Leukocyte depletion during cardiopulmonary bypass in routine adult cardiac surgery

Neuroprotective Strategies during Cardiac Surgery with Cardiopulmonary Bypass

Aortocoronary bypass or valve surgery usually require cardiac arrest using cardioplegic solutions. Although, in principle, in a number of cases beating heart surgery (so-called off-pump technique) is possible, aortic or valve surgery or correction of congenital heart diseases mostly require cardiopulmonary arrest. During this condition, the heart-lung machine also named cardiopulmonary bypass (CPB) has to take over the circulation. It is noteworthy that the invention of a machine bypassing the heart and lungs enabled complex cardiac operations, but possible negative effects of the CPB on other organs, especially the brain, cannot be neglected. Thus, neuroprotection during CPB is still a matter of great interest. In this review, we will describe the impact of CPB on the brain and focus on pharmacological and non-pharmacological strategies to protect the brain.

Leucoreduction of blood components: an effective way to increase blood safety?

Over the past 30 years, it has been demonstrated that removal of white blood cells from blood components is effective in preventing some adverse reactions such as febrile non-haemolytic transfusion reactions, immunisation against human leucocyte antigens and human platelet antigens, and transmission of cytomegalovirus. In this review we discuss indications for leucoreduction and classify them into three categories: evidence-based indications for which the clinical efficacy is proven, indications based on the analysis of observational clinical studies with very consistent results and indications for which the clinical efficacy is partial or unproven.

The effect of systemic arterial-line leukocyte filtration on the outcome of adult patients undergoing cardiac surgery

BACKGROUND

It is known that cardiopulmonary bypass causes an inflammatory reaction with associated morbidity and mortality. Several anti-inflammatory strategies have been implemented to reduce this response, including leukocyte removal from the circulation using specialized filters.

OBJECTIVES

The aim of this randomized clinical study was to assess the impact of arterial-line systemic leukocyte filtration on the postoperative outcome of adult patients undergoing elective cardiac surgery.

PATIENTS AND METHODS

114 patients undergoing CABG or valve replacement in Baqiyatallah hospital, Tehran, Iran from May to August 2011 were randomly assigned to two groups: with and without leukocyte filtration and their outcomes were compared.

RESULTS

The postoperative intubation time was significantly shorter in patients with leukocyte filters (0.014). There was no significant difference between two groups regarding other outcome relatedvariables.

CONCLUSIONS

Systemic arterial leukocyte filtration reduces the intubation time but has no other beneficial effect on the outcome of patients undergoing CABG or valve surgery.

Clinical evaluation of leukocyte filtration as an alternative anti-inflammatory strategy to aprotinin in high-risk patients undergoing coronary revascularization

PURPOSE

The use of aprotinin in cardiac surgery is associated with overriding safety concerns. Therefore, there is increased research on alternatives. This study investigated the relative benefits of strategic leukofiltration on polymer-coated extracorporeal circuits (ECC), aprotinin, and combined therapy in high-risk patients.

METHODS

Eight hundred and seventy-five patients (EuroSCORE 6+) undergoing coronary revascularization over a 4-year period were prospectively randomized to one of four perfusion protocols: Group 1: polymethoxyethylacrylate (PMEA)-coated circuits + leukocyte filters (n = 214); Group 2: uncoated ECC + full Hammersmith aprotinin (n = 212); Group 3: PMEA-coated ECC + leukofilters + full Hammersmith aprotinin (n = 199); and Group 4: control-no treatment (n = 250). Blood samples were collected at times T1: following the induction of anesthesia; T2: following heparin administration; T3: 15 min after cardiopulmonary bypass (CPB); T4: before cessation of CPB; T5: 15 min after protamine reversal; and T6: in the intensive care unit.

RESULTS

The serum interleukin-2 levels were significantly lower at T3, T4, and T5 in all study groups. C3a levels were significantly lower at T3. Creatine kinase MB and lactate levels demonstrated well-preserved myocardia in both leukofiltration groups (P < 0.05). Neutrophil CD11b/CD18 levels were significantly lower for all study groups. Postoperative bleeding and respiratory support time were lower in all study groups.

CONCLUSION

Leukofiltration on coated circuits significantly reduced bleeding and inflammatory response related to CPB with no adverse effects, and may be a possible alternative to pharmacological intervention.