Cardiopulmonary Bypass In Adults Research Articles

Management of priming fluids in cardiopulmonary bypass for adult cardiac surgery: network meta-analysis

Background Cardiopulmonary bypass (CPB) is frequently employed for cardiac surgery, and selecting a suitable priming fluid is a prerequisite for CPB. Currently, the commonly used priming fluids in clinics are classified as crystalloids and colloids, including balanced crystalloids, albumin, dextran, gelatin and hydroxyethyl starch (HES). This network meta-analysis compared the effects of eight fluids used during CPB in adults to determine optimal priming fluid during CPB surgery. Methods Randomised controlled trials assessing priming fluids for CPB in adult cardiac surgery published before 13 April 2023 were searched across Ovid MEDLINE(R) ALL, OVID EMbase, and Cochrane Central Register of Controlled Trials. Various priming fluids were classified into eight categories, including balanced crystalloids, 0.9% NaCl, iso-oncotic human albumin, hyperoncotic human albumin, HES with molecular weight 130k, HES with molecular weight 200k, gelatin and dextran. Results The NMA of platelet counts revealed no significant differences in any result. In direct comparison results, only the comparison of HES with molecular weight 130k vs. gelatin (standard mean difference = −0.40, 95% confidence interval [95%CI: −0.63, −0.16) revealed a significant difference. According to the SUCRA, balanced crystalloids had the highest platelet count, followed by gelatin, and HES with a molecular weight of 130k had the lowest platelet, followed by HES with a molecular weight of 200k. Conclusion Patients using dextran have a low mortality rate and a short mean CPB time, the use of balanced crystalloids is beneficial in terms of platelet count, and HES with molecular weight 130k is beneficial for postoperative urine volume at 24h. However, all priming fluids have pros and cons quite, and the optimal choice of priming fluids remains unsupported by current evidences. When performing CPB surgery, the type of priming fluid should be selected according to the actual situation in CPB for adult cardiac surgery.

Retracted: Activating Transcription Factor 3 Based Early Alarm Model of Acute Kidney Injury after Cardiopulmonary Bypass in Adults.

[This retracts the article DOI: 10.1155/2022/8076718.].

Activating Transcription Factor 3 Based Early Alarm Model of Acute Kidney Injury after Cardiopulmonary Bypass in Adults.

Acute kidney injury (AKI) is a common complication after cardiopulmonary bypass (CPB) for cardiac surgery, and there is no effective treatment. This study was aimed at constructing an early warning model of AKI after CPB in adults and investigating the performance of this model. Patients who underwent CPB in the Department of Cardiac Surgery, Shanghai Tenth People's Hospital, from January 2018 to December 2019 were recruited into the present study. Blood and urine samples were collected preoperatively (0 h) and 2 h, 6 h, 12 h, 24 h, and 48 h after surgery, and the creatinine and activating transcription factor 3 (ATF3) were detected. According to the diagnostic criteria of AKI, patients were divided into the AKI group and the non-AKI group, and the risk factors for AKI after CPB were screened. The receiver operating characteristic (ROC) curve analysis was used to identify the optimal biomarkers for the establishment of early warning model of AKI after CPB. Finally, the performance of this model was further verified. A total of 83 patients were included in this study, 42 of whom developed AKI after surgery. After CPB, the serum and urine levels of creatinine and ATF3 increased to different degrees, and the increase in urine ATF3 was the most obvious in the AKI group. The area under ROC (AUC) of urine ATF3 at 12 h after surgery was 0.691 (95% CI: 0.576-0.807). When ATF3 was higher than 1216 pg/mL, the sensitivity and specificity of ATF3 in the diagnosis of AKI were 0.43 and 0.85, respectively. The height, conjugated bilirubin on the surgery day, urine ATF3 12 h after surgery, and serum creatinine 24 h after surgery were independent risk factors for postoperative AKI. Urine ATF3 and other factors were used to establish AKI warning model after CPB, which showed good fitting and accuracy. In conclusion, ATF3 is an early biomarker of post-CPB AKI. Addition of urine ATF3 to AKI risk factors can improve the accuracy of early AKI prediction.

