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Cahalan P, Hegy M, Cahalan L, Curry B, Ubl S, Jeffers H, Wolf MF. Development of a novel low-background noise blood loop model for testing blood-contacting biomaterials and medical devices in fresh human blood. J Biomed Mater Res B Appl Biomater 2023; 111:38-50. [PMID: 35833248 DOI: 10.1002/jbm.b.35130] [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: 03/09/2022] [Revised: 06/11/2022] [Accepted: 06/28/2022] [Indexed: 11/10/2022]
Abstract
A novel low volume blood loop model (Ension Triad System [ETS]) incorporating pulsatile flow and a proprietary low-activation blood-contacting surface (Ension bioactive surface [EBS]) enabling high signal-to-noise performance is described. The ETS system incorporates a test chamber that allows direct comparison of material samples or finished medical devices such as catheters with varying compositions and/or surface treatments. ETS performance is presented from two independent organizations (Medtronic and MLM Labs) and includes results for hemolysis (pfHgb), platelet count, platelet activation (βTG), coagulation (TAT), inflammation (PMN Elastase, PMN CD112b, and monocyte CD112b) and immune response (SC5b-9) were made on: (1) the EBS-treated system itself without a test material (No Material, NM); (2) the EBS-treated system with an idealized untreated catheter (UC); and (3) the EBS-treated system with the prototype catheter treated with the EBS surface treatment (CC). The untreated catheter (UC) was associated with significant elevation of all activation marker levels (pfHgb excluded). The EBS-treated catheter, in direct comparison to the UC and NM catheters, appeared invisible with respect to the activation markers (all markers statistically different than the UC and equivalent to the NM control). Based on these data, we conclude that using a relatively small surface area test sample and a small volume of fresh human blood, the high signal-to-noise performance of the ETS system demonstrates comprehensive and statistically significant material differences in the major ISO 10993-4 categories of blood interaction. These data underscore the important benefit of minimal confounding of test/device responses with non-test-material/model-related responses. ETS offers a practical alternative to the common one-test-category-at-a-time approach when assessing blood/medical device interactions.
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Affiliation(s)
| | - Michael Hegy
- Whitaker College of Engineering, Florida Gulf Coast University, Fort Myers, Florida, USA
| | | | - Ben Curry
- Medical Device Testing, MLM Medical Labs, Memphis, Tennessee, USA
| | - Samantha Ubl
- Medical Device Testing, MLM Medical Labs, Memphis, Tennessee, USA
| | - Hannah Jeffers
- Corporate Science and Technology, Medtronic, Minneapolis, Minnesota, USA
| | - Michael F Wolf
- Corporate Science and Technology, Medtronic, Minneapolis, Minnesota, USA
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Rajsic S, Breitkopf R, Jadzic D, Popovic Krneta M, Tauber H, Treml B. Anticoagulation Strategies during Extracorporeal Membrane Oxygenation: A Narrative Review. J Clin Med 2022; 11:jcm11175147. [PMID: 36079084 PMCID: PMC9457503 DOI: 10.3390/jcm11175147] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Revised: 08/24/2022] [Accepted: 08/29/2022] [Indexed: 11/30/2022] Open
Abstract
The development of extracorporeal life support technology has added a new dimension to the care of critically ill patients who fail conventional treatment options. Extracorporeal membrane oxygenation (ECMO)—specialized temporary life support for patients with severe cardiac or pulmonary failure—plays a role in bridging the time for organ recovery, transplant, or permanent assistance. The overall patient outcome is dependent on the underlying disease, comorbidities, patient reaction to critical illness, and potential adverse events during ECMO. Moreover, the contact of the blood with the large artificial surface of an extracorporeal system circuit triggers complex inflammatory and coagulation responses. These processes may further lead to endothelial injury and disrupted microcirculation with consequent end-organ dysfunction and the development of adverse events like thromboembolism. Therefore, systemic anticoagulation is considered crucial to alleviate the risk of thrombosis and failure of ECMO circuit components. The gold standard and most used anticoagulant during extracorporeal life support is unfractionated heparin, with all its benefits and disadvantages. However, therapeutic anticoagulation of a critically ill patient carries the risk of clinically relevant bleeding with the potential for permanent injury or death. Similarly, thrombotic events may occur. Therefore, different anticoagulation strategies are employed, while the monitoring and the balance of procoagulant and anticoagulatory factors is of immense importance. This narrative review summarizes the most recent considerations on anticoagulation during ECMO support, with a special focus on anticoagulation monitoring and future directions.
