Introduction: Acute kidney injury (AKI) and intestinal injury negatively impact patient outcome after cardiac surgery. Enhanced nitric oxide (NO) consumption due to intraoperative intravascular hemolysis, may play an important role in this setting. This study investigated the impact of hemolysis on plasma NO consumption, AKI, and intestinal tissue damage, after cardiac surgery.Methods: Hemolysis (by plasma extracellular (free) hemoglobin; fHb), plasma NO-consumption, plasma fHb-binding capacity by haptoglobin (Hp), renal tubular injury (using urinary N-Acetyl-β-D-glucosaminidase; NAG), intestinal mucosal injury (through plasma intestinal fatty acid binding protein; IFABP), and AKI were studied in patients undergoing off-pump cardiac surgery (OPCAB, N = 7), on-pump coronary artery bypass grafting (CABG, N = 30), or combined CABG and valve surgery (CABG+Valve, N = 30).Results: FHb plasma levels and NO-consumption significantly increased, while plasma Hp concentrations significantly decreased in CABG and CABG+Valve patients (p < 0.0001) during surgery. The extent of hemolysis and NO-consumption correlated significantly (r2 = 0.75, p < 0.0001). Also, NAG and IFABP increased in both groups (p < 0.0001, and p < 0.001, respectively), and both were significantly associated with hemolysis (Rs = 0.70, p < 0.0001, and Rs = 0.26, p = 0.04, respectively) and NO-consumption (Rs = 0.55, p = 0.002, and Rs = 0.41, p = 0.03, respectively), also after multivariable logistic regression analysis. OPCAB patients did not show increased fHb, NO-consumption, NAG, or IFABP levels. Patients suffering from AKI (N = 9, 13.4%) displayed significantly higher fHb and NAG levels already during surgery compared to non-AKI patients.Conclusions: Hemolysis appears to be an important contributor to postoperative kidney injury and intestinal mucosal damage, potentially by limiting NO-bioavailability. This observation offers a novel diagnostic and therapeutic target to improve patient outcome after cardiothoracic surgery.

For over a century, centrifugal pumps (CP) have been used in various applications, from large industrial pumps to flow pumps for aquariums. However, the use of CP as blood pumps has a rather short history. Consequently, the hydraulic performance data for a blood CP are limited. The aim of our investigation was to study the hydraulic performance and the heat generation of three commercially available CP: Bio-Medicus Bio-Pump BP80 (Medtronic), Rotaflow (Jostra Medizintechnik), and DeltaStream DP2 (MEDOS Medizintechnik AQ). The study was performed using a circuit primed with a water-glycerin mixture with a dynamic viscosity of 0.00272 pa/s. Pressure-flow curves were obtained by a stepwise stagnation of the pump outlet or inlet. The temperature changes were observed using ThermaCAM SC2000 (Flir Systems). The pumps' performance in close to clinical conditions ('operating region') was analysed in this report. The 'operating region' in the case of the BP80 is positioned around the pressure-flow curve at a pump speed of 3000 rpm. In the case of the Rotaflow, the 'operating region' was between the pump pressure-flow curves at a speed of 3000 and 4000 rpm, and the DP2 was found between 7000 and 8000 rpm. The standard deviation of mean pressure through the pump was used to characterise the stability of the pump. In experiments with outlet stagnation, the BP80 demonstrated high negative association between flow and pressure variability (r = -0.68, p < 0.001). In experiments with the DP2, this association was positive (r = 0.68, p < 0.001). All pumps demonstrated significantly higher variability of pressure in experiments with inlet stagnation in comparison to the experiments with outlet stagnation. The rise of relative temperature in the inlet of a pump was closely related to the flow rate. The heating of fluid was more pronounced in the 'zero-flow' mode, especially in experiments with inlet stagnation. In summary, (1) the 'zero-flow' regime, which is described in the manuals of some commercially-available pumps, is the use of the pump outside the allowable operating region. It is potentially dangerous and should, therefore, never be used in clinical settings. (2) Using centrifugal pumps for kinetic-assisted venous return can only be performed safely when the negative pressure at the inlet of the pump is monitored continuously. The maximum allowable negative pressure has to be defined for each type of pump, and must be based on pump performance.

