Con: Modified Ultrafiltration Should Not Be Routinely Used in Adult Cardiac Surgery

Abstract

CARDIOPULMONARY BYPASS (CPB) is known to induce a systemic proinflammatory state and may contribute to postoperative organ dysfunction, primarily through complement activation secondary to blood passing through an artificial extracorporeal circuit. 1 Hall RI Smith MS Rocker G. The systemic inflammatory response to cardiopulmonary bypass: Pathophysiological, therapeutic, and pharmacological considerations. Anesth Analg. 1997; 85: 766-782 Crossref PubMed Google Scholar , 2 Wang W Huang HM Zhu DM et al. Modified ultrafiltration in paediatric cardiopulmonary bypass. Perfusion. 1998; 13: 304-310 Crossref PubMed Scopus (39) Google Scholar , 3 Thapmongkol S Masaratana P Subtaweesin T et al. The effects of modified ultrafiltration on clinical outcomes of adult and pediatric cardiac surgery. Asian Biomedicine. 2015; 9: 591-599 Crossref Scopus (4) Google Scholar Ultrafiltration may minimize some of the impact of the CPB-induced systemic inflammatory response. 4 Huang H Yao T Wang W et al. Continuous ultrafiltration attenuates the pulmonary injury that follows open heart surgery with cardiopulmonary bypass. Ann Thorac Surg. 2003; 76: 136-140 Abstract Full Text Full Text PDF PubMed Scopus (85) Google Scholar Traditionally, ultrafiltration may be conventional (CUF) or modified (MUF). Conventional ultrafiltration has been employed extensively during CPB, and involves hemoconcentration of both the priming volume and patient's blood volume at any point during CPB. 5 Darup J Bleese N Kalmar P et al. Hemofiltration during extracorporeal circulation (ECC). Thorac Cardiovasc Surg. 1979; 27: 227-230 Crossref PubMed Scopus (30) Google Scholar ,6 Klineberg PL Kam CA Johnson DC et al. Hematocrit and blood volume control during cardiopulmonary bypass with the use of hemofiltration. Anesthesiology. 1984; 60: 478-480 Crossref PubMed Scopus (19) Google Scholar In the early 1990s, Naik et al. introduced the concept of MUF 7 Elliott MJ. Ultrafiltration and modified ultrafiltration in pediatric open heart operations. Ann Thorac Surg. 1993; 56: 1518-1522 Abstract Full Text PDF PubMed Scopus (205) Google Scholar ,8 Andreasson S Gothberg S Berggren H et al. Hemofiltration modifies complement activation after extracorporeal circulation in infants. Ann Thorac Surg. 1993; 56: 1515-1517 Abstract Full Text PDF PubMed Scopus (88) Google Scholar ,9 Naik SK Knight A Elliott MJ. A successful modification of ultrafiltration for cardiopulmonary bypass in children. Perfusion. 1991; 6: 41-50 Crossref PubMed Scopus (164) Google Scholar in which the patient's blood volume is hemoconcentrated after separation from CPB. 10 Wang S Palanzo D Undar A. Current ultrafiltration techniques before, during and after pediatric cardiopulmonary bypass procedures. Perfusion. 2012; 27: 438-446 Crossref PubMed Scopus (40) Google Scholar Naik et al. postulated it may permit blood-free cardiac surgery. 11 Naik SK Knight A Elliott M. A prospective randomized study of a modified technique of ultrafiltration during pediatric open-heart surgery. Circulation. 1991; 84 (III422-31) PubMed Google Scholar Blood is typically removed from the arterial cannula and returned through the venous cannula. Others employ a modified technique in which blood is removed from the right atrium and infused into the aorta, potentially reducing concerns about cerebral shunting. 12 Myers GJ Leadon RB Mitchell LB et al. Simple modified ultrafiltration. Perfusion. 2000; 15: 447-452 Crossref PubMed Scopus (16) Google Scholar