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Banerjee D, Feng J, Sellke FW. Strategies to attenuate maladaptive inflammatory response associated with cardiopulmonary bypass. Front Surg 2024; 11:1224068. [PMID: 39022594 PMCID: PMC11251955 DOI: 10.3389/fsurg.2024.1224068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 06/07/2024] [Indexed: 07/20/2024] Open
Abstract
Cardiopulmonary bypass (CPB) initiates an intense inflammatory response due to various factors: conversion from pulsatile to laminar flow, cold cardioplegia, surgical trauma, endotoxemia, ischemia-reperfusion injury, oxidative stress, hypothermia, and contact activation of cells by the extracorporeal circuit. Redundant and overlapping inflammatory cascades amplify the initial response to produce a systemic inflammatory response, heightened by coincident activation of coagulation and fibrinolytic pathways. When unchecked, this inflammatory response can become maladaptive and lead to serious postoperative complications. Concerted research efforts have been made to identify technical refinements and pharmacologic interventions that appropriately attenuate the inflammatory response and ultimately translate to improved clinical outcomes. Surface modification of the extracorporeal circuit to increase biocompatibility, miniaturized circuits with sheer resistance, filtration techniques, and minimally invasive approaches have improved clinical outcomes in specific populations. Pharmacologic adjuncts, including aprotinin, steroids, monoclonal antibodies, and free radical scavengers, show real promise. A multimodal approach incorporating technical, circuit-specific, and pharmacologic strategies will likely yield maximal clinical benefit.
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Affiliation(s)
| | | | - Frank W. Sellke
- Division of Cardiothoracic Surgery, Department of Surgery, Brown University/Rhode Island Hospital, Providence, RI, United States
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Nteliopoulos G, Nikolakopoulou Z, Chow BHN, Corless R, Nguyen B, Dimarakis I. Lung injury following cardiopulmonary bypass: a clinical update. Expert Rev Cardiovasc Ther 2022; 20:871-880. [PMID: 36408601 DOI: 10.1080/14779072.2022.2149492] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Cardiopulmonary bypass (CPB) is an integral component of cardiac surgery; however, one of its most critical complications is acute lung injury induced by multiple factors including systemic inflammatory response. AREAS COVERED The objective of this review is to investigate the multiple factors that can lead to CPB-induced lung injury. These include contact of blood components with the artificial surface of the CPB circuit, local and systemic inflammatory response syndrome (SIRS), lung ischemia/re-perfusion injury, arrest of ventilation, and circulating endotoxins. We also focus on possible interventions to curtail the negative impact of CPB, such as off-pump surgery, impregnation of the circuit with less biologically active substances, leukocyte depletion filters and ultrafiltration, and pharmacological agents such as steroids and aprotinin. EXPERT OPINION Although many aspects of CPB are proposed to contribute to lung injury, its overall role is still not clear. Multiple interventions have been introduced to reduce the risk of pulmonary dysfunction, with many of these interventions having shown promising results, significantly attenuating inflammatory mediators and improving post-operative outcome. However, since lung injury is multifactorial and affected by inextricably linked components, multiple interventions tackling each of them is required.
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Affiliation(s)
| | - Zacharoula Nikolakopoulou
- Department of Department of Immunology and Inflammation, Centre for Haematology, Imperial College London, London, UK
| | - Bobby Hiu Nam Chow
- Division of Cardiovascular Sciences, University of Manchester, Manchester, UK
| | | | - Bao Nguyen
- Department of Cardiothoracic Surgery, Derriford Hospital, Plymouth, UK
| | - Ioannis Dimarakis
- Division of Cardiovascular Sciences, University of Manchester, Manchester, UK.,Department of Cardiothoracic Transplantation and Mechanical Circulatory Support, Wythenshawe Hospital, Manchester, UK
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Urbanowicz T, Michalak M, Olasińska-Wiśniewska A, Rodzki M, Witkowska A, Gąsecka A, Buczkowski P, Perek B, Jemielity M. Neutrophil Counts, Neutrophil-to-Lymphocyte Ratio, and Systemic Inflammatory Response Index (SIRI) Predict Mortality after Off-Pump Coronary Artery Bypass Surgery. Cells 2022; 11:cells11071124. [PMID: 35406687 PMCID: PMC8997598 DOI: 10.3390/cells11071124] [Citation(s) in RCA: 33] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Revised: 03/18/2022] [Accepted: 03/23/2022] [Indexed: 02/06/2023] Open
Abstract
Background: Several perioperative inflammatory markers are postulated to be significant factors for long-term survival after off-pump coronary artery bypass surgery (OPCAB). Hematological parameters, whether single or combined as indices, provide higher predictive values. Methods: The study group comprised 538 consecutive patients (125 (23%) females and 413 (77%) males) with a mean age of 65 ± 9 years, who underwent OPCAB with a mean follow-up time of 4.7 ± 1.7 years. This single-center retrospective analysis included perioperative inflammatory markers such as the neutrophil-to-lymphocyte ratio (NLR), systemic inflammatory response index (SIRI), aggregate index of systemic inflammation (AISI), and systemic inflammatory index (SII). Results: Multivariable analysis identified levels of neutrophils above 4.3 × 109/L (HR 13.44, 95% CI 1.05−3.68, p = 0.037), values of SIRI above 5.4 (HR 0.29, 95% CI 0.09−0.92, p = 0.036) and values of NLR above 3.5 (HR 2.21, 95% CI 1.48−3.32, p < 0.001) as being significant predictors of long-term mortality. The multifactorial models revealed the possibility of strong prediction by combining preoperative factors (COPD, stroke, PAD, and preoperative PLR) and postoperative neutrophil counts (p = 0.0136) or NLR (p = 0.0136) or SIRI (p = 0.0136). Conclusions: Among the postoperative inflammatory indices, the levels of neutrophils, NLR, and SIRI are the most prominent markers for long-term survival after off-pump coronary artery bypass surgery, when combined with preoperative characteristics.
