusion remains debated. Beneficial effects on tissue perfusion, inflammation, and microvascular fluid exchange have been linked to pulsatile perfusion by some investigators and denied by others. This study evaluated fluid extravasation and tissue perfusion during nonpulsatile or pulsatile roller pump-induced CPB perfusion. METHODS Fourteen pigs underwent roller pump-induced pulsatile (n = 7) or nonpulsatile CPB perfusion (n = 7) for 90 minutes. Fluid input/losses, colloid osmotic pressures (plasma/interstitium), hematocrit, serum electrolytes, serum proteins, tissue perfusion, and total tissue water content were measured, and plasma volume and fluid extravasation were calculated. RESULTS Fluid additions/losses, plasma volume, and fluid extravasation changed similarly in both groups during CPB with no between-group differences. Neither was between-group differences observed for tissue perfusion and total tissue water content, with one exception. Total tissue water content of the right (3.92 ± 0.26 versus 4.32 ± 0.28 g/g dry weight) and left ventricle (4.02 ± 0.25 versus 4.33 ± 0.24 g/g dry weight) was lowered in the pulsatile group. CONCLUSIONS No important differences were found between pulsatile and nonpulsatile CPB perfusion for microvascular fluid balance and tissue perfusion.
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Affiliation(s)
- Bjørg Elvevoll
- Department of Anesthesia and Surgical Services, Haukeland University Hospital, Bergen, Norway
| | - Steinar Lundemoen
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
| | - Øyvind S Svendsen
- Department of Anesthesia and Surgical Services, Haukeland University Hospital, Bergen, Norway
| | - Arve Mongstad
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
| | - Ketil Grong
- Department of Clinical Science, Faculty of Medicine and Dentistry, University of Bergen, Bergen, Norway
| | - Venny L Kvalheim
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway; Department of Clinical Science, Faculty of Medicine and Dentistry, University of Bergen, Bergen, Norway
| | - Paul Husby
- Department of Anesthesia and Surgical Services, Haukeland University Hospital, Bergen, Norway; Department of Clinical Medicine, Faculty of Medicine and Dentistry, University of Bergen, Bergen, Norway.
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Minor Postoperative Increases of Creatinine Are Associated with Higher Mortality and Longer Hospital Length of Stay in Surgical Patients. Anesthesiology 2016; 123:1301-11. [PMID: 26492475 DOI: 10.1097/aln.0000000000000891] [Citation(s) in RCA: 116] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Surgical patients frequently experience postoperative increases in creatinine levels. The authors hypothesized that even small increases in postoperative creatinine levels are associated with adverse outcomes. METHODS The authors examined the association of postoperative changes from preoperative baseline creatinine with all-cause in-hospital mortality and hospital length of stay (HLOS) in a retrospective analysis of surgical patients at a single tertiary care center between January 2006 and June 2012. RESULTS The data of 39,369 surgical patients (noncardiac surgery n = 37,345; cardiac surgery n = 2,024) were analyzed. Acute kidney injury (AKI)-by definition of the Kidney Disease: Improving Global Outcome group-was associated with a five-fold higher mortality (odds ratio [OR], 4.8; 95% CI, 4.1 to 5.7; P < 0.001) and a longer HLOS of 5 days (P < 0.001) after adjusting for age, sex, comorbidities, congestive heart failure, preoperative hemoglobin, preoperative creatinine, exposure to radiocontrast agent, type of surgery, and surgical AKI risk factors. Importantly, even minor creatinine increases (Δcreatinine 25 to 49% above baseline but < 0.3 mg/dl) not meeting AKI criteria were associated with a two-fold increased risk of death (OR, 1.7; 95% CI, 1.3 to 2.4; P < 0.001) and 2 days longer HLOS (P < 0.001). This was more pronounced in noncardiac surgery patients. Patients with minor creatinine increases had a five-fold risk of death (OR, 5.4; 95% CI, 1.5 to 20.3; P < 0.05) and a 3-day longer HLOS (P < 0.01) when undergoing noncardiac surgery. CONCLUSIONS Even minor postoperative increases in creatinine levels are associated with adverse outcomes. These results emphasize the importance to find effective therapeutic approaches to prevent or treat even mild forms of postoperative kidney dysfunction to improve surgical outcomes.
