Clinical and Laboratory Predictors for the Development of Low Cardiac Output Syndrome in Infants Undergoing Cardiopulmonary Bypass: A Pilot Study
Sarah DrennanKathryn BurgeEdgardo SzyldJeffrey EckertArshid MirAndrew K. GormleyRandall M. SchwartzSuanne M. DavesJess L. ThompsonHarold M. BurkhartHala Chaaban
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Abstract:
Cardiac surgery employing cardiopulmonary bypass exposes infants to a high risk of morbidity and mortality. The objective of this study was to assess the utility of clinical and laboratory variables to predict the development of low cardiac output syndrome, a frequent complication following cardiac surgery in infants. We performed a prospective observational study in the pediatric cardiovascular ICU in an academic children’s hospital. Thirty-one patients with congenital heart disease were included. Serum levels of nucleosomes and a panel of 20 cytokines were measured at six time points in the perioperative period. Cardiopulmonary bypass patients were characterized by increased levels of interleukin-10, -6, and -1α upon admission to the ICU compared to non-bypass cardiac patients. Patients developing low cardiac output syndrome endured longer aortic cross-clamp time and required greater inotropic support at 12 h postoperatively compared to bypass patients not developing the condition. Higher preoperative interleukin-10 levels and 24 h postoperative interleukin-8 levels were associated with low cardiac output syndrome. Receiver operating characteristic curve analysis demonstrated a moderate capability of aortic cross-clamp duration to predict low cardiac output syndrome but not IL-8. In conclusion, low cardiac output syndrome was best predicted in our patient population by the surgical metric of aortic cross-clamp duration.Keywords:
Aortic cross-clamp
The institution of cardiopulmonary bypass generates many pro-inflammatory cytokines and several clinical variables, including temperature, have been shown to influence cytokine release during and after cardiopulmonary bypass. The release of tumour necrosis factor and interleukin-6 are the best predictors of post-cardiopulmonary bypass related morbidity. Their release during normothermic and hypothermic cardiopulmonary bypass and the correlation with clinical parameters of organ injury was studied. This prospective study was carried out in 52 adult patients, scheduled for cardiac surgery, exposed to normothermic and 27 to hypothermic cardiopulmonary bypass. Samples for estimation of tumour necrosis factor and interleukin-6 were collected preoperatively, 1 hour and 24 hours post cardiopulmonary bypass and analysed by ELISA. Haemodynamic parameters and respiratory parameters were noted and lung injury scores calculated. Interleukin-6 levels were raised in both the groups at 1 hour and 24 hours post cardiopulmonary bypass and the response was higher in the normothermic group. Tumour necrosis factor response was, however, similar in both the groups, with a rise at 1 hour returning back to baseline by 24 hours post cardiopulmonary bypass. The normothermic group had a better respiratory index in the postoperative period, early extubation was possible, had better clinical haemodynamics, a shorter cardiopulmonary bypass time and had reduced requirement of defibrillation after the release of aortic cross clamp. We conclude that the release of interleukin-6 was thermo-dependent but did not correlate with the clinical signs of organ injury. Tumour necrosis factor levels were significantly raised after the cardiopulmonary bypass but the rise was not thermo-dependent.
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Proinflammatory cytokines have been implicated in mediating tissue injury after cardiopulmonary bypass. Causative factors of inflammatory response after cardiopulmonary bypass include contact of the blood with the extracorporeal circuit and heart-lung reperfusion injury when discontinuing bypass. To evaluate proinflammatory cytokine release during cardiopulmonary bypass, plasma levels of interleukin-6, 8, and monocyte chemoattractant factor were measured in the radial artery (for systemic blood) and left atrium before and after cardiopulmonary bypass. A total of 13 patients were studied, with no deaths or complications. In both radial artery and left atrium, interleukin-6, 8, and monocyte chemoattractant factor rose significantly after cardiopulmonary bypass (p < 0.05 versus before cardiopulmonary bypass). These changes may have been caused by removal of the aortic cross clamp and recommencement of artificial ventilation, which result in reperfusion of the pulmonary capillary beds. There were no differences in cytokine levels after cardiopulmonary bypass in the radial artery and left atrium. This result suggested that lung reperfusion injury after cardiopulmonary bypass may not be the major causative factor of the release of proinflammatory cytokines.
