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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 Radiographics2011:31:1201-1214
HYPOPERFUSION IMPEDES THE CLEARANCE (WASHOUT)
OF EMBOLI
INFRACTS/STROKES
SMALL INJURY
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
T1 = following cardioplegiaT2 = in the middle of bypass time T3 = end of aortic cross clamping time
cCPB
MiECC
*p < 0.05
Artificial Organs 2004:1082-1088
JECT:2010;42:30-39
Changes in functional capillary density indicate afaster recovery of the microvascular perfusion inMECC during the reperfusion period. Beneficialrecovery of microvascular organ perfusion couldpartly explain the perioperative advantages reportedfor MECC.
J Thorac Cardiovasc Surg 2012;144:677-83
Orthogonal Polarization Spectral imaging
Donndorf et al; J Thorac Cardiovasc Surg 2012;144:677-863.
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
Heart. 2009 Jun;95(12):964-9.
• stroke• blood loss• mortality?
• stroke• transfusion• myocardial protection
Int J Cardiol 2013;164:158-69.
• mortality
• Ht• PLT• blood loss• transfusion• PMI• myocardial protection• inotropic support• ARF• arrhythmias• mechanical ventilation• ICU stay
Study or Subgroup
1.6.1 CABG
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
Heterogeneity: Tau² = 0.00; Chi² = 4.68, df = 8 (P = 0.79); I² = 0%
Test for overall effect: Z = 1.44 (P = 0.15)
1.6.2 AVR
Remadi 2004
Kutschka 2009
Castiglioni 2009
Subtotal (95% CI)
Total events
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)
Total events
Heterogeneity: Tau² = 0.00; Chi² = 6.85, df = 11 (P = 0.81); I² = 0%
Test for overall effect: Z = 1.74 (P = 0.08)
Events
0
1
0
1
1
0
2
8
4
1
18
2
1
1
4
22
Total
101
200
25
34
50
30
102
52
146
18
758
50
85
60
195
953
Events
1
7
0
6
1
1
2
8
4
0
30
7
1
0
8
38
Total
103
200
24
64
30
30
97
40
145
22
755
50
85
60
195
950
Weight
3.2%
7.3%
7.0%
4.1%
3.1%
8.3%
27.9%
16.5%
3.1%
80.4%
12.3%
4.2%
3.1%
19.6%
100.0%
M-H, Random, 95% CI
0.34 [0.01, 8.36]
0.14 [0.02, 1.14]
Not estimable
0.29 [0.03, 2.54]
0.59 [0.04, 9.83]
0.32 [0.01, 8.24]
0.95 [0.13, 6.88]
0.73 [0.25, 2.14]
0.99 [0.24, 4.05]
3.86 [0.15, 100.58]
0.63 [0.33, 1.19]
0.26 [0.05, 1.30]
1.00 [0.06, 16.25]
3.05 [0.12, 76.39]
0.53 [0.14, 2.01]
0.60 [0.34, 1.06]
Year
2005
2006
2007
2008
2008
2008
2009
2009
2010
2010
2004
2009
2009
MECC Control Odds Ratio Odds Ratio
M-H, Random, 95% CI
0.01 0.1 1 10 100
Favours MECC Favours Control
Neurologic damage
Int J Cardiol 2013;164:158-69.
cCPB
cCPB
MiECC ATTENUATES
COGNITIVE DECLINE
Heart 2011;97:1082-1088.
Better neurocognitive performance 3 months postop
Higher rSO2 values in patients operated with MiECC
Fewer episodes of cerebral desaturation
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.