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Affiliation(s)
- Sasa Rajsic
- Department of Anaesthesiology and Intensive Care Medicine, Medical University Innsbruck, 6020 Innsbruck, Austria
| | - Robert Breitkopf
- Department of Anaesthesiology and Intensive Care Medicine, Medical University Innsbruck, 6020 Innsbruck, Austria
| | - Dragana Jadzic
- Anaesthesia and Intensive Care Department, Pain Therapy Service, Cagliari University, 09042 Cagliari, Italy
| | | | - Helmuth Tauber
- Department of Anaesthesiology and Intensive Care Medicine, Medical University Innsbruck, 6020 Innsbruck, Austria
| | - Benedikt Treml
- Department of Anaesthesiology and Intensive Care Medicine, Medical University Innsbruck, 6020 Innsbruck, Austria
- Correspondence: ; Tel.: +43-50504-82231
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Heparin coatings for improving blood compatibility of medical devices. Adv Drug Deliv Rev 2017; 112:12-23. [PMID: 28042080 DOI: 10.1016/j.addr.2016.12.002] [Citation(s) in RCA: 157] [Impact Index Per Article: 22.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2016] [Revised: 10/29/2016] [Accepted: 12/25/2016] [Indexed: 12/15/2022]
Abstract
Blood contact with biomaterials triggers activation of multiple reactive mechanisms that can impair the performance of implantable medical devices and potentially cause serious adverse clinical events. This includes thrombosis and thromboembolic complications due to activation of platelets and the coagulation cascade, activation of the complement system, and inflammation. Numerous surface coatings have been developed to improve blood compatibility of biomaterials. For more than thirty years, the anticoagulant drug heparin has been employed as a covalently immobilized surface coating on a variety of medical devices. This review describes the fundamental principles of non-eluting heparin coatings, mechanisms of action, and clinical applications with focus on those technologies which have been commercialized. Because of its extensive publication history, there is emphasis on the CARMEDA® BioActive Surface (CBAS® Heparin Surface), a widely used commercialized technology for the covalent bonding of heparin.
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Gunaydin S. Clinical significance of coated extracorporeal circuits: a review of novel technologies. Perfusion 2016; 19 Suppl 1:S33-41. [PMID: 15161062 DOI: 10.1191/0267659104pf718oa] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Coating of extracorporeal circuits may be a solution to prevent adverse effects induced by the contact of blood elements and proteins with foreign surfaces. This paper reviews the recent novel coating technologies and compares their documented in vitro and ex vivo advantages under the clinical setting. Data presented have also been supported by postclinical biomaterial research to verify biocompatibility and hemocompatibility.
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van den Goor JM, van Oeveren W, Rutten PM, Tijssen JG, Eijsman L. Adhesion of thrombotic components to the surface of a clinically used oxygenator is not affected by Trillium coating. Perfusion 2016; 21:165-72. [PMID: 16817289 DOI: 10.1191/0267659106pf859oa] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The Trillium® coating is designed to minimize adsorption of protein and the attachment of cells and other particles. The present study was undertaken to investigate the effect of surface coating on the adhesion of thrombotic components (activated platelets, white blood cells and fibrin) to the surface of a clinically used oxygenator. Twenty patients undergoing elective coronary artery bypass grafting (CABG) were randomized to one of the two oxygenator groups: non-coated (NC, n=10) or Trillium®-coated (TC, n=10). Platelet and white blood cell counts and factor XIIa concentrations were determined prior to the induction of anesthesia and at the end of cardiopulmonary bypass (CPB). Binding of activated platelets, white blood cells and fibrin to the artificial surfaces was quantified by means of antibody binding and histological validation was achieved by scanning electron microscopy. Patient demographic and CPB data were similar for the two groups. No significant differences between the groups were found for any of the tested thrombotic components. However, observations from our scanning electron microscopy suggested a release of formed particles from the Trillium®-coated surface. Primary adhesion of activated platelets, white blood cells and fibrin to the artificial surface of the venous blood inlet from an oxygenator is not affected by the Trillium® surface coating under conditions of full systemic heparinization.
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Affiliation(s)
- Jeanette M van den Goor
- Department of Cardio-Thoracic Surgery, Academic Medical Center of the University of Amsterdam, Amsterdam, The Netherlands.
