MiECC AND THE BRAIN Helena Argiriadou Ass. Professor of Anesthesiology Aristotle University of Thessaloniki, Cardiothoracic Department AHEPA University Hospital Thessaloniki, Greece
NEUROLOGIC INJURY AND CARDIAC SURGERY POSTOPERATIVE NEUROLOGICAL IMPAIRMENT > 50% after CABG (Newman MF, NEJM 2001) - Stroke - Neurocognitive decline ETIOLOGY AND MECHANISM NOT WELL DEFINED - Cerebral hypoperfusion - Microebolism (solid, gaseous) INCREASES POSTOPERATIVE MORBIDITY PROLONGES HOSPITALIZATION ADVERSE EFFECT ON POSTOPERATIVE QUALITY OF LIFE
NEUROLOGIC INJURY Tuman KJ; J Thor Cardiovasc Surg 1992
NEUROLOGIC INJURY TYPE 1 (2-8%) major focal neurologic deficits stupor coma TYPE 2 (10-79%) deterioration of cognitive function delirium
BORDER ZONE (watershed) INFRACTS - probable locations EXTERNAL embolism INTERNAL hemodynamic compromise Mangla et al Radiographics 2011:31:1201-1214
SMALL INJURY HYPOPERFUSION IMPEDES THE CLEARANCE (WASHOUT) OF EMBOLI INFRACTS/STROKES
FACTORS ASSOCIATED WITH PERIOPERATIVE NEUROLOGIC INJURY Atheroemboli Aortic manipulation HYPOPERFUSION inadequate perfusion pressure anaemia cerebrovascular disease cerebral vasoconstriction cannula malposition Systemic Inflammatory Response Syndrome (SIRS)
POSTOPERATIVE NEUROLOGIC ADVERSE OUTCOME AND INTRAOPERATIVE CEREBRAL HYPOPERFUSION STROKE
MiECC ENSURES BETTER BRAIN PERFUSION AND LESS NEUROLOGIC DAMAGE
ccpb MiECC T1 = following cardioplegia T2 = in the middle of bypass time T3 = end of aortic cross clamping time *p < 0.05 Artificial Organs 2004:1082-1088
JECT:2010;42:30-39
Changes in functional capillary density indicate a faster recovery of the microvascular perfusion in MECC during the reperfusion period. Beneficial recovery of microvascular organ perfusion could partly explain the perioperative advantages reported for MECC. Orthogonal Polarization Spectral imaging J Thorac Cardiovasc Surg 2012;144:677-83
Beneficial recovery of microvascular organ perfusion for MiECC skin incision 10 min after aortic clamp 10 before end CPB end CPB Orthogonal Polarization Spectral imaging Donndorf et al; J Thorac Cardiovasc Surg 2012;144:677-863.
Heart. 2009 Jun;95(12):964-9. stroke blood loss mortality?
stroke transfusion myocardial protection
mortality Ht PLT blood loss transfusion PMI myocardial protection inotropic support ARF arrhythmias mechanical ventilation ICU stay Int J Cardiol 2013;164:158-69.
