Perfusion Literature

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TOP TEN SELECTED PAPERS
- April 2011

1

Int J Artif Organs. 2011 Apr;34(4):374-82. doi: 10.5301/IJAO.2011.7749.

Clinical evaluation of the air removal characteristics of an oxygenator with
integrated arterial filter in a minimized extracorporeal circuit.

Stehouwer MC, Boers C, de Vroege R, C Kelder J, Yilmaz A, Bruins P.

Department of Extracorporeal Circulation, St Antonius Hospital, Nieuwegein - The 
Netherlands.

The use of minimized extracorporeal circuits (MECC) in cardiac surgery is an
important measure to increase the biocompatibility of cardiopulmonary bypass
during coronary artery bypass grafting (CABG). These circuits eliminate volume
storage reservoirs and bubble traps to minimize the circuit. However, the
reduction in volume may increase the risk of gaseous microemboli (GME). The MECC 
system as used by our group consists of a venous bubble trap, centrifugal pump,
and an oxygenator. To further reduce the risk of introducing GME, an oxygenator
with an integrated arterial filter was developed based on the concept of minimal 
volume and foreign surface. We studied the air removal characteristics of this
oxygenator with and without integrated arterial filter. The quantity and volume
of GME were measured with precision at both the inlet and outlet of the devices. 
Our results showed that integration of an arterial filter into this oxygenator
increased GME reducing capacity from 69.2% to 92%. Moreover, we were able to
obtain data on the impact of an arterial filter on the exact size-distribution of
GME entering the arterial line. The present study demonstrates that an MECC
system and oxygenator with integrated arterial filter significantly reduces the
volume and size of GME. The use of an integrated arterial filter in an MECC
system may protect the patient from the deleterious effects of CPB and may
further improve patient safety.

 Eur J Cardiothorac Surg. 2011 Apr 29. [Epub ahead of print]

The impact of deep and moderate body temperatures on end-organ function during
hypothermic circulatory arrest.

Khaladj N, Peterss S, Pichlmaier M, Shrestha M, von Wasielewski R, Hoy L,
Haverich A, Hagl C.

Division of Cardiac, Thoracic, Transplantation and Vascular Surgery, Hannover
Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany.

Objective: Hypothermic circulatory arrest (HCA) at different temperatures is a
protection technique for operations involving the aortic arch. In combination
with selective cerebral perfusion, higher arrest temperatures for the remaining
body may be permitted. However, the ischaemic/reperfusion injury (I/R) in various
organ systems, other than the brain, related to the specific HCA temperature has 
so far not been evaluated. Methods: Fourteen pigs were randomly assigned to 60min
of sole HCA at 20 or 30°C temperature, weaned from cardiopulmonary bypass (CPB)
and followed 4h after HCA. Besides complex haemodynamic monitoring, laser-Doppler
spectrophotometry for measuring capillary blood flow, tissue oxygen saturation
and post-capillary venous filling pressures of the bowel was installed. At the
end of experiment, organs were perfusion fixated and harvested. Results: During
the entire experiment, haemodynamics revealed no differences between the groups. 
CPB bypass times were 177±12min in the 20°C and 158±11min in the 30°C group,
respectively (p=0.02). During reperfusion, lactate levels were initially
significantly higher in the 30°C animals (p=0.001) but subsequently declined.
Microcirculatory blood flow and velocity in the bowel were significantly reduced 
during cooling and reperfusion (p<0.05), but were independent of final HCA
temperature. Histological evaluation revealed significantly more oedema formation
in the bowel wall of the 30°C animals (p=0.05). Conclusions: Higher levels of
circulating lactate levels during reperfusion indicate less effective organ
protection at 30 than at 20°C after 60min of HCA. This is further substantiated
by histological evidence for a more pronounced oedema inflammatory response
within the bowel wall.

J Heart Lung Transplant. 2011 Apr 28. [Epub ahead of print]

Inhaled nitric oxide after left ventricular assist device implantation: A
prospective, randomized, double-blind, multicenter, placebo-controlled trial.

Potapov E, Meyer D, Swaminathan M, Ramsay M, El Banayosy A, Diehl C, Veynovich B,
Gregoric ID, Kukucka M, Gromann TW, Marczin N, Chittuluru K, Baldassarre JS,
Zucker MJ, Hetzer R.

Deutsches Herzzentrum Berlin, Berlin, Germany.

