Transition from VA-ECMO to Durable VAD Systems. Do We Need Cardiopulmonary Bypass Machine? On Behalf of ECMO-VAD Study Group

Background: The aim of the present study was to investigate the cardioprotective effects of the perioperative use of N(2)-L-alanyl-L-glutamine (GLN) in patients with ischemic heart disease (IHD) who undergo their operations under cardiopulmonary bypass (CPB).Methods: This double-blind, placebo-controlled, randomized study included 50 patients who underwent cardiac surgery with CPB. Exclusion criteria were a left ventricular ejection fraction <50%, diabetes mellitus, <3 months since the onset of myocardial infarction, and emergency surgery. Patients in the study group (n = 25) received 0.4 g/kg GLN (Dipeptiven, 20% solution) per day. Patients in the control group (n = 25) were administered a placebo (0.9% NaCl). The primary end point was the dynamics of troponin I at the following stages: (1) prior to anesthesia, (2) 30 minutes after CPB, (3) 6 hours after CPB, (4) 24 hours after surgery, and (5) 48 hours after surgery. Secondary end points included measurements of hemodynamics with a Swan-Ganz catheter.Results: On the first postoperative day after the surgery, the median troponin I level was significantly lower in the study group than in the placebo group: 1.280 ng/mL (interquartile range [IQR], 0.840-2.230 ng/mL) versus 2.410 ng/mL (IQR, 1.060-6.600 ng/mL) (P = .035). At 4 hours after cardiopulmonary bypass (CPB), the median cardiac index was higher in the patients in the study group: 2.58 L/min per m2 (IQR, 2.34-2.91 L/min per m2) versus 2.03 L/min per m2 (IQR, 1.76-2.32 L/min per m2) (P = .002). The median stroke index also was higher in the patients who received GLN: 32.8 mL/m2 (IQR, 27.8-36.0 mL/m2) versus 26.1 mL/m2 (IQR, 22.6-31.8 mL/m2) (P = .023). The median systemic vascular resistance index was significantly lower in the study group than in the placebo group: 1942 dyn�s/cm5 per m2 (IQR, 1828-2209 dyn�s/cm5 per m2) versus 2456 dyn�s/cm5 per m2 (IQR, 2400-3265 dyn�s/cm5 per m2) (P = .001).Conclusion: Perioperative administration of GLN during the first 24 hours has cardioprotective effects in IHD patients following CPB. This technique enhances the troponin concentration at 24 hours after surgery and is associated with improved myocardial function.

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EVALUATION OF THE EFFECTIVENESS OF A CLOSED CIRCUIT IN COMPARISON WITH AN OPEN CIRCUIT OF CARDIOPULMONARY BYPASS

BULLETIN OF SURGERY IN KAZAKHSTAN ◽

10.35805/bsk2021iii044 ◽

2021 ◽

pp. 44-47

Author(s):

Berik Tuishiev ◽

Gulzhan Bayzhan ◽

Sabina Samitova

Keyword(s):

Cardiopulmonary Bypass ◽

Aortic Valve ◽

Postoperative Period ◽

Open Circuit ◽

Closed Circuit ◽

Control Group ◽

Study Group ◽

Valve Insufficiency ◽

Group 5 ◽

Group 2

Objective is to evaluate the effectiveness of closed-loop surgeries with the planned duration of cardiopulmonary bypass more than 2 hours in the immediate postoperative period. Materials and methods. A study was carried out in the clinic over 10 patients (average age 47-56 years) with Diagnoses: Ascending aortic aneurysm, FC 3 aortic valve insufficiency, who underwent surgery for ascending aorta replacement, aortic valve replacement with coronary artery reimplantation. The patients were divided into 2 groups, the 1st group (5 patients) is the control group using an open cardiopulmonary bypass circuit, the 2nd group (5 patients) is the patients using a closed cardiopulmonary bypass circuit. The total time of cardiopulmonary bypass in both groups was 125-187 minutes. Results. In the 2nd study group, drainage blood loss significantly decreased, on average 60-100 ml compared to the control group, where the average drainage loss was 600-1500 ml. The need for blood transfusion was 5.1% in the 2nd group, compared with 43.4% in the control group. In the study group 2, the number of platelets in the postoperative period in patients was higher than in the control group. Conclusion. This study shows that a closed circuit, compared to an open one, allows complex heart surgeries with a planned duration of extracorporeal circulation of more than 2-3 hours.

