Tailor-made Cardiopulmonary Bypass

Abstract

Background: often standardization and security are two interdependent variables, especially in complex procedures such as cardiopulmonary bypass. Great scientific and clinical interest was born in recent years, by the international scientific community on the effects related to the outcome of cardiac surgery and extra-corporeal circulation. This has allowed an evolution of the profession and skills, today we talk about a clinical approach of the perfusionist to cardiopulmonary bypass, structured on patient characteristics, this article presents the results in a comparative retrospective review analysis in a single center of a Cardiopulmonary bypass (CPB) tailor-made methodology, in terms of management, selection of the methods and technique and materials compared to the standard technique.

Objective: Demonstrate the superiority, in the selection of extracorporeal circulation techniques on the types of procedures and patient characteristics, versus non-selection and the conventional method in terms of out-come.

Materials and Methods: this article describes a comparative retrospective analysis in a single center ,between 2014 and 2018 on three hundred patients (201men and 99 women) candidate for elective cardiac surgery procedures with a mean age of 68.1 ± 11.4 years (range, 58 to 79 years) ;  between two historical times (2014-2016 vs 2016-2018) , the first historical period (2014-2016) provides only one system of use conventional extracorporeal circulation without metabolic monitoring systems; the second historical period (2016-2018) involves a change of approach to cardiopulmonary bypass structured on the type of procedure, type of patient, surgical technique with four different methodologies with metabolic monitoring system, Compact extra-corporeal circulation; Closed System; Minimal invasive extra-corporeal circulation; Fibonacci extra-corporeal circulation. The data collected and compared between the two groups were: the consumption of blood products, the incidence of acute kidney injury, markers of myocardial ischemia; and time of stay in intensive care unit, the incidence of post-operative cognitive disorders (POCD), and adverse events during procedures.

Results :A statistically significant difference was reported, among the study group that used cardiopulmonary bypass (CPB) tailormade technique Vs the control group that used conventional (CPB) , in terms of consumption of blood products in operating room and intensive care units 35% less in the study group p-value (0.035); reduction in the incidence of acute kidney injury (AKI) 15% less in the study group vs. control group , p-value (0.046);  23% reduction  time of stay in intensive care unit for the study group vs. control group p-value (0.035); an reduction of markers for myocardial ischemia TnT ng/L (24 h) in the study group vs. control group p-value (0.041) ; the reduction in incidence of post-operative cognitive disorders (POCD) 15% less in the group of study vs. control group (0.005); no adverse events (accidents) were recorded in the two groups, study and control.

Discussion: in recent years, there has been a great development in technologies and monitoring tools, effective reference nadirs have been developed supported by studies and literature as the delivery value of O2 (DO2_i) <280ml / min / m2 is been associated as a predictive value of renal insufficiency. This value has matured in our experience, a different approach on the way to reach these nadirs or reducing the corrective factors during the conduct, (administration of liquids and blood derivatives, use of ultrafiltration, use of diuretics, and vasoconstrictors) working through a selection of materials and techniques on (CPB), through different extracorporeal circulation techniques, less hemolytic, low surface, low hemodilution, low blood-air contact and low micro-embolic activity (GME). The tailor-made approach involves a knowledge of the pathophysiology and a shared working method; The main limitations of this study are: 1 only selected patients were chosen mainly with a low risk of mortality.

Conclusion: the tailor-made CPB showed in this retrospective analysis a better outcome in the patient candidate for cardiac surgery with statistically significant values for incidence of time of stay in intensive care units, consumption of blood products, markers of myocardial ischemia , incidence of POCD, and AKI. However, this technique needs larger samples and the treatments of more fragile patients to have more evidence.