Yuruk Koray, Bezemer Rick, Euser Mariska, Milstein Dan M J, de Geus Hilde H R, Scholten Evert W, de Mol Bas A J M, Ince Can
Department of Translational Physiology, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands.
Interact Cardiovasc Thorac Surg. 2012 Sep;15(3):364-70. doi: 10.1093/icvts/ivs271. Epub 2012 Jun 14.
OBJECTIVES To reduce the complications associated with cardiopulmonary bypass (CPB) during cardiac surgery, many modifications have been made to conventional extracorporeal circulation systems. This trend has led to the development of miniaturized extracorporeal circulation systems. Cardiac surgery using conventional extracorporeal circulation systems has been associated with significantly reduced microcirculatory perfusion, but it remains unknown whether this could be prevented by an mECC system. Here, we aimed to test the hypothesis that microcirculatory perfusion decreases with the use of a conventional extracorporeal circulation system and would be preserved with the use of an miniaturized extracorporeal circulation system. METHODS Microcirculatory density and perfusion were assessed using sublingual side stream dark-field imaging in patients undergoing on-pump coronary artery bypass graft (CABG) surgery before, during and after the use of either a conventional extracorporeal circulation system (n = 10) or a miniaturized extracorporeal circulation system (n = 10). In addition, plasma neutrophil gelatinase-associated lipocalin and creatinine levels and creatinine clearance were assessed up to 5 days post-surgery to monitor renal function. RESULTS At the end of the CPB, one patient in the miniaturized extracorporeal circulation-treated group and five patients in the conventional extracorporeal circulation-treated group received one bag of packed red blood cells (300 ml). During the CPB, the haematocrit and haemoglobin levels were slightly higher in the miniaturized extracorporeal circulation-treated patients compared with the conventional extracorporeal circulation-treated patients (27.7 ± 3.3 vs 24.7 ± 2.0%; P = 0.03; and 6.42 ± 0.75 vs 5.41 ± 0.64 mmol/l; P < 0.01). The density of perfused vessels with a diameter <25 µm (i.e. perfused vessel density) decreased slightly in the conventional extracorporeal circulation-treated group from 16.4 ± 3.8 to 12.8 ± 3.3 mm/mm(2) (P < 0.01) and remained stable in the miniaturized extracorporeal circulation-treated group (16.3 ± 2.7 and 15.2 ± 2.9 mm/mm(2) before and during the pump, respectively). Plasma neutrophil gelatinase-associated lipocalin levels were increased following the use of extracorporeal circulation in both groups, and no differences were observed between the groups. Plasma creatinine levels and creatinine clearance were not affected by CABG surgery or CPB. CONCLUSIONS The results from this relatively small study suggest that the use of the miniaturized extracorporeal circulation system is associated with a statistically significant (but clinically insignificant) reduction in haemodilution and microcirculatory hypoperfusion compared with the use of the conventional extracorporeal circulation system.
目的 为减少心脏手术期间与体外循环（CPB）相关的并发症，人们对传统体外循环系统进行了诸多改进。这一趋势促使了小型化体外循环系统的发展。使用传统体外循环系统进行心脏手术与显著降低的微循环灌注相关，但小型体外循环（mECC）系统能否预防这一情况仍不明确。在此，我们旨在验证以下假设：使用传统体外循环系统会导致微循环灌注降低，而使用小型化体外循环系统可维持微循环灌注。方法 采用舌下旁流暗视野成像技术，对10例使用传统体外循环系统和10例使用小型化体外循环系统进行体外循环冠状动脉旁路移植术（CABG）的患者，在使用体外循环系统前、期间及术后进行微循环密度和灌注评估。此外，在术后5天内评估血浆中性粒细胞明胶酶相关脂质运载蛋白和肌酐水平以及肌酐清除率，以监测肾功能。结果 在CPB结束时，小型化体外循环治疗组有1例患者、传统体外循环治疗组有5例患者接受了一袋浓缩红细胞（300 ml）。在CPB期间，小型化体外循环治疗患者的血细胞比容和血红蛋白水平略高于传统体外循环治疗患者（分别为27.7±3.3%对24.7±2.0%；P = 0.03；以及6.42±0.75对5.41±0.64 mmol/l；P < 0.01）。传统体外循环治疗组中直径<25 µm的灌注血管密度（即灌注血管密度）略有下降，从16.4±3.8降至12.8±3.3 mm/mm(2)（P < 0.01），而小型化体外循环治疗组保持稳定（泵前和泵期间分别为16.3±2.7和15.2±2.9 mm/mm(2)）。两组在使用体外循环后血浆中性粒细胞明胶酶相关脂质运载蛋白水平均升高，且两组间未观察到差异。血浆肌酐水平和肌酐清除率不受CABG手术或CPB的影响。结论 这项规模相对较小的研究结果表明，与使用传统体外循环系统相比，使用小型化体外循环系统在统计学上显著（但临床意义不显著）降低了血液稀释和微循环灌注不足。
