As a consequence of an aging population demographic, now more than ever, researchers in cardiac surgery must focus on means to improve the methods and technologies related to cardiopulmonary bypass. This review presents a classification of the currently available options for biomaterial modification for cardiopulmonary bypass circuits. Hypotheses are given relating the mechanism of action by which some of these surfaces afford improved biocompatibility. Finally, nonpharmacologic biomaterial-independent strategies for minimizing the effects of cardiopulmonary bypass, such as the use of hemofiltration and leukocyte filtration, and the minimization of the use of cardiotomy suction blood are outlined.
Get full access to this article
View all access options for this article.
References
1.
1. Campbell EJ, O'Byrne V, Stratford PW, et al: Biocompatible surfaces using methacryloylphosphorylcholine laurylmethacrylate copolymer. ASAIO J40:M853-M857, 1994.
2.
2. De Somer F, Francois K, van Oeveren W, et al: Phosphorylcholine coating of extracorporeal circuits provides natural protection against blood activation by the material surface. Eur J Cardiothorac Surg18:602-606, 2000.
4. Larm O, Larsson R, Olsson P: A new non-thrombogenic surface prepared by selective covalent binding of heparin via a modified reducing terminal residue. Biomater Med Devices Artif Organs11:161-173, 1983.
5.
5. Ovrum E, Holen EA, Tangen G, et al: Completely heparinized cardiopulmonary bypass and reduced systemic heparin: Clinical and hemostatic effects. Ann Thorac Surg60:365-371, 1995.
6.
6. von Segesser LK, Weiss BM, Pasic M, Garcia E, Turina MI: Risk and benefit of low systemic heparinization during open heart operations. Ann Thorac Surg58:391-398, 1994.
7.
7. Shapira OM, Aldea GS, Zelingher J, et al: Enhanced blood conservation and improved clinical outcome after valve surgery using heparin-bonded cardiopulmonary bypass circuits. J Card Surg11:307-317, 1996.
8.
8. Aldea GS, Doursounian M, O'Gara P, et al: Heparin-bonded circuits with a reduced anticoagulation protocol in primary CABG: A prospective, randomized study. Ann Thorac Surg62:410-418, 1996.
10. te Velthuis H, Baufreton C, Jansen PGM, et al: Heparin coating of extracorporeal circuits inhibits contact activation during cardiac operations. J Thorac Cardiovasc Surg114:117-122, 1997.
11.
11. Baufreton C, Jansen PG, Le Besnerais P, et al: Heparin coating with aprotinin reduces blood activation during coronary artery operations. Ann Thorac Surg63:50-56, 1997.
12.
12. Gorman RC, Ziats NP, Rao AK, et al: Surface-bound heparin fails to reduce thrombin formation during clinical cardiopulmonary bypass. J Thorac Cardiovasc Surg111: 1-12, 1996.
13.
13. Edmunds LH: Surface-bound heparin-Panacea or peril?Ann Thorac Surg58:285-286, 1994.
14.
14. Khuri S, Valeri CR, Loscalzo J, et al: Heparin causes platelet dysfunction and induces fibrinolysis before cardiopulmonary bypass. Ann Thorac Surg60:1008-1014, 1995.
15.
15. Muriithi EW, Belcher PR, Day SP, Menys VC, Wheatley DJ: Heparin-induced platelet dysfunction and cardiopulmonary bypass. Ann Thorac Surg69:1827-1832, 2000.
16.
16. Shigeta O, Kojima H, Hiramatsu Y, et al: Low-dose protamine based on heparin-protamine titration method reduces platelet dysfunction after cardiopulmonary bypass. J Thorac Cardiovasc Surg118:354-360, 1999.
17.
17. Ovrum E, AmHolen E, Tangen G, Ringdal M-AL: Heparinized cardiopulmonary bypass and full heparin dose marginally improve clinical performance. Ann Thorac Surg62:1128-1133, 1996.
18.
18. Wildevuur CR, Jansen PG, Bezemer PD, et al. Clinical evaluation of Duraflo II heparin treated extracorporeal circulation circuits (2nd version). The European Working Group on heparin coated extracorporeal circulation circuits. Eur J Cardiothorac Surg11:616-623, 1997.
19.
19. Ranucci M, Mazzucco A, Pessotto R, et al: Heparin-coated circuits for high-risk patients: A multicenter, prospective, randomized trial. Ann Thorac Surg67:994-1000, 1999.
20.
20. Videm V, Mollnes TE, Fosse E, et al: Heparin-coated cardiopulmonary bypass equipment. I. Biocompatibility markers and development of complications in a high-risk population. J Thorac Cardiovasc Surg117:794-802, 1999.
21.
21. Videm V, Mollnes TE, Bergh K, et al: Heparin-coated cardiopulmonary bypass equipment. II. Mechanisms for reduced complement activation in vivo. J Thorac Cardiovasc Surg117:803-809, 1999.
22.
22. Pekna M, Hagman L, Halden E, Nilsson UR, Nilsson B, Thelin S: Complement activation during cardiopulmonary bypass: Effects of immobilized heparin. Ann Thorac Surg58:421-424, 1994.
23.
23. Nilsson T: On the interaction between human plasma kallikrein and Cl-esterase inhibitor. Thromb Haemost49: 193-195, 1983.
24.