Predictive effect of high density lipoprotein on acute kidney injury after adult heart surgery

Objective To investigate the effect of preoperative serum high-density lipoprotein on acute kidney injury (AKI) after cardiac surgery. Methods A retrospective analysis of 295 cases of adult patients undergoing cardiopulmonary bypass during our hospital from March 2017 to May 2017 was retrospectively analyzed. According to whether AKI was divided into two groups, AKI group(n=40) and non-AKI group(n=255). The clinical data were collected and the risk factors of AKI were analyzed by single factor and multivariate logistic regression. Results Five patients(12.5%) in the AKI group underwent bedside continuous renal replacement therapy (CRRT), 5 died in the AKI group, and 5 patients died in the non-AKI group. Multivariate logistic regression analysis showed that the high-density lipoprotein content was lower than the normal value of 1 mmol/L in patients with age, sex(male), comorbidities (hypertension and diabetes mellitus), cardiopulmonary bypass and preoperative uric acid value>420 μmol/L was also an independent risk factor for AKI after cardiopulmonary bypass. Conclusions AKI is a common complication after cardiopulmonary bypass in adults. Preoperative serum high-density lipoprotein less than 1 mmol / L can increase the probability of occurrence of AKI after surgery. Key words: Acute Kidney Injury; Cardiac Surgical Procedures; Lipoproteins, HDL

Systemic Angiopoietin-1/2 Dysregulation Following Cardiopulmonary Bypass in Adults

Aim:Vascular leakage following cardiopulmonary bypass contributes to morbidity. Angiopoietin-1 and -2 are biomarkers of endothelial dysfunction. Our aim was to characterize Ang-1 and -2 association with clinical characteristics and outcomes.Methods:Observational cohort study measuring Ang-1/-2 with a panel of cytokines in adults undergoing cardiopulmonary bypass.Results:Ang-2 levels increased immediately postop whereas Ang-1 levels decreased over time. No significant correlation was found with other inflammatory mediators. High correlation was found between the hospital length of stay and Ang-2 increase at 24 h (rho = 0.590; p < 0.0001). The predictors of Ang-2 increase were female gender, cross clamp time, transfusion of blood and absence of angiotensin-converting enzyme inhibitor as a pre-op medication.Conclusion:Angiopoietins can detect vascular leakage early and could impact patient's management to decrease length of stay after cardiac surgery.

Near Infrared Spectroscopy as a Hemodynamic Monitor in Critical Illness.

The objectives of this review are to discuss the technology and clinical interpretation of near infrared spectroscopy oximetry and its clinical application in patients with congenital heart disease. MEDLINE and PubMed. Near infrared spectroscopy provides a continuous noninvasive assessment of tissue oxygenation. Over 20 years ago, near infrared spectroscopy was introduced into clinical practice for monitoring cerebral oxygenation during cardiopulmonary bypass in adults. Since that time, the utilization of near infrared spectroscopy has extended into the realm of pediatric cardiac surgery and is increasingly being used in the cardiac ICU to monitor tissue oxygenation perioperatively.

Trends of central and somatic rSO2 during cardiopulmonary bypass in adults and their interaction with cardiopulmonary bypass parameters

Trends of central and somatic rSO2 during cardiopulmonary bypass in adults and their interaction with cardiopulmonary bypass parameters

Cerebral microembolic load in open heart surgery with different extracorporeal circulation systems

Somanetics 5100C was used to assess regional tissue oxygen saturation. DO2 and VO2 values to assess the oxygen delivery and consumption were also calculated. The association between cerebral and somatic rSO2 trends and mean arterial pressure, pump flow and blood gases were also studied. Results. it was found that prolonged episodes of decrease of somatic rSO2 during cardiopulmonary bypass with lower haemoglobin levels and DO2 values were strongly associated with occurrence of post-op organ disorders especially acute kidney injury. As the results of the correspondence analysis it was shown that for positive outcome without organ disorders greater importance have absolute values of DO2, VO2 and rSO2 (both cerebral and somatic), but for the poor outcome with complications the length of episodes of rSO2 decrease has the greater influence. It was also found that somatic rSO2 values are not strongly associated with pump flow or mean arterial pressure or arterial pO2. Discussion. the use of continuous monitoring of cerebral and even somatic rSO2 during cardiopulmonary bypass in adults may help the prefusionist to assess the adequacy of tissue oxygenation. To improve the somatic and cerebral rSO2 complex strategy is needed to be worked out because the routine increase of pump or gas flow was shown to be not enough and sometimes controversial [2].

Optimizing Thrombin Generation with 4-Factor Prothrombin Complex Concentrates in Neonatal Plasma After Cardiopulmonary Bypass.

