Hemolysis during open heart surgery in patients with hereditary spherocytosis - systematic review of the literature and case study

BACKGROUND

Due to the distinctive nature of cardiac surgery, patients suffering from hereditary spherocytosis (HS) are potentially at a high risk of perioperative complications resulting from hemolysis. Despite being the most prevalent cause of hereditary chronic hemolysis, the standards of surgical management are based solely on expert opinion.

OBJECTIVE

We analyze the risk of hemolysis in HS patients after cardiac surgery based on a systematic review of the literature. We also describe a case of a patient with hereditary spherocytosis who underwent aortic valve repair.

METHODS

This systematic review was registered in the PROSPERO international prospective register of systematic reviews (CRD42023417666) and included records from Embase, MEDLINE, Web of Science, and Google Scholar databases. The case study investigates a 38-year-old patient who underwent surgery for an aortic valve defect in mid-2022.

RESULTS

Of the 787 search results, 21 studies describing 23 cases of HS undergoing cardiac surgery were included in the final analysis. Hemolysis was diagnosed in five patients (one coronary artery bypass graft surgery, two aortic valve bioprosthesis, one ventricular septal defect closure, and one mitral valve plasty). None of the patients died in the perioperative period. Also, no significant clinical hemolysis was observed in our patient during the perioperative period.

CONCLUSIONS

The literature data show that hemolysis is not common in patients with HS undergoing various cardiac surgery techniques. The typical management of a patient with mild/moderate HS does not appear to increase the risk of significant clinical hemolysis. Commonly accepted beliefs about factors inducing hemolysis during cardiac surgery may not be fully justified and require further investigation.

Biomechanical Assessment of Red Blood Cells in Pulsatile Blood Flows

As rheological properties are substantially influenced by red blood cells (RBCs) and plasma, the separation of their individual contributions in blood is essential. The estimation of multiple rheological factors is a critical issue for effective early detection of diseases. In this study, three rheological properties (i.e., viscoelasticity, RBC aggregation, and blood junction pressure) are measured by analyzing the blood velocity and image intensity in a microfluidic device. Using a single syringe pump, the blood flow rate sets to a pulsatile flow pattern (Q_b[t] = 1 + 0.5 sin(2πt/240) mL/h). Based on the discrete fluidic circuit model, the analytical formula of the time constant (λ_b) as viscoelasticity is derived and obtained at specific time intervals by analyzing the pulsatile blood velocity. To obtain RBC aggregation by reducing blood velocity substantially, an air compliance unit (ACU) is used to connect polyethylene tubing (i.d. = 250 µm, length = 150 mm) to the blood channel in parallel. The RBC aggregation index (AI) is obtained by analyzing the microscopic image intensity. The blood junction pressure (β) is obtained by integrating the blood velocity within the ACU. As a demonstration, the present method is then applied to detect either RBC-aggregated blood with different concentrations of dextran solution or hardened blood with thermally shocked RBCs. Thus, it can be concluded that the present method has the ability to consistently detect differences in diluent or RBCs in terms of three rheological properties.

In vitro and ex vivo measurement of the biophysical properties of blood using microfluidic platforms and animal models

Haemorheologically impaired microcirculation, such as blood clotting or abnormal blood flow, causes interrupted blood flows in vascular networks. The biophysical properties of blood, including blood viscosity, blood viscoelasticity, haematocrit, red blood bell (RBC) aggregation, erythrocyte sedimentation rate and RBC deformability, have been used to monitor haematological diseases. In this review, we summarise several techniques for measuring haemorheological properties, such as blood viscosity, RBC deformability and RBC aggregation, using in vitro microfluidic platforms. Several methodologies for the measurement of haemorheological properties with the assistance of an extracorporeal rat bypass loop are also presented. We briefly discuss several emerging technologies for continuous, long-term, multiple measurements of haemorheological properties under in vitro or ex vivo conditions.