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Investigation of hemodynamics during cardiopulmonary bypass: A multiscale multiphysics fluid–structure-interaction study. Med Eng Phys 2016; 38:380-90. [DOI: 10.1016/j.medengphy.2016.01.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2014] [Revised: 01/04/2016] [Accepted: 01/31/2016] [Indexed: 11/23/2022]
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Good BC, Deutsch S, Manning KB. Continuous and Pulsatile Pediatric Ventricular Assist Device Hemodynamics with a Viscoelastic Blood Model. Cardiovasc Eng Technol 2016; 7:23-43. [PMID: 26643646 PMCID: PMC4767652 DOI: 10.1007/s13239-015-0252-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2015] [Accepted: 11/23/2015] [Indexed: 11/25/2022]
Abstract
To investigate the effects of pulsatile and continuous pediatric ventricular assist (PVAD) flow and pediatric blood viscoelasticity on hemodynamics in a pediatric aortic graft model. Hemodynamic parameters of pulsatility, along with velocity and wall shear stress (WSS), are analyzed and compared between Newtonian and viscoelastic blood models at a range of physiological pediatric hematocrits using computational fluid dynamics. Both pulsatile and continuous PVAD flow lead to a decrease in pulsatility (surplus hemodynamic energy, ergs/cm(3)) compared to healthy aortic flow but with continuous PVAD pulsatility up to 2.4 times lower than pulsatile PVAD pulsatility at each aortic outlet. Significant differences are also seen between the two flow modes in velocity and WSS. The higher velocity jet during systole with pulsatile flow leads to higher WSSs at the anastomotic toe and at the aortic branch bifurcations. The lower velocity but continuous flow jet leads to a much different flow field and higher WSSs into diastole. Under a range of physiological pediatric hematocrit (20-60%), both velocity and WSS can vary significantly with the higher hematocrit blood model generally leading to higher peak WSSs but also lower WSSs in regions of flow separation. The large decrease in pulsatility seen from continuous PVAD flow could lead to complications in pediatric vascular development while the high WSSs during peak systole from pulsatile PVAD flow could lead to blood damage. Both flow modes lead to similar regions prone to intimal hyperplasia resulting from low time-averaged WSS and high oscillatory shear index.
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Affiliation(s)
- Bryan C Good
- Department of Biomedical Engineering, The Pennsylvania State University, 205 Hallowell Building, University Park, PA, 16802, USA
| | - Steven Deutsch
- Department of Biomedical Engineering, The Pennsylvania State University, 205 Hallowell Building, University Park, PA, 16802, USA
| | - Keefe B Manning
- Department of Biomedical Engineering, The Pennsylvania State University, 205 Hallowell Building, University Park, PA, 16802, USA.
- Department of Surgery, Penn State Hershey Medical Center, Hershey, PA, 17033, USA.
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Physiologic outcome of varying speed rotary blood pump support algorithms: a review study. AUSTRALASIAN PHYSICAL & ENGINEERING SCIENCES IN MEDICINE 2015; 39:13-28. [DOI: 10.1007/s13246-015-0405-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/07/2015] [Accepted: 11/05/2015] [Indexed: 10/22/2022]
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Sangalli F, Guazzi M, Senni S, Sala W, Caruso R, Costa MC, Formica F, Avalli L, Fumagalli R. Assessing Endothelial Responsiveness After Cardiopulmonary Bypass: Insights on Different Perfusion Modalities. J Cardiothorac Vasc Anesth 2015; 29:912-6. [DOI: 10.1053/j.jvca.2014.11.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2014] [Indexed: 11/11/2022]
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Tovedal T, Thelin S, Lennmyr F. Cerebral oxygen saturation during pulsatile and non-pulsatile cardiopulmonary bypass in patients with carotid stenosis. Perfusion 2015; 31:72-7. [PMID: 25948696 DOI: 10.1177/0267659115586280] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Pulsatile and non-pulsatile cardiopulmonary bypass (CPB) flows may have different impact on cerebral oxygen saturation in patients with restricted cerebral arterial blood supply. Twenty patients, ten diagnosed with carotid stenosis (CS, n = 10) and ten without known carotid disease (Controls, n = 10), were subjected to one period of pulsatile and one period of non-pulsatile flow (6-8 min each) during CPB at 32°C. Cerebral oxygen saturation was registered by near-infrared light spectroscopy (NIRS).The mean arterial pressure (MAP) was significantly lowered by pulsatile CPB flow. The NIRS tissue oxygenation index (TOI) tended to decrease in the CS group and increase in the Controls during pulsatile flow compared with non-pulsatile; however, the changes were not statistically significant.No significant correlations were seen between the changes in MAP and TOI across the observation periods.In conclusion, pulsatile CPB flow caused slightly decreased mean arterial pressure while the effect on cerebral oxygenation was unclear. Pulsatile flow was not found superior to non-pulsatile flow in patients with or without carotid stenosis.