Bleeding is a serious complication after pediatric cardiopulmonary bypass (CPB) that is associated with an increase in perioperative morbidity and mortality. Four-factor prothrombin complex concentrates (4F-PCCs) have been used off-label to supplement transfusion protocols for bleeding after CPB in adults; however, data on their use in neonates are limited. In this study, we hypothesized that 4F-PCCs administered ex vivo to neonatal plasma after CPB will increase thrombin generation. Fifteen neonates undergoing complex cardiac repairs requiring CPB were enrolled in this prospective study. Arterial blood was obtained after anesthesia induction but before CPB (baseline), after CPB following heparin reversal, and after our standardized transfusion of a quarter of a platelet apheresis unit (approximately 20 mL·kg) and 3 units of cryoprecipitate. Kcentra (CSL Behring), a 4F-PCC with nonactivated factor VII (FVII), and factor 8 inhibitor bypassing activity (FEIBA; Baxter Healthcare Corporation), a 4F-PCC with activated FVII, were added ex vivo to plasma obtained after CPB to yield concentrations of 0.1 and 0.3 IU·mL. Calibrated automated thrombography was used to determine thrombin generation for each sample. The addition of Kcentra to plasma obtained after CPB resulted in a dose-dependent increase in the median (99% confidence interval) peak amount of thrombin generation (42.0 [28.7-50.7] nM for Kcentra 0.1 IU·mL and 113.9 [99.0-142.1] nM for Kcentra 0.3 IU·mL). The rate of thrombin generation was also increased (15.4 [6.5-24.6] nM·min for Kcentra 0.1 IU·mL and 48.6 [29.9-66.6] nM·min for Kcentra 0.3 IU·mL). The same was true for FEIBA (increase in peak: 39.8 [27.5-49.2] nM for FEIBA 0.1 IU·mL and 104.6 [92.7-124.4] nM for FEIBA 0.3 IU·mL; increase in rate: 17.4 [7.4-28.8] nM·min FEIBA 0.1 IU·mL and 50.5 [26.7- 63.1] nM·min FEIBA 0.3 IU·mL). In the posttransfusion samples, there was a significant increase with Kcentra in the median (99% confidence interval) peak amount (41.1 [21.0-59.7] nM for Kcentra 0.1 IU·mL and 126.8 [106.6- 137.9] nM for Kcentra 0.3 IU·mL) and rate (18.1 [-6.2 to 29.2] nM·min for Kcentra 0.1 IU·mL and 53.2 [28.2-83.1] nM·min for Kcentra 0.3 IU·mL) of thrombin generation. Again, the results were similar for FEIBA (increase in peak: 43.0 [36.4-56.7] nM for FEIBA 0.1 IU·mL and 109.2 [90.3-136.1] nM for FEIBA 0.3 IU·mL; increase in rate: 25.0 [9.1-32.6] nM·min for FEIBA 0.1 IU·mL and 59.7 [38.5-68.7] nM·min for FEIBA 0.3 IU·mL). However, FEIBA produced in a greater median reduction in lag time of thrombin generation versus Kcentra in samples obtained after CPB (P = 0.003 and P = 0.0002 for FEIBA versus Kcentra at 0.1 and 0.3 IU·mL, respectively) and in samples obtained after transfusion (P < 0.0001 for FEIBA versus Kcentra at 0.1 and 0.3 IU·mL). After CPB, thrombin generation in neonatal plasma was augmented by the addition of 4F-PCCs. The peak amount and rate of thrombin generation were enhanced in all conditions, whereas the lag time was shortened more with FEIBA. Our findings suggest that the use of 4F-PCCs containing activated FVII may be an effective adjunct to the initial transfusion of platelets and cryoprecipitate to augment coagulation and control bleeding in neonates after CPB.

