Ann Thorac Surg 2007;83:2215-2216
© 2007 The Society of Thoracic Surgeons
Case Reports
Intraoperative Veno-Arterial Hemofiltration During Miniaturized Extracorporeal Bypass
Fabio Capuano, MDa,*,
Roberto Bianchini, MDa,
Massimo Goracci, MDb,
Antonino Roscitano, MDa,
Remo Luciani, MDb,
Caterina Simon, MDa,
Leda Giusti, MDa,
Riccardo Sinatra, MDa
a Division of Cardiac Surgery, St. Andrea Hospital, University of Rome "La Sapienza," Rome, Italy
b Division of Nephrology, St. Andrea Hospital, University of Rome "La Sapienza," Rome, Italy
Accepted for publication December 4, 2006.
* Address correspondence to Dr Capuano, Via di Grottarossa 1035-1039, Rome, 00189, Italy (Email: capmd{at}katamail.com).
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Abstract
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We report the case of a 71-year-old man with creatinine clearance of 41 mL/min and acute anterior ST-segment elevation who underwent urgent coronary artery bypass grafting. A continuous intraoperative veno-arterial hemofiltration with high volumes of exchange (35 mL/kg/h) was used in a series for a miniaturized extracorporeal bypass system to minimize the inflammatory response and to protect the kidneys of this patient who had preoperative renal dysfunction. The patient had an uneventful postoperative recovery.
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Introduction
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Preoperative renal dysfunction is an important risk factor in cardiac surgery and it is a major cause of mortality and morbidity. Preoperative renal dysfunction is estimated with creatinine clearance (ClCr) particularly in patients with normal plasma creatinine levels [1]. Many reports [2] demonstrated that preoperative ClCr < 70 mL/min is a risk factor for the development of acute renal failure and mortality after cardiac surgery, mainly in patients who are operated on urgently. Moreover, the mortality risk increases exponentially among patients who have postoperative acute renal failure develop. The mortality rate in these patients is >60%. The use of intraoperative continuous veno-venous hemofiltration or veno-arterial hemofiltration can protect the kidneys of patients with preoperative renal dysfunction during cardiac surgery procedures. Miniaturized extracorporeal bypass has been developed to reduce deleterious effects (ie, systemic inflammatory response) of standard cardiopulmonary bypass [3], and we believe that this technique is also safe and feasible in patients that need urgent coronary artery bypass grafting. Moreover, the majority of clinical studies investigating the miniaturized extracorporeal bypass system have shown significantly decreased blood loss and transfusion requirements in the perioperative period. In this report we present a male patient with preoperative renal dysfunction who underwent urgent coronary artery bypass grafting using continuous intraoperative veno-arterial hemofiltration with high volumes of exchange during miniaturized extracorporeal bypass.
A 71-year-old man, who is a smoker with diabetes, hypertension, angina at rest, and a ClCr of 41 mL/min, estimated through the Cockroft-Gault formula [4] (National Kidney Foundation, stage 3 [5]) was referred for coronary revascularization after a coronary angiography that showed three-vessel coronary artery disease and a mildly impaired (40%) ejection fraction of his left ventricle. Preoperative creatinine of the patient was 1.6 mg/dL and the catheterization did not have an influence on his creatinine level. The day after admission the patient presented with sudden onset of severe chest pain at rest radiating to his arm and back associated with hypotension, and electrocardiographic changes consisting of ST-segment elevation in anterior leads with progressively worsening shortness of breath. His blood test revealed a raised level of troponin I and creatine kinase MB isoenzyme. He suffered ongoing angina despite being treated with continues intravenous heparin and glycerin trinitrate. Therefore he was immediately transferred to the intensive care unit after insertion of an intraaortic balloon pump. He was referred for surgical treatment, and urgent coronary artery bypass grafting was performed. A miniaturized extracorporeal bypass system was carried out; the circuit consisted of a membrane oxygenator, centrifugal pump, and arterial filter. The tubing was treated with a proprietary heparin coating that provides biocompatibility with protection of all blood components and the tubing length was less than 100 cm. Priming at 700 mL included a balanced electrolyte solution and mannitol. We used left ventricular venting and the blood from the pleuro-pericardial space was exclusively collected in a cell-saving device. The cardiotomy sucker was not used. A bovine heparin (300 UI/kg) was intravenously infused before the onset of cardiopulmonary bypass and was verified by an activated clotting time of more than 400 seconds. Myocardial protection was accomplished using antegrade intermittent tepid (29°C) hyperkalemic Calafiore blood cardioplegia, which was repeated every 20 minutes. The operation was performed under normothermia. A continuous intraoperative veno-arterial hemofiltration with high volumes of exchange (35 mL/kg/h) was used in a series for a miniaturized extracorporeal bypass system (Fig 1) to minimize the inflammatory response and to protect the kidneys of the patient with preoperative renal dysfunction. The left internal mammary artery was used as a conduit for the left anterior descending artery while the saphenous vein graft was used for the posterior descending artery and the first obtuse marginal artery anastomoses. The cardiopulmonary bypass time was 106 minutes, and the aortic cross-clamp time was 81 minutes. The hematocrit target on bypass was 24%. The procedure was completed without any complications. No blood transfusion was required and no inotropic drugs were used; the patient was extubated after 6 hours. The day after the intraaortic balloon pump was removed there were no postoperative complications, and the patient had a progressive recovery before being discharged from the hospital 1 week postoperatively with a ClCr of 66 mL/min (National Kidney Foundation, stage 2) and a plasma creatinine level of 1.00 mg/dL.