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Tsakiridis K, Mpakas A, Kesisis G, Arikas S, Argyriou M, Siminelakis S, Zarogoulidis P, Katsikogiannis N, Kougioumtzi I, Tsiouda T, Sarika E, Katamoutou I, Zarogoulidis K. Lung inflammatory response syndrome after cardiac-operations and treatment of lornoxicam. J Thorac Dis 2014; 6 Suppl 1:S78-98. [PMID: 24672703 DOI: 10.3978/j.issn.2072-1439.2013.12.07] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2013] [Accepted: 12/04/2013] [Indexed: 12/19/2022]
Abstract
The majority of patients survive after extracorporeal circulation without any clinically apparent deleterious effects. However, disturbances exist in various degrees sometimes, which indicate the harmful effects of cardiopulmonary bypass (CPB) in the body. Several factors during extracorporeal circulation either mechanical dependent (exposure of blood to non-biological area) or mechanical independent (surgical wounds, ischemia and reperfusion, alteration in body temperature, release of endotoxins) have been shown to trigger the inflammatory reaction of the body. The complement activation, the release of cytokines, the leukocyte activation and accumulation as well as the production of several "mediators" such as oxygen free radicals, metabolites of arachidonic acid, platelet activating factors (PAF), nitric acid, and endothelin. The investigation continues today on the three metabolites of lornoxicam (the hydroxylated metabolite and two other metabolites of unknown chemical composition) to search for potential new pharmacological properties and activities.
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Affiliation(s)
- Kosmas Tsakiridis
- 1 Cardiothoracic Surgery Department, 2 Oncology Department, "Saint Luke" Private Hospital, Panorama, Thessaloniki, Greece ; 3 Cardiac Surgery Department, Evaggelismos General Hospital, Veikou 9-11, 11146 Athens, Greece ; 4 Department of Cardiac Surgery, University of Ioannina, School of Medicine, Greece ; 5 Pulmonary Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 6 Surgery Department (NHS), University General Hospital of Alexandroupolis, Alexandroupolis, Greece ; 7 Internal Medicine Department, "Theiageneio" Anticancer Hospital, Thessaloniki, Greece
| | - Andreas Mpakas
- 1 Cardiothoracic Surgery Department, 2 Oncology Department, "Saint Luke" Private Hospital, Panorama, Thessaloniki, Greece ; 3 Cardiac Surgery Department, Evaggelismos General Hospital, Veikou 9-11, 11146 Athens, Greece ; 4 Department of Cardiac Surgery, University of Ioannina, School of Medicine, Greece ; 5 Pulmonary Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 6 Surgery Department (NHS), University General Hospital of Alexandroupolis, Alexandroupolis, Greece ; 7 Internal Medicine Department, "Theiageneio" Anticancer Hospital, Thessaloniki, Greece
| | - George Kesisis
- 1 Cardiothoracic Surgery Department, 2 Oncology Department, "Saint Luke" Private Hospital, Panorama, Thessaloniki, Greece ; 3 Cardiac Surgery Department, Evaggelismos General Hospital, Veikou 9-11, 11146 Athens, Greece ; 4 Department of Cardiac Surgery, University of Ioannina, School of Medicine, Greece ; 5 Pulmonary Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 6 Surgery Department (NHS), University General Hospital of Alexandroupolis, Alexandroupolis, Greece ; 7 Internal Medicine Department, "Theiageneio" Anticancer Hospital, Thessaloniki, Greece
| | - Stamatis Arikas
- 1 Cardiothoracic Surgery Department, 2 Oncology Department, "Saint Luke" Private Hospital, Panorama, Thessaloniki, Greece ; 3 Cardiac Surgery Department, Evaggelismos General Hospital, Veikou 9-11, 11146 Athens, Greece ; 4 Department of Cardiac Surgery, University of Ioannina, School of Medicine, Greece ; 5 Pulmonary Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 6 Surgery Department (NHS), University General Hospital of Alexandroupolis, Alexandroupolis, Greece ; 7 Internal Medicine Department, "Theiageneio" Anticancer Hospital, Thessaloniki, Greece
| | - Michael Argyriou
- 1 Cardiothoracic Surgery Department, 2 Oncology Department, "Saint Luke" Private Hospital, Panorama, Thessaloniki, Greece ; 3 Cardiac Surgery Department, Evaggelismos General Hospital, Veikou 9-11, 11146 Athens, Greece ; 4 Department of Cardiac Surgery, University of Ioannina, School of Medicine, Greece ; 5 Pulmonary Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 6 Surgery Department (NHS), University General Hospital of Alexandroupolis, Alexandroupolis, Greece ; 7 Internal Medicine Department, "Theiageneio" Anticancer Hospital, Thessaloniki, Greece
| | - Stavros Siminelakis
