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Management of Cardiopulmonary Bypass in Cardiovascular Surgery

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A special issue of Journal of Clinical Medicine (ISSN 2077-0383). This special issue belongs to the section "Intensive Care".

Deadline for manuscript submissions: closed (15 December 2022) | Viewed by 22470

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Prof. Dr. Matthias Thielmann

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West-German Heart and Vascular Center, Department of Thoracic and Cardiovascular Surgery, University of Duisburg Essen, 45122 Essen, Germany
Interests: acute coronary syndromes; cardiac biomarker research; ischemia/reperfusion injury research; cardio-protection and conditioning; coronary artery bypass grafting; minimal invasive valve surgery; aortic valve surgery; mitral and tricuspid valve repair; transcatheter and endovascular techniques; outcome research; beating heart surgery
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Dear Colleagues,

The multifaceted application of cardiopulmonary bypass is a fundamental component of cardiovascular surgery, which initiated the beginning of contemporary cardiac surgery but also enabled the continuous development of modern cardiac surgery in its entire spectrum and has become an important, reliable, and indispensable tool for the cardiac surgeon today.

The cardiopulmonary bypass enables a controlled blood circulation and continuous organ perfusion of the human body, allowing—not surprisingly—cardioplegic cardiac arrest with accurately controlled myocardial ischemia and reperfusion while maintaining total body circulation under quite different physiological conditions and situations.

In fact, cardiopulmonary bypass is far more than a simple roller pump with an oxygenator—this complex and broad topic encompasses very many important research areas and specialties within cardiac surgery.

This Special Issue in JCM, titled "Management of Cardiopulmonary Bypass in Cardiovascular Surgery", is therefore intended to provide an overview and inventory of current research in the field of management and the various uses of cardiopulmonary bypass in contemporary cardiovascular surgery.

It is my great pleasure to invite all colleagues to contribute to this Special Issue, primarily with original research articles, but also with highly interesting review articles that highlight noteworthy aspects and innovative findings that have the potential to broaden the perspective and focus of the application and management of cardiopulmonary bypass in cardiovascular surgery.

Prof. Dr. Matthias Thielmann
Guest Editor

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Keywords

Cardiopulmonary bypass
Cardiovascular surgery
Perfusion strategies
Ischemia and reperfusion injury
Organ conditioning
Blood management
Cardiocirculatory support
Extracorporeal membrane oxygenation
SIRS
Less and minimal invasiveness
Outcomes research

Published Papers (9 papers)

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Editorial

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7 pages, 503 KiB

Open AccessEditorial

The Conundrum of Systemic Arterial Pressure Management on Cardiopulmonary Bypass

by Marco Ranucci, Mauro Cotza and Umberto Di Dedda

J. Clin. Med. 2023, 12(3), 806; https://doi.org/10.3390/jcm12030806 - 19 Jan 2023

Cited by 2 | Viewed by 1851

Abstract

The recently released EACTS/EACTA/EBCP guidelines on cardiopulmonary bypass (CPB) in adult cardiac surgery [...] Full article

(This article belongs to the Special Issue Management of Cardiopulmonary Bypass in Cardiovascular Surgery)

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Research

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11 pages, 338 KiB

Open AccessArticle

Cell-Free Hemoglobin Concentration in Blood Prime Solution Is a Major Determinant of Cell-Free Hemoglobin Exposure during Cardiopulmonary Bypass Circulation in the Newborn

by Åsa Jungner, Suvi Vallius, Magnus Gram and David Ley

J. Clin. Med. 2022, 11(14), 4071; https://doi.org/10.3390/jcm11144071 - 14 Jul 2022

Viewed by 1210

Abstract

Exposure to circulating cell-free hemoglobin is a ubiquitous feature of open-heart surgery on cardiopulmonary bypass circulation. This study aims to determine the origins and dynamics of circulating cell-free hemoglobin and its major scavenger proteins haptoglobin and hemopexin during neonatal cardiopulmonary bypass. Forty neonates with an isolated critical congenital heart defect were included in a single-center prospective observational study. Blood samples were obtained preoperatively, hourly during bypass circulation, after bypass separation, at admission to the pediatric intensive care unit, and at postoperative days 1–3. Concentrations of cell-free hemoglobin, haptoglobin and hemopexin were determined using ELISA. Neonates were exposed to significantly elevated plasma concentrations of cell-free hemoglobin and a concomitant depletion of scavenger protein supplies during open-heart surgery. The main predictor of cell-free hemoglobin exposure was the concentration of cell-free hemoglobin in blood prime solution. Concentrations of haptoglobin and hemopexin in prime solution were important determinants for intra- and postoperative circulating scavenger protein resources. Full article

