The response of the microcirculation to cardiac surgery

Kara, Atila; Akın, Şakir; İnce, Can

doi:10.1097/aco.0000000000000280

Cited by 34 publications

(29 citation statements)

References 67 publications

(74 reference statements)

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“…Even though global hemodynamics were comparable between patients with and without successful weaning, microcirculatory parameters were significantly different. The occurrence of such disassociation between macro-circulation and microcirculation, referred to as a loss of hemodynamic coherence, has been described before in other conditions of cardiovascular compromise [ 11 , 23 – 28 ].…”

Section: Discussionmentioning

confidence: 95%

Functional evaluation of sublingual microcirculation indicates successful weaning from VA-ECMO in cardiogenic shock

et al. 2017

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BackgroundVeno-arterial extracorporeal membrane oxygenation (VA-ECMO) is increasingly adopted for the treatment of cardiogenic shock (CS). However, a marker of successful weaning remains largely unknown. Our hypothesis was that successful weaning is associated with sustained microcirculatory function during ECMO flow reduction. Therefore, we sought to test the usefulness of microcirculatory imaging in the same sublingual spot, using incident dark field (IDF) imaging in assessing successful weaning from VA-ECMO and compare IDF imaging with echocardiographic parameters.MethodsWeaning was performed by decreasing the VA-ECMO flow to 50% (F50) from the baseline. The endpoint of the study was successful VA-ECMO explantation within 48 hours after weaning. The response of sublingual microcirculation to a weaning attempt (WA) was evaluated. Microcirculation was measured in one sublingual area (single spot (ss)) using CytoCam IDF imaging during WA. Total vessel density (TVDss) and perfused vessel density (PVDss) of the sublingual area were evaluated before and during 50% flow reduction (TVDssF50, PVDssF50) after a WA and compared to conventional echocardiographic parameters as indicators of the success or failure of the WA.ResultsPatients (n = 13) aged 49 ± 18 years, who received VA-ECMO for the treatment of refractory CS due to pulmonary embolism (n = 5), post cardiotomy (n = 3), acute coronary syndrome (n = 2), myocarditis (n = 2) and drug intoxication (n = 1), were included. TVDssF50 (21.9 vs 12.9 mm/mm2, p = 0.001), PVDssF50 (19.7 vs 12.4 mm/mm2, p = 0.01) and aortic velocity–time integral (VTI) at 50% flow reduction (VTIF50) were higher in patients successfully weaned vs not successfully weaned. The area under the curve (AUC) was 0.99 vs 0.93 vs 0.85 for TVDssF50 (small vessels) >12.2 mm/mm2, left ventricular ejection fraction (LVEF) >15% and aortic VTI >11 cm. Likewise, the AUC was 0.91 vs 0.93 vs 0.85 for the PVDssF50 (all vessels) >14.8 mm/mm2, LVEF >15% and aortic VTI >11 cm.ConclusionThis study identified sublingual microcirculation as a novel potential marker for identifying successful weaning from VA-ECMO. Sustained values of TVDssF50 and PVDssF50 were found to be specific and sensitive indicators of successful weaning from VA-ECMO as compared to echocardiographic parameters.Electronic supplementary materialThe online version of this article (doi:10.1186/s13054-017-1855-2) contains supplementary material, which is available to authorized users.

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Section: Discussionmentioning

confidence: 95%

Functional evaluation of sublingual microcirculation indicates successful weaning from VA-ECMO in cardiogenic shock

et al. 2017

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“…Therefore, these patients may have had different microcirculation properties prior to presentation. Another limitation was the exclusion of patients dying within 24 h. Fourth, apart from global hemodynamics, VA-ECMO can adversely affect the microcirculation for many reasons such as hemodilution, hemolysis, coagulopathy, non-pulsatile flow, and hypothermia [38]. T1 measurements were performed within 24 h after the initiation of VA-ECMO, which can be considered a long time period.…”