24. Olson ST, Sheffer R, Francis AM: High molecular weight kininogen potentiates the heparin-accelerated inhibition of plasma kallikrein by antithrombin: Role for antithrombin in the regulation of kallikrein. Biochem32:12136-12147, 1993.
25.
25. Okano T, Nishiyama S, Shinohara I, et al: Effect of hydrophilic and hydrophobic microdomains on mode of interaction between block polymer and blood platelets. J Biomed Mater Res15:393-402, 1981.
26.
26. Okano T, Aoyagi T, Kataoka K, et al: Hydrophilic-hydrophobic microdomain surfaces having an ability to suppress platelet aggregation and their in vitro anti-thrombogenicity. J Biomed Mater Res20:919-927, 1986.
27.
27. Rubens FD, Labow RS, Lavallee GR, et al: Hematologic evaluation of cardiopulmonary bypass circuits prepared with a novel block copolymer. Ann Thorac Surg67:689-698, 1999.
28.
28. Defraigne JO, Pincemail J, Dekoster G, et al: SMA circuits reduce platelet consumption and platelet factor release during cardiac surgery. Ann Thorac Surg70:2075-2081, 2000.
29.
29. Suhara H, Sawa Y, Nishimura M, et al: Efficacy of a new coating material, PMEA, for cardiopulmonary bypass circuits in a porcine model. Ann Thorac Surg71:1603-1608, 2001.
30.
30. Packham MA, Evans G, Glynn MF, Mustard JF: The effect of plasma proteins on the interaction of platelets with glass surfaces. J Lab Clin Med73:686-697, 1969.
31.
31. Tengvall P, Askendal A, Lundstrom I: Temporal studies on the deposition of complement on human colostrum IgA and serum IgG immobilized on methylated silicon. J Biomed Mater Res35:81-92, 1997.
32.
32. Saito N, Motoyama S, Sawamoto J: Effects of new polymer-coated extracorporeal circuits on biocompatibility during cardiopulmonary bypass. Artif Organs24:547-554, 2000.
33.
33. Fearon DT: Identification of the membrane glycoprotein that is the C3b receptor of the human erythrocyte, polymorphonuclear leukocyte, B lymphocyte, and monocyte. J Exp Med152:20-30, 1980.
34.
34. Chung JH, Gikakis N, Rao K, Drake TA, Colman RW, Edmunds LH: Pericardial blood activates the extrinsic coagulation pathway during clinical cardiopulmonary bypass. Circulation93:2014-2018, 1996.
35.
35. Barstad RM, Ovrum E, Ringdal M-AL, et al: Induction of monocyte tissue factor procoagulant activity during coronary artery bypass surgery is reduced with heparin-coated extracorporeal circuit. Br J Haematol94:517-525, 1996.
36.
36. Ernofsson M, Thelin S, Siegbahn A: Monocyte tissue factor expression, cell activation, and thrombin formation during cardiopulmonary bypass: A clinical study. J Thorac Cardiovasc Surg113:576-584, 1997.
37.
37. Tabuchi N, de Haan J, Boonstra PW, van Oeveren W: Activation of fibrinolysis in the pericardial cavity during cardiopulmonary bypass. J Thorac Cardiovasc Surg106: 828-833, 1993.
38.
38. Weitz JI, Hudoba M, Massel D, Maraganore J, Hirsh J: Clot-bound thrombin is protected from inhibition by heparin-antithrombin III but is susceptible to inactivation by antithrombin III-independent inhibitors. J Clin Invest86: 385-391, 1990.
39.
39. Schonberger JPAM, Everts PAM, Hoffmann JJ: Systemic blood activation with open and closed venous reservoirs. Ann Thorac Surg59:1549-1555, 1995.
40.
40. Brown MC, Donnelly JE: Impact of closed versus open venous reservoirs on patient outcomes in isolated coronary artery bypass graft surgery. Perfusion15:467-472, 2000.
41.
41. Millar AB, Armstrong L, van der LJ, et al: Cytokine production and hemofiltration in children undergoing cardiopulmonary bypass. Ann Thorac Surg56:1499-1502, 1993.
42.
42. Journois D, Pouard P, Greeley WJ, Mauriat P, Vouhe P, Safran D: Hemofiltration during cardiopulmonary bypass in pediatric cardiac surgery. Effects on hemostasis, cytokines, and complement components. Anesthesiology81: 1181-1189, 1994.
43.
43. Bando K, Pillai R, Cameron DE, et al: Leukocyte depletion ameliorates free radical-mediated lung injury after cardiopulmonary bypass. J Thorac Cardiovasc Surg99:873-877, 1990.
44.
44. Hachida M, Hanayama N, Okamura T, et al: The role of leukocyte depletion in reducing injury to myocardium and lung during cardiopulmonary bypass. ASAIO J41:M291-M294, 1995.
45.
45. Matheis G, Schotz M, Gerber J, Abdel-Rahman U, Wimmer Greinecker G, Moritz A: Leukocyte filtration in the early reperfusion phase on cardiopulmon Wr; bypass reduces myocardial injury. Perfusion16:43-49, 2001.
46.
46. Johnson D, Thomson D, Mycyk T, Burbridge B, Mayers I: Depletion of neutrophils by filter during aortocoronary bypass surgery transiently improves postoperative cardiorespiratory status. Chest107:1253-1259, 1995.