(This article belongs to the Special Issue Management of Cardiopulmonary Bypass in Cardiovascular Surgery)

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13 pages, 701 KiB

Open AccessArticle

Single-Centre Retrospective Evaluation of Intraoperative Hemoadsorption in Left-Sided Acute Infective Endocarditis

by Jurij Matija Kalisnik, Spela Leiler, Hazem Mamdooh, Janez Zibert, Thomas Bertsch, Ferdinand Aurel Vogt, Erik Bagaev, Matthias Fittkau and Theodor Fischlein

J. Clin. Med. 2022, 11(14), 3954; https://doi.org/10.3390/jcm11143954 - 07 Jul 2022

Cited by 10 | Viewed by 1980

Abstract

Background: Cardiac surgery in patients with infective endocarditis (IE) is still associated with high mortality and morbidity; an already present inflammation might further be aggravated due to a cardiopulmonary bypass-induced dysregulated immune response. Intraoperative hemoadsorption therapy may attenuate this septic response. Our objective was therefore to assess the efficacy of intraoperative hemoadsorption in active left-sided native- and prosthetic infective endocarditis. Methods: Consecutive high-risk patients with active left-sided infective endocarditis were enrolled between January 2015 and April 2021. Patients with intraoperative hemoadsorption (Cytosorbents, Princeton, NJ, USA) were compared to patients without hemoadsorption (control). Endpoints were the incidence of postoperative sepsis, sepsis-associated death and in-hospital mortality. Predictors for sepsis-associated mortality and in-hospital mortality were analysed by multivariable logistic regression. Results: A total of 202 patients were included, 135 with active left-sided native and 67 with prosthetic valve infective endocarditis. Ninety-nine patients received intraoperative hemoadsorption and 103 patients did not. Ninety-nine propensity-matched pairs were selected for final analyses. Postoperative sepsis and sepsis-related mortality was reduced in the hemoadsorption group (22.2% vs. 39.4%, p = 0.014 and 8.1% vs. 22.2%, p = 0.01, respectively). In-hospital mortality tended to be lower in the hemoadsorption group (14.1% vs. 26.3%, p = 0.052). Key predictors for sepsis-associated mortality and in-hospital mortality were preoperative inotropic support, lactate-levels 24 h after surgery, C-reactive protein levels on postoperative day 1, chest tube output, cumulative inotropes and white blood cell counts on postoperative day 2, and new onset of dialysis. Multivariate regression analysis revealed intraoperative hemoadsorption to be associated with lower sepsis-associated (OR 0.09, 95% CI 0.013–0.62, p = 0.014) as well as in-hospital mortality (OR 0.069, 95% CI 0.006–0.795, p = 0.032). Conclusions: Intraoperative hemoadsorption holds promise to reduce sepsis and sepsis-associated mortality after cardiac surgery for active left-sided native and prosthetic valve infective endocarditis. Full article

(This article belongs to the Special Issue Management of Cardiopulmonary Bypass in Cardiovascular Surgery)

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14 pages, 640 KiB

Open AccessArticle

Severe Pulmonary Bleeding after Assist Device Implantation: Incidence, Risk Factors and Prognostic Impact

by Bernd Panholzer, Kevin Pilarczyk, Katharina Huenges, Charlotte Aldinger, Christine Friedrich, Ulrike Nowak-Göttl, Jochen Cremer and Assad Haneya