Simultaneous measurement of blood pressure and RBC aggregation by monitoring on–off blood flows supplied from a disposable air-compressed pump

A simple method for simultaneously measuring RBC aggregation and blood pressure is demonstrated by analyzing blood flows supplied from a disposable air-compressed pump.

Microfluidic-Based Technique for Measuring RBC Aggregation and Blood Viscosity in a Continuous and Simultaneous Fashion

Hemorheological properties such as viscosity, deformability, and aggregation have been employed to monitor or screen patients with cardiovascular diseases. To effectively evaluate blood circulating within an in vitro closed circuit, it is important to quantify its hemorheological properties consistently and accurately. A simple method for measuring red blood cell (RBC) aggregation and blood viscosity is proposed for analyzing blood flow in a microfluidic device, especially in a continuous and simultaneous fashion. To measure RBC aggregation, blood flows through three channels: the left wide channel, the narrow channel and the right wide channel sequentially. After quantifying the image intensity of RBCs aggregated in the left channel () and the RBCs disaggregated in the right channel (), the RBC aggregation index (AIPM) is obtained by dividing by . Simultaneously, based on a modified parallel flow method, blood viscosity is obtained by detecting the interface between two fluids in the right wide channel. RBC aggregation and blood viscosity were first evaluated under constant and pulsatile blood flows. AIPM varies significantly with respect to blood flow rate (for both its amplitude and period) and the concentration of the dextran solution used. According to our quantitative comparison between the proposed aggregation index (AIPM) and the conventional aggregation index (AICM), it is found that AIPM provides consistent results. Finally, the suggested method is employed to obtain the RBC aggregation and blood viscosity of blood circulating within an in vitro fluidic circuit. The experimental results lead to the conclusion that the proposed method can be successfully used to measure RBC aggregation and blood viscosity, especially in a continuous and simultaneous fashion.

Periodic and simultaneous quantification of blood viscosity and red blood cell aggregation using a microfluidic platform under in-vitro closed-loop circulation

To evaluate variations of blood circulating in closed loops, hemorheological properties including blood viscosity and red blood cells (RBCs) are quantitatively measured with independent in-vitro instruments after collecting blood from a closed loop. But, most previous methods require periodic blood collections which induce several problems such as geometric differences between the fluidic channel and the in-vitro method, hemodilution, storage time, and unspecific blood flow rates. To resolve these issues, in this study, blood viscosity and RBC aggregation of blood circulating within a closed loop are measured with a microfluidic platform periodically and simultaneously. To demonstrate the proposed method, in-vitro closed-loop circulation is established by connecting several components (peristaltic pump, air compliance unit, fluid divider, and reservoir) in series. In addition, to measure blood viscosity and RBC aggregation, a microfluidic platform composed of a microfluidic device, pinch valve, and syringe pump is created. During each period, blood viscosity and RBC aggregation are measured by monitoring blood flow at constant blood flow, and image intensity at stationary blood flow. The proposed method is first employed to evaluate the effect of hematocrits and dextran concentrations on the RBC aggregation and blood viscosity by using a syringe pump (i.e., specific blood flow-rate). The method is then applied to detect the blood viscosity and RBC aggregation under in-vitro closed-loop circulation (i.e., unspecific blood flow-rate). From these experimental demonstrations, it is found that the suggested method can be effectively used to monitor the RBC aggregation and blood viscosity under in-vitro closed-loop circulation. Since this method does not require periodic collection from closed-loop circulation or an additional procedure for estimating blood flow-rate with a syringe pump, it will be effectively used to monitor variations of blood circulating in extracorporeal bypass loops.

Continuous and simultaneous measurement of the biophysical properties of blood in a microfluidic environment

A new measurement method is proposed to quantify blood viscosity, blood viscoelasticity, and RBC aggregation, in a continuous and simultaneous fashion.

