563779 research-article2014
PRF0010.1177/0267659114563779PerfusionNg et al.
Original Paper
The inflammatory response between miniaturised and conventional cardiopulmonary bypass after cardiac surgery in an Asian population
Perfusion 2015, Vol. 30(6) 487–494 © The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0267659114563779 prf.sagepub.com
RRG Ng,1 STH Chew,2,3 W Liu,1 P Ong,4 MG Caleb4 and LK Ti1,5
Abstract Introduction: We compared the systemic inflammatory response of the MCPB system to the CCPB system with cell salvage and phosphorylcholine-coated tubing amongst Asian patients undergoing coronary artery bypass grafting. Methods: Seventy-eight patients were randomly assigned to the MCPB or the CCPB groups equally and followed up in a prospective, single-blinded, randomised, controlled trial. Levels of TNF-α, IL-6, CRP and LDH were measured perioperatively. Results: The systemic inflammatory response was similar in both groups (TNF-α: p=0.222; IL-6: p=0.991; CRP: p=0.258). Only haemolysis was significantly higher in the CCPB group (LDH: p=0.011). The MCPB system was twice more expensive, but had a near 4-fold cost saving in tranfusions. Overall, the MCPB system cost 20% more than the modified CCPB system. Conclusion: These results corroborate with studies that demonstrated the avoidance of cardiotomy suction rather than the MCPB system, itself, leads to an attenuated inflammatory response. The absence of obvious clinical benefit and the higher costs involved with the MCPB system would preclude its routine use. Keywords cardiopulmonary bypass; coronary artery bypass grafting; cost analysis; haemolysis; inflammation; miniaturised
Introduction The theoretical benefits of the use of the miniaturised cardiopulmonary bypass (MCPB) system in cardiac surgery are remarkable as it tackles many of the problems associated with the use of a conventional cardiopulmonary bypass (CCPB) system. It reduces haemodilution, minimises the air-blood interface by removing the venous reservoir, replaces the use of cardiotomy suction with cell salvage and uses biocompatible coating for its circuits.1 While the preservation of the haematocrit during cardiopulmonary bypass (CPB) is undisputable with the MCPB system,1-3 the other clinical benefits, including the reduction of the systemic inflammatory response, stroke, renal injury, post-operative blood loss and mortality, remains uncertain.1,4-6 The systemic inflammatory response is triggered not only by cardiac surgery, itself, but is further augmented by CPB.7 The mechanism of the systemic inflammatory reaction is complex and has deleterious systemic sideeffects, including coagulopathy and end organ failure.1 Clinical trials have shown that this inflammatory
response and inflammatory biomarkers, such as tumour necrosis factor-alpha (TNF-α), interleukin-6 (IL-6) and C-reactive protein (CRP), are markedly reduced with 1Yong
Loo Lin School of Medicine, National University of Singapore, Singapore 2Department of Anaesthesiology, Singapore General Hospital, Singapore 3Department of Cardiovascular and Metabolic Disorders, DukeNational University of Singapore Graduate Medical School, Singapore 4Department of Cardiac, Thoracic and Vascular Surgery, National University Heart Centre, Singapore 5Department of Anaesthesia, National University Health System, Singapore Corresponding author: A/Prof Lian Kah Ti Department of Anaesthesia National University Health System 5 Lower Kent Ridge Road 119074 Singapore. Email: [email protected]
Downloaded from prf.sagepub.com at University College London on June 5, 2016
488
Perfusion 30(6)
the use of the MCPB system.2,7,8 Haemolysis was also shown to be significantly reduced; however, this has not been studied as extensively.7,8 A prospective randomised study by Kiaii et al. has shown that replacement of cardiotomy suction with cell salvage in the CCPB system reduced the systemic inflammatory response after cardiac surgery to comparable levels with that of the MCPB system.7 In their study, the circuit tubing was neither heparin-bonded nor surface-coated. Therefore, it is not known if the reduction of the air-blood interface or the biocompatible coating of the MCPB system further attenuates this inflammatory reaction. We, thus, standardised the CCPB circuit to be comparable to the MCPB circuit by utilising a cell-saver device instead of the cardiotomy suction and incorporated surface-coated tubing. This allowed us to study the components of the MCPB that decrease the inflammatory response. We embarked on this prospective, randomised, controlled trial to determine the systemic inflammatory response and haemolysis with the use of the MCPB system as compared to the modified CCPB system with cell salvage and biocompatible circuit amongst Asian patients undergoing CPB for coronary artery bypass graft (CABG) surgery.
Methods and Methodology Study Design and Population Selection This is a prospective, single-blinded, randomised, controlled trial. With institutional board review approval (DSRB 2008/00332) and written informed consent, 78 patients undergoing elective and isolated CABG surgery were recruited between February 2009 and December 2012. These 78 patients were then randomly assigned to the MCPB or the CCPB group, using the sealed envelope technique. The inclusion criteria were Asian patients aged between 21 and 85 years with no previous cardiac surgery done. The exclusion criteria were patients with poor left ventricular ejection fraction (
PRF0010.1177/0267659114563779PerfusionNg et al.
