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Updated: Jul 13, 2025
Author Spotlight: Enhancing Coronary Artery Revascularization
Published on: September 15, 2023
Cardiopulmonary Bypass Settings for the Prevention of Early Hypotension During CABG
Giuseppe Nasso1, Giuseppe Speziale1, Francesco Bartolomucci2
1Department of Cardiac Surgery, Anthea Hospital, GVM Care & Research, Bari, Italy.
Insights
Retrograde autologous priming (RAP) with pulsatile flow during cardiopulmonary bypass (CPB) significantly reduced hypotension and vasopressor use in patients undergoing coronary artery bypass graft (CABG) surgery. This strategy improves hemodynamic stability and reduces transfusion needs.
Area of Science:
- Cardiovascular Surgery
- Anesthesiology
- Critical Care Medicine
Background:
- Vasoplegic syndrome, a form of vasodilatory shock, can complicate cardiopulmonary bypass (CPB) during cardiac surgery.
- Early hypotension during Coronary Artery Bypass Graft (CABG) procedures is a significant concern.
Purpose of the Study:
- To introduce and evaluate a perioperative strategy to reduce the incidence of early hypotension during CABG procedures.
- To compare the hemodynamic effects of retrograde autologous priming (RAP) with pulsatile flow versus standard CPB management.
Main Methods:
- A prospective cohort study involving 100 patients undergoing elective CABG.
- The study group (50 patients) received RAP, 3-minute stepwise CPB initiation, and pulsatile flow (PP).
- The control group (50 patients) underwent standard CPB without RAP, with rapid initiation, and non-pulsatile (NP) flow.
Main Results:
- The study group demonstrated significantly higher mean arterial pressure (MAP), systemic vascular resistance index (SVRI), and indexed oxygen delivery (DO2i) during CPB.
- Hypotensive phenomena were reduced (3 vs 8), as was the use of norepinephrine (1 vs 8 boluses) in the study group.
- The study group required fewer red blood cell units for transfusion (16 vs 27) and had a lower positive fluid balance (750 vs 1450 ml).
Conclusions:
- The perioperative approach combining RAP, stepwise CPB initiation, and pulsatile flow effectively preserves MAP, SVRI, and DO2i.
- This strategy significantly reduces vasoconstrictor use and transfusion requirements during CPB in CABG patients.
- Further research is warranted to validate this perioperative CPB management technique.
Background:
Vasoplegic syndrome is a form of vasodilatory shock that can occur before, during or after cardiopulmonary bypass (CPB). We introduce a strategy to reduce the incidence of early hypotension phenomena during Coronary Artery Bypass Graft (CABG) procedures.
Materials And Methods:
In this prospective cohort study, 100 patients underwent elective CABG with two perioperative CPB settings. The study group (50 patients) was managed with retrograde autologous priming (RAP), 3-minute stepwise for the institution of CPB, and pulsatile flow (PP). The control group (50 patients) was managed without RAP, with the rapid initiation of CPB, and non-pulsatile (NP) flow. The primary endpoints were MAP (mmHg), number of hypotensive phenomena (MAP < 50 mmHg for > 30 sec), the venous return volume on CPB (ml), the cardiac index (L/min/m2), hemoglobin (g/dL), indexed oxygen delivery (DO2i, ml/min/m2), the systemic vascular resistance index (SVRI, dynes s m2/cm5), number of 1-ml boluses of a vasoactive substance (norepinephrine), the positive fluid balance (ml), and the number of red blood cell units for transfusion.
Results:
During CPB, the mean values in the study and control groups were as follows: MAP, 68± 7 vs 56 ± 7 (p-value, 0.0019); hypotensive phenomena, 3 ± 1 vs 8 ±2 (p-value, 0.019); venous return volume, 840±79 vs 1129 ±123 (p-value, 0.0017); cardiac index, 2.4 ± 0.4 vs 2.7 ±0.2 (p-value, 0.0023); hemoglobin, 9.13 ± 0.29 vs 7.8± 0.23 (p-value, 0.0001); DO2i, 301± 12 vs 276±23 (p-value, 0.0011); SVRI, 1879 ±280 vs 2210 ±140 (p-value, 0.0017); norepinephrine, 1±2 vs 8 ±3 (p-value, 0.0023); positive fluid balance, 750 ±212 vs 1450 ±220 (p-value, 0.005); and total number of red blood cell units for transfusion, 16 ±4.2 vs 27 ± 5.3 (p-value, 0.008).
Conclusions:
In this prospective cohort study, during CPB, the study group showed a better preservation of MAP, SVRI, and DO2i, and a reduction of vasoconstrictor use in a CPB setting with the RAP technique, 3-minute stepwise for the initiation of CPB and pulsatile pump flow, compared to the control group. Further studies are needed to validate this perioperative approach to CPB.
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