- 1 Cardiothoracic Surgery Department, 2 Oncology Department, "Saint Luke" Private Hospital, Panorama, Thessaloniki, Greece ; 3 Cardiac Surgery Department, Evaggelismos General Hospital, Veikou 9-11, 11146 Athens, Greece ; 4 Department of Cardiac Surgery, University of Ioannina, School of Medicine, Greece ; 5 Pulmonary Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 6 Surgery Department (NHS), University General Hospital of Alexandroupolis, Alexandroupolis, Greece ; 7 Internal Medicine Department, "Theiageneio" Anticancer Hospital, Thessaloniki, Greece
| | - Paul Zarogoulidis
- 1 Cardiothoracic Surgery Department, 2 Oncology Department, "Saint Luke" Private Hospital, Panorama, Thessaloniki, Greece ; 3 Cardiac Surgery Department, Evaggelismos General Hospital, Veikou 9-11, 11146 Athens, Greece ; 4 Department of Cardiac Surgery, University of Ioannina, School of Medicine, Greece ; 5 Pulmonary Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 6 Surgery Department (NHS), University General Hospital of Alexandroupolis, Alexandroupolis, Greece ; 7 Internal Medicine Department, "Theiageneio" Anticancer Hospital, Thessaloniki, Greece
| | - Nikolaos Katsikogiannis
- 1 Cardiothoracic Surgery Department, 2 Oncology Department, "Saint Luke" Private Hospital, Panorama, Thessaloniki, Greece ; 3 Cardiac Surgery Department, Evaggelismos General Hospital, Veikou 9-11, 11146 Athens, Greece ; 4 Department of Cardiac Surgery, University of Ioannina, School of Medicine, Greece ; 5 Pulmonary Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 6 Surgery Department (NHS), University General Hospital of Alexandroupolis, Alexandroupolis, Greece ; 7 Internal Medicine Department, "Theiageneio" Anticancer Hospital, Thessaloniki, Greece
| | - Ioanna Kougioumtzi
- 1 Cardiothoracic Surgery Department, 2 Oncology Department, "Saint Luke" Private Hospital, Panorama, Thessaloniki, Greece ; 3 Cardiac Surgery Department, Evaggelismos General Hospital, Veikou 9-11, 11146 Athens, Greece ; 4 Department of Cardiac Surgery, University of Ioannina, School of Medicine, Greece ; 5 Pulmonary Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 6 Surgery Department (NHS), University General Hospital of Alexandroupolis, Alexandroupolis, Greece ; 7 Internal Medicine Department, "Theiageneio" Anticancer Hospital, Thessaloniki, Greece
| | - Theodora Tsiouda
- 1 Cardiothoracic Surgery Department, 2 Oncology Department, "Saint Luke" Private Hospital, Panorama, Thessaloniki, Greece ; 3 Cardiac Surgery Department, Evaggelismos General Hospital, Veikou 9-11, 11146 Athens, Greece ; 4 Department of Cardiac Surgery, University of Ioannina, School of Medicine, Greece ; 5 Pulmonary Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 6 Surgery Department (NHS), University General Hospital of Alexandroupolis, Alexandroupolis, Greece ; 7 Internal Medicine Department, "Theiageneio" Anticancer Hospital, Thessaloniki, Greece
| | - Eirini Sarika
- 1 Cardiothoracic Surgery Department, 2 Oncology Department, "Saint Luke" Private Hospital, Panorama, Thessaloniki, Greece ; 3 Cardiac Surgery Department, Evaggelismos General Hospital, Veikou 9-11, 11146 Athens, Greece ; 4 Department of Cardiac Surgery, University of Ioannina, School of Medicine, Greece ; 5 Pulmonary Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 6 Surgery Department (NHS), University General Hospital of Alexandroupolis, Alexandroupolis, Greece ; 7 Internal Medicine Department, "Theiageneio" Anticancer Hospital, Thessaloniki, Greece
| | - Ioanna Katamoutou
- 1 Cardiothoracic Surgery Department, 2 Oncology Department, "Saint Luke" Private Hospital, Panorama, Thessaloniki, Greece ; 3 Cardiac Surgery Department, Evaggelismos General Hospital, Veikou 9-11, 11146 Athens, Greece ; 4 Department of Cardiac Surgery, University of Ioannina, School of Medicine, Greece ; 5 Pulmonary Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 6 Surgery Department (NHS), University General Hospital of Alexandroupolis, Alexandroupolis, Greece ; 7 Internal Medicine Department, "Theiageneio" Anticancer Hospital, Thessaloniki, Greece
| | - Konstantinos Zarogoulidis
- 1 Cardiothoracic Surgery Department, 2 Oncology Department, "Saint Luke" Private Hospital, Panorama, Thessaloniki, Greece ; 3 Cardiac Surgery Department, Evaggelismos General Hospital, Veikou 9-11, 11146 Athens, Greece ; 4 Department of Cardiac Surgery, University of Ioannina, School of Medicine, Greece ; 5 Pulmonary Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 6 Surgery Department (NHS), University General Hospital of Alexandroupolis, Alexandroupolis, Greece ; 7 Internal Medicine Department, "Theiageneio" Anticancer Hospital, Thessaloniki, Greece