Section: Discussionmentioning

confidence: 99%

Microcirculatory assessment of patients under VA-ECMO

et al. 2016

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BackgroundVeno-arterial extracorporeal membrane oxygenation (VA-ECMO) is an effective technique for providing emergency mechanical circulatory support for patients with cardiogenic shock. VA-ECMO enables a rapid restoration of global systemic organ perfusion, but it has not been found to always show a parallel improvement in the microcirculation. We hypothesized in this study that the response of the microcirculation to the initiation of VA-ECMO might identify patients with increased chances of intensive care unit (ICU) survival.MethodsTwenty-four patients were included in this study. Sublingual microcirculation measurements were performed using the CytoCam-IDF (incident dark field) imaging device. Microcirculatory measurements were performed at baseline, after VA-ECMO insertion (T1), 48–72 h after initiation of VA-ECMO (T2), 5–6 days after (T3), 9–10 days after (T4), and within 24 h of VA-ECMO removal.ResultsOf the 24 patients included in the study population, 15 survived and 9 died while on VA-ECMO. There was no significant difference between the systemic global hemodynamic variables at initiation of VA-ECMO between the survivors and non-survivors. There was, however, a significant difference in the microcirculatory parameters of both small and large vessels at all time points between the survivors and non-survivors. Perfused vessel density (PVD) at baseline (survivor versus non-survivor, 19.21 versus 13.78 mm/mm2, p = 0.001) was able to predict ICU survival on initiation of VA-ECMO; the area under the receiver operating characteristic curve (ROC) was 0.908 (95 % confidence interval 0.772–1.0).ConclusionPVD of the sublingual microcirculation at initiation of VA-ECMO can be used to predict ICU mortality in patients with cardiogenic shock.Electronic supplementary materialThe online version of this article (doi:10.1186/s13054-016-1519-7) contains supplementary material, which is available to authorized users.

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“…Variants of impaired microcirculation include impaired microcirculatory perfusion where obstructed capillaries are observed next to capillaries with flow, often seen in clinical conditions such as sepsis or reperfusion injury; microcirculatory alterations characterized by increased diffusion distance between oxygen-carrying red blood cells and tissue cells, often seen in hemodilution that accompanies cardiopulmonary bypass; microcirculatory tamponade, often associated with excessive use of vasopressors and/or increased venous pressure. This fluid overload causes tissue edema that consequently leads to a damage of endothelial cells and losses of hemodynamic coherence, glycocalyx barriers, and/or the compromise of adherence and tight junctions [45].…”

Section: Impaired Endothelium-dependent Vascular Function In the Clinmentioning

confidence: 99%

Perioperative Inflammation and Microcirculation in Surgery: Clinical Strategies for Improved Surgical Outcomes

Schier¹,

Zimmer²,

Riedel³

2016

Microcirculation Revisited - From Molecules to Clinical Practice

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Impaired microcirculation secondary to underlying vascular endothelial dysfunction is increasingly recognized to play a central role in the pathophysiology associated with numerous postoperative complications. Noxious stimuli, including direct injury from surgical trauma and hypoxia (e.g., ischemia-reperfusion injury), trigger adrenergicinflammatory-thrombotic-immune cascades to impair the microcirculation, with consequent perfusion-related postoperative complications. The endothelium, characterized by exquisite sensitivity to inflammation and low proliferative potential, has limited self-repair capacity that is dependent on circulating bone marrow-derived endothelial progenitor cells for regeneration. As such, the extent to which the endothelial physical and functional integrity is preserved mirrors not only underlying cardiovascular health but is also an important factor in susceptibility to postoperative morbidity. This review explores the effect of perioperative inflammation on the microcirculation and some of the current protective strategies available to clinicians. "Prehabilitation," with preoperative exercise to improve the underlying endothelial function and bone marrow responsiveness for endogenous endothelial repair mechanisms, and anti-inflammatory strategies to limit activation of the endothelial-thrombotic-inflammatory cascades may provide clinical strategies to preserve the microcirculation to engender optimal surgical outcomes.

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The response of the microcirculation to cardiac surgery

Cited by 34 publications

References 67 publications

Functional evaluation of sublingual microcirculation indicates successful weaning from VA-ECMO in cardiogenic shock

Functional evaluation of sublingual microcirculation indicates successful weaning from VA-ECMO in cardiogenic shock

Microcirculatory assessment of patients under VA-ECMO

Perioperative Inflammation and Microcirculation in Surgery: Clinical Strategies for Improved Surgical Outcomes

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