Study or Subgroup 1.6.1 CABG MECC Control Odds Ratio Odds Ratio Events Total Events Total Weight M-H, Random, 95% CI Year M-H, Random, 95% CI Neurologic damage Abdel-Rahman 2005 Remadi 2006 Huybregts 2007 Ohata 2008 Kofidis 2008 Schottler 2008 Sakwa 2009 Camboni 2009 El-Essawi 2010 Bauer 2010 Subtotal (95% CI) Total events 0 1 0 1 1 0 2 8 4 1 18 101 200 25 34 50 30 102 52 146 18 758 1 7 0 6 1 1 2 8 4 0 30 103 200 24 64 30 30 97 40 145 22 755 3.2% 7.3% 7.0% 4.1% 3.1% 8.3% 27.9% 16.5% 3.1% 80.4% Heterogeneity: Tau² = 0.00; Chi² = 4.68, df = 8 (P = 0.79); I² = 0% Test for overall effect: Z = 1.44 (P = 0.15) 0.34 [0.01, 8.36] 2005 0.14 [0.02, 1.14] 2006 Not estimable 2007 0.29 [0.03, 2.54] 2008 0.59 [0.04, 9.83] 2008 0.32 [0.01, 8.24] 2008 0.95 [0.13, 6.88] 2009 0.73 [0.25, 2.14] 2009 0.99 [0.24, 4.05] 2010 3.86 [0.15, 100.58] 2010 0.63 [0.33, 1.19] 1.6.2 AVR Remadi 2004 2 50 7 50 12.3% 0.26 [0.05, 1.30] 2004 Kutschka 2009 1 85 1 85 4.2% 1.00 [0.06, 16.25] 2009 Castiglioni 2009 Subtotal (95% CI) 1 60 195 0 60 195 3.1% 19.6% 3.05 [0.12, 76.39] 0.53 [0.14, 2.01] 2009 Total events 4 8 Heterogeneity: Tau² = 0.08; Chi² = 2.10, df = 2 (P = 0.35); I² = 5% Test for overall effect: Z = 0.94 (P = 0.35) Total (95% CI) 953 950 100.0% 0.60 [0.34, 1.06] Int J Cardiol 2013;164:158-69. Total events 22 38 Heterogeneity: Tau² = 0.00; Chi² = 6.85, df = 11 (P = 0.81); I² = 0% Test for overall effect: Z = 1.74 (P = 0.08) 0.01 0.1 1 10 100 Favours MECC Favours Control
ccpb
ccpb
MiECC ATTENUATES COGNITIVE DECLINE
Better neurocognitive performance 3 months postop Higher rso 2 values in patients operated with MiECC Fewer episodes of cerebral desaturation Heart 2011;97:1082-1088.
Neurocognitive function at one month observed in patients operated on MiECC was better preserved (neurocognitive dysfunction: 16.7% MiECC vs. 36% ccpb, p=0.2). Reduced GME activity could have contributed to this preserved cognitive result since there were no major desaturated episodes intraoperatively as recorder by NIRS. CONCLUSION: Use of MiECC in coronary surgery is associated with reduced GME formation in the CPB circuit which may be related to better neurocognitive outcome. submitted for publication
TIME POINTS GME-MiECC (μl ) GME-cCPB (μl ) p TOTAL VOLUME OF GME IN THE ARTERIAL LINE VENOUS LINE GME DURING INITIATION OF CPB AFTER X-CLAMPING THE AORTA AFTER CARDIOPLEGIA ADMINISTRATION AFTER WEANING-OFF CPB TOTAL COUNT OF MACROBUBBLES (>500 ΜL) IN THE ARTERIAL LINE 0.2±0.1 1.1±1.1 p=0.004 0.17±0.2 0.43±0.5 p=0.07 0.001±0.002 0.28±0.7 p<0.001 0.003±0.007 0.3±0.7 p<0.001 <0.0001 5.4±27.6 p<0.001 0.2±0.8 0.7±2.5 p=0.5
MiECC REDUCES GASEOUS MICROEMBOLI Liebold et al; J Thorac Cardiovasc Surg 2006;131:268-276.