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Affiliation(s)
- T Tovedal
- Department of Surgical Sciences, Section for Anaesthesiology and Intensive Care, Uppsala University, Uppsala, Sweden
| | - S Thelin
- Department of Surgical Sciences, Section for Thoracic Surgery, Uppsala University, Uppsala, Sweden
| | - F Lennmyr
- Department of Surgical Sciences, Section for Anaesthesiology and Intensive Care, Uppsala University, Uppsala, Sweden
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Picard NA, Zanardi CA. Brain motion and volume transmission: Keeping the interstice flowing. Med Hypotheses 2015; 85:41-4. [PMID: 25840847 DOI: 10.1016/j.mehy.2015.03.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2014] [Revised: 03/16/2015] [Accepted: 03/21/2015] [Indexed: 12/31/2022]
Abstract
Human brain undergoes two different kinds of movements: subtle pulsatile ones associated with the cardiac cycle and others of a greater magnitude related to breathing activity. These motions constitute a pumping force for the circulation of cerebrospinal fluid (CSF). Moreover, brain motion (BM) plays a fundamental role as a driving force for the interstitial and CSF flow of tracers. We hypothesize that BM is more than a mere consequence of cardiac and respiratory activities; that it would be part of a fundamental physiological mechanism by propelling the interstitial flow of messengers, a mechanism also known as 'non-synaptic transmission' or 'volume transmission' (VT). Intracranial hypertension (ICH), a frequent complication of severe head trauma, is related to brain stiffness. Under this circumstance, not only brain perfusion could be at risk, but BM could be engaged as well. Decompressive craniectomy, presently indicated to reduce ICH refractory to medical treatment, could play a role in helping BM and VT. Once brain swelling is overcome, the closure of the cranial bone defect would ensure the recovery of the spatial and temporal patterns of BM. We discuss evidence supportive of the necessary role of a minimal and sequential BM for an adequate VT.
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Affiliation(s)
- Nelson A Picard
- Neurosurgery Unit, "Dr. Abraham Piñeyro" Hospital, Junín (B), Argentina.
| | - Carlos A Zanardi
- Neurosurgery Unit, "Dr. Abraham Piñeyro" Hospital, Junín (B), Argentina
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Zhang Z, Xu J, Zhu E, Zhang Q, Yu L, Qiu Y, Tang J, Fei Z, Li X, Tu L, Han C, Liu Y, Guo Z, Zhou C, Shi M, Qian Y, Bao Y, Ji X. Effect of pulsatile perfusion during cardiopulmonary bypass in terms of radial artery sphygmogram. J TRADIT CHIN MED 2015; 34:673-7. [PMID: 25618971 DOI: 10.1016/s0254-6272(15)30081-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To investigate a quantitative method for using radial artery pulse waveforms to assess the effect of pulsatile flow during cardiopulmonary bypass (CPB). METHODS A total of 34 adults with heart disease who underwent open-heart surgery between April 2010 and January 2011 were randomized into a pulsatile perfusion group (n = 17) and a non-pulsatile perfusion group (n = 17). Radial arterial pulse waveforms of pulsatile and non-pulsatile perfusion patients were observed and compared before and during CDB. RESULTS No pulse waveform could be detected at patients' radial artery in both groups when the aorta was cross-clamped. Pulse waveforms could be detected at pulsatile perfusion patients' radial artery, but could not be detected at non-pulsatile perfusion patients' radial artery during CPB. Additionally, patients' pulse waveforms during pulsatile perfusion were lower than those before the operation. CONCLUSION Our findings indicate that radial artery sphygmogram can be used as a valid indicator to evaluate the effectiveness of pulsatile perfusion during CPB.