BACKGROUND: Used frequently for right ventricular dysfunction (RVD), the clinical
benefit of inhaled nitric oxide (iNO) is still unclear. We conducted a
randomized, double-blind, controlled trial to determine the effect of iNO on
post-operative outcomes in the setting of left ventricular assist device (LVAD)
placement. METHODS: Included were 150 patients undergoing LVAD placement with
pulmonary vascular resistance ≥200 dyne/sec/cm(-5). Patients received iNO (40
ppm) or placebo (an equivalent concentration of nitrogen) until 48 hours after
separation from cardiopulmonary bypass, extubation, or upon meeting study-defined
RVD. For ethical reasons, crossover to open-label iNO was allowed during the
48-hour treatment period if RVD criteria were met. RESULTS: RVD criteria were met
by 7 of 73 patients (9.6%; 95% confidence interval, 2.8-16.3) in the iNO group
compared with 12 of 77 (15.6%; 95% confidence interval, 7.5-23.7) who received
placebo (p = 0.330). Time on mechanical ventilation decreased in the iNO group
(median days, 2.0 vs 3.0; p = 0.077), and fewer patients in the iNO group
required an RVAD (5.6% vs 10%; p = 0.468); however, these trends did not meet
statistical boundaries of significance. Hospital stay, intensive care unit stay, 
and 28-day mortality rates were similar between groups, as were adverse events.
Thirty-five patients crossed over to open-label iNO (iNO, n = 15; placebo, n =
20). Eighteen patients (iNO, n = 9; placebo, n = 9) crossed over before RVD
criteria were met. CONCLUSIONS: Use of iNO at 40 ppm in the perioperative phase
of LVAD implantation did not achieve significance for the primary end point of
reduction in RVD. Similarly, secondary end points of time on mechanical
ventilation, hospital or intensive care unit stay, and the need for RVAD support 
after LVAD placement were not significantly improved.

 Heart Surg Forum. 2011 Apr 1;14(2):E105-9.

Atrial Myxomas: A Single Unit's Experience in the Modern Era.

Owers CE, Vaughan P, Braidley PC, Wilkinson GA, Locke TJ, Cooper GJ, Briffa NP,
Hopkinson DN, Sarkar PK.

Department of Cardiothoracic Surgery, Northern General Hospital, Sheffield,
United Kingdom.

Background: Although an atrial myxoma is the commonest cardiac tumor, it is still
relatively rare, with an annual incidence of approximately 0.5 per million. In
our unit, which performs 1000 major cardiac procedures per year, this equates to 
approximately 3 patients annually. We therefore sought to evaluate our experience
of managing this type of tumor over the last 5 years.Methods: A retrospective
review was performed of prospectively collected data from the departmental
database. We analyzed consecutive patients who were operated upon between 2002
and 2007. Three patients with a papillary fibroelastoma on histological
examination were excluded from this study.Results: We have performed excision of 
atrial myxoma in 18 patients. Twelve patients (66%) were female; the median age
was 64 years (range, 35-80 years), and the median logistic euroSCORE was 5.22%
(range, 1.51-27.82%). Fifteen patients (83%) were deemed urgent, 2 elective, and 
1 emergency. Sixteen tumors (89%) were left sided. Symptoms attributable to the
tumor were found in 16 of the 18 patients (embolic, n = 9; chest pain, n = 3;
palpitations, n = 2; incidental finding, n = 2, others n = 4), and the mean time 
from diagnosis to operation was 3 days (range, 0-22 months). The median
cardiopulmonary bypass time was 87 minutes (range, 28-228 minutes), with the
median aortic cross clamp time being 61 minutes (16-175 minutes).The approaches
used were transeptal via right atriotomy (n = 8), biatrial/Dubost (n = 4), left
atrial (n = 4), and right atrial (n = 2); the interatrial septum was involved in 
14 patients. The resultant defect was closed using a pericardial (n = 8) or
prosthetic patch (n = 5) or directly sutured (n = 5). Concomitant procedures were
performed in 8 patients (coronary artery bypass graft [CABG], n = 4; mitral valve
replacement [MVR], n = 2; valve + grafts, n = 2). All tumors were completely
excised.Postoperatively there were no deaths within 30 days of the procedure.
Indeed, only 2 patients have died at 4 and 25 months postoperatively,
respectively, both of unrelated causes. Median intensive therapy unit (ITU) stay 
was 2 days (range, 1-9 days), and median hospital stay was 10 days (range, 5-20
days). A permanent pacemaker was required in only 1 patient, and median blood
loss was 340 mL (range, 140-1760 mL). Atrial fibrillation was the commonest
complication affecting 6/18 patients (33%).Conclusions: Excision of atrial myxoma
can be performed using a variety of intraoperative approaches and closure
techniques, all with acceptable postoperative morbidity and low mortality rates. 
To date, no recurrences have been found at median 2-year follow-up.