Neurocognitive function at one month observed in patients operated on MiECCwas better preserved (neurocognitive dysfunction: 16.7% MiECC vs. 36% cCPB, p=0.2).Reduced GME activity could have contributed to this preserved cognitive result sincethere were no major desaturated episodes intraoperatively as recorder by NIRS.
submitted for publication
TIME POINTS GME-MiECC (μl ) GME-cCPB (μl ) p
TOTAL VOLUME OF GME IN THE
ARTERIAL LINE
0.2±0.1 1.1±1.1 p=0.004
VENOUS LINE GME DURING INITIATION
OF CPB
0.17±0.2 0.43±0.5 p=0.07
AFTER X-CLAMPING THE AORTA
0.001±0.002 0.28±0.7 p<0.001
AFTER CARDIOPLEGIA ADMINISTRATION
0.003±0.007 0.3±0.7 p<0.001
AFTER WEANING-OFF CPB
<0.0001 5.4±27.6 p<0.001
TOTAL COUNT OF MACROBUBBLES (>500 ΜL) IN THE
ARTERIAL LINE
0.2±0.8 0.7±2.5 p=0.5
Liebold et al; J Thorac Cardiovasc Surg 2006;131:268-276.
MiECC REDUCES GASEOUS MICROEMBOLI
In Press: EJCTS 2016
CONCLUSIONS: The current study proves that MiECC significantly improves HRQoL after coronary surgery compared with cCPB. Thisfinding, combined with results from large-scale studies showing superior clinical outcomes from its use, enhances the role of MiECCas a dominant technique in coronary revascularization surgery.
The SF-36 provides quantifiedinformation (on a scale from 0 to 100with higher scores indicating betterhealth) 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
POCD erythromycin had significantly lower occurrence compared to the controlgroup (47.4% vs. 95.2%, p<0.001) just after hospital discharge. Three months aftersurgery the respective values were still significantly lower in the erythromycingroup (31.6% vs. 76.2%, p<0.01).
TAU levels in the control group where significantly increased postoperatively.
Evanthia Thomaidou, Helena Argiriadou, Georgios Vretzakis, Kalliopi Megari, Nikolaos Taskos, Georgios Chatzigeorgiou, Kyriakos Anastasiadis
submitted for publication
MiECC systems reduce cerebral gaseous microembolismand 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
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.
ST
RO
KE
RA
TE
0-1
2-3
4-5
>5
PRBC units
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
P Ht = Predicted Pump Ht
Pt BV = Patient Calculated Blood Volume
Pt Ht = Patient Ht
Prime BV = Total Priming Volume
PHt = PtBV x PtHt
PtBV + PrimeBV
Retrograde Autologous Priming
PLOS ONE | DOI:10.1371/May 18, 2015
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
increm
entally
real time
rSO2
Lac
urine output
SvO2
CCO DO2i / VCO2i
DO2i SvO2
CCO
PO2
PCO2
action
1. Ht
2. CO
3. drugs
real time
rSO2
Lac
urine output
SVO2
CCO DO2/DCO2i
DO2i SVO2
CCO
LEVEL ALARM
PO2
PCO2
action
1. Ht
2. CO
3. drugs
CEREBRAL PROTECTION
• Period 2012-2015
• 975 cardiac procedures
• All case-mix
• Emergency operations
• < 50% CABG
• Stroke:0.4% (4/975 pts)
0
0,5
1
1,5
2
2,5
3
3,5
4
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, LVEF30%, ongoing ischemia
on
CP
B
off
C
PB
INTRAOPERATIVE
BASELINE CEREBRALL/R 48/53
BASELINESOMATICL/R 55/47
Cerebral and somatic (biceps) sensors
NIRS stable during procedure
NIRS POSTOPERATIVELY –ICU CEREBRAL AND SOMATIC VALUES
BASELINE CEREBRALL/R 64/59
BASELINE SOMATICL/R 76/64
EXTUBATION
NIRS stable postoperatively in the ICU
Extubated 3h post-op, neurologically intact
CASE 2
PATIENT DESCRIPTION
77 yr ♀
Renal dysfunction, poor mobility
MVR+CABGX2
MiECC
SOMATIC SENSORS
CEREBRAL SENSORS
CPB
NIRS stable during procedure
Extubated 5h post-op, neurologically intact
MiECC is
not only a circuit
a perfusion strategy
physiologic perfusion
NEUROPROTECTION
end-organ protection