The influence of gaseous microemboli on various biomarkers after minimized cardiopulmonary bypass

Abstract

Introduction:

Gaseous microemboli that originate from the cardiopulmonary bypass circuit may contribute to adverse outcome after cardiac surgery. We prospectively evaluated the influence of gaseous microemboli on the release of various biomarkers after use of a minimally invasive extracorporeal technology system.

Methods:

In 70 patients undergoing coronary artery bypass grafting with minimized cardiopulmonary bypass, gaseous microemboli were measured intraoperatively with a bubble counter. Intra- and postoperative biomarker levels for inflammatory response (interleukin-6, C5b-9), endothelial damage (von Willebrand factor, soluble vascular cell adhesion molecule-1), oxidative stress (malondialdehyde, 8-isoprostane, neuroketal), and neurological injury (neuron-specific enolase, brain-type fatty acid-binding protein) were analyzed using immune assay techniques. The relationship between gaseous microemboli number or volume and the incremental area under the curve (iAUC_24h) or peak change for the biomarkers was calculated.

Results:

All biomarkers except for malondialdehyde increased at least temporarily after coronary artery bypass grafting with a minimally invasive extracorporeal technology system. The median total gaseous microemboli number was 6,174 (interquartile range: 3,507-10,531) and the median total gaseous microemboli volume was 4.31 µL (interquartile range: 2.71-8.50). There were no significant correlations between total gaseous microemboli number or volume and iAUC_24h or peak change for any of the biomarkers. After controlling for the variance of possible other predictor variables, multiple linear regression analysis showed no association between gaseous microemboli parameters and release of biomarkers.

Conclusion:

This study showed no evidence that gaseous microemboli contribute to increased biomarker levels after coronary artery bypass grafting with cardiopulmonary bypass. A reason for the absence of damage by gaseous microemboli may be the relative and considerably small amount of gaseous microemboli entering the patients in this study.

Keywords

gaseous microemboli minimally invasive extracorporeal technology minimized cardiopulmonary bypass biomarkers adverse effects cardiopulmonary bypass

Get full access to this article

View all access options for this article.

References

Gasz

Benko

Jancso

et al. Comparison of inflammatory response following coronary revascularization with or without cardiopulmonary bypass. Exp Clin Cardiol 2004; 9: 26–30.

Vohra

Whistance

Modi

et al. The inflammatory response to miniaturised extracorporeal circulation: a review of the literature. Mediators Inflamm 2009; 2009: 707042.

Muth

Shank

ES.

Gas embolism. N Engl J Med 2000; 342: 476–482.

Paparella

Yau

Young

Cardiopulmonary bypass induced inflammation: pathophysiology and treatment. An update. Eur J Cardiothorac Surg 2002; 21: 232–244.

Barak

Katz

Microbubbles: pathophysiology and clinical implications. Chest 2005; 128: 2918–2932.

Newman

Mathew

Grocott

et al. Central nervous system injury associated with cardiac surgery. Lancet 2006; 368: 694–703.

Borger

Feindel

CM.

Cerebral emboli during cardiopulmonary bypass: effect of perfusionist interventions and aortic cannulas. J Extra Corpor Technol 2002; 34: 29–33.

Rodriguez

Williams

Babaev

et al. Effect of perfusionist technique on cerebral embolization during cardiopulmonary bypass. Perfusion 2005; 20: 3–10.

Biglioli

Cannata

Alamanni

et al. Biological effects of off-pump vs. on-pump coronary artery surgery: focus on inflammation, hemostasis and oxidative stress. Eur J Cardiothorac Surg 2003; 24: 260–269.

10.

Kumar

Cann

Hall

et al. Predictive value of IL-18 and SC5b-9 for neurocognitive dysfunction after cardiopulmonary bypass. Br J Anaesth 2007; 98: 317–322.

11.

Bruins

te Velthuis

Yazdanbakhsh

et al. Activation of the complement system during and after cardiopulmonary bypass surgery: postsurgery activation involves C-reactive protein and is associated with postoperative arrhythmia. Circulation 1997; 96: 3542–3548.

12.

Nossum

Koteng

Brubakk

AO.

Endothelial damage by bubbles in the pulmonary artery of the pig. Undersea Hyperb Med 1999; 26: 1–8.

13.

Anastasiadis

Antonitsis

Haidich

et al. Use of minimal extracorporeal circulation improves outcome after heart surgery; a systematic review and meta-analysis of randomized controlled trials. Int J Cardiol 2013; 164: 158–169.

14.

Sun

Gong

Yuan

et al. What we have learned about minimized extracorporeal circulation versus conventional extracorporeal circulation: an updated meta-analysis. Int J Artif Organs 2015; 38: 444–453.