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Propofol requirement titrated to bispectral index: a comparison between hypothermic and normothermic cardiopulmonary bypass

Perfusion ◽

10.1177/0267659109106071 ◽

2009 ◽

Vol 24 (1) ◽

pp. 27-32 ◽

Cited By ~ 6

Author(s):

PJ Mathew ◽

GD Puri ◽

RS Dhaliwal

Keyword(s):

Cardiac Surgery ◽

Cardiopulmonary Bypass ◽

Bispectral Index ◽

Adult Patients ◽

Study Group ◽

Factors Affecting ◽

Inter Quartile Range ◽

Elective Cardiac Surgery ◽

Quartile Range ◽

Hypothermic Group

Though propofol requirement is expected to decrease during cardiopulmonary bypass (CPB), a few studies have failed to demonstrate this. The factors affecting pharmacokinetics of propofol and, therefore, the requirement, are different during hypothermic and normothermic CPB. We evaluated and compared the requirement of propofol during hypothermic and normothermic CPB. Fifty adult patients scheduled for elective cardiac surgery on CPB were recruited and randomly allocated into hypothermic CPB (28–300 C) (Group H) and normothermic CPB (35–370 C) (Group N) groups. Patients were induced and maintained with propofol titrated to maintain a target bispectral index (BIS) of 50 ± 10. Propofol requirement (mean ± SD) was similar in normothermic and hypothermic groups, both before CPB (4.9 ± 1.5 mg.kg−1hr−1 in Group N, 4.6 ± 1.5 mg.kg−1hr−1 in Group H) and after cessation of bypass (p > 0.05) (4.6 ± 1.8 mg.kg−1hr−1 in Group N and 4.3 ± 1.7 mg.kg−1hr−1 in Group H). CPB significantly reduced (p < 0.001) propofol requirements in both arms of the study (Group N: 2.9 ± 1.4 mg.kg−1hr−1and Group H: 1.3 ± 0.7 mg.kg−1hr−1). This reduction was more pronounced in the hypothermic group (p < 0.001). The BIS (median ± inter quartile range) remained constant during normothermic CPB (50 ± 8.8), but declined significantly during hypothermic CPB (41 ± 5.6) despite decreased usage of propofol during hypothermia. No patient had recall of intra-operative events. CPB decreases the magnitude of propofol requirements and the effect of hypothermic CPB is significantly more than that of normothermic CPB.

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Strategic leukocyte depletion reduces pulmonary microvascular pressure and improves pulmonary status post-cardiopulmonary bypass

Perfusion ◽

10.1191/0267659103pf625oa ◽

2003 ◽

Vol 18 (1_suppl) ◽

pp. 23-31 ◽

Cited By ~ 23

Author(s):

A H Olivencia-Yurvati ◽

C A Ferrara ◽

N Tierney ◽

N Wallace ◽

R T Mallet

Keyword(s):