Steroids for surgery during cardiopulmonary bypass in adults: a meta-analysis

Study ObjectiveTo evaluate the effect of steroid administration on myocardial infarction (MI), stroke, renal insufficiency, death, intensive care (ICU) length of stay (LOS) and hospital LOS of patients undergoing cardiopulmonary bypass (CPB). DesignMeta-analysis of parallel randomized controlled trials. SettingUniversity hospital. MeaurementsA search was conducted in PubMed, EMBASE, MEDLINE(R) and the Cochrane Central Register of Controlled Trials of studies on adults undergoing surgery with CPB who received steroid administration. Effect size (risk ratio or mean difference) for MI, stroke, renal insufficiency, death, ICU LOS, and hospital LOS were evaluated. Main Results48 RCTs published between 1977 and 2012 were retained for analysis. Steroids had no effect on the MI risk ratio (RR) 0.91 (95% confidence interval [CI] 0.63, 1.32); death at 30 days RR 0.84 (0.59, 1.20); stroke RR 0.92 (0.60, 1.42) or renal insufficiency RR 0.83 (0.52, 1.32). Administration of steroids reduced ICU LOS (P = 0.00001; I2 87.5%) and hospital LOS (P = 0.03; I2 81.1%). Metaregressions showed that duration of steroid administration was correlated with the reduction in ICU LOS (P = 0.0004) and hospital LOS (P < 0.00001). ConclusionsIncreasing the duration of steroid administration may reduce ICU and hospital LOS greater than increasing the dose.

Gaseous Micro‐Emboli Activity During Cardiopulmonary Bypass in Adults: Pulsatile Flow Versus Nonpulsatile Flow

Cardiopulmonary bypass (CPB) has a risk of cerebral injury, with an important role of gaseous micro-emboli (GME) coming from the CPB circuit. Pulsatile perfusion is supposed to perform specific conditions for supplementary GME activity. We aimed to determine whether pulsatile CPB augments production and delivery of GME and evaluate the role of different events in GME activity during either type of perfusion. Twenty-four patients who underwent on-pump coronary artery bypass grafting surgery at the University of Verona were divided equally into two groups-pulsatile perfusion (PP) group and nonpulsatile perfusion (NP) group. The circuit included a JostraHL-20 roller pump set in pulsatile or nonpulsatile mode, an open Sorin Synthesis membrane oxygenator with integrated screen-type arterial filter, and phosphorylcholine-coated tubes. Hemodynamic flow evaluation was performed in terms of energy equivalent pressure and surplus hemodynamic energy (SHE). GME were counted by means of a GAMPT BCC200 bubble counter (GAMPT, Zappendorf, Germany) with two probes placed at postpump and postarterial filter positions. Results were evaluated in terms of GME number, GME volume, number of over-ranged GME from both probes, and series of filtering indexes. In PP mode, the pump produced and delivered along the circuit significantly higher amounts of SHE than in NP mode. At the venous postpump site, GME number was significantly higher during PP but no difference was found in terms of GME volume or number of over-ranged bubbles. No significant difference in GME number, GME volume, or number of over-ranges was found at the postarterial filter site. Filtering indexes were similar between the two groups. Neither type of perfusion was shown to contribute to excessive GME production during the most important perfusionist manipulation. Pulsatility leads to GME increment by splitting and size diminishing of the existing bubbles but not by additional gas production. PP augmented GME number at the venous postpump site, while mean volume remained comparable with NP. Sorin Synthesis oxygenator showed high efficacy in GME removal during either type of perfusion. Supplementary GME production and delivery during typical perfusionist manipulations did not depend on perfusion type.

Prophylactic corticosteroids for cardiopulmonary bypass in adults.

High-dose prophylactic corticosteroids are often administered during cardiac surgery. Their use, however, remains controversial, as no trials are available that have been sufficiently powered to draw conclusions on their effect on major clinical outcomes. The objective of this meta-analysis was to estimate the effect of prophylactic corticosteroids in cardiac surgery on mortality, cardiac and pulmonary complications. Major medical databases (CENTRAL, MEDLINE, EMBASE, CINAHL and Web of Science) were systematically searched for randomised studies assessing the effect of corticosteroids in adult cardiac surgery. Database were searched for the full period covered, up to December 2009. No language restrictions were applied. Randomised controlled trials comparing corticosteroid treatment to either placebo treatment or no treatment in adult cardiac surgery were selected. There were no restrictions with respect to length of the follow-up period. All selected studies qualified for pooling of results for one or more end-points. The processes of searching and selection for inclusion eligibility were performed independently by two authors. Also, quality assessment and data-extraction of selected studies were independently performed by two authors. The primary endpoints were mortality, cardiac and pulmonary complications. The main effect measure was the Peto odds ratio comparing corticosteroids to no treatment/placebo. Fifty-four randomised studies, mostly of limited quality, were included. Altogether, 3615 patients were included in these studies. The pooled odds ratio for mortality was 1.12 (95% CI 0.65 to 1.92), showing no mortality reduction in patients treated with corticosteroids. The odds ratios for myocardial and pulmonary complications were 0.95, (95% CI 0.57 to 1.60) and 0.83 (95% CI 0.49 to 1.40), respectively. The use of a random effects model did not substantially influence study results. Analyses of secondary endpoints showed a reduction of atrial fibrillation and an increase in gastrointestinal bleeding in the corticosteroids group. This meta-analysis showed no beneficial effect of corticosteroid use on mortality, cardiac and pulmonary complications in cardiac surgery patients.