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Hoefeijzers MP, ter Horst LH, Koning N, Vonk AB, Boer C, Elbers PWG. The pulsatile perfusion debate in cardiac surgery: answers from the microcirculation? J Cardiothorac Vasc Anesth 2014; 29:761-7. [PMID: 25534761 DOI: 10.1053/j.jvca.2014.07.025] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2014] [Indexed: 11/11/2022]
Affiliation(s)
| | | | | | - Alexander B Vonk
- Cardiothoracic Surgery, Research Intensive Care VUmc (REVIVE), Institute for Cardiovascular Research (Icar-VU) VU University Medical Center, Amsterdam, The Netherlands
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The Effect of Pulsatile Cardiopulmonary Bypass on Lung Function in Elderly Patients. Int J Artif Organs 2014; 37:679-87. [DOI: 10.5301/ijao.5000352] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/13/2014] [Indexed: 01/04/2023]
Abstract
Purpose Cardiopulmonary bypass is still a major cause of lung injury and delay in pulmonary recovery after cardiac surgery. Although it has been shown that pulsatile flow induced by intra-aortic balloon pumping is beneficial for preserving lung function, it is not clear if the same beneficial effect can be accomplished with pulsatile flow generated in the extracorporeal circuit. Therefore, we investigated the effect of pulsatile flow, produced by a centrifugal pump, on lung function in elderly patients. Methods Serial measurements of lung biomarkers Clara cell 16 kD protein, surfactant protein D, and elastase were performed on blood samples from 37 elderly patients (≥75 years) who underwent elective aortic valve replacement surgery with CPB, either with pulsatile perfusion or continuous perfusion. Pulmonary function was assessed by postoperative ventilation time, the arterial blood oxygenation (PaO2/FiO2), the alveolar-arterial oxygen gradient (Aa-O2 gradient) and the pulmonary vascular resistance indexed by body surface area (PVRi). Results There was no difference in lung function between both groups, as assessed by the postoperative ventilation time, the PaO2/FiO2 ratio, and the Aa-O2 gradient. The PVRi, however, was significantly lower in the pulsatile perfusion group 15 mins after the administration of protamine (p<0.05). The plasma concentrations of the lung biomarkers increased during surgery and peaked at 1 h ICU, there were however no differences between groups. Conclusions Pulsatile flow does not seem beneficial to postoperative lung function in elderly patients. Moreover, pulsatile flow does not affect lung function on a subclinical level as assessed by lung biomarkers.