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Saczkowski R, Maklin M, Mesana T, Boodhwani M, Ruel M. Centrifugal Pump and Roller Pump in Adult Cardiac Surgery: A Meta-Analysis of Randomized Controlled Trials. Artif Organs 2012; 36:668-76. [DOI: 10.1111/j.1525-1594.2012.01497.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Prospective, Randomized Study Comparing Two Different Minimized versus Conventional Cardiopulmonary Bypass Systems. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2010; 5:270-7. [DOI: 10.1097/imi.0b013e3181ee6cb1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Objective Conventional cardiopulmonary bypass (CCPB) is a major trigger of inflammatory response. We aimed to assess the impact of two different minimized cardiopulmonary bypass systems (mini-CPB) with and without Bioline-coating compared with CCPB regarding organ function, inflammatory response, and early clinical outcome. Methods In a prospective, randomized study, 120 patients underwent elective coronary artery bypass grafting and were randomized into three groups: mini-CPB using a Bioline-coated (group A, n = 40) or an uncoated (group B, n = 40) circuit, or CCPB (group C, n = 40). Cytokines (interleukin-6, interleukin-8, and tumor necrosis factor-alpha), myocardial markers (creatine kinase [CK], CK-MB, and troponin-T), hematocrit, and platelet counts were measured up to 48 hours postoperatively. Early clinical outcome was assessed at 3 months postoperatively. Results Demographics, number of distal anastomoses, ventilation time, blood loss, intensive care unit, and hospital stay were comparable (P = not significant). Extracorporeal circulation and cross-clamp time were significantly longer in group A and B versus C (P < 0.005). No significant differences could be found in the release of interleukin-6, interleukin-8, and tumor necrosis factor-alpha among groups. Myocardial markers were significantly reduced in group A and B versus group C (P < 0.001). Hematocrit and platelet counts did not differ among the groups. No differences could be found in early clinical outcome up to 3 months. Conclusions This study showed significant better myocardial preservation with lower CK-MB and troponin-T levels in both mini-CPB groups. No significant differences could be found in terms of inflammation, hematologic effects, and early clinical outcome.
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Schoenebeck J, Haddad M, Wegscheider K, Joubert-Huebner E, Reichenspurner H, Detter C. Prospective, Randomized Study Comparing Two Different Minimized versus Conventional Cardiopulmonary Bypass Systems. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2010. [DOI: 10.1177/155698451000500405] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Jeannette Schoenebeck
- Department of Cardiovascular Surgery, University Heart Center Hamburg, Hamburg, Germany
| | - Munif Haddad
- Departments of Clinical Chemistry, Hamburg, Germany
| | - Karl Wegscheider
- Medical Biometry and Epidemiology, University of Hamburg, Hamburg, Germany
| | | | | | - Christian Detter
- Department of Cardiovascular Surgery, University Heart Center Hamburg, Hamburg, Germany
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Hussaini BE, Treanor PR, Healey NA, Tilahun D, Srey R, Lu XG, Khuri SF, Thatte HS. Evaluation of blood components exposed to coated arterial filters in extracorporeal circuits. Perfusion 2009; 24:317-23. [DOI: 10.1177/0267659109353818] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Biocompatible surfaces play an important role in the inflammatory response during cardiopulmonary bypass (CBP), with the arterial filter contributing a large surface area of the circuit. Different filter-coating materials designed to improve blood-filter biocompatibility are currently used in CPB circuits. This study evaluates eight biocompatible coatings used for arterial filters and their effects on blood components during circulation. Methods: Arterial filters were randomly assigned in eight independent heparin-bonded tubing loops and perfused by a single swine (n=8). Arterial blood was routed simultaneously, but separately, into each circuit and circulated for 30 minutes at 37°C. Blood samples were drawn for CBC, ACT, and TAT III measurements at baseline, post-heparinization and post-circulation. At study completion, filters were imaged using multiphoton microscopy. Results: RBC, platelet, and WBC counts, and TAT III complex were all decreased after 30 minutes of circulation; however, WBC count was the only parameter that showed statistically significant differences between the filters. Circulating WBC reduction ranged from 6% (Carmeda and Trillium) to 41% (Terumo-X-coating) with corresponding microscopic confirmation of increased WBC entrapment. Conclusion: All eight filter coatings altered the blood components to varying degrees. Selection of the most effective filter, in conjunction with a heparin-bonded circuit for CPB, may decrease the intraoperative foreign-surface activation of blood cells.