The Cochrane Database of Systematic Reviews – Issue 5 2011

The Cochrane Database of Systematic Reviews – Issue 5 2011

The usefulness of an earphone-type infrared tympanic thermometer during cardiac surgery with cardiopulmonary bypass: clinical report

We evaluated the usefulness of a novel earphone-type infrared tympanic thermometer (IRT) during cardiac surgery with cardiopulmonary bypass. Tympanic membrane temperature (T(Tym)) was monitored using the IRT inserted into the right ear canal of 12 adult patients (ASA III) who had been scheduled for elective cardiac surgery with cardiopulmonary bypass under general anesthesia. Rectum (T(Rec)) and nasopharyngeal temperatures (T(Naso)) were also monitored, and all temperatures were recorded at 5-min intervals during cardiopulmonary bypass. Operating room temperature was kept at 20°-27°C; a conductive warming/cooling system was used to control the patient's body temperature. Of 265 measurements obtained, body temperature range was 31.6°-37.6°C. No complications were related to site of insertion of the monitoring probe. Significant correlations were seen between T(Tym) and T(Naso) (r = 0.971, P < 0.001), and T(Tym) and T(Rec) (r = 0.759, P < 0.001). A Bland-Altman plot showed that average temperature of T (Tym) was 0.06°C above T(Naso) (±0.66°C, 2 SD) and 0.12°C below T(Rec) (±1.78°C, 2 SD). We conclude that an earphone-type IRT is noninvasive and hygienic and could continuously evaluate selective cerebral temperature during cardiopulmonary bypass in adults.

Leukocyte depletion during cardiopulmonary bypass in routine adult cardiac surgery

Cardiopulmonary bypass (CPB) elicits an inflammatory response which is potentially harmful and that is partly caused by activation of leukocytes. Despite promise from earlier studies, however, the value of intraoperative leukocyte-depletion (LD) remains equivocal. We studied the effect of LD during routine cardiac surgery. For a short period (2.5 months), all operations at our institution were performed with leukocyte filters (Pall, East Hills, NY, USA) in the arterial and cardioplegia lines of the CPB. Those patients operated immediately before and after this period served as controls. In each group, 266 predominantly male (70%) patients were studied. A broad spectrum of operations including emergency surgery was evaluated, which was comparable between the groups (P=0.41). There were no significant differences regarding the preoperative data, but the preoperative leukocyte count tended to be lower in the leukodepletion-group (7961±2415 vs. 8444±2951, P=0.050). Despite this, no difference between the groups regarding the postoperative leukocyte count was observed. Significantly more LD-patients were extubated within 12 h postoperatively (69% vs. 60% in the control-group, P=0.029), but there were no significant differences regarding 30-day mortality (0.4% vs. 1.1%, P=0.37), transfusion requirements or major morbidity. In a retrospective study on adding LD filters to all cardiac operations with CPB in adults, we did not observe a clear benefit of intraoperative LD with the strategy used (continuous filtration plus filtration of cardioplegia).

Cardiopulmonary Bypass.