 Transfus Med. 2011 Apr 24. doi: 10.1111/j.1365-3148.2011.01075.x. [Epub ahead of 
print]

The effect of RBC transfusions on cytokine gene expression after cardiac surgery 
in patients developing post-operative multiple organ failure.

Sitniakowsky LS, Later AF, van de Watering LM, Bogaerts M, Brand A, Klautz RJ,
Smit NP, van Hilten JA.

Department of Transfusion Medicine, Sanquin Blood Supply, Research Division
Department of Cardiothoracic Surgery, LUMC Department of Immunohematology and
Blood Transfusion, LUMC Department of Clinical Chemistry, LUMC, Leiden, The
Netherlands.

Aim: To determine the effect of red blood cell (RBC) transfusions during cardiac 
surgery on cytokine gene expression (GE) in relation to multiple organ failure
(MOF) development after systemic inflammatory response syndrome (SIRS).
Background: RBC transfusion in cardiac surgery patients is dose-dependently
associated with post-operative MOF, possibly acting as a second hit after
cardiopulmonary bypass. Methods: For this observational study, 29 patients
divided into four groups of cardiac surgery patients were selected from a
randomised controlled trial (RCT). Group 1: no-RBC, no-MOF (N = 8); group 2: MOF,
no-RBC (N = 7); group 3: RBC, no-MOF (N = 6); group 4: RBC and MOF (N = 8).
Selection was based on age, gender, number of (leukocyte-depleted) RBC
transfusions, type and duration of surgery. A 114 cytokine GE array was applied
to blood samples withdrawn before and 24 h after surgery. Expression of selected 
genes was confirmed with reverse transcriptase real time-polymerase chain
reaction (RT-PCR). Results: Nineteen of the 39 detectable genes showed a
significant change in GE after surgery. Confirmed by RT-PCR, transfused MOF
patients exhibit significantly less downregulation of CD40 ligand than control
patients. Patients who would develop MOF show significantly larger increases in
GE of transforming growth factor-α (TGF-α), tumour necrosis factor
(TNF)-superfamily members 10 and 13B (TNFsf10/13B). Conclusions: When tested at
24 h after surgery, cytokine GE in peripheral blood leucocytes showed no
significant differences between those transfused and those not transfused. Some
alterations were seen in those developing MOF compared to those who did not, but 
the findings offer no role of leukocyte depleted (LD) RBC transfusion in the
development of MOF.

Urol Oncol. 2011 Apr 20. [Epub ahead of print]

The perioperative management of an inferior vena caval tumor thrombus in patients
with renal cell carcinoma.

Woodruff DY, Van Veldhuizen P, Muehlebach G, Johnson P, Williamson T,
Holzbeierlein JM.

Department of Urology, University of Kansas, Kansas City, KS 66160, USA.

OBJECTIVES: Inferior vena caval tumor thrombus (IVC-TT) occurs in 10% of patients
diagnosed with renal cell carcinoma (RCC). The perioperative management of these 
patients remains challenging. Despite multiple publications outlining surgical
approaches and outcomes there have been few studies detailing the best
peri-operative management of patients with IVC-TT. Our goal was to define the
optimal management of patients with RCC and IVC-TT. MATERIALS AND METHODS: A
review of all published literature regarding the management of RCC with IVC-TT
was performed utilizing Pub Med and the Cochrane Database. Reviews were also made
of all relevant literature regarding the need for cardiopulmonary bypass and
recommendations regarding thrombus in any location in patients with malignancy.
Specific items critically examined included: need for preoperative heart
catheterization, need for anticoagulation and type of anticoagulation, need for
additional studies such as lower extremity duplex or venogram, and indications
for vena caval filter placement. The results were then presented to a
multidisciplinary group made up of experts in the fields of Urology, Hematology, 
Oncology, Cardiothoracic Surgery, Interventional Radiology, and
Pulmonary/Critical Care. Based on the available literature a best practice
guidelines regarding the management of RCC with IVC-TT was established at our
institution. RESULTS: Our institutional recommendations include (1) preoperative 
cardiac catheterization in all patients believed to require cardiopulmonary
bypass for removal of the thrombus but only cardiac clearance for those who
bypass is unlikely, (2) preoperative anticoagulation using a low molecular weight
heparin such as enoxaparin unless contraindicated due to bleeding from the tumor 
or other contraindication, (3) avoidance of vena caval filters whenever possible 
is recommended due the potential for caval thrombosis and the difficulties they
present during surgical resection. CONCLUSION: This study identified the
available literature on the management of IVC-TT in association with RCC and was 
carefully reviewed by a multidisciplinary team. As a result, we have established 
a set of practice guidelines at our institution to help optimally manage patients
with renal cell carcinoma and an inferior venal caval thrombus.