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The effect of cardiopulmonary bypass (CPB) on the cardiopulmonary function after open heart surgery was evaluated by multiple regression analysis in relation with preoperative factors. In cases without decompensated heart failure, the depression of cardiac function and its recovery after CPB were mostly related to cross-clamp time. The pulmonary oxygenation was affected with operation time, and the duration of artificial ventilation correlated with CPB time. From these results, we conclude that CPB is the most important factor determining the cardiopulmonary function after CPB.
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Minimizing cardiac surgery related mortality and furthermore morbidity remains at the center of patient focused care and quality improvement. We present our experience with single cross-clamp technique following coronary artery bypass graft surgery (CABG) with or without aortic valve replacement (AVR).
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OBJECTIVE To evaluate the effect of cardiopulmonary bypass(CPB) on nutrition in children.METHODSForty children,less than 15 kg,with congenital heart defects were chosen in the study.The blood samples were collected at pre-operation,aortic clamp on,aortic clamp off,CPB wean off,MUF cessation,post-operative 2 hours and post-operative 20 hours for measurement of the concentration of glucose,protein and fatty acid.RESULTS The concentration of glucose increased significantly at the beginning of CPB(P0.01),and didn't change during bypass.Post-operatively,it increased first and decreased 20 hours later.The concentration of free fatty acid decreased when CPB began(P0.01),and increased during MUF(P0.01).Post-operatively,it decreased progressively and was significantly lower than baseline(P0.01) at postoperative 20 hours.The concentration of total protein decreased during CPB(P0.01) and increased progressively after CPB.However,it was still lower than baseline(P0.05) at postoperative 20 hours.CONCLUSION The metabolism of nutrition substances is unique in children.Unlike adults,the concentrations of blood glucose and free fatty acid didn't raise significantly during CPB,and the glucose,fatty acid and protein are in low level postoperatively.The nutrition support plays an important roles in pediatric cardiac surgery and more attention should be paid to this area.
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Results Our results showed highly significant difference in the registrars group compared to consultants for cumulative cardiopulmonary bypass time, and aortic cross clamp time; p < 0.01. While there was significant difference concerning post operative chest infection, p < 0.05 in the registrars group. There was no statistically significant difference in logistic euro score, in-hospital mortality, incidence of post operative infection, post operative renal impairment, post operative arrhythmias, ICU readmission, post operative stay, reopening or the need for inotropes.
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Objective: Apoptotic cardiomyocyte death is induced during open heart surgery, but its determinants are poorly understood. Prolonged aortic clamping time is associated with adverse clinical outcomes. The purpose of this study was to determine whether occurrence of cardiomyocyte apoptosis is related to the duration of aortic clamping in experimental pig model of cardiac surgery with cardiopulmonary bypass. Methods: The pigs (mean weight 29 ± 1 kg) were randomly divided to undergo cardioplegic arrest for 60 (n = 4) or 90 (n = 4) min followed by reperfusion period of 120 min. Control group (n = 5) was connected to cardiopulmonary bypass for 120 min without cardioplegic arrest. Cardiomyocyte apoptosis was detected (TUNEL assay and immunohistochemical staining of active caspase-3) in left ventricular tissue samples obtained before ischemia and after the ischemia-reperfusion period. Results: Apoptotic cardiomyocytes were found in all samples obtained after cardioplegic arrest and cardiopulmonary bypass alone with the TUNEL assay. The amount of apoptosis after the 120 min of cardiopulmonary bypass alone in the control group was 0.006 ± 0.001%. Compared with this, cardiomyocyte apoptosis was increased after cardioplegic arrest. After 60 min of aortic cross-clamp the amount of apoptosis was 0.019 ± 0.004% (p = 0.031). After 90 min of aortic cross-clamp the amount was 0.042 ± 0.005% (p ≪ 0.001) being significantly higher than after 60 min (p = 0.001). Aortic cross-clamp of 90 min also resulted in a detectable increase in caspase-3 activation when compared with controls. Conclusions: The occurrence of cardiomyocyte apoptosis increases with prolonged aortic clamping time during open heart surgery.
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