Loyola University Medical Center, Maywood, Illinois. jkwak@lumc.eduCardiopulmonary Bypass. Edited by Sunit Ghosh, M.B.B.S., F.R.C.A., Florian Falter, M.D., Ph.D., F.R.C.A., and David J. Cook, M.D. Cambridge, United Kingdom, Cambridge University Press, 2009. Pages: 207. Price: $60.00.The development of cardiopulmonary bypass (CPB) changed the realms of cardiac, thoracic, and vascular surgery. Continuing research and development feed a growing wealth of information about CPB. Cardiopulmonary Bypass provides a complete overview of the field for all providers involved with the practice of CPB in a book of manageable size and length. The editors of this book are experienced anesthesiologists from world-renowned centers in the United Kingdom and the United States. Experts from both the United Kingdom and the United States contributed to this book and include surgeons, anesthesiologists, and perfusionists.The opening chapters are filled with figures of equipment and monitors and how they come together in a system for CPB. They provide an appropriate introduction to those who are new to CPB while providing a review for those who are already familiar with the system. The chapters on the conduct of CPB and weaning from CPB are easy to follow and thorough, providing information about different clinical applications and alternatives.The chapter on anticoagulation and coagulopathies is written with a contribution from Linda Shore-Lesserson, M.D., who is known for her expertise on this topic. The chapter reviews the coagulation cascade, current strategies in anticoagulation and monitoring, and bleeding disorders in the setting of CPB. Information about medications used for anticoagulation, its reversal, and the prevention of bleeding is up to date. The topic of heparin-induced thrombocytopenia is well covered from pathophysiology to diagnosis to management in patients undergoing cardiac surgery. The chapter ends with a brief, but useful, section on the management of a bleeding patient.Although it changed the scope of cardiothoracic surgery, CPB is associated with organ dysfunction. There is a general chapter that gives an overview of the effects of CPB on each organ system, and then there are chapters appropriately dedicated to myocardial protection, deep hypothermic circulatory arrest, cerebral morbidity, and renal protection. The chapter on myocardial protection is written by Constantine Athanasuleas, M.D., and Gerald D. Buckberg, M.D., cardiothoracic surgeons who are known for their contributions to the fields of myocardial protection and cardiac failure. The chapter on deep hypothermic circulatory arrest flows well, covering history to neuroprotective techniques, and the chapter on cerebral morbidity builds on that chapter, providing more information about neurophysiology and neurologic complications. Information on acute kidney injury is written by a nephrologist and is a great update and review for all providers of CPB.The book spends an appropriate amount of time on extracorporeal membrane oxygenation and circulatory devices as well as the use of CPB in noncardiac procedures. The chapter on extracorporeal membrane oxygenation is impressively thorough for a review book. Some of the recent advances that use the concepts and components of CPB have occurred in the use of circulatory devices. The chapter gives an overview of the different devices used, with relevant figures. In addition, the different indications for device implantation are discussed.The editors have fulfilled their goal of writing an “easily readable source of material for the everyday practice of clinical perfusion.” Each chapter is written with references that are current and complete without being overwhelming. Because this book covers the fundamentals of CPB in adults, it does not venture into details on newer techniques, such as those used in minimally invasive surgery or pediatric surgery. For those learning and teaching about CPB, this book is a wonderful companion to reference textbooks that are already available.Loyola University Medical Center, Maywood, Illinois. jkwak@lumc.edu

Statin prophylaxis and inflammatory mediators following cardiopulmonary bypass: a systematic review

IntroductionInduction of an inflammatory response is thought to have a significant role in the complications that follow cardiopulmonary bypass (CPB). The statin drugs are increasingly being recognized as having potent anti-inflammatory effects and hence have potential to influence an important mechanism of injury in CPB, although there is no current confirmation that this is indeed the case. Our objective was to systematically review if pre-operative prophylactic statin therapy, compared with placebo or standard of care, can decrease the inflammatory response in people undergoing heart surgery with CPB.MethodsWe performed a systematic and comprehensive literature search for all randomized controlled trials (RCTs) of open heart surgery with CPB in adults or children who received prophylactic statin treatment prior to CPB, with reported outcomes which included markers of inflammation. Two authors independently identified eligible studies, extracted data, and assessed study quality using standardized instruments. Weighted mean difference (WMD) was the primary summary statistic with data pooled using a random effects model. Descriptive analysis was used when data could not be pooled.ResultsEight RCTs were included in the review, with the number of trials for each inflammatory outcome being even more limited. Pooled data demonstrated benefit with the use of statin to attenuate the post-CPB increase in interleukins 6 and 8 (IL-6, IL-8), peak high sensitivity C-reactive protein (hsCRP), and tumor necrosis factor-alpha (TNF-α) post-CPB (WMD [95% confidence interval (CI)] -23.5 pg/ml [-36.6 to -10.5]; -23.4 pg/ml [-35.8 to -11.0]; -15.3 mg/L [CI -26.9 to -3.7]; -2.10 pg/ml [-3.83 to -0.37] respectively). Very limited RCT evidence suggests that prophylactic statin therapy may also decrease adhesion molecules following CPB including neutrophil CD11b and soluble P (sP)-selectin.ConclusionsAlthough the RCT evidence may suggest a reduction in post-CPB inflammation by statin therapy, the evidence is not definitive due to significant limitations. Several of the trials were not methodologically rigorous and statin intervention was highly variable in this small number of studies. This systematic review demonstrates that there is a significant gap that exists in the current literature in regards to the potential anti-inflammatory effect of statin therapy prior to CPB.