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Affiliation(s)
- Bader E. Hussaini
- Cardiothoracic Division, Department of Surgery, VA Boston Healthcare System, Massachusetts, USA, Brigham and Women's Hospital, Boston, Massachusetts, USA, Harvard Medical School, Boston, Massachusetts, USA
| | - Patrick R. Treanor
- Cardiothoracic Division, Department of Surgery, VA Boston Healthcare System, Massachusetts, USA
| | - Nancy A. Healey
- Cardiothoracic Division, Department of Surgery, VA Boston Healthcare System, Massachusetts, USA
| | - Daniel Tilahun
- Cardiothoracic Division, Department of Surgery, VA Boston Healthcare System, Massachusetts, USA
| | - Rithy Srey
- Cardiothoracic Division, Department of Surgery, VA Boston Healthcare System, Massachusetts, USA
| | - Xiu-Gui Lu
- Cardiothoracic Division, Department of Surgery, VA Boston Healthcare System, Massachusetts, USA, Brigham and Women's Hospital, Boston, Massachusetts, USA, Harvard Medical School, Boston, Massachusetts, USA
| | - Shukri F. Khuri
- Cardiothoracic Division, Department of Surgery, VA Boston Healthcare System, Massachusetts, USA, Brigham and Women's Hospital, Boston, Massachusetts, USA, Harvard Medical School, Boston, Massachusetts, USA
| | - Hemant S. Thatte
- Cardiothoracic Division, Department of Surgery, VA Boston Healthcare System, Massachusetts, USA, , Brigham and Women's Hospital, Boston, Massachusetts, USA, Harvard Medical School, Boston, Massachusetts, USA
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Schulze CJ, Han L, Ghorpade N, Etches WS, Stang L, Koshal A, Wang SH. Phosphorylcholine-Coated Circuits Improve Preservation of Platelet Count and Reduce Expression of Proinflammatory Cytokines in CABG: A Prospective Randomized Trial. J Card Surg 2009; 24:363-8. [DOI: 10.1111/j.1540-8191.2009.00895.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Murphy GS, Hessel EA, Groom RC. Optimal Perfusion During Cardiopulmonary Bypass: An Evidence-Based Approach. Anesth Analg 2009; 108:1394-417. [DOI: 10.1213/ane.0b013e3181875e2e] [Citation(s) in RCA: 233] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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13
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Shann KG, Likosky DS, Murkin JM, Baker RA, Baribeau YR, DeFoe GR, Dickinson TA, Gardner TJ, Grocott HP, O'Connor GT, Rosinski DJ, Sellke FW, Willcox TW. An evidence-based review of the practice of cardiopulmonary bypass in adults: A focus on neurologic injury, glycemic control, hemodilution, and the inflammatory response. J Thorac Cardiovasc Surg 2006; 132:283-90. [PMID: 16872951 DOI: 10.1016/j.jtcvs.2006.03.027] [Citation(s) in RCA: 136] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2005] [Revised: 01/10/2006] [Accepted: 03/13/2006] [Indexed: 01/04/2023]
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Rubens FD. Cardiopulmonary bypass technology transfer: musings of a cardiac surgeon. JOURNAL OF BIOMATERIALS SCIENCE. POLYMER EDITION 2003; 13:485-99. [PMID: 12160305 DOI: 10.1163/156856202320253974] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
The development of cardiopulmonary bypass (CPB) has been one of the greatest technical advancements in cardiovascular medicine. With heparin anticoagulation, this device can safely replace the circulatory and gas-exchanging functions of the heart and lung, facilitating complex cardiac operations. Limitations still exist however, related to blood reactions at the biomaterial surface, such as cell activation, inflammation and low-grade thrombosis. In this brief review, the thought processes which paralleled the development of CPB biocompatible surfaces such as heparin-coating, will be explored, as well as current theories on the suspected mechanisms by which heparin-coated surfaces act as an anti-inflammatory device during CPB. Results with new surfaces for CPB designed to capitalize on superior protein adsorption properties, such as surface modifying additive (SMA) and poly (2-methoxyethylacrylate) (PMEA), will also be described. Finally, the significance of biomaterial-independent blood activation will be discussed, emphasizing the current need to develop strategies utilizing optimal biomaterials, modified surgical technique and pharmacologic therapy to minimize the systemic complications of CPB.
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Affiliation(s)
- F D Rubens
- Ottawa Heart Institute, Ontario, Canada.
