Microcirculatory perfusion disturbances following cardiopulmonary bypass: a systematic review

Abstract

Background: Microcirculatory perfusion disturbances are associated with increased morbidity and mortality in patients undergoing cardiac surgery with cardiopulmonary bypass (CPB). Technological advancements made it possible to monitor sublingual microcirculatory perfusion over time. The goal of this review is to provide an overview of the course of alterations in sublingual microcirculatory perfusion following CPB. The secondary goal is to identify which parameter of sublingual microcirculatory perfusion is most profoundly affected by CPB. Methods: PubMed and Embase databases were systematically searched according to PRISMA guidelines and as registered in PROSPERO. Studies that reported sublingual microcirculatory perfusion measurements before and after onset of CPB in adult patients undergoing cardiac surgery were included. The primary outcome was sublingual microcirculatory perfusion, represented by functional capillary density (FCD), perfused vessel density (PVD), total vessel density (TVD), proportion of perfused vessels (PPV), and microvascular flow index (MFI). Results: The search identified 277 studies, of which 19 fulfilled all eligibility criteria. Initiation of CPB had a profound effect on FCD, PVD, or PPV. Seventeen studies (89%) reported one or more of these parameters, and in 11 of those studies (65%), there was a significant decrease in these parameters during cardiac surgery; the other 6 studies (35%) reported no effect. In 29% of the studies, FCD, PVD, or PPV normalized by the end of cardiac surgery, and in 24% percent of the studies, this effect lasted at least 24 h. There was no clear effect of CPB on TVD and a mixed effect on MFI. Conclusion: CPB during cardiac surgery impaired sublingual microcirculatory perfusion as reflected by reduced FCD, PVD, and PPV. Four studies reported this effect at least 24 h after surgery. Further research is warranted to conclude on the duration of CPB-induced microcirculatory perfusion disturbances and the relationship with clinical outcome.

Comparison of Microcirculatory Perfusion in Obese and Non-Obese Patients Undergoing Cardiac Surgery with Cardiopulmonary Bypass

“…Microcirculatory perfusion disturbances in patients undergoing cardiac surgery with CPB were previously shown by our group and others [5][6][7][8]. Unexpectedly, we did not find a more detrimental effect of cardiac surgery with CPB on sublingual microcirculatory perfusion in obese compared to lean patients.…”

“…Microcirculatory perfusion disturbances are commonly present in patients undergoing cardiac surgery with cardiopulmonary bypass (CPB) [ 5 , 6 , 7 , 8 ] and are associated with the development of multiple organ failure [ 9 ]. Several perioperative aspects are known to affect microvascular function [ 10 ], such as anesthetics [ 5 , 11 , 12 ], surgical stress, vasoactive drugs, and fluid therapy [ 10 ].…”

Effects of Rewarming with Extracorporeal Membrane Oxygenation to Restore Oxygen Transport and Organ Blood Flow After Hypothermic Cardiac Arrest in a Porcine Model.

“…However, a recent review has documented impaired micro-vascular integrity as a consequence of CPB during cardiac surgery [50]. By use of sublingual microcirculatory measurements, numerous reports have documented impaired micro-circulatory perfusion with subsequent reduction of functional capillary density, and these changes may last 24 h after CPB [50]. The reduction in functional capillary density after CPB shear great similarities with those taking place during hypothermia with spontaneous circulation mentioned above.…”

“…Extracorporeal circulation has evolved to become the method of choice for rewarming patients with hypothermic cardiac arrest. However, a recent review has documented impaired micro-vascular integrity as a consequence of CPB during cardiac surgery [50]. By use of sublingual microcirculatory measurements, numerous reports have documented impaired micro-circulatory perfusion with subsequent reduction of functional capillary density, and these changes may last 24 h after CPB [50].…”

Microvascular dysfunction following cardioplegic arrest and cardiopulmonary bypass

“…For example, when atrial and skeletal muscle arterioles harvested from patients were examined, the contractile response elicited by vasopressin in atrial coronary vessels was increased after surgery [3] . In contrast, the responses to norepinephrine, endothelin-1, and thromboxane A2 (TXA2) were decreased [4][5][6][7] . This demonstrates a differential effect of cardiovascular surgery on vascular reactivity depending on the agonist examined and even which vascular bed is examined.…”