Cerebral protection during open-heart surgery.

Åberg, Torkel; Kihlgren, Margareta

doi:10.1136/thx.32.5.525

Cited by 101 publications

(20 citation statements)

References 27 publications

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“…22 However, the evidence that microemboli can cause severe brain injury is most impressively shown in the fatal case reported by Hodge et al 41 Furthermore, the use of filters in the CPB apparatus has reduced the number of microemboli and the incidence of neurological injury. 8,23,25,42 Cerebral microemboli may also cause neuronal dysfunction without killing the cells, 8 as has been observed in cases of intermittent monocular blindness. 43,44 Vision returned when the retinal microvascular emboli moved and circulation was restored.…”

Section: Discussionmentioning

confidence: 99%

“…[23][24][25][26][27][28][29] Both brain emboli and brain injury were found to increase with prolonged CPB. 5,9 However, because current membrane oxygenators release far fewer antifoam emboli into the blood than did bubble oxygenators, the association between CPB duration and cerebral dysfunction is likely to be weaker now.…”

Section: Discussionmentioning

confidence: 99%

“…Subsequent studies with the lipid stains oil red O and osmium demonstrated that SCADs represent microemboli that contain fat. 21,22 More than 40 reports, of which we cite 7, [23][24][25][26][27][28][29] have shown an association between cerebral dysfunction and the duration of CPB. It is also suspected that longer duration of CPB results in a greater numbers of cerebral fat emboli, but this relationship has never been clearly demonstrated.…”

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confidence: 99%

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Longer Duration of Cardiopulmonary Bypass Is Associated With Greater Numbers of Cerebral Microemboli

Brown

Moody

Challa

et al. 2000

Stroke

206

107

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Background and Purpose-Many patients who undergo cardiac surgery assisted with cardiopulmonary bypass (CPB) experience cerebral injury, and microemboli are thought to play a role. Because an increased duration of CPB is associated with an increased risk of subsequent cerebral dysfunction, we investigated whether cerebral microemboli were also more numerous with a longer duration of CPB. Methods-Brain specimens were obtained from 36 patients who died within 3 weeks after CPB. Specimens were embedded in celloidin, sectioned 100 m thick, and stained for endogenous alkaline phosphatase, which outlines arterioles and capillaries. In such preparations, emboli can be seen as swellings in the vessels. Cerebral microemboli were counted in equal areas and scored as small, medium, or large to estimate the embolic load (volume of emboli). Results-With increasing survival time after CPB, the embolic load declined (PϽ0.0001). (Lipid emboli are known to pump slowly through the brain.) Also with increasing time after CPB, the percentage of large and medium emboli became lower (Pϭ0.0034). This decline is consistent with the concept that the emboli break into smaller globules as they pass through the capillary network. A longer duration of CPB was associated with increased embolic load (Pϭ0.0026).For each 1-hour increase in the duration of CPB, the embolic load increased by 90.5%. Conclusions-Thousands of microemboli were found in the brains of patients soon after CPB, and an increasing duration of CPB was associated with an increasing embolic load. (Stroke. 2000;31:707-713.)

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

mentioning

confidence: 99%

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Longer Duration of Cardiopulmonary Bypass Is Associated With Greater Numbers of Cerebral Microemboli

Brown

Moody

Challa

et al. 2000

Stroke

206

107

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“…In this setting, neurological abnormalities are often minor or asymptomatic, and though studies suggest the majority have no long-term sequelae (Shaw et al, 1986), they still contribute to post operative morbidity and mortality. The cause of the neurological damage remains controversial, although macro-and micro-embolic material from various sources have been implicated (Aberg & Kihlgren, 1977;Barash, 1980;Shaw et al, 1986Shaw et al, , 1989Woods et al, 1993). In particular, the role of cardiopulmonary bypass (rather than the other components of major surgery) is contentious (Smith et al, 1986).…”

Section: Discussionmentioning

confidence: 99%

The effect of cardiopulmonary bypass on circulating megakaryocytes

Wilde¹,

Burgess²,

Keenan

et al. 1997

Br J Haematol

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Summary. Megakaryocytes (Mks) are found in the lungs and the blood stream as well as in the bone marrow. We modified a whole blood filtration method for Mks by immunostaining for CD61 using biotin streptavidin, and used this technique to study Mks and their morphology in the central venous and arterial circulations before, during and after cardiopulmonary bypass (CPB) in haematologically normal patients undergoing routine cardiac surgery.Blood samples were taken immediately after the insertion of central venous (V) and arterial (A) catheters and after thoracotomy, immediately before bypass. Further samples were taken after 60-90 min on-CPB and 180-240 min postbypass. In comparison with the steady state before bypass, circulating Mk levels in blood on bypass increased dramatically, from (V) 10 . 93 Ϯ 3 . 94/ml (mean Ϯ SD) to 36 . 48 Ϯ 11 . 52/ml and from (A) 8 . 37 Ϯ 4 . 39/ml to 38 . 65 Ϯ 20 . 68/ml. This effect was still present, to a lesser extent, 180-240 min post-bypass. Circulating levels of Mks were consistently lower in the arterial circulation than in the venous circulation off bypass, but levels in the two circulations were comparable during CPB, confirming previous suggestions that the lungs are net removers of Mks from the circulation. Type 4 Mks, the largest and most normal morphologically, were rarely seen in arterial blood, but increased significantly during CPB, indicating that the lungs selectively remove large Mks.The lungs appear to play an active role in the regulation of Mk levels. This is lost during CPB and despite the extracorporeal 40 mm arterial line filter, large Mks enter the systemic circulation. More effective extracorporeal filtration of large Mks might reduce the neurological impairment seen in some patients who have undergone CPB.

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“…6,7 Soon it became clear that central neurological complications of heart surgery were not limited to intracardiac (open heart) surgery but were seen in extracardiac (coronary artery bypass surgery) as well. 8 The precise prevalence of cognitive decline after coronary artery bypass grafting varies widely, presumably depending on the sensitivity of the neuropsychological tests used, but have been found by some to be much more prevalent than the roughly 8% found in the present study by Jensen et al 1 Newman and colleagues, 9 who defined a significant decline as a 20% reduction from baseline, found a cognitive decline in 53% of patients at discharge, 36% at 6 weeks, 24% at 6 months, and 42% at 5 years.…”

Section: Article P 2790mentioning

confidence: 99%