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Neidlin M, Jansen S, Moritz A, Steinseifer U, Kaufmann TAS. Design Modifications and Computational Fluid Dynamic Analysis of an Outflow Cannula for Cardiopulmonary Bypass. Ann Biomed Eng 2014; 42:2048-57. [DOI: 10.1007/s10439-014-1064-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2014] [Accepted: 06/30/2014] [Indexed: 11/30/2022]
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Lundemoen S, Kvalheim VL, Mongstad A, Andersen KS, Grong K, Husby P. Microvascular fluid exchange during pulsatile cardiopulmonary bypass perfusion with the combined use of a nonpulsatile pump and intra-aortic balloon pump. J Thorac Cardiovasc Surg 2013; 146:1275-82. [DOI: 10.1016/j.jtcvs.2013.06.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2012] [Revised: 04/29/2013] [Accepted: 06/14/2013] [Indexed: 11/29/2022]
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Extracorporeal membrane oxygenation versus counterpulsatile, pulsatile, and continuous left ventricular unloading for pediatric mechanical circulatory support. Pediatr Crit Care Med 2013; 14:e424-37. [PMID: 24108116 PMCID: PMC3913264 DOI: 10.1097/pcc.0b013e3182a551b0] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Despite progress with adult ventricular assist devices, limited options exist to support pediatric patients with life-threatening heart disease. Extracorporeal membrane oxygenation remains the clinical standard. To characterize (patho)physiologic responses to different modes of mechanical unloading of the failing pediatric heart, extracorporeal membrane oxygenation was compared to intra-aortic balloon pump, pulsatile-flow ventricular assist device, or continuous-flow ventricular assist device support in a pediatric heart failure model. DESIGN Experimental. SETTING Large animal laboratory operating room. SUBJECTS Yorkshire piglets (n = 47; 11.7 ± 2.6 kg). INTERVENTIONS In piglets with coronary ligation-induced cardiac dysfunction, mechanical circulatory support devices were implanted and studied during maximum support. MEASUREMENTS AND MAIN RESULTS Left ventricular, right ventricular, coronary, carotid, systemic arterial, and pulmonary arterial hemodynamics were measured with pressure and flow transducers. Myocardial oxygen consumption and total-body oxygen consumption were calculated from arterial, venous, and coronary sinus blood sampling. Blood flow was measured in 17 organs with microspheres. Paired Student t tests compared baseline and heart failure conditions. One-way repeated-measures analysis of variance compared heart failure, device support mode(s), and extracorporeal membrane oxygenation. Statistically significant (p < 0.05) findings included 1) an improved left ventricular blood supply/demand ratio during pulsatile-flow ventricular assist device, continuous-flow ventricular assist device, and extracorporeal membrane oxygenation but not intra-aortic balloon pump support, 2) an improved global myocardial blood supply/demand ratio during pulsatile-flow ventricular assist device and continuous-flow ventricular assist device but not intra-aortic balloon pump or extracorporeal membrane oxygenation support, and 3) diminished pulsatility during extracorporeal membrane oxygenation and continuous-flow ventricular assist device but not intra-aortic balloon pump and pulsatile-flow ventricular assist device support. A profile of systems-based responses was established for each type of support. CONCLUSIONS Each type of pediatric ventricular assist device provided hemodynamic support by unloading the heart with a different mechanism that created a unique profile of physiological changes. These data contribute novel, clinically relevant insight into pediatric mechanical circulatory support and establish an important resource for pediatric device development and patient selection.
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Durandy Y, Wang S, Ündar A. An Original Versatile Nonocclusive Pressure-Regulated Blood Roller Pump for Extracorporeal Perfusion. Artif Organs 2013; 38:469-73. [DOI: 10.1111/aor.12192] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Yves Durandy
- Intensive Care Department; Pediatric Cardiac Surgery CCML; Le Plessis-Robinson France
| | - Shigang Wang
- Penn State Hershey Pediatric Cardiovascular Research Center; Departments of Pediatrics, 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
| | - Akif Ündar
- Penn State Hershey Pediatric Cardiovascular Research Center; Departments of Pediatrics, 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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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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Change in myocardial oxygen consumption employing continuous-flow LVAD with cardiac beat synchronizing system, in acute ischemic heart failure models. J Artif Organs 2013; 16:119-28. [DOI: 10.1007/s10047-012-0682-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2012] [Accepted: 12/13/2012] [Indexed: 11/26/2022]