Original Paper
The inflammatory response between miniaturised and conventional cardiopulmonary bypass after cardiac surgery in an Asian population
Perfusion 2015, Vol. 30(6) 487–494 © The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0267659114563779 prf.sagepub.com
RRG Ng,1 STH Chew,2,3 W Liu,1 P Ong,4 MG Caleb4 and LK Ti1,5
Abstract Introduction: We compared the systemic inflammatory response of the MCPB system to the CCPB system with cell salvage and phosphorylcholine-coated tubing amongst Asian patients undergoing coronary artery bypass grafting. Methods: Seventy-eight patients were randomly assigned to the MCPB or the CCPB groups equally and followed up in a prospective, single-blinded, randomised, controlled trial. Levels of TNF-α, IL-6, CRP and LDH were measured perioperatively. Results: The systemic inflammatory response was similar in both groups (TNF-α: p=0.222; IL-6: p=0.991; CRP: p=0.258). Only haemolysis was significantly higher in the CCPB group (LDH: p=0.011). The MCPB system was twice more expensive, but had a near 4-fold cost saving in tranfusions. Overall, the MCPB system cost 20% more than the modified CCPB system. Conclusion: These results corroborate with studies that demonstrated the avoidance of cardiotomy suction rather than the MCPB system, itself, leads to an attenuated inflammatory response. The absence of obvious clinical benefit and the higher costs involved with the MCPB system would preclude its routine use. Keywords cardiopulmonary bypass; coronary artery bypass grafting; cost analysis; haemolysis; inflammation; miniaturised
Introduction The theoretical benefits of the use of the miniaturised cardiopulmonary bypass (MCPB) system in cardiac surgery are remarkable as it tackles many of the problems associated with the use of a conventional cardiopulmonary bypass (CCPB) system. It reduces haemodilution, minimises the air-blood interface by removing the venous reservoir, replaces the use of cardiotomy suction with cell salvage and uses biocompatible coating for its circuits.1 While the preservation of the haematocrit during cardiopulmonary bypass (CPB) is undisputable with the MCPB system,1-3 the other clinical benefits, including the reduction of the systemic inflammatory response, stroke, renal injury, post-operative blood loss and mortality, remains uncertain.1,4-6 The systemic inflammatory response is triggered not only by cardiac surgery, itself, but is further augmented by CPB.7 The mechanism of the systemic inflammatory reaction is complex and has deleterious systemic sideeffects, including coagulopathy and end organ failure.1 Clinical trials have shown that this inflammatory
response and inflammatory biomarkers, such as tumour necrosis factor-alpha (TNF-α), interleukin-6 (IL-6) and C-reactive protein (CRP), are markedly reduced with 1Yong
Loo Lin School of Medicine, National University of Singapore, Singapore 2Department of Anaesthesiology, Singapore General Hospital, Singapore 3Department of Cardiovascular and Metabolic Disorders, DukeNational University of Singapore Graduate Medical School, Singapore 4Department of Cardiac, Thoracic and Vascular Surgery, National University Heart Centre, Singapore 5Department of Anaesthesia, National University Health System, Singapore Corresponding author: A/Prof Lian Kah Ti Department of Anaesthesia National University Health System 5 Lower Kent Ridge Road 119074 Singapore. Email: [email protected]
Downloaded from prf.sagepub.com at University College London on June 5, 2016
488
Perfusion 30(6)
the use of the MCPB system.2,7,8 Haemolysis was also shown to be significantly reduced; however, this has not been studied as extensively.7,8 A prospective randomised study by Kiaii et al. has shown that replacement of cardiotomy suction with cell salvage in the CCPB system reduced the systemic inflammatory response after cardiac surgery to comparable levels with that of the MCPB system.7 In their study, the circuit tubing was neither heparin-bonded nor surface-coated. Therefore, it is not known if the reduction of the air-blood interface or the biocompatible coating of the MCPB system further attenuates this inflammatory reaction. We, thus, standardised the CCPB circuit to be comparable to the MCPB circuit by utilising a cell-saver device instead of the cardiotomy suction and incorporated surface-coated tubing. This allowed us to study the components of the MCPB that decrease the inflammatory response. We embarked on this prospective, randomised, controlled trial to determine the systemic inflammatory response and haemolysis with the use of the MCPB system as compared to the modified CCPB system with cell salvage and biocompatible circuit amongst Asian patients undergoing CPB for coronary artery bypass graft (CABG) surgery.
Methods and Methodology Study Design and Population Selection This is a prospective, single-blinded, randomised, controlled trial. With institutional board review approval (DSRB 2008/00332) and written informed consent, 78 patients undergoing elective and isolated CABG surgery were recruited between February 2009 and December 2012. These 78 patients were then randomly assigned to the MCPB or the CCPB group, using the sealed envelope technique. The inclusion criteria were Asian patients aged between 21 and 85 years with no previous cardiac surgery done. The exclusion criteria were patients with poor left ventricular ejection fraction (