Microfluidic-based measurement of erythrocyte sedimentation rate for biophysical assessment of blood in an in vivo malaria-infected mouse

This study suggests a new erythrocyte sedimentation rate (ESR) measurement method for the biophysical assessment of blood by using a microfluidic device. For an effective ESR measurement, a disposable syringe filled with blood is turned upside down and aligned at 180° with respect to gravitational direction. When the blood sample is delivered into the microfluidic device from the top position of the syringe, the hematocrit of blood flowing in the microfluidic channel decreases because the red blood cell-depleted region is increased from the top region of the syringe. The variation of hematocrit is evaluated by consecutively capturing images and conducting digital image processing technique for 10 min. The dynamic variation of ESR is quantitatively evaluated using two representative parameters, namely, time constant (λ) and ESR-area (AESR). To check the performance of the proposed method, blood samples with various ESR values are prepared by adding different concentrations of dextran solution. λ and AESR are quantitatively evaluated by using the proposed method and a conventional method, respectively. The proposed method can be used to measure ESR with superior reliability, compared with the conventional method. The proposed method can also be used to quantify ESR of blood collected from malaria-infected mouse under in vivo condition. To indirectly compare with the results obtained by the proposed method, the viscosity and velocity of the blood are measured using the microfluidic device. As a result, the biophysical properties, including ESR and viscosity of blood, are significantly influenced by the parasitemia level. These experimental demonstrations support the notion that the proposed method is capable of effectively monitoring the biophysical properties of blood.

A microfluidic device for simultaneous measurement of viscosity and flow rate of blood in a complex fluidic network

Blood viscosity has been considered as one of important biophysical parameters for effectively monitoring variations in physiological and pathological conditions of circulatory disorders. Standard previous methods make it difficult to evaluate variations of blood viscosity under cardiopulmonary bypass procedures or hemodialysis. In this study, we proposed a unique microfluidic device for simultaneously measuring viscosity and flow rate of whole blood circulating in a complex fluidic network including a rat, a reservoir, a pinch valve, and a peristaltic pump. To demonstrate the proposed method, a twin-shaped microfluidic device, which is composed of two half-circular chambers, two side channels with multiple indicating channels, and one bridge channel, was carefully designed. Based on the microfluidic device, three sequential flow controls were applied to identify viscosity and flow rate of blood, with label-free and sensorless detection. The half-circular chamber was employed to achieve mechanical membrane compliance for flow stabilization in the microfluidic device. To quantify the effect of flow stabilization on flow fluctuations, a formula of pulsation index (PI) was analytically derived using a discrete fluidic circuit model. Using the PI formula, the time constant contributed by the half-circular chamber is estimated to be 8 s. Furthermore, flow fluctuations resulting from the peristaltic pumps are completely removed, especially under periodic flow conditions within short periods (T < 10 s). For performance demonstrations, the proposed method was applied to evaluate blood viscosity with respect to varying flow rate conditions [(a) known blood flow rate via a syringe pump, (b) unknown blood flow rate via a peristaltic pump]. As a result, the flow rate and viscosity of blood can be simultaneously measured with satisfactory accuracy. In addition, the proposed method was successfully applied to identify the viscosity of rat blood, which circulates in a complex fluidic network. These observations confirm that the proposed method can be used for simultaneous measurement of viscosity and flow rate of whole blood circulating in the complex fluid network, with sensorless and label-free detection. Furthermore, the proposed method will be used in evaluating variations in the viscosity of human blood during cardiopulmonary bypass procedures or hemodialysis.

Does pulsatile perfusion improve outcome after cardiac surgery? A propensity-matched analysis of 1959 patients

OBJECTIVE

We analyzed the influence of pulsatile perfusion on recovery after coronary bypass grafting (CABG) or aortic valve replacement (AVR).

PATIENTS AND METHODS

Between January 2008 and December 2010, 1959 consecutive patients underwent CABG, AVR, or both. The choice for pulsatile perfusion (PP, n=220) or non-pulsatile perfusion (NPP, n=1739) was made by the surgeon. Patient propensity score to receive PP or NPP was calculated according to 15 preoperative variables. Resulting propensity scores, logistic EuroSCORE, perfusion type and surgeon were analyzed to evaluate their role for mortality, length of postoperative ICU and hospital stay (LOHS), transfusion requirements and renal function. Risk stratified non-parametric univariate analyses and propensity adjusted multivariate analyses were performed.