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Affiliation(s)
- Tomasz Urbanowicz
- Cardiac Surgery and Transplantology Department, Poznan University of Medical Sciences, 61-848 Poznan, Poland; (A.O.-W.); (M.R.); (A.W.); (P.B.); (B.P.); (M.J.)
- Correspondence: ; Tel.: +48-61-854-9210
| | - Michał Michalak
- Department of Computer Science and Statistics, Poznan University of Medical Sciences, 61-806 Poznan, Poland;
| | - Anna Olasińska-Wiśniewska
- Cardiac Surgery and Transplantology Department, Poznan University of Medical Sciences, 61-848 Poznan, Poland; (A.O.-W.); (M.R.); (A.W.); (P.B.); (B.P.); (M.J.)
| | - Michał Rodzki
- Cardiac Surgery and Transplantology Department, Poznan University of Medical Sciences, 61-848 Poznan, Poland; (A.O.-W.); (M.R.); (A.W.); (P.B.); (B.P.); (M.J.)
| | - Anna Witkowska
- Cardiac Surgery and Transplantology Department, Poznan University of Medical Sciences, 61-848 Poznan, Poland; (A.O.-W.); (M.R.); (A.W.); (P.B.); (B.P.); (M.J.)
| | - Aleksandra Gąsecka
- 1st Chair and Department of Cardiology, Medical University of Warsaw, 02-091 Warsaw, Poland;
| | - Piotr Buczkowski
- Cardiac Surgery and Transplantology Department, Poznan University of Medical Sciences, 61-848 Poznan, Poland; (A.O.-W.); (M.R.); (A.W.); (P.B.); (B.P.); (M.J.)
| | - Bartłomiej Perek
- Cardiac Surgery and Transplantology Department, Poznan University of Medical Sciences, 61-848 Poznan, Poland; (A.O.-W.); (M.R.); (A.W.); (P.B.); (B.P.); (M.J.)
| | - Marek Jemielity
- Cardiac Surgery and Transplantology Department, Poznan University of Medical Sciences, 61-848 Poznan, Poland; (A.O.-W.); (M.R.); (A.W.); (P.B.); (B.P.); (M.J.)
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Tusman G, Acosta CM, Wallin M, Hallbäck M, Esperatti M, Peralta G, Gonzalez ME, Sipmann FS. PERIOPERATIVE CONTINUOUS NON-INVASIVE CARDIAC OUTPUT MONITORING IN CARDIAC SURGERY PATIENTS BY A NOVEL CAPNODYNAMIC METHOD. J Cardiothorac Vasc Anesth 2022; 36:2900-2907. [DOI: 10.1053/j.jvca.2022.02.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Revised: 01/20/2022] [Accepted: 02/02/2022] [Indexed: 11/11/2022]
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Lin X, Ma X, Cui X, Zhang R, Pan H, Gao W. Effects of Erythropoietin on Lung Injury Induced by Cardiopulmonary Bypass After Cardiac Surgery. Med Sci Monit 2020; 26:e920039. [PMID: 32310911 PMCID: PMC7191960 DOI: 10.12659/msm.920039] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Lung injury after cardiopulmonary bypass (CPB) is a serious postoperative complication and can affect the postoperative recovery. The purpose of this study was to explore whether erythropoietin (EPO) has an effect on lung injury caused by CPB. MATERIAL AND METHODS Sixty patients who received the CPB were randomly divided into a saline group and the EPO group. All the patients received saline or EPO preoperatively, respectively. The ventilation function, including dynamic compliance, peak airway pressure, and plateau pressure, were recorded. The level of tumor necrosis factor (TNF)-alpha, interleukin (IL)-1ß, and IL-10 in serum and arterial blood gas were analyzed. The mechanical ventilation time in the intensive care unit (ICU), the length of time spent in the ICU, the time from operation to discharge, and the total time of hospitalization were recorded. Adverse events in the ICU were monitored and recorded. RESULTS EPO significantly decreased the level of TNF-alpha and IL-1ß, but increased the level of IL-10 after CPB. EPO significantly improved pulmonary ventilated function and gas exchange function after CPB. EPO significantly shortened the mechanical ventilation time and stay in the ICU. CONCLUSIONS Preoperative EPO injection reduced lung injury and promoted lung function in patients who underwent CPB. The protection effect of EPO may be associated with inhibition of inflammatory response.
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Affiliation(s)
- Xue Lin
- Department of Anesthesiology, Second Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China (mainland)
| | - Xiaobei Ma
- Department of Anesthesiology, Second Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China (mainland)
| | - Xiaoguang Cui
- Department of Anesthesiology, Second Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China (mainland)
| | - Ruiqin Zhang
- Department of Anesthesiology, Second Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China (mainland)
| | - Hong Pan
- Department of Anesthesiology, Second Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China (mainland)
| | - Wei Gao
- Department of Anesthesiology, Second Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China (mainland)
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