Cardiopulmonary Bypass ◽

Pulmonary Function ◽

Control Group ◽

Study Group ◽

Pulmonary Dysfunction ◽

Shunt Fraction ◽

Pulmonary Shunt ◽

Leukocyte Depletion ◽

Pulmonary Capillary ◽

Leukocyte Filtration

Cardiopulmonary bypass (CPB) precipitates inflammation that causes marked pulmonary dysfunction. Leukocyte filtration has been proposed to reduce these deleterious effects. Other studies show an improvement with aprotinin. We proposed that a combination of these two therapies would synergistically improve pulmonary outcomes. Two hundred and twenty-five patients participated in a randomized prospective study comparing pulmonary microvascular function and pulmonary shunt fraction postcoronary artery bypass grafting (CABG). The study group underwent leukocyte depletion with aprotinin during the procedure. Pulmonary microvascular function was assessed by pulmonary microvascular pressure (PMVP), a measure of pulmonary capillary edema, and pulmonary function was evaluated by comparing pulmonary shunt fractions. Elevated PMVP and increased pulmonary shunting compromise pulmonary performance. The leukocyte-depleted group had significantly reduced PMVP and pulmonary shunt fraction for at least the first 24 hours postbypass. The combination of strategic leukocyte filtration and aprotinin therapy can effectively reduce postoperative decline in pulmonary function. Cardiopulmonary bypass precipitates a variety of inflammatory effects that can cause marked pulmonary dysfunction to the point of respiratory failure, necessitating prolonged mechanical ventilation. Leukocyte filtration has been investigated previously and appears to be beneficial in improving pulmonary outcome by preventing direct neutrophil-induced inflammatory injury. Recent studies of leukocyte reduction profiles suggest that leukoreduction via leukofiltration is short lived with filter saturation occurring 30 - 45 minutes after onset of filtration. This phenomenon may explain the limited utility observed with higher risk patients. These patients typically require longer pump runs, so leukocyte reduction capability is suboptimal at the time of pulmonary vascular reperfusion. To more effectively protect the lung from reperfusion injury, leukocyte filtration can be delayed so that reduction of activated neutrophils is maximal at the time of pulmonary vascular reperfusion. It is, thus, conceivable that a timely use of arterial line leukoreducing filters may improve, more substantially, pulmonary function postbypass. Two hundred and twenty-five isolated coronary revascularization patients participated in this prospective, randomized trial. The patients received moderately hypothermic CBP alone (control group: n = 110) or combined with leukocyte depletion, initiated 30 minutes before crossclamp release, with filters placed in the bypass circuit (study group: n = 115). All patients also received full Hammersmith aprotinin dosing during the operation. Pulmonary microvascular pressures were lower in the study group at three hours postbypass, and continued to fall until 24 hours postbypass. In contrast, the control group measured a rise in PMVP and a continued plateau throughout 24 hours postbypass (p B /0.028). The calculated pulmonary shunt fraction also was reduced significantly throughout the study interval, with the greatest reduction occurring approximately three to six hours post-CPB (p B /0.002). Shunt fractions eventually converged at 24 hours postbypass. Outcome measures included hospital charges and length of stay, which were also markedly reduced in the treatment group. Increasing PMVPs are a direct reflection of pulmonary capillary edema, which, in conjunction with increased pulmonary shunt ratio, lead to an overall worsening of pulmonary function. Intraoperative strategic leukocyte filtration combined with aprotinin treatment improves post-CPB lung performance by reducing significantly the reperfusion inflammatory response and its sequelae. These benefits are manifested by reductions in ventilator times, hospital stay and patient morbidity.

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Haemolysis during cardiopulmonary bypass: how to reduce the free haemoglobin by managing the suctioned blood separately

Perfusion ◽

10.1177/026765910101600612 ◽

2001 ◽

Vol 16 (6) ◽

pp. 519-524 ◽

Cited By ~ 21

Author(s):

A Pierangeli ◽

V Masieri ◽

F Bruzzi ◽

E De Toni ◽

G Grillone ◽

...

Keyword(s):

Cardiopulmonary Bypass ◽

Artery Bypass ◽

Bypass Graft ◽

Control Group ◽

Study Group ◽

Artery Bypass Graft ◽

Operative Field ◽

Free Plasma Haemoglobin ◽

Free Plasma

During cardiopulmonary bypass (CPB) the collection of the patient’s blood from the operating area is of fundamental importance. This blood is collected in the cardiotomy reservoir using field suckers and can be managed in different ways. It can be filtered in the cardiotomy reservoir and redirected to the venous reservoir, then oxygenated and returned to the patient, or it can be managed separately: collected in the cardiotomy reservoir, treated at the end of the operation and only after this, returned to the patient. The aim of this study is to determine in vivo the effect of a separate management of the suction blood from the operative field, using the Avant D903 oxygenator (Dideco, Mirandola, Italy). Twenty-one patients undergoing coronary artery bypass graft surgery with CPB were selected and put into two groups at random. In the control group ( n 10) the suction blood in the cardiotomy reservoir was filtered and immediately redirected into the venous reservoir, oxygenated and returned to the patient. In the study group ( n 11) the suctioned blood was collected in the D903 Avant’s (Dideco) cardiotomy reservoir and returned to the patient only after having been washed at the end of the operation, using a Compact Advanced (Dideco), as required. Clinical data demonstrated that while in the study group it was possible to keep the free plasma haemoglobin (FPH) concentrations the same as at the beginning, in the control group there was a significant increase in FPH from 5.0 3.5 mg/dl (baseline) to 37 16.7 mg/dl (120 min after CPB).

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Effect of Subzero-Balanced Ultrafiltration on Lung Gas Exchange Capacity after Cardiopulmonary Bypass in Adult Patients with Heart Valve Disease

The Heart Surgery Forum ◽

10.1532/hsf98.20101075 ◽

2011 ◽

Vol 14 (1) ◽

pp. 22 ◽

Cited By ~ 1

Author(s):

Tao Zhang ◽

Sheng-li Jiang ◽

Chang-qing Gao ◽

Jin Luo ◽

Lan Ma ◽

...