15.

Aboud

Liebing

Borgermann

et al. Excessive negative venous line pressures and increased arterial air bubble counts during miniaturized cardiopulmonary bypass: an experimental study comparing miniaturized with conventional perfusion systems. Eur J Cardiothorac Surg 2014; 45: 69–74.

16.

Longmire

Swift

Roberts

2nd

et al. Effect of oxygen tension on the generation of F2-isoprostanes and malondialdehyde in peroxidizing rat liver microsomes. Biochem Pharmacol 1994; 47: 1173–1177.

17.

Lapenna

Ciofani

Pierdomenico

et al. Reaction conditions affecting the relationship between thiobarbituric acid reactivity and lipid peroxides in human plasma. Free Radic Biol Med 2001; 31: 331–335.

18.

Collard

Gelman

Pathophysiology, clinical manifestations, and prevention of ischemia-reperfusion injury. Anesthesiology 2001; 94: 1133–1138.

19.

Castellheim

Hoel

Videm

et al. Biomarker profile in off-pump and on-pump coronary artery bypass grafting surgery in low-risk patients. Ann Thorac Surg 2008; 85: 1994–2002.

20.

Eikemo

Sellevold

Videm

Markers for endothelial activation during open heart surgery. Ann Thorac Surg 2004; 77: 214–219.

21.

Gunaydin

Sari

McCusker

et al. Clinical evaluation of minimized extracorporeal circulation in high-risk coronary revascularization: impact on air handling, inflammation, hemodilution and myocardial function. Perfusion 2009; 24: 153–162.

22.

Fromes

Gaillard

Ponzio

et al. Reduction of the inflammatory response following coronary bypass grafting with total minimal extracorporeal circulation. Eur J Cardiothorac Surg 2002; 22: 527–533.

23.

Huybregts

Morariu

Rakhorst

et al. Attenuated renal and intestinal injury after use of a mini-cardiopulmonary bypass system. Ann Thorac Surg 2007; 83: 1760–1766.

24.

Skrabal

Choi

Kaminski

et al. Circulating endothelial cells demonstrate an attenuation of endothelial damage by minimizing the extracorporeal circulation. J Thorac Cardiovasc Surg 2006; 132: 291–296.

25.

Stehouwer

Boers

de Vroege

et al. Clinical evaluation of the air removal characteristics of an oxygenator with integrated arterial filter in a minimized extracorporeal circuit. Int J Artif Organs 2011; 34: 374–382.

26.

Reinsfelt

Ricksten

Zetterberg

et al. Cerebrospinal fluid markers of brain injury, inflammation, and blood-brain barrier dysfunction in cardiac surgery. Ann Thorac Surg 2012; 94: 549–555.

27.

Gerriets

Schwarz

Sammer

et al. Protecting the brain from gaseous and solid micro-emboli during coronary artery bypass grafting: a randomized controlled trial. Eur Heart J 2010; 31: 360–368.

28.

Doganci

Gunaydin

Kocak

et al. Impact of the intensity of microemboli on neurocognitive outcome following cardiopulmonary bypass. Perfusion 2013; 28: 256–262.

29.

Liu

Wang

et al. The effects of cardiopulmonary bypass on the number of cerebral microemboli and the incidence of cognitive dysfunction after coronary artery bypass graft surgery. Anesth Analg 2009; 109: 1013–1022.

30.

Van Dijk

Kalkman

. Why are cerebral microemboli not associated with cognitive decline? Anesth Analg 2009; 109: 1006–1008.

31.

Branger

Eckmann

DM.

Theoretical and experimental intravascular gas embolism absorption dynamics. J Appl Physiol 1999; 87: 1287–1295.

32.

Segers

Stehouwer

de Somer

FMJJ

et al. Optical verification and in-vitro characterization of two commercially available acoustic bubble counters for cardiopulmonary bypass systems. Perfusion 2018; 33: 16–24.

33.

Chung

Banahan

Patel

et al. Size distribution of air bubbles entering the brain during cardiac surgery. PLoS ONE 2015; 10: e0122166.

34.

Haines

Stewart

Barka

et al. Microembolism and catheter ablation II: effects of cerebral microemboli injection in a canine model. Circ Arrhythm Electrophysiol 2013; 6: 23–30.

35.

Willcox

Mitchell

SJ.

Microemboli in our bypass circuits: a contemporary audit. J Extra Corpor Technol 2009; 41: P31–P37.

36.

Mitchell

Merry

AF.

Perspective on cerebral microemboli in cardiac surgery: significant problem or much ado about nothing?

J Extra Corpor Technol 2015; 47: 10–15.