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Heparin-bonded cardiopulmonary bypass circuits reduce cognitive dysfunction
Eric J Heyer1, Kevin S Lee, Heather E Manspeizer
1Departments of Anesthesiology, Surgery, and Neurology, College of Physicians and Surgeons of Columbia University, and Columbia--Presbyterian Medical Center, New York, NY 10032, USA. ejh3@columbia.edu
Insights
Heparin-bonded cardiopulmonary bypass (HB-CPB) circuits reduce postoperative cognitive dysfunction in cardiac surgery patients compared to nonheparin-bonded (NH-CPB) circuits. This improvement in cognitive function was observed despite no significant difference in inflammatory markers or coagulation activation.
Area of Science:
- Cardiovascular Surgery
- Neuroscience
- Inflammation Research
Background:
- Cardiopulmonary bypass (CPB) is associated with a risk of cerebral dysfunction.
- The use of heparin-bonded (HB-CPB) circuits aims to mitigate the inflammatory response during CPB.
Purpose of the Study:
- To compare the incidence of cerebral dysfunction between HB-CPB and nonheparin-bonded (NH-CPB) circuits.
- To correlate neuropsychometric findings with systemic inflammatory response markers.
Main Methods:
- Prospective, randomized, blinded clinical trial involving 61 elective cardiac surgery patients.
- Neuropsychometric testing at baseline, postoperative day 5, and postoperative week 6.
- Measurement of inflammatory markers (cytokines, C3a) and coagulation markers (thrombin-antithrombin complex).
Main Results:
- Patients using HB-CPB showed significantly better performance on specific neuropsychometric tests at 5 days and 6 weeks post-surgery.
- Event-rate analysis indicated less cognitive dysfunction in the HB-CPB group at 5 days (p < 0.05).
- Complement activation (C3a) was higher in the NH-CPB group, while coagulation activation (TAT) was higher in the HB-CPB group postoperatively.
Conclusions:
- Heparin-bonded CPB circuits are associated with reduced postoperative cognitive dysfunction in cardiac surgery patients.
- The observed cognitive benefits did not directly correlate with reduced intraoperative complement activation or postoperative coagulation activation.
Objective:
To determine the incidence of cerebral dysfunction in cardiac surgical patients exposed to heparin-bonded cardiopulmonary bypass (HB-CPB) versus nonheparin-bonded cardiopulmonary bypass (NH-CPB) circuits through neuropsychometric testing and to correlate these findings with markers of the systemic inflammatory response to CPB.
Design:
Prospective, randomized, blinded clinical trial.
Setting:
University hospital.
Participants:
Sixty-one patients undergoing elective cardiac surgery.
Interventions:
A cohort of 61 patients scheduled for elective coronary artery bypass graft surgery were prospectively randomized to receive either HB-CPB or NH-CPB circuits during surgery. Patients were evaluated for cerebral injury using a battery of neuropsychometric tests at the following 3 time points: (1) before surgery as a baseline examination, (2) postoperative day 5, and (3) postoperative week 6. Blood samples were drawn to measure inflammatory markers at the following time points: (1) preincision, after induction of anesthesia, (2) 15 minutes after onset of CPB, (3) 30 minutes after CPB, (4) 6 hours postoperatively, and (5) 24 hours postoperatively.
Measurements And Main Results:
Neuropsychometric performance was evaluated by group-rate and event-rate analyses. By group-rate analysis, patients undergoing surgery with HB-CPB performed significantly better at 5 days after surgery on 2 neuropsychometric tests (trails A [p < 0.01] and finger tapping with the dominant hand [p < 0.01]) and at 6 weeks after surgery on one neuropsychometric test (trails A [p < 0.01]). By event-rate analysis, at 5 days, patients undergoing surgery with HB-CPB circuits had less cognitive dysfunction (p < 0.05) compared with patients undergoing surgery with NH-CPB circuits. Serum samples were analyzed to evaluate markers of complement activation (C3a), proinflammatory cytokines (tumor necrosis factor-alpha, interleukin-1 beta, and interleukin-6), and coagulation (thrombin-antithrombin complex [TAT]) using the quantitative sandwich enzyme immunoassay technique. Although there were no significant differences in cytokine activation in either group, C3a was significantly higher in the NH-CPB group intraoperatively at 1 hour after CPB (p < 0.05), and TAT was higher in the HB-CPB group at 24 hours after surgery (p < 0.05).
Conclusions:
Patients undergoing cardiac surgery with CPB have less postoperative cognitive dysfunction during CPB when HB-CPB circuits are employed. Although there was a relationship, this finding did not correlate with decreased complement activation intraoperatively and activation of coagulation postoperatively.