PurposeProper cannula positioning in single site veno-venous extracorporeal life support (vv-ELS) is cumbersome and necessitates image guidance to obtain a safe and stable position within the heart and the caval veins. Importantly, image-guided cannula positioning alone is not sufficient, as possible recirculation cannot be quantified.Methods and resultsWe present an ultrasound dilution technique allowing quantification of recirculation for optimizing vv-ELS.ConclusionWe suggest quantification of recirculation in addition to image guidance to provide optimal vv-ELS.

Although a growing body of evidence indicates superiority of minimized cardiopulmonary bypass (mCPB) systems over conventional CPB systems, limited venous return can result in severe fluctuations of venous line pressure which can result in gaseous emboli. In this study, we investigated the influence of sub-atmospheric pressures and volume buffer capacity added to the venous line on the generation of gaseous emboli in the mCPB circuit. Two different mCPB systems (MEC - Maquet, n=7 and ECC.O - Sorin, n=8) and a conventional closed cardiopulmonary bypass (cCPB) system (n=12) were clinically evaluated. In the search for a way to increase volume buffer capacity of mCPB systems, we additionally evaluated the 'Better Bladder' (BB) in a mock circulation by simulating, repeatedly, decreased venous return while measuring pressure and gaseous embolic activity. Arterial gaseous emboli activity during clinical perfusion with a cCPB system was the lowest in comparison to the mCPB systems (312±465 versus 311±421 with MEC and 1,966±1,782 with ECC.O, counts per 10 minute time interval, respectively; p=0.03). The average volume per bubble in the arterial line was the highest in cases with cCPB (12.5±8.3 nL versus 8.0±4.2 nL with MEC and 4.6±4.8 nL with ECC.O; p=0.04 for both). Significant cross-correlation was obtained at various time offsets from 0 to +35 s between sub-atmospheric pressure in the venous line and gaseous emboli activity in both the venous and arterial lines. The in vitro data showed that incorporation of the BB dampens fluctuations of venous line pressure by approximately 30% and decreases gaseous emboli by up to 85%. In conclusion, fluctuations of sub-atmospheric venous line pressure during kinetic-assisted drainage are related to gaseous emboli. Volume buffer capacity added to the venous line can effectively dampen pressure fluctuations resulting from abrupt changes in venous return and, therefore, can help to increase the safety of minimized cardiopulmonary bypass by reducing gaseous microemboli formation resulting from degassing.

Next to severely decreased pump flow, hypovolemia in extracorporeal life support (ELS) can result in subatmospheric venous line pressure. Such pressure may lead to degassing and resultant gaseous microemboli (GME), with potential changes in neurological clinical outcome. CME activity resulting from degassing was investigated in relation to subatmospheric venous line pressure, partial oxygen pressure (pO2 ), and hematocrit in a model of a centrifugal pump-based circuit for long-term ELS. Additionally, a device that provides instantaneous volume buffer capacity during hypovolemia was evaluated in relation to GME appearance. An exponential relationship was found between decreasing venous line pressure and GME downstream of the centrifugal pump (P = 0.001). Arterial bubble activity appeared at subatmospheric venous line pressures of -200 mm Hg and less. A rising (pO2 ) increased formation of GME (P = 0.05). A rise in hematocrit, in contrast, did not affect embolic activity (P = 0.22). With simulated hypovolemia, volume buffer capacity added to the venous line dampened fluctuations of venous line pressure by approximately 40%, but a significant reduction in GME formation could not be found (P = 0.22). Moreover, the device enabled a 14% higher support flow. With ELS flow being related to patient volume status, hypovolemia can diminish support. A coherent decrease of venous line pressure triggers degassing of blood-dissolved gases and causes arterial GME, which can become massive during persistent conditions of limited venous return. Incorporation of a volume buffer capacity device into the extracorporeal support circuit enables a higher and more stable support flow in critically low patient filling.