CONCLUSIONS: The current study proves that MiECC significantly improves HRQoL after coronary surgery compared with ccpb. This finding, combined with results from large-scale studies showing superior clinical outcomes from its use, enhances the role of MiECC as a dominant technique in coronary revascularization surgery. In Press: EJCTS 2016
The SF-36 provides quantified information (on a scale from 0 to 100 with higher scores indicating better health) in 8 domains of health: physical functioning, role physical, bodily pain, general health, vitality, social functioning, role emotional and mental health
multiple technologic advancements in the CPB apparatus were also identified, thus forming the early basis for non-pharmacologic methods to prevent neurologic injury
PERIOPERATIVE USE OF ERYTHROMYCIN REDUCES COGNITIVE DECLINE AFTER CORONARY ARTERY BYPASS GRAFTING SURGERY; A PILOT STUDY Evanthia Thomaidou, Helena Argiriadou, Georgios Vretzakis, Kalliopi Megari, Nikolaos Taskos, Georgios Chatzigeorgiou, Kyriakos Anastasiadis POCD erythromycin had significantly lower occurrence compared to the control group (47.4% vs. 95.2%, p<0.001) just after hospital discharge. Three months after surgery the respective values were still significantly lower in the erythromycin group (31.6% vs. 76.2%, p<0.01). TAU levels in the control group where significantly increased postoperatively. submitted for publication
MiECC systems reduce cerebral gaseous microembolism and better preserve neurocognitive function (Class IIA, LOE B) IMPROVED CEREBRAL PERFUSION DURING CPB AND REDUCED - incidence of stroke - neurological damage - gaseous microemboli
MiECC PRESERVES HAEMATOCRIT
STROKE RATE 4-5 2-3 >5 0-1 PRBC units Postoperative stroke based on quartile of transfusion, comparing individuals with post cardiopulmonary bypass (CPB) hemoglobin levels below (dark bars) and above (light bars) the median.
Artificial Organs 2012
stroke transfusion myocardial protection
mortality Ht PLT blood loss transfusion PMI myocardial protection inotropic support ARF arrhythmias mechanical ventilation ICU stay 2,770 patients Anastasiadis et al; Int J Cardiol 2012
Retrograde Autologous Priming P Ht = Pt BV Pt BV x Pt Ht + Prime BV P Ht = Predicted Pump Ht Pt BV = Patient Calculated Blood Volume Pt Ht = Patient Ht Prime BV = Total Priming Volume
PLOS ONE DOI:10.1371/May 18,
BETTER BRAIN PERFUSION IS BETTER TISSUE PERFUSION
Βecause there are physiologic mechanisms to preserve cerebral blood flow at the expense of relative systemic hypoperfusion, the presence of low ScO2 may thus reflect significant systemic circulatory compromise
without brain monitoring..
Kyriakos Anastasiadis Polychronis Antonitsis Helena Argiriadou Apostolos Deliopoulos
rso2 SvO2 CCO DO2i DO2i / VCO2i SvO2 CCO real time Lac urine output incrementally action 1. Ht 2. CO 3. drugs PO2 PCO2
rso2 SVO2 CCO DO2i DO2/DCO2i SVO2 CCO real time LEVEL ALARM Lac urine output action 1. Ht 2. CO 3. drugs PO2 PCO2
CEREBRAL PROTECTION Period 2012-2015 975 cardiac procedures All case-mix Emergency operations < 50% CABG Stroke:0.4% (4/975 pts) 4 3,5 3 2,5 2 1,5 1 0,5 0 Stroke rate after Cardiac Surgery STS Database (1996-1997) Mount Sinai (1998-2004) AHEPA (2011-2015)
CASE 1 PATIENT DESCRIPTION 72 yr MI, preoperative cardiogenic shock on inotropic support Emergency CABGX3 MiECC CLINICAL COURSE SUMMARY pulmonary oedema, systolic BP 75 mmhg, systolic PAP 60 mmhg, CVP, LVEF 30%, ongoing ischemia
on CPB off CPB Cerebral and somatic (biceps) sensors NIRS stable during procedure INTRAOPERATIVE BASELINE CEREBRAL L/R 48/53 BASELINE SOMATIC L/R 55/47
BASELINE SOMATIC L/R 76/64 NIRS POSTOPERATIVELY ICU CEREBRAL AND SOMATIC VALUES BASELINE CEREBRAL L/R 64/59 NIRS stable postoperatively in the ICU Extubated 3h post-op, neurologically intact EXTUBATION
CASE 2 PATIENT DESCRIPTION 77 yr Renal dysfunction, poor mobility MVR+CABGX2 MiECC
CEREBRAL SENSORS SOMATIC SENSORS CPB NIRS stable during procedure Extubated 5h post-op, neurologically intact
MiECC is not only a circuit a perfusion strategy physiologic perfusion end-organ protection NEUROPROTECTION