Keyword(s):

Cardiac Surgery ◽

Cardiopulmonary Bypass ◽

Gas Exchange ◽

Heart Valve ◽

Exchange Capacity ◽

Adult Patients ◽

Heart Valve Disease ◽

Arterial Oxygen ◽

Control Group ◽

Study Group

Objectives: This study was conducted to evaluate the effect of a new ultrafiltration techniquethe subzerobalanced ultrafiltration (SBUF)on lung gas exchange capacity after cardiopulmonary bypass (CPB) in adult patients with heart valve disease.Background: Attenuation of lung gas exchange capacity is one of the most common manifestations of an inflammatory response after CPB.Methods: Ninety-four patients who required CPB for cardiac surgery were randomized into 2 groups according to whether they received SBUF. Gas exchange capacity expressed as the oxygen index (OI), the respiratory index (RI), and the alveolar-arterial oxygen pressure difference (P(A-a)O2) were measured after intubation (T1), at the termination of CPB (T2), on admission to the intensive care unit (ICU) (T3), at postoperative hour 6 (T4), and at postoperative hour 12 (T5).Results: There were no significant differences in gas exchange capacity between the 2 groups at T1, T4, and T5. CPB produced significant changes in OI, RI, and P(A-a)O2 in the control group, whereas these changes were not significantly different in the study group. The OI in the study group was significantly higher at T2, and RI and P(A-a)O2 were significantly lower at T2 and T3. In the study group, the intubation time was shorter, and the transfusion volume within 24 hours postoperatively was less. The 2 groups were comparable with respect to the incidence of respiratory complications, length of stay in the ICU, duration of hospital stay, need for infusions of inotropic agents, and drainage volumes within 24 hours postoperatively.Conclusions: SBUF during CPB can produce an immediate improvement in lung gas exchange capacity, which may effectively minimize pulmonary dysfunction in adult patients undergoing cardiac surgery.

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Impact of Venoarterial Extracorporeal Membrane Oxygenation on Alkaline Phosphatase Metabolism after Cardiac Surgery

Biomolecules ◽

10.3390/biom11050748 ◽

2021 ◽

Vol 11 (5) ◽

pp. 748

Author(s):

Thomas Poschner ◽

Anne-Kristin Schaefer ◽

Doris Hutschala ◽

Georg Goliasch ◽

Julia Riebandt ◽

...

Keyword(s):

Alkaline Phosphatase ◽

Cardiac Surgery ◽

Cardiopulmonary Bypass ◽

Negative Impact ◽

Ecmo Support ◽

Blood Samples ◽

Postoperative Course ◽

Venoarterial Extracorporeal Membrane Oxygenation ◽

Vienna General Hospital ◽

Va Ecmo

(1) Alkaline phosphatase (AP) is consumed during cardiopulmonary bypass (CPB). A high AP depletion leads to an impaired outcome after cardiac surgery. However, data is scarce on the postoperative course of AP under venoarterial ECMO (VA-ECMO) support. (2) A total of 239 patients with VA-ECMO support between 2000 and 2019 at the Department of Cardiac Surgery (Vienna General Hospital, Austria) were included in this retrospective analysis. Blood samples were collected at several timepoints (baseline, postoperative day (POD) 1–7, POD 14 and 30). Patients were categorized according to the relative AP drop (<60% vs. ≥60%) and ECMO duration (<5 days vs. ≥5 days). (3) Overall, 44.4% reached the baseline AP values within 5 days—this was only the case for 28.6% with a higher AP drop (compared to 62.7% with a lower drop; p = 0.000). A greater AP drop was associated with a significantly higher need for renal replacement therapy (40.9% vs. 61.9%; p = 0.002) and an impaired 1-year survival (51.4% vs. 66.0%; p = 0.031). (4) CPB exceeds the negative impact of VA-ECMO; still, ECMO seems to delay alkaline phosphatase recovery. A greater initial AP drop bears the risk of higher morbidity and mortality.

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Incidence of Thrombocytopenia and Heparin Induced Thrombocytopenia in Patients Receiving Extracorporeal Membrane Oxygenation (ECMO) Compared to Cardiopulmonary Bypass and the Limited Sensitivity of Pre-Test Probability Score

Blood ◽

10.1182/blood-2018-99-119143 ◽

2018 ◽

Vol 132 (Supplement 1) ◽

pp. 2451-2451

Author(s):

Deepa Jayakody Arachchillage ◽

Sanjay Khanna ◽

Christophe Vandenbriele ◽

Jonthan Dutton ◽

Alex Rosenberg ◽

...

