Continuous pulmonary perfusion during cardiopulmonary bypass prevents lung injury in infants

doi:10.1016/S0003-4975(99)01332-6

The Annals of Thoracic Surgery

Volume 69, Issue 2, February 2000, Pages 602-606

https://doi.org/10.1016/S0003-4975(99)01332-6 Get rights and content

Abstract

Background. Lung injury after cardiopulmonary bypass is a serious complication for infants with congenital heart disease and pulmonary hypertension. Excessive neutrophil sequestration in the lung occurring after reestablishment of pulmonary circulation implies that interaction between neutrophils and pulmonary endothelium is the major cause of lung injury.

Methods. Thirty infants with either ventricular septal defect or atrioventricular septal defect and with pulmonary hypertension were enrolled in this study. We performed continuous pulmonary perfusion during total cardiopulmonary bypass on 16 patients (perfused group) and conventional cardiopulmonary bypass on 14 patients (control group). PaO₂/FiO₂ and neutrophil counts were assessed from immediately before surgery to 24 hours after termination of cardiopulmonary bypass.

Results. PaO₂/FiO₂ was higher in the perfused group than in the control group, and the difference was significant throughout the study period. Neutrophil counts decreased below prebypass values in both groups at 30 minutes after aortic unclamping, and the difference was significant in the control group but was not in the perfused group. Duration of postoperative ventilatory support was significantly less in the perfused group.

Conclusions. Our study demonstrates that arrested pulmonary circulation during cardiopulmonary bypass is the major risk factor of lung injury and that continuous pulmonary perfusion is effective in preventing lung injury.

Section snippets

Patients

Thirty infants with either ventricular septal defect (VSD) or atrioventricular septal defect (AVSD) and with pulmonary hypertension were enrolled in this study. Pulmonary hypertension was defined as pulmonary-to-systemic arterial systolic pressure ratio of greater than 0.5 (Pp/Ps > 0.5). The ages of the patients at the definitive surgical repair were limited to less than 1 year, so as to make their perioperative conditions uniform. Hence, their ages ranged from 1 to 11 months (mean 5.8 ± 0.5

Results

There were no significant differences between groups with respect to age, body weight, duration of CPB, duration of the aortic cross-clamp, preoperative pulmonary-to-systemic arterial systolic pressure ratio, pulmonary-to-systemic flow ratio, and pulmonary-to-systemic vascular resistance ratio (Table 1). Pulmonary-to-systemic arterial systolic pressure ratio at the termination of CPB revealed no significant difference between the groups (0.35 ± 0.03 vs 0.33 ± 0.02, p = 0.5083).

Comment

Despite the extensive investigations in relevance to CPB, postoperative dysfunction of the lung remains as a life-threatening problem, particularly among infants with congenital heart diseases revealing high pulmonary blood flow and pressure [1]. Previous studies have demonstrated that exposure of blood to the synthetic surface of the CPB circuit activates the complements, thereby provoking a systemic inflammatory response [2], and CPB elevates the values of the circulating inflammatory

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Citation Excerpt :
Impaired production of NO, a key vasodilator, may be associated with an increased postoperative pulmonary vascular resistance (PVR) and subsequent lung injury. Restoring pulmonary perfusion during CPB had been shown to improve oxygenation value (oxygen index and alveolar-arterial O2 gradient) in human (infant) studies [7–9]. Recently, pulsatile perfusion has been shown to provide better protection as opposed to continuous perfusion in a piglet model [10].
Post-cardiopulmonary bypass (CPB) lung injury is the combination of whole body inflammatory response and local ischemia-reperfusion (IR) injury. We investigated the benefit of pulmonary perfusion with L-arginine in protection against post-CPB lung injury.
New Zealand white rabbits (n = 50, weight, 2.5–2.8 kg) were divided into five groups (n = 10 each): sham (sham sternotomy), CPB (CPB without pulmonary perfusion), perfusion (CPB with pulmonary perfusion), L-arginine (CPB with perfusion + L-arginine), and L-NAME (CPB with perfusion + L-NAME). The duration of CPB was 60 min followed by 2 h of reperfusion. Pulmonary perfusion was performed every 20 min through the pulmonary artery during CPB. Checking parameters included: (1) pulmonary vascular resistance, (2) pulmonary artery endothelium relaxation (organ chamber study), and (3) IR marker (myeloperoxidase) and inflammatory markers (TNF-α, IL-B, NF-κB).
CPB induced pulmonary artery endothelium dysfunction manifested by increased pulmonary vascular resistance and impaired pulmonary artery relaxation. Pulmonary perfusion could significantly reverse the phenomenon (P < 0.01) while provision of NO precursor-L-arginine with pulmonary perfusion together further possessed significant relaxation ability for pulmonary arterial endothelium compared with perfusion alone (P < 0.05). Accordingly, lung parenchyma myeloperoxidase activity and inflammatory cytokine level were also markedly increased after CPB (P < 0.05). Pulmonary perfusion could partially decrease the response, whereas additional L-arginine further attenuated inflammatory cytokine release (P < 0.05).
Pulmonary perfusion during CPB partially ameliorates CPB-induced lung injury. Pulmonary perfusion with L-arginine could further attenuate lung injury by restoring endothelial function and decreasing inflammatory response.
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Original ArticlesContinuous pulmonary perfusion during cardiopulmonary bypass prevents lung injury in infants

Abstract

Section snippets

Patients

Results

Comment

J Thorac Cardiovasc Surg

Blood

J Thorac Cardiovasc Surg

Ann Thorac Surg

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

Ann Thorac Surg

J Am Coll Cardiol

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

The effect of cardiopulmonary bypass on the lung

Effects of cardiopulmonary bypass on pulmonary leukostasis and complement activation

Arch Surg

Original Articles
Continuous pulmonary perfusion during cardiopulmonary bypass prevents lung injury in infants