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Ann Thorac Surg 2006;81:790-791
© 2006 The Society of Thoracic Surgeons
Department of Cardiac Surgery, University Hospital of Angers, 4 rue Larrey, Angers Cedex 01, 49033 France
(Email: chbaufreton{at}chu-angers.fr).
I read with interest the article by Lindholm regarding the improved biocompatibility that may be obtained in elderly patients by using a combination of closed heparin-coated circuits and centrifugal pumps for cardiopulmonary bypass (CPB) [1]. It has been reported that such a perfusion system compared with a conventional approach reduced the inflammatory response during surgery and improved the postoperative outcome. The authors have to be congratulated for their efforts toward the reduction of blood activation after cardiac surgery in such in a high-risk population of patients, including some undergoing combined valve and coronary operations. They postulated that the improvements previously published by other groups may be combined with a synergistic effect. Many clinical trials have demonstrated that heparin-coated circuits reduce the inflammatory response induced by CPB, whereas only several have reported evidence for better biocompatibility of closed circuits compared with open circuits due to the limitation of blood-air interface. However, it is amazing that the authors did not pay attention to controlled suction of pericardial shed blood (the main source of the hemolytic process during cardiac surgery), and that they considered centrifugal pumps as potentially decreasing blood activation. The article of Dr Moen to which they are referring demonstrates that complement activation is reduced only by heparin-coating and not by centrifugal pumps when they are combined [2]. As another British group [3], we have previously found that complement and leukocyte activation were surprisingly more elevated after CPB using centrifugal pumps when compared with roller pumps [4]. No clear explanation of this more pronounced inflammatory response could be proposed, but the magnitude of this phenomenon was as important as the reduction of complement activation (30% to 50%) that may be afforded by heparin-coating. So far it is possible to speculate that the improved biocompatibility observed with the combined perfusion system may be due mainly to closed circuits as opposed to open circuits. Would the extent of the systemic inflammatory response have been even more reduced with a CPB design including a closed heparin-coated circuit with a roller pump known to generate a slight pulsatile and more physiologic flow [5]? This question is not just a detail. Standardization of biocompatibility is increasingly imposed by sale forces, particularly through minimally invasive CPB sets including centrifugal pumps. It is important that surgeons keep the possibility to customize their CPB equipment based on evidences derived from clinical trials to provide our high-risk patients with the best that can be done.
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