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Rubens FD, Mesana T. Surface Modified Cardiopulmonary Bypass Circuits: Modifying the Inflammatory Response. Semin Cardiothorac Vasc Anesth 2002. [DOI: 10.1177/108925320200600404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
As a consequence of an aging population demographic, now more than ever, researchers in cardiac surgery must focus on means to improve the methods and technologies related to cardiopulmonary bypass. This review presents a classification of the currently available options for biomaterial modification for cardiopulmonary bypass circuits. Hypotheses are given relating the mechanism of action by which some of these surfaces afford improved biocompatibility. Finally, nonpharmacologic biomaterial-independent strategies for minimizing the effects of cardiopulmonary bypass, such as the use of hemofiltration and leukocyte filtration, and the minimization of the use of cardiotomy suction blood are outlined.
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Affiliation(s)
- F. D. Rubens
- Division of Cardiac Surgery, University of Ottawa Heart Institute, Room H211, 40 Ruskin St., Ottawa, Ontario K1Y 4W7, Canada
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Baufreton C, de Brux JL, Binuani P, Corbeau JJ, Subayi JB, Daniel JC, Treanor P. A combined approach for improving cardiopulmonary bypass in coronary artery surgery: a pilot study. Perfusion 2002; 17:407-13. [PMID: 12470029 DOI: 10.1191/0267659102pf615oa] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND This is a pilot study carried out to assess the feasibility and the clinical impact of a combined approach of cardiopulmonary bypass (CPB) with reduced anti-coagulation. METHODS We used a retrospective, non-randomized analysis of 45 consecutive patients undergoing coronary artery bypass using standard CPB with full anticoagulation (activated clotting time, ACT, > 450 s) (Group 1; n = 23) or closed, heparin-coated CPB with low anticoagulation (ACT>250 s), precise heparin and protamine titration, controlled suction, and retrograde autologous prime (Group 2; n = 22). RESULTS Patients were similar except for a higher incidence of three-vessel disease in Group 2 (77.3% versus 47.8%; p < 0.03). Heparin was reduced by 41% in Group 2 and protamine by 56% (p < 0.0001). Total postoperative blood loss was similar between Groups 1 and 2 (429 +/- 149 versus 435+/-168 ml, respectively). However, the operative hematocrit decrease was lower in Group 2 (-1.6 +/- 7.5% versus -6.9 +/- 4.8%; p = 0.007), although hemodilution was similar, as reflected by the blood protein level. The need for postoperative inotropic support was less frequent in Group 2 (36.4% versus 65.2%; p = 0.05). Within the subgroup of patients weaned from CPB without requiring inotropic support (n = 35), the cardiac index dropped significantly in Group 1 (p = 0.003) 6 h after the start of CPB, whereas it remained stable in Group 2 (p = 0.92). Using multivariate analyses, Group 2 was found to be more protected than Group 1 against myocardial cellular injury (p = 0.046) and need for postoperative inotropic support (p = 0.014). CONCLUSION The pejorative postoperative outcome in coronary artery surgery was attenuated through a combined approach aimed at improving CPB.
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Affiliation(s)
- Christophe Baufreton
- Service de Chirurgie Cardio-Vasculaire et Thoracique, CHU d'Angers, Angers Cedex, France.
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Murphy JA, Savage CM, Alpard SK, Deyo DJ, Jayroe JB, Zwischenberger JB. Low-dose versus high-dose heparinization during arteriovenous carbon dioxide removal. Perfusion 2001; 16:460-8. [PMID: 11761085 DOI: 10.1177/026765910101600605] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The purpose of this study was to compare low-dose (LD) and high-dose (HD) systemic heparinization in a prospective randomized study of arteriovenous carbon dioxide removal (AVCO2R) during acute respiratory distress syndrome, using a commercially available heparin-coated oxygenator. Adult sheep (n = 13) received an LD50 smoke inhalation and 40% TBSA third degree cutaneous flame burn injury. At 40-48 h post-injury, animals underwent cannulation of the carotid artery and jugular vein and were then randomized to HD heparin (activated clotting time, ACT > 300s, n = 6) and LD heparin (ACT < 200s, n =7) and placed on AVCO2R for approximately 72 h using an oxygenator with the Trillium Bio-Passive Surface. Mean ACTs were significantly different, as expected (HD: 446 +/- 26s, LD: 213 +/- 12s, p < 0.05). AVCO2R shunt flow averaged approximately 13% of cardiac output with mean CO2 removal similar in HD and LD, p = NS. The hematocrit, platelet count, and fibrin degradation products for the two groups were not different. No differences in thrombosis or bleeding were noted. In conclusion, LD systemic heparin (ACT < 200s) with a heparin-coated oxygenator does not increase thrombogenicity during AVCO2R for smoke/burn-induced severe lung injury in sheep.