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Fig 1. Continuous intraoperative veno-arterial hemofiltration during miniaturized extracorporeal bypass. (CH = continuous hemofiltration; LV = left ventricle; RA = right atrium.)
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Comment
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The identification of a preoperative risk factor for adverse outcomes after cardiac surgery is an important component of preoperative care. Preoperative renal dysfunction is strongly estimated with ClCr. Postoperative acute renal failure is a well-known complication of cardiac surgery [6] with incidences between 5% and 31% [7]. Acute renal failure is linked to multiple postoperative complications leading to prolonged hospitalization and increased costs. Durmaz and colleagues [8] demonstrated that perioperative prophylactic hemodialysis decreases both operative mortality and morbidity in high-risk patients. Elahi and colleagues [9] have suggested that early and aggressive use of continuous veno-venous hemofiltration is associated with better than expected survival in severe acute renal failure after cardiac surgery. We believe that patients who are referred to us for urgent coronary artery bypass grafting, the intraoperative use of continuous veno-venous hemofiltration or veno-arterial hemofiltration is safe and feasible. We use intraoperative continuous veno-venous hemofiltration in all patients with ClCr < 70 mL/min. Moreover, recent developments tend to minimize the systemic inflammatory response of cardiopulmonary bypass using a miniaturized closed circuit [10]. The miniaturized cardiopulmonary bypass system was developed to allow the ease of on-pump surgery, but avoid the disadvantages. Mini bypass reduces on-pump hemodilution; therefore donor blood usage in routine coronary artery bypass grafting patients as compared with conventional cardiopulmonary bypass can reduce postoperative bleeding as compared with a traditional system. Veno-arterial hemofiltration does not reduce the margin of safety of the miniaturized circuit; on the contrary it helps to improve the outcome of the patients undergoing coronary artery bypass grafting surgery. We believe that this is the first report of a successful application of continuous intraoperative veno-arterial hemofiltration with high volumes of exchange during miniaturized extracorporeal bypass in patients with preoperative renal dysfunction undergoing urgent coronary artery bypass grafting. Further studies must be done to demonstrate the effectiveness of this treatment.
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References
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- Nakayama Y, Sakata R, Ura M, Itoh T. Long-term results of coronary artery bypass grafting in patients with renal insufficiency Ann Thorac Surg 2003;75:496-500.[Abstract/Free Full Text]
- Van de Wal RMA, Van Brussel BL, Voors AA, et al. Mild preoperative renal dysfunction as a predictor of long-term clinical outcome after coronary bypass surgery J Thorac Cardiovasc Surg 2005;129:330-335.[Abstract/Free Full Text]
- Fromes Y, Gaillard D, Ponzio O, et al. Reduction of inflammatory response following coronary bypass grafting with total minimal extracorporeal circulation Eur J Cardiothorac Surg 2002;22:527-533.[Abstract/Free Full Text]
- Crockcroft DW, Gault MH. Prediction of creatinine clearance from serum creatinine Nephron 1976;16:31-36.[Medline]
- Levey AS, Coresh J, Balk E, et al. the National Kidney Foundation National Kidney Foundation practice guidelines for chronic kidney disease: evaluation, classification, and stratification Ann intern Med 2003;139:137-147.[Abstract/Free Full Text]
- Lassnigg A, Schmidlin D, Mouhieddine M. Minimal changes of serum creatinine predict prognosis in patients after cardiothoracic surgery: a prospective cohort study J Am Soc Nephrol 2004;15:1597-1605.[Abstract/Free Full Text]
- Stallwood M, Grayson AD, Mills K, Scawn N. Acute renal failure in coronary artery bypass surgery: independent effect of cardiopulmonary bypass Ann Thorac Surg 2004;77:968-972.[Abstract/Free Full Text]
- Durmaz I, Yagdi T, Calkavur T, et al. Prophylactic dialysis in patients with renal dysfunction undergoing on-pump coronary artery bypass surgery Ann Thorac Surg 2003;75:859-864.[Abstract/Free Full Text]
- Elahi MM, Lim MY, Joseph RN, Dhannapuneni RRV, Spyt TJ. Early hemofiltration improves survival in post-cardiotomy patients with acute renal failure Eur J Cardiothorac Surg 2004;26:1027-1031.[Abstract/Free Full Text]
- Bical OM, Fromes Y, Gaillard D, et al. Comparison of the inflammatory response between miniaturized and standard CPB circuit in aortic valve surgery Eur J Cardiothorac Surg 2006;29:699-702.[Abstract/Free Full Text]
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Abstract
Introduction