J. Clin. Med. 2022, 11(7), 1908; https://doi.org/10.3390/jcm11071908 - 29 Mar 2022

Viewed by 1538

Abstract

Background: Continuous flow left ventricular assist devices (CF-LVAD) improve survival in patients with advanced heart failure but confer risk of bleeding complications. Whereas pathophysiology and risk factors for many bleeding complications are well investigated, the literature lacks reports about pulmonary bleeding. Therefore, it was the aim of the present study to assess incidence, risk factors, and clinical relevance of pulmonary bleeding episodes after LVAD implantation. Methods: We retrospectively analyzed our institutional database of 125 consecutive patients who underwent LVAD implantation between 2008 and 2017. Demographic and clinical variables related to bleeding were collected. The primary endpoint was incidence of severe pulmonary bleeding (SPB). Results: Nine out of 125 patients suffered from SPB during the postoperative course (7.2%) 11 days after surgery in the median. None of them had a known history of lung disease or bleeding disorder. History of prior myocardial infarction (0% vWD. 42.2%, p = 0.012) and ischemic cardiomyopathy (25.0% vs. 50.0%, p = 0.046) were less frequent in the SBP group. Concomitant aortic valve replacement was more common in the group with SPB (33.3% versus 7.0%, p = 0.034). Surgical (blood loss 9950 vs. 3800 mL, p = 0.012) as well as ear-nose-throat (ENT) bleedings (33% vs. 4.6%, p = 0.015) were observed more frequently in patients with SPB. SPB was associated with a complicated postoperative course with a higher incidence of acute kidney failure (100% versus 36.7%, p = 0.001) and delirium (44.4% versus 14.8%, p = 0.045); a higher need for red blood cell (26 packs versus 7, p < 0.001), fresh frozen plasma (18 units versus 6, p = 0.002), and platelet transfusion (8 pools versus 1, p = 0.001); longer ventilation time (1206 versus 171 h, p = 0.001); longer ICU-stay (58 versus 13 days, p = 0.002); and higher hospital mortality (66.7% vs. 29%, p = 0.029). Conclusion: SPB is a rare but serious complication after LVAD implantation and is significantly associated with higher morbidity and mortality. The pathophysiology and potential risk factors are unknown but may include coagulation disorders and frequent suctioning or empiric bronchoscopy causing airway irritation. Full article

(This article belongs to the Special Issue Management of Cardiopulmonary Bypass in Cardiovascular Surgery)

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15 pages, 2370 KiB

Open AccessArticle

Acute Kidney Injury in Patients with Severe ARDS Requiring Extracorporeal Membrane Oxygenation: Incidence, Prognostic Impact and Risk Factors

by Kevin Pilarczyk, Katharina Huenges, Burkhard Bewig, Lorenz Balke, Jochen Cremer, Assad Haneya and Bernd Panholzer

J. Clin. Med. 2022, 11(4), 1079; https://doi.org/10.3390/jcm11041079 - 18 Feb 2022

Cited by 5 | Viewed by 2155

Abstract

(1) Background: Acute kidney injury (AKI) is a common but under-investigated complication in patients receiving extracorporeal membrane oxygenation (ECMO). We aimed to define the incidence and clinical course, as well as the predictors of AKI in adults receiving ECMO support. (2) Materials and Methods: This is a retrospective analysis of all patients undergoing veno-venous ECMO treatment in a tertiary care center between December 2008 and December 2017. The primary endpoint was the new occurrence of an AKI of stage 2 or 3 according to the Kidney Disease: Improving Global Outcomes (KDIGO) classification after ECMO implantation. (3) Results: During the observation period, 103 patients underwent veno-venous ECMO implantation. In total, 59 patients (57.3%) met the primary endpoint with an AKI of stage 2 or 3 and 55 patients (53.4%) required renal replacement therapy. Patients with an AKI of 2 or 3 suffered from more bleeding and infectious complications. Whereas weaning failure from ECMO (30/59 (50.8%) vs. 15/44 (34.1%), p = 0.08) and 30-day mortality (35/59 (59.3%) vs. 17/44 (38.6%), p = 0.06) only tended to be higher in the group with an AKI of stage 2 or 3, long-term survival of up to five years was significantly lower in the group with an AKI of stage 2 or 3 (p = 0.015). High lactate, serum creatinine, and ECMO pump-speed levels, and low platelets, a low base excess, and a low hematocrit level before ECMO were independent predictors of moderate to severe AKI. Primary hypercapnic acidosis was more common in AKI non-survivors (12 (32.4%) vs. 0 (0.0%), p < 0.01). Accordingly, pCO₂-levels prior to ECMO implantation tended to be higher in AKI non-survivors (76.12 ± 27.90 mmHg vs. 64.44 ± 44.31 mmHg, p = 0.08). In addition, the duration of mechanical ventilation prior to ECMO-implantation tended to be longer (91.14 ± 108.16 h vs. 75.90 ± 86.81 h, p = 0.078), while serum creatinine (180.92 ± 115.72 mmol/L vs. 124.95 ± 77.77 mmol/L, p = 0.03) and bicarbonate levels were significantly higher in non-survivors (28.22 ± 8.44 mmol/L vs. 23.36 ± 4.19 mmol/L, p = 0.04). (4) Conclusion: Two-thirds of adult patients receiving ECMO suffered from moderate to severe AKI, with a significantly increased morbidity and long-term mortality. Full article