Anaesthesia. 2011 Apr 18. doi: 10.1111/j.1365-2044.2011.06709.x. [Epub ahead of
print]

A comparison of low vs conventional-dose heparin for minimal cardiopulmonary
bypass in coronary artery bypass grafting surgery.

Fromes Y, Daghildjian K, Caumartin L, Fischer M, Rouquette I, Deleuze P, Bical
OM.

 Research Director, Laboratory of Experimental Physiology, Institute of Myology, 
Paris, France  Head of Perfusion Unit, Department of Cardiac Surgery  Pharmacist 
 Cardiac Surgeon, Department of Cardiac Surgery  Cardiologist  Anaesthetist,
Department of Anaesthesiology and Intensive Care, Groupe Hospitalier Paris Saint 
Joseph, Paris, France.

The biocompatibility of minimal extracorporeal circuits has improved; however,
anticoagulation is still required. We compared standard high-dose anticoagulation
with a low-dose heparin regimen in a retrospective study of patients who
underwent coronary bypass surgery using minimal cardiopulmonary bypass. One
hundred patients who received 300 IU.kg(-1) heparin were compared with 68
patients who received heparin according to an individually adjusted activated
coagulation time target of 300 s, resulting in a mean (SD) heparin dose of 145
(30) IU.kg(-1) . There were no thromboembolic events in either group; however,
patients in the low-dose group had lower 24-hour mean (SD) postoperative blood
loss than the conventional group (545 (61) vs 680 (88) ml, p = 0.001) and a
reduced rate of transfusion of allogeneic blood (15% patients transfused vs 32%, 
p = 0.01). An individually tailored low-dose heparin regimen for minimal
cardiopulmonary bypass is safe and may be associated with reduced bleeding and
lower transfusion requirements.

Eur J Cardiothorac Surg. 2011 Apr 14. [Epub ahead of print]

Early severe digestive complications after lung transplantation.

Lahon B, Mordant P, Thabut G, Georger JF, Dauriat G, Mal H, Lesèche G, Castier Y.

Service de chirurgie thoracique, vasculaire, et de transplantation pulmonaire,
Hôpital Bichat, AP-HP, Université Denis Diderot - Paris 7, Paris, France.

Objective: This study aimed to describe and to analyze early severe digestive
complications (ESDC) after lung transplantation (LT) in our center. Methods: A
retrospective study included 351 patients, who underwent LT without
cardiopulmonary bypass (CPB) at our center between March 1988 and December 2009. 
There were 86 double LTs and 265 single LTs. ESDCs were defined as complications 
(1) occurring during the first 30 days after transplantation or during initial
hospitalization if longer; (2) involving the gastrointestinal tract; and (3)
jeopardizing survival or requiring invasive therapeutic procedure. Patients'
characteristics, associated risk factors, and influence of ESDC on early outcome 
have been analyzed. Results: During the first 30 days after LT or initial
hospitalization if longer, 26 ESDCs occurred in 26 patients (rate 7.4%, sex ratio
M/F 66%, mean age 56±6 years). This included 10 acute cholecystitis (38%), four
angiocholitis (15%), three perforated gastroduodenal ulcers (11%), three
digestive perforations (11%), two intestinal occlusions (8%), two mesenteric
ischemia (8%), and two acute pancreatitis (8%). ESDC occurred after a mean
postoperative follow-up of 14 days (5-46), required emergency surgical treatment 
in 20 cases (77%), significantly prolonged the mean duration of hospitalization
(96 days with ESDC vs 55 days without ESDC, p<0.0001), and was responsible for
death in five cases (19%). Surgical treatment included cholecystectomy (n=11),
bowel resection (n=3), ulcer surgery (n=2), subtotal colectomy (n=2), Hartmann
procedure (n=1), and open coelioscopy (n=1). Age and bilateral LT were found to
be significant risk factors for ESDC in both uni- and multivariate analyses.
Conclusion: ESDC occurred in 7.4% of patients after LT without CPB, and was
responsible for longer in-hospital stay. Relevant risk factors included older age
and bilateral LT, interfering with current debate regarding recipients' selection
and procedure's choice.

