Optimization of the perfusion circuit and its possible impact on the inflammatory response

Although there has been a steady improvement in cardiopulmonary bypass (CPB) techniques since its early introduction, it is still associated with some morbidity. Further attenuation of bypass-related systemic inflammatory reaction demands multidisciplinary action because the basic physiopathology is complex and cannot be controlled by one approach alone. This is an overview of the literature. Introduction of "mini" CPB circuits makes it easier to compare perfusion outcomes between different centers. Indeed, these circuits have a comparable fluid dynamic characteristic and surface area. All of them have a hemocompatible coating, and the technique avoids return of the pleuropericardial aspirations into the systemic circulation. As a consequence, results are very comparable to those obtained by beating heart surgery. However, vascular access and the resultant change in flow pattern in the aorta still have a negative correlation with neurocognitive outcome. A better understanding of the delicate balance between fluid dynamics, foreign material, coagulation, and inflammation is still a major requirement, especially because recent research combining pharmacologic, surgical, and anesthesia techniques with perfusion techniques has shown attenuation of the inflammatory response sequelae. For example, a better neurologic outcome is achieved by combining separation of suction, reducing hemodilution, administration of high-dose aprotinin, and volatile anesthetics and alternative cannulation techniques. Further improvement of CPB requires more uniform CPB circuits with known characteristics. The design should be based on evidence-based medicine philosophy. Combined efforts should be made by anesthesiologists, perfusionists, and surgeons to attenuate contact activation, ischemia-reperfusion injury, blood-material interaction, cell damage, and neurocognitive outcome.