(This article belongs to the Special Issue Management of Cardiopulmonary Bypass in Cardiovascular Surgery)

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14 pages, 1084 KiB

Open AccessArticle

Prediction of Acute Kidney Injury by Cystatin C and [TIMP-2]*[IGFBP7] after Thoracic Aortic Surgery with Moderate Hypothermic Circulatory Arrest

by Kevin Pilarczyk, Bernd Panholzer, Katharina Huenges, Mohamed Salem, Toni Jacob, Jochen Cremer and Assad Haneya

J. Clin. Med. 2022, 11(4), 1024; https://doi.org/10.3390/jcm11041024 - 16 Feb 2022

Cited by 3 | Viewed by 1968

Abstract

(1) Background: Acute kidney injury (AKI) is a common complication following thoracic aortic surgery (TAS), with moderate hypothermic circulatory arrest (MHCA). However, prediction of AKI with classical tools remains uncertain. Therefore, it was the aim of the present study to evaluate the role of new biomarkers in patients after MHCA. (2) Methods: 101 consecutive patients were prospectively enrolled. Measurements of urinary [TIMP-2]*[IGFBP7] and Cystatin C in the blood were performed perioperatively. Primary endpoint was the occurrence of AKI stage 2 or 3 (KDIGO-classification) within 48 h after surgery (AKI group). (3) Results: Mean age of patients was 69.1 ± 10.9 years, 35 patients were female (34%), and 13 patients (13%) met the primary endpoint. Patients in the AKI group had a prolonged ICU-stay (6.9 ± 7.4 days vs. 2.5 ± 3.1 days, p < 0.001) as well as a higher 30-day-mortality (9/28 vs. 1/74, p < 0.001). Preoperative serum creatinine (169.73 ± 148.97 μmol/L vs. 89.74 ± 30.04 μmol/L, p = 0.027) as well as Cystatin C (2.41 ± 1.54 mg/L vs. 1.13 ± 0.35 mg/L, p = 0.029) were higher in these patients. [TIMP-2]*[IGFBP7] increased significantly four hours after surgery (0.6 ± 0.69 mg/L vs. 0.37 ± 0.56 mg/L, p = 0.03) in the AKI group. Preoperative Cystatin C (AUC 0.828, p < 0.001) and serum creatinine (AUC 0.686, p = 0.002) as well as [TIMP-2]*[IGFBP7] 4 h after surgery (AUC 0.724, p = 0.020) were able to predict postoperative AKI. The predictive capacity of Cystatin C was superior to serum creatinine (p = 0.0211) (4) Conclusion: Cystatin C represents a very sensitive and specific biomarker to predict AKI in patients undergoing thoracic surgery with MHCA even before surgery, whereas the predictive capacity of [TIMP-2]*[IGFBP7] is only moderate and inferior to that of serum creatinine. Full article

(This article belongs to the Special Issue Management of Cardiopulmonary Bypass in Cardiovascular Surgery)

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Review

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19 pages, 2105 KiB

Open AccessReview

How to Solve the Conundrum of Heparin-Induced Thrombocytopenia during Cardiopulmonary Bypass

by Etienne Revelly, Emmanuelle Scala, Lorenzo Rosner, Valentina Rancati, Ziyad Gunga, Matthias Kirsch, Zied Ltaief, Marco Rusca, Xavier Bechtold, Lorenzo Alberio and Carlo Marcucci

J. Clin. Med. 2023, 12(3), 786; https://doi.org/10.3390/jcm12030786 - 18 Jan 2023

Cited by 2 | Viewed by 2369

Abstract

Heparin-induced thrombocytopenia (HIT) is a major issue in cardiac surgery requiring cardiopulmonary bypass (CPB). HIT represents a severe adverse drug reaction after heparin administration. It consists of immune-mediated thrombocytopenia paradoxically leading to thrombotic events. Detection of antibodies against platelets factor 4/heparin (anti-PF4/H) and aggregation of platelets in the presence of heparin in functional in vitro tests confirm the diagnosis. Patients suffering from HIT and requiring cardiac surgery are at high risk of lethal complications and present specific challenges. Four distinct phases are described in the usual HIT timeline, and the anticoagulation strategy chosen for CPB depends on the phase in which the patient is categorized. In this sense, we developed an institutional protocol covering each phase. It consisted of the use of a non-heparin anticoagulant such as bivalirudin, or the association of unfractionated heparin (UFH) with a potent antiplatelet drug such as tirofiban or cangrelor. Temporary reduction of anti-PF4 with intravenous immunoglobulins (IvIg) has recently been described as a complementary strategy. In this article, we briefly described the pathophysiology of HIT and focused on the various strategies that can be applied to safely manage CPB in these patients. Full article