RESULTS

EuroSCORE and hospital mortality did not differ significantly between PP and NPP. EuroSCORE was the best predictive factor for all examined variables (p<0.001). PP was superior concerning LOHS (p=0.019) and this benefit increased with higher logistic EuroSCORE. The surgeon significantly influenced ventilation time, ICU stay and transfusion requirements.

CONCLUSION

Pulsatile perfusion did not influence perioperative outcome parameters, renal function and mortality, but resulted in shorter hospital stay, especially in critically ill patients.

Artificial organs 2010: a year in review

In this Editor's Review, articles published in 2010 are organized by category and briefly summarized. As the official journal of The International Federation for Artificial Organs, The International Faculty for Artificial Organs, and the International Society for Rotary Blood Pumps, Artificial Organs continues in the original mission of its founders "to foster communications in the field of artificial organs on an international level."Artificial Organs continues to publish developments and clinical applications of artificial organ technologies in this broad and expanding field of organ Replacement, Recovery, and Regeneration from all over the world. We take this time also to express our gratitude to our authors for offering their work to this journal. We offer our very special thanks to our reviewers who give so generously of time and expertise to review, critique, and especially provide such meaningful suggestions to the author's work whether eventually accepted or rejected and especially to those whose native tongue is not English. Without these excellent and dedicated reviewers the quality expected from such a journal could not be possible. We also express our special thanks to our Publisher, Wiley-Blackwell, for their expert attention and support in the production and marketing of Artificial Organs. In this Editor's Review, that historically has been widely received by our readership, we aim to provide a brief reflection of the currently available worldwide knowledge that is intended to advance and better human life while providing insight for continued application of technologies and methods of organ Replacement, Recovery, and Regeneration. We look forward to recording further advances in the coming years.

Effects of pulsatile and nonpulsatile perfusion on cerebral regional oxygen saturation and endothelin-1 in tetralogy of fallot infants

Although benefits of pulsatile flow during cardiopulmonary bypass (CPB) in pediatric heart surgery remain controversial and nonpulsatile CPB is still widely used in clinical cardiac surgery, pulsatile CPB must be reconsidered due to its physiologic features. In this study, we aimed to evaluate the effects of pulsatile perfusion (PP) and nonpulsatile perfusion (NP) on cerebral regional oxygen saturation (rSO₂) and endothelin-1 (ET-1) in pediatric tetralogy of Fallot (TOF) patients undergoing open heart surgery with CPB. Forty pediatric patients were randomly divided into the PP group (n = 20) and the NP group (n = 20). Pulsatile patients used a modified roller pump during the cross-clamp period in CPB, while NP patients used a roller pump with continuous flat flow perfusion. The subjects were monitored for rSO₂ from the beginning of the operation until 6 h after returning to the intensive care unit (ICU). We also monitored the hemodynamic status and ET-1 concentration and plasma free hemoglobin (PFH) in blood samples of all patients over time. Effective PP was monitored in PP patients, and pulse pressure was significantly higher in the PP group than in the NP group (P < 0.01). rSO₂ of the PP group was higher than that of the NP group (P < 0.01) during the cross-clamp period, and this advantage of PP would be maintained until 2 h after patients returned to the ICU (P < 0.05). ET-1 level in blood samples was lower at clamping off and CPB weaning and early ICU period in the PP group than in the NP group (P < 0.01), and ET-1 concentration remained at a normal level after patients were transferred to the ICU 24 h in all patients. PFH levels in the PP group at pre-clamp off and CPB weaned off were higher than those of the NP group (P < 0.05) in these cyanotic patients. PP can increase rSO₂ and improve microcirculation during cross-clamping period in TOF pediatric patients, while PP resulted in more severe hemolysis in these cyanotic patients than NP.