Pulmonary Perfusion and Ventilation during Cardiopulmonary Bypass Are Not Associated with Improved Postoperative Outcomes after Cardiac Surgery

Rodriguez-Blanco, Yiliam F.; Gologorsky, Angela; Salerno, Tomás A.; Lo, Kaming; Gologorsky, Edward

doi:10.3389/fcvm.2016.00047

Cited by 4 publications

(4 citation statements)

References 36 publications

(37 reference statements)

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“…The autologous oxygenation technique avoids all the main contributors to inflammation, such as the extracorporeal membrane oxygenator, pulmonary atelectasis/ reinflation cycle, and the ischemia‐reperfusion injury. However, our studies of concomitant pulmonary perfusion and ventilation during conventionally conducted CPB did not show the desired protective effects . Whether that was due to inadequate pulmonary perfusion and/or ventilation, or reflected the complex interplay of multiple other proinflammatory factors, remains unclear.…”

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confidence: 63%

Pulmonary protective ventilation during cardiopulmonary bypass revisited

Gologorsky

Salerno

2019

J Card Surg

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Pulmonary complications after cardiac surgery is a topic of significant interest to cardiac surgeons and anesthesiologists. Despite its relevance and importance to clinical practice, our understanding of its pathophysiology remains woefully incomplete. Multiple plausible hypotheses were advanced, offering many interesting insights, but their empiric confirmation remains elusive. Thus, we (again!) attempt to speculate on the ever-present dichotomy between the theoretical expectations of pulmonary protective ventilation during cardiopulmonary bypass (CPB) and the empiric evidence for its benefits (or lack thereof). Fiorentino et al 1 present the readers with the results of their randomized controlled trial relating the effects of low frequency ventilation (LFV) on the pulmonary inflammatory pathways and indices of gas exchange. To their surprise, they observed no significant differences in outcomes between the cohort of interest (patients ventilated with air during CPB at 6 to 8 mL/ kg, 5 breaths/minute, and zero end-expiratory pressure) and the controls (patients whose lungs were disconnected from the breathing circuit and remained collapsed for the duration of CPB). Furthermore, the tissue expression of IL-6 and IL-1B genes favored the controls, and the need for hemodynamic support was higher in the LFV group. While the study was neither powered nor designed to test the associations between the biochemical markers and the clinical outcomes, the authors could not escape the conclusion that, contrary to their expectations, LFV during CPB did not demonstrate the desired anti-inflammatory effects.The authors are to be saluted for the meticulously executed research and integrity in reporting the results that clearly contradict their previously published experimental results. 2 But how are we to view these newly presented data that seem to upend the theoretical foundations of clinical gestalt and practice?We believe that the study is important is several aspects. As the experimental design involved a conventional conduct of CPB with complete diversion of venous blood away from the pulmonary artery into the CPB circuit, their findings may point to the possibility of harm associated with alveolar ventilation in the absence of pulmonary perfusion. Local and regional inflammatory pathways, activated within the ischemic alveolar unit and potentiated by the subsequent ischemiareperfusion injury, could contribute to pulmonary inflammation as significantly as alveolar collapse and atelectasis. 3 Seen in this light, it is easy to imagine that the uptick in tissue inflammatory expression observed in the LFV group may reflect further potentiation of the ischemic insult by the continuous ventilation of the nonperfused alveolar unit.Another potential consideration is the mode of on-bypass ventilation in the authors' experimental design. LFV with volumes < 8 mL/kg and zero end-expiratory pressure could be deleterious in of itself. 4 It may potentiate airway closure, promote significant regional ventilatory heterogeneity associated w...

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confidence: 63%

Pulmonary protective ventilation during cardiopulmonary bypass revisited

Gologorsky

Salerno

2019

J Card Surg

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“…In humans, the impact of continuous pulmonary perfusion during extracorporeal circulation on reducing postoperative lung injury remains controversial [96][97][98] . Santini et al [96] compared pulsatile pulmonary perfusion during CPB with conventional CPB in patients undergoing cardiac surgery.…”

Section: And Pulmonary Perfusion During Cpbmentioning

confidence: 99%

Mechanical ventilation and cardiopulmonary bypass: a narrative review of the mechanistic lung protective measures

Villalobos¹,

Munlemvo²,

Fiorda-Diaz³

et al. 2019

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Postoperative pulmonary dysfunction is a multifactorial complication in patients undergoing cardiac surgery with cardiopulmonary bypass (CPB). Numerous risk factors including individual, surgery-and anesthesia-related have been identified. Exacerbated systemic and pulmonary inflammatory response to CPB is one of the most studied mechanisms of lung injury in this patient setting. However, current literature lacks specific intraoperative mechanical ventilation (MV) strategies associated with a significant improvement in patients' outcomes. We reviewed the randomized clinical trials and other reports published within the last 5 years involving patients undergoing cardiac surgery with CPB in order to summarize the existing MV strategies used in these patients and their associated outcomes. Moreover, we described the pathophysiological mechanisms involved in post-CPB lung injury and the mechanistic effects of protective ventilation.

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“…3 Patients with COPD are at a higher risk for postoperative complications, such as respiratory failure, pneumonia, atrial fibrillation (AF) and acute respiratory distress syndrome (ARDS). 4 The technique of on-pump coronary artery bypass (OPCAB) has progressed, and this may be more beneficial to patients with COPD by avoiding the side effects of cardiopulmonary bypass (CPB). 5 Coronary artery bypass grafting (CABG) is the most frequent operation performed in the field of adult cardiac surgery, ad although OPCAB represents 15-30% of all CABG cases, there is still an active debate regarding its superiority.…”

Section: Introductionmentioning

confidence: 99%