Clin Exp Nephrol. 2011 Apr 12. [Epub ahead of print]

Predictors of acute kidney injury post-cardiopulmonary bypass in children.

Sethi SK, Goyal D, Yadav DK, Shukla U, Kajala PL, Gupta VK, Grover V, Kapoor P,
Juneja A.

Department of Pediatrics, PGIMER and Associated RML Hospital, New Delhi, 110001, 
India, sidsdoc@gmail.com.

OBJECTIVE: To investigate the incidence, implicating factors and outcome of acute
kidney injury (AKI) after cardiopulmonary bypass (CPB) in patients admitted to a 
pediatric cardiothoracic intensive care unit (ICU). MATERIALS AND METHODS:
Design: A retrospective review study. Setting: A 10-bed cardiothoracic ICU.
Patients: One hundred and twenty-four children (<18 years of age) admitted to the
cardiothoracic ICU following CPB between January 2007 and December 2009. Methods:
Age, sex, diagnosis, baseline and post-surgery hemoglobin, total leukocyte count,
platelet count and biochemistry were recorded. Baseline and postoperative urea
(mg/dl), creatinine (mg/dl), urine output (ml/kg/h) and inotrope dose were also
recorded daily. The duration of CPB was noted. Postoperative cardiac, renal,
hepatic, neurologic and respiratory dysfunctions were recorded. RESULTS: Seven
(5%) children developed AKI stage I, five children (4%) developed AKI stage II
and two children developed AKI stage III (2%). All patients with AKI had a longer
stay in hospital and increased mortality. Two children required dialysis for AKI 
and none developed chronic renal impairment. All patients with AKI stage III died
during the ICU stay. Using stepwise regression, younger age (<1 year), weight
<10 kg, pump failure, sepsis and duration of CPB >90 min were significant risk
factors identified for developing AKI. CONCLUSIONS: AKI is common and occurred in
11% of our patients following CPB; however, AKI requiring renal replacement
therapy is uncommon.

 Eur J Cardiothorac Surg. 2011 Apr 1. [Epub ahead of print]

New technique of off-pump atrial septostomy for complex congenital cardiac
anomalies.

Kandakure PR, Vejendla G, Ramodoss N, Rani U, Prasad S, Chakravarthy S, Rao IM,
Kona SM.

Department of Paediatric Cardiac Surgery, Paediatric Cardiology and Cardiac
Anaesthesiology, Innova Children's Heart Hospital, Tarnaka, Secunderabad 500017, 
Andhra Pradesh, India.

Objectives: Atrial septostomy is essential for palliation of some complex
congenital cardiac anomalies, such as transposition of the great arteries and
left-/right-sided atrioventricular valve stenosis or atresia. Conventionally,
balloon atrial septostomy is done in neonates. Beyond the neonatal period,
surgical septostomy is done using cardiopulmonary bypass and can lead to
increased morbidity and mortality. We report a new technique of atrial septostomy
without cardiopulmonary bypass and its follow-up. Methods: Eleven cases underwent
atrial septostomy without using cardiopulmonary bypass from January 2009 to June 
2010. Median age of patients was 7 months (2-12 months) and median weight was
6.3kg (range 4.5-10kg). Surgical septostomy was performed through the right
atrial appendage with a Tubb's dilator, aided by intra-operative transesophageal 
echocardiography. Atrial septal defect (ASD) less than 5mm was enlarged with a
Kerrison bone punch and then dilated with a Tubb's dilator. Associate procedures 
performed were off-pump Glenn in seven cases, pulmonary artery (PA) banding in
three cases, and shunt with PA band in one case. Results: All the restricted ASDs
were successfully enlarged with adequate interatrial shunting without any
gradient. Echocardiography revealed no evidence of introduction of air or
particulate emboli, and no tricuspid valve injury or heart block. There was no
postoperative mortality. Follow-up ranged from 1 to 18 months (median 11months). 
Echocardiography showed good PA band gradient/well-functioning Glenn shunt and
unobstructed ASD with good oxygen saturation. Conclusions: This technique
demonstrates the surgical feasibility of a beating-heart atrial septostomy. It
avoids the adverse effects of cardiopulmonary bypass, reduces morbidity, and has 
no mortality. It is safe, economical, and easily reproducible. To our knowledge, 
this technique has not been reported in literature so far.

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