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Kaufmann TA, Schmitz-Rode T, Steinseifer U. Implementation of Cerebral Autoregulation Into Computational Fluid Dynamics Studies of Cardiopulmonary Bypass. Artif Organs 2012; 36:754-8. [DOI: 10.1111/j.1525-1594.2012.01519.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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Lomivorotov VV, Fominskiy EV, Efremov SM, Nepomniashchikh VA, Lomivorotov VN, Chernyavskiy AM, Shilova AN, Karaskov AM. Hypertonic solution decreases extravascular lung water in cardiac patients undergoing cardiopulmonary bypass surgery. J Cardiothorac Vasc Anesth 2012; 27:273-82. [PMID: 22841526 DOI: 10.1053/j.jvca.2012.06.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2012] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To test the hypothesis that the infusion of hypertonic solution would decrease extravascular lung water postoperatively and thus improve pulmonary function. DESIGN Prospective, randomized, blinded trial. SETTING Tertiary cardiothoracic referral center. PARTICIPANTS Twenty-six patients with coronary artery disease who underwent surgery with cardiopulmonary bypass (CPB). INTERVENTIONS Patients were allocated randomly to receive 4 mL/kg of 7.2% NaCl/hydroxyethyl starch, 200/0.5 (HSH group) or an equal volume of 0.9% NaCl (control group) for 30 minutes starting after anesthesia induction. The extravascular lung water index, hemodynamic and biochemical data, and the rate of complications were analyzed. MEASUREMENTS AND MAIN RESULTS The extravascular lung water index was significantly lower (7 v 9.5 mL/kg) in the HSH group at the first postoperative day (p < 0.01). The index of arterial oxygenation efficiency was significantly higher at 5 minutes and 2 and 4 hours after cardiopulmonary bypass (CPB) in the HSH group (p < 0.05). The alveolar-arterial oxygen tension difference was significantly lower at 5 minutes and 2 and 4 hours after CPB in the HSH group (p < 0.01). The cardiac index was significantly higher at 5 minutes after infusion in the HSH group (p < 0.05). CONCLUSIONS The infusion of HSH leads to significant decreases in the extravascular lung water index during and after cardiac surgery and is associated with better preservation of pulmonary function and transient increases in the cardiac index. Further trials are needed to clarify the clinical advantages of hypertonic solution administration in patients undergoing surgery with CPB.
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Affiliation(s)
- Vladimir V Lomivorotov
- Department of Anesthesiology and Intensive Care, Academician EN Meshalkin Novosibirsk State Budget Research Institute of Circulation Pathology, Novosibirsk, Russia
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Pulsatile versus nonpulsatile flow during cardiopulmonary bypass: microcirculatory and systemic effects. Ann Thorac Surg 2012; 94:2046-53. [PMID: 22835552 DOI: 10.1016/j.athoracsur.2012.05.065] [Citation(s) in RCA: 127] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2012] [Revised: 05/07/2012] [Accepted: 05/11/2012] [Indexed: 12/29/2022]
Abstract
BACKGROUND Controversy exists regarding the optimal perfusion modality during cardiopulmonary bypass (CPB). Here we compare the effects of pulsatile versus nonpulsatile perfusion on microvascular blood flow during and after CPB. METHODS High-risk cardiac surgical patients were randomly assigned to have pulsatile (n=10) or nonpulsatile (n=10) flow during CPB. The sublingual microcirculation was assessed using orthogonal polarization spectral imaging. Hemodynamic and microvascular variables were obtained after anesthesia (baseline), during CPB, and post-CPB. RESULTS Compared with baseline, a normal microcirculatory blood flow pattern was accomplished at all time points under pulsatile flow conditions. Peaking 24 hours postoperatively, a higher proportion of normally perfused microvessels occurred under pulsatile versus nonpulsatile flow (56.0%±3.9% vs 33.3%±4.1%; p<0.05). Concurrently, pulsatility resulted in a reduction in the prevalence of pathologic hyper-dynamically perfused vessels (6.0%±3.4% vs 19.6%±8.8%; p<0.05). Leukocyte adherence decreased relative to the nonpulsatile group both during and after CPB. Furthermore, peak lactate levels were reduced under pulsatile flow conditions postoperatively. CONCLUSIONS Pulsatile perfusion is superior to nonpulsatile perfusion at preserving the microcirculation, which may reflect attenuation of the systemic inflammatory response during CPB. We suggest the implementation of pulsatile flow can better optimize microvascular perfusion, and may lead to improved patient outcomes in high-risk cardiac surgical procedures requiring prolonged CPB time.
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In Vitro Performance Testing of a Pediatric Oxygenator With an Integrated Pulsatile Pump. ASAIO J 2012; 58:420-5. [DOI: 10.1097/mat.0b013e318251dc70] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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