Keyword(s):

Platelet Count ◽

Cardiopulmonary Bypass ◽

Extracorporeal Membrane Oxygenation ◽

Screening Test ◽

Screening Tests ◽

Heparin Induced Thrombocytopenia ◽

Educational Meeting ◽

Va Ecmo ◽

Test Probability ◽

Vv Ecmo

Abstract Introduction Extracorporeal membrane oxygenation (ECMO) is a life saving measure for severe respiratory (veno-venous ECMO [VV-ECMO]) or cardiac (veno-arterial ECMO [VA-ECMO]) failure. Heparin induced thrombocytopenia (HIT) is a special concern in these patients because ECMO uses a modified cardiopulmonary bypass (CPB) resulting in continuous exposure to artificial surfaces and unfractionated heparin (UFH) over several days to weeks, compared to CPB in which these exposures are for only a few hours. In addition, most of the patients undergoing CPB do not have underlying systemic inflammation and have a normal platelet count at the time of first exposure to UFH. It is possible that patients receiving ECMO are at higher risk of developing HIT compared to patients having CPB. The prevalence of HIT in adult patients receiving VV-ECMO is unknown. We determined to ascertain the incidence of thrombocytopenia and the reliability of pre-test probability score (PTPS) in predicting HIT, in patients receiving VV-ECMO or VA-ECMO compared to CPB. Differences in the PTPS of patients on ECMO compared to patients who received CPB and the effect of HIT on 30-day mortality in ECMO patients compared to patients who did not have HIT were also assessed. Methods This was a single centre retrospective study of patients undergoing CPB (median 4.6 [2-16.5] hrs. or receiving ECMO for ≥ 48hrs (median 7.1 [3-42] days. HIT screening was performed in all patients who showed a typical pattern of platelet drop in first 5 to 12 days after exposure to UFH with or without thrombosis. A citrated blood sample and a completed PTPS (4Ts) were collected from all patients prior to a screening test for HIT antibody performed on an ACL TOP500 analyser using Hemosil HIT-Ab (PF4-H) kit (Werfen UK). Those with positive HIT screening had confirmatory testing by ELISA (HYPHEN BioMed, France). Clinical data were collected from electronic records. From January 2016 to April 2018, 296 ECMO patients (142 VA-ECMO, 156 VV-ECMO) and 2998 CPB patients were studied. Results CPB patients were older than the patients who received ECMO; mean age (standard deviation) for EMCO and CPB were 45.4 (±15.6) and 64.9 (±13), p< 0.00001. A significantly higher proportion of men had CPB (71.3%) and ECMO (58.5%) than women, P<0.0001. Thrombocytopenia was divided into mild (platelet count 100-150x109/L), moderate (50-99x109/L) and severe (<50x109/L)). Table 1 demonstrates the percentages of patients in ECMO and CPB with different degrees of thrombocytopenia on day 1, 2, 5 and 10. The incidences of severe thrombocytopenia and moderate thrombocytopenia were 4.4% and 40% already on the first day of ECMO which were significantly higher than in patients having CPB (p<0.0001) and this difference remained significant in day 2, 5 and 10. The proportion of CPB patients with moderate thrombocytopenia rose to 32.4% on day 2 from 14.5% on day 1 but by day 10 platelet count was normal in 83% compared to 42.3 % patients receiving ECMO. A total of 96 patients had HIT screening tests (64/296 ECMO and 32/2988 CPB). Twenty patients (20/296, 6.8%) on ECMO (11/142, 7.7% VA-ECMO and 9/156, 5.8% VV-ECMO) had a positive screening test compared to 18 patients (18/2998, 0.6%) on CPB (p<0.001). All positive screening tests were confirmed by ELISA (100% positive predictive value). The median PTPS for patients on ECMO was 4 (3-7) whilst for patients who received CPB it was 5 (4-7). Four ECMO patients had PTPS of 3 and would not normally been screened according current guidelines. All patients with confirmed HIT were treated with argatroban. There was no difference in mortality between ECMO patients who did or did not developed HIT; overall mortality: 95/296, 32.1%, mortality in patients without HIT: 89/276, 32.2% and patients with HIT 6/20, 30%) In conclusion, severe and moderate thrombocytopenia is already common in patients receiving ECMO on the day of the ECMO initiation. Patients who had CPB dropped their platelet count to mild to moderate levels on day 2 and 5 and then recovered by day 10. HIT is more frequent in patients receiving ECMO (both VV and VA-ECMO) compared to patients who had CPB. Although the PTPS was good at predicting HIT in patients who had CPB, it failed to detect HIT in 4/20 (20%) ECMO patients. Disclosures Jayakody Arachchillage: Bayer: Other: Sponsored to attend educational meetings; Octapharma: Other: Sponsored to attend an educational meeting; Mitsubishi Phama: Other: Sponsored to attend an educational meeting. Laffan:Roche: Consultancy, Speakers Bureau; Pfizer: Honoraria.

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