Effects of Extreme Hemodilution during Cardiac Surgery on Cognitive Function in the Elderly

Strategies for neuroprotection including hypothermia and hemodilution have been routinely practiced since the inception of cardiopulmonary bypass. Yet postoperative neurocognitive deficits that diminish the quality of life of cardiac surgery patients are frequent. Because there is uncertainty regarding the impact of hemodilution on perioperative organ function, the authors hypothesized that extreme hemodilution during cardiac surgery would increase the frequency and severity of postoperative neurocognitive deficits. Patients undergoing coronary artery bypass grafting surgery were randomly assigned to either moderate hemodilution (hematocrit on cardiopulmonary bypass >or=27%) or profound hemodilution (hematocrit on cardiopulmonary bypass of 15-18%). Cognitive function was measured preoperatively and 6 weeks postoperatively. The effect of hemodilution on postoperative cognition was tested using multivariable modeling accounting for age, years of education, and baseline levels of cognition. After randomization of 108 patients, the trial was terminated by the Data Safety and Monitoring Board due to the significant occurrence of adverse events, which primarily involved pulmonary complications in the moderate hemodilution group. Multivariable analysis revealed an interaction between hemodilution and age wherein older patients in the profound hemodilution group experienced greater neurocognitive decline (P = 0.03). In this prospective, randomized study of hemodilution during cardiac surgery with cardiopulmonary bypass in adults, the authors report an early termination of the study because of an increase in adverse events. They also observed greater neurocognitive impairment among older patients receiving extreme hemodilution.

Selection of priming solutions for cardiopulmonary bypass in adults

The issue of choosing the right priming solution for adult cardiopulmonary bypass patients has been studied and argued for at least three decades. However, there is still no general consensus with regard to making the right choice. Basically, priming solutions can be classified into two categories, i.e. crystalloids and colloids. The former consists of dextrose, balanced crystalloid fluids, and mannitol, and the latter consists of albumin, dextrans, gelatins, and hydroxyethyl starch. In general, crystalloids are simple volume expanding solutions that mimic the normal plasma electrolyte concentrations. They can be used as clear priming solutions resulting in effective hemodilution but they lack oncotic activity. On the contrary, colloids have the advantage in maintaining the colloid oncotic pressure and reducing tissue oedema. However, colloids have been associated with increased incidence of anaphylactoid reactions and clinical coagulopathy. In this paper, we will describe the basic characteristics, the clinical efficiency and the safety of different types of priming fluids and make an overview on how to select the ideal priming solution for cardiopulmonary bypass in adults.

The short term effects of cardiopulmonary bypass on neurologic function in children and young adults

Cognitive deficits are common in adults following surgery utilizing cardiopulmonary bypass (CPB). A previous retrospective study suggested that surgical closure of an ASD in children was associated with neurologic injury, while transcather therapy was not. In a prospective study, we sought to determine whether neurologic deficits occur following repair of non-complex congenital heart lesions in school-age children and young adults. Inclusion criteria were: age between 5 and 20 years, cardiac surgery utilizing CPB without deep hypothermic circulatory arrest, and no prior cardiac surgery. Patients underwent psychometric testing 1-3 days prior to surgery and re-evaluation 7-18 days after surgery. In order to determine the test/re-test effect an age-matched cohort of children undergoing transcather closure of ASD under general anesthesia was also evaluated. The primary outcome measures were verbal and picture memory. Additional psychometric tests included: computerized performance test (CPT) and Digit Span (DS). Forty-one patients were enrolled, 29 undergoing surgery with CPB and 12 controls. Surgical procedures included ASD closure (n=13), VSD closure (n=10), resection of sub-aortic stenosis (n=3), mitral valvuloplasty (n=3). Mild hypothermia was used in all cases. The mean duration of CPB was 54+/-22 min. There was no significant difference in any of the psychometric test scores between subjects undergoing surgery with CPB or controls. There are no marked adverse neurologic effects of CPB in school-age children and young adults undergoing non-complex open-heart surgery. These data are important in counseling patients and families and should be considered in the debate as to the relative merits of transcather versus open-heart repair of various heart lesions.