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Affiliation(s)
- J A Murphy
- Department of Surgery, The University of Texas Medical Branch, Galveston 77555-0528, USA
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Stammers AH. Biocompatibility of trillium biopassive surface–coated oxygenator during cardiopulmonary bypass. J Cardiothorac Vasc Anesth 2001. [DOI: 10.1053/jcan.2001.26521] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Larson DF, Arzouman D, Kleinert L, Patula V, Williams S. Comparison of Sarns 3M heparin bonded to Duraflo II and control circuits in a porcine model: macro- and microanalysis of thrombi accumulation in circuit arterial filters. Perfusion 2000; 15:13-20. [PMID: 10676863 DOI: 10.1177/026765910001500103] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Heparin-bonded perfusion circuits have been reported to reduce the thrombus formation during various levels of systemic heparinization. The goal of this study was to compare the efficacy of thrombo-resistance of the Sarns 3M heparin-bonded circuit to Baxter Duraflo II and untreated control in a porcine model. Fifteen Yorkshire pigs (60-65 kg) were anesthetized, heparinized with 3000 IU, intravenously (i.v.) and surgically cannulated with an internal jugular outflow and a femoral vein inflow. All circuits consisted of a 22-Fr venous cannula, centrifugal pump, arterial filter, an 18-Fr cannula for return and connected with equal lengths of 3/8" polyvinyl chloride tubing. The flows were maintained at 2.0 l/min for 4 h. Thrombus formation in filter samples were morphometrically analyzed through macro-densitometry, light microscopy, and scanning electron microscopy (SEM). Our findings revealed that the 3M circuit had significantly less gross thrombus (p < 0.001), 66% and 84% less microscopic thrombi and fivefold less SEM-measured aggregates (p = 0.03) compared to the Duraflo II and uncoated groups. This study demonstrated that the 3M heparin-bonded circuit had significantly reduced the formation of micro- and macro-thrombi in the minimally heparinized pig model compared to the Duraflo II and untreated control circuits.
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Affiliation(s)
- D F Larson
- Department of Surgery, University Heart Center, University of Arizona, Tucson, USA
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Wendel HP, Ziemer G. Coating-techniques to improve the hemocompatibility of artificial devices used for extracorporeal circulation. Eur J Cardiothorac Surg 1999; 16:342-50. [PMID: 10554855 DOI: 10.1016/s1010-7940(99)00210-9] [Citation(s) in RCA: 209] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
OBJECTIVE Extracorporeal circulation procedures have been shown to induce complement and leukocyte activation, release of endotoxin and inflammatory mediators, including cytokines, nitric oxide, oxygen free radicals, and platelet activating factors. The contact between the blood and the various artificial surfaces of the extracorporeal system results in an unspecific post-perfusion syndrome. For diminishing these negative side effects several coating-techniques have been developed to create devices with improved hemocompatibility. METHODS This review deals with the current knowledge of heparin-coated and otherwise surface-modified perfusion systems. The pathway how heparin-coated surfaces work is discussed and techniques for surface-coatings, both clinically introduced as well as newly developed are presented. RESULTS Numerous clinical studies compared heparin-coated versus non-coated circuits. Heparin-bonded devices showed lessened humoral and cellular activation, in particular a reduced complement activation with a reduced inflammatory post-perfusion syndrome. Also platelet protection and more favorable post-operative lung function are of particular note. Recent clinical trials demonstrated shortened hospital stays, less drainage bleeding, and reduced cerebral complications using heparin-coated oxygenation systems. The diminished expression of the leukocyte adhesion molecules CD 11b/c in CBAS devices points to a decreased activation of neutrophils. In addition, one research group found a reduced production of oxygen radicals. Heparin-bonding minimizes oxygenator failure by a significant reduced pressure gradient across the oxygenator, probably caused by decreased fibrin and platelet deposition at the hollow fiber surfaces. A meta analysis examined the impact of heparin-bonded systems on clinical outcomes and resulting costs. Using heparin-bonded circuits led to total cost savings from US $1000 to 3000. Several authors demonstrated reduced blood loss and better clinical outcome by reduction of systemic heparinization and the employment of heparin-coated devices. CONCLUSION Above and beyond the long-term applications, routine heart operations have also markedly begun to utilize heparin-coated devices. This trend will assuredly continue in the coming years and is an important step toward higher hemocompatibility of blood-contacting surfaces in the ECC device. Heparin-coatings are merely the beginning of improved hemocompatibility for all materials that come into contact with human blood or tissues. Intelligent materials with almost completely physiological surfaces will be at the surgeon's disposal within the next few years.
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Affiliation(s)
- H P Wendel
- Department of Surgery, Eberhard-Karls-University, Tuebingen, Germany.
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