(This article belongs to the Special Issue Management of Cardiopulmonary Bypass in Cardiovascular Surgery)

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19 pages, 838 KiB

Open AccessReview

Vasoplegic Syndrome after Cardiopulmonary Bypass in Cardiovascular Surgery: Pathophysiology and Management in Critical Care

by Zied Ltaief, Nawfel Ben-Hamouda, Valentina Rancati, Ziyad Gunga, Carlo Marcucci, Matthias Kirsch and Lucas Liaudet

J. Clin. Med. 2022, 11(21), 6407; https://doi.org/10.3390/jcm11216407 - 29 Oct 2022

Cited by 7 | Viewed by 7432

Abstract

Vasoplegic syndrome (VS) is a common complication following cardiovascular surgery with cardiopulmonary bypass (CPB), and its incidence varies from 5 to 44%. It is defined as a distributive form of shock due to a significant drop in vascular resistance after CPB. Risk factors of VS include heart failure with low ejection fraction, renal failure, pre-operative use of angiotensin-converting enzyme inhibitors, prolonged aortic cross-clamp and left ventricular assist device surgery. The pathophysiology of VS after CPB is multi-factorial. Surgical trauma, exposure to the elements of the CPB circuit and ischemia-reperfusion promote a systemic inflammatory response with the release of cytokines (IL-1β, IL-6, IL-8, and TNF-α) with vasodilating properties, both direct and indirect through the expression of inducible nitric oxide (NO) synthase. The resulting increase in NO production fosters a decrease in vascular resistance and a reduced responsiveness to vasopressor agents. Further mechanisms of vasodilation include the lowering of plasma vasopressin, the desensitization of adrenergic receptors, and the activation of ATP-dependent potassium (K_ATP) channels. Patients developing VS experience more complications and have increased mortality. Management includes primarily fluid resuscitation and conventional vasopressors (catecholamines and vasopressin), while alternative vasopressors (angiotensin 2, methylene blue, hydroxocobalamin) and anti-inflammatory strategies (corticosteroids) may be used as a rescue therapy in deteriorating patients, albeit with insufficient evidence to provide any strong recommendation. In this review, we present an update of the pathophysiological mechanisms of vasoplegic syndrome complicating CPB and discuss available therapeutic options. Full article

(This article belongs to the Special Issue Management of Cardiopulmonary Bypass in Cardiovascular Surgery)

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Other

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9 pages, 1017 KiB

Open AccessBrief Report

Gene Expression of Inflammatory Cytokines in Major Organs by Extracorporeal Circulation

by Takuya Abe, Haruo Hanawa and Yutaka Fujii

J. Clin. Med. 2023, 12(8), 2813; https://doi.org/10.3390/jcm12082813 - 11 Apr 2023

Cited by 2 | Viewed by 1038

Abstract

(1) Background: Extracorporeal circulation (ECC) is indispensable for cardiac surgery. Despite the fact that ECC causes non-physiological damage to blood components, its pathophysiology has not been fully elucidated. In our previous study, we constructed a rat ECC system and observed a systemic inflammatory response during and after blood tests assessing ECC, while the damage per organ localization caused by ECC was not examined. In this study, we used a rat model to assess the gene expression of inflammatory cytokines in major organs during ECC. (2) Methods: The ECC system consisted of a membranous oxygenator, tubing line, and a small roller pump. Rats were divided into a SHAM (which received surgical preparation only, without ECC) group and an ECC group. Proinflammatory cytokines were measured using real-time PCR in major organs after ECC to evaluate local inflammatory responses in the organs. (3) Results: Interleukin (IL)-6 levels were significantly elevated in the ECC group compared to the SHAM group, especially in the heart and lungs. (4) Conclusions: This study suggests that ECC promotes organ damage and the inflammatory response, but the degree of gene expression of proinflammatory cytokines varies from organ to organ, suggesting that it does not uniformly cause organ damage. Full article

(This article belongs to the Special Issue Management of Cardiopulmonary Bypass in Cardiovascular Surgery)

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