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MiECC AND THE BRAIN

Helena Argiriadou

Ass. Professor of Anesthesiology

Aristotle University of Thessaloniki,

Cardiothoracic Department

AHEPA University Hospital

Thessaloniki, Greece

NEUROLOGIC INJURY AND CARDIAC SURGERY

POSTOPERATIVE NEUROLOGICAL IMPAIRMENT

> 50% after CABG (Newman MF, NEJM 2001)

- Stroke

- Neurocognitive decline

ETIOLOGY AND MECHANISM NOT WELL DEFINED

- Cerebral hypoperfusion

- Microebolism (solid, gaseous)

INCREASES POSTOPERATIVE MORBIDITY

PROLONGES HOSPITALIZATION

ADVERSE EFFECT ON POSTOPERATIVE QUALITY OF LIFE

NEUROLOGIC INJURY

Tuman KJ; J Thor Cardiovasc Surg 1992

NEUROLOGIC INJURY

TYPE 1 (2-8%)

– major focal neurologic deficits

– stupor

– coma

TYPE 2 (10-79%)

– deterioration of cognitive function

– delirium

BORDER ZONE (watershed) INFRACTS -probable locations

EXTERNAL

embolism

INTERNAL

hemodynamic compromise

Mangla et al Radiographics2011:31:1201-1214

HYPOPERFUSION IMPEDES THE CLEARANCE (WASHOUT)

OF EMBOLI

INFRACTS/STROKES

SMALL INJURY

FACTORS ASSOCIATED WITH PERIOPERATIVE NEUROLOGIC INJURY

Atheroemboli– Aortic manipulation

HYPOPERFUSION– inadequate perfusion pressure– anaemia– cerebrovascular disease– cerebral vasoconstriction– cannula malposition

Systemic Inflammatory Response Syndrome (SIRS)

POSTOPERATIVE NEUROLOGIC ADVERSE OUTCOME

AND INTRAOPERATIVE CEREBRAL HYPOPERFUSION

STROKE

MiECC ENSURES

BETTER BRAIN PERFUSION

AND LESS NEUROLOGIC DAMAGE

T1 = following cardioplegiaT2 = in the middle of bypass time T3 = end of aortic cross clamping time

cCPB

MiECC

*p < 0.05

Artificial Organs 2004:1082-1088

JECT:2010;42:30-39

Changes in functional capillary density indicate afaster recovery of the microvascular perfusion inMECC during the reperfusion period. Beneficialrecovery of microvascular organ perfusion couldpartly explain the perioperative advantages reportedfor MECC.

J Thorac Cardiovasc Surg 2012;144:677-83

Orthogonal Polarization Spectral imaging

Donndorf et al; J Thorac Cardiovasc Surg 2012;144:677-863.

Beneficial recovery of microvascular organ perfusion for MiECC

skin incision 10 min after aortic clamp

10 before end CPB end CPB

Orthogonal Polarization Spectral imaging

Heart. 2009 Jun;95(12):964-9.

• stroke• blood loss• mortality?

• stroke• transfusion• myocardial protection

Int J Cardiol 2013;164:158-69.

• mortality

• Ht• PLT• blood loss• transfusion• PMI• myocardial protection• inotropic support• ARF• arrhythmias• mechanical ventilation• ICU stay

Study or Subgroup

1.6.1 CABG

Abdel-Rahman 2005

Remadi 2006

Huybregts 2007

Ohata 2008

Kofidis 2008

Schottler 2008

Sakwa 2009

Camboni 2009

El-Essawi 2010

Bauer 2010

Subtotal (95% CI)

Total events

Heterogeneity: Tau² = 0.00; Chi² = 4.68, df = 8 (P = 0.79); I² = 0%

Test for overall effect: Z = 1.44 (P = 0.15)

1.6.2 AVR

Remadi 2004

Kutschka 2009

Castiglioni 2009

Subtotal (95% CI)

Total events

Heterogeneity: Tau² = 0.08; Chi² = 2.10, df = 2 (P = 0.35); I² = 5%

Test for overall effect: Z = 0.94 (P = 0.35)

Total (95% CI)

Total events

Heterogeneity: Tau² = 0.00; Chi² = 6.85, df = 11 (P = 0.81); I² = 0%

Test for overall effect: Z = 1.74 (P = 0.08)

Events

0

1

0

1

1

0

2

8

4

1

18

2

1

1

4

22

Total

101

200

25

34

50

30

102

52

146

18

758

50

85

60

195

953

Events

1

7

0

6

1

1

2

8

4

0

30

7

1

0

8

38

Total

103

200

24

64

30

30

97

40

145

22

755

50

85

60

195

950

Weight

3.2%

7.3%

7.0%

4.1%

3.1%

8.3%

27.9%

16.5%

3.1%

80.4%

12.3%

4.2%

3.1%

19.6%

100.0%

M-H, Random, 95% CI

0.34 [0.01, 8.36]

0.14 [0.02, 1.14]

Not estimable

0.29 [0.03, 2.54]

0.59 [0.04, 9.83]

0.32 [0.01, 8.24]

0.95 [0.13, 6.88]

0.73 [0.25, 2.14]

0.99 [0.24, 4.05]

3.86 [0.15, 100.58]

0.63 [0.33, 1.19]

0.26 [0.05, 1.30]

1.00 [0.06, 16.25]

3.05 [0.12, 76.39]

0.53 [0.14, 2.01]

0.60 [0.34, 1.06]

Year

2005

2006

2007

2008

2008

2008

2009

2009

2010

2010

2004

2009

2009

MECC Control Odds Ratio Odds Ratio

M-H, Random, 95% CI

0.01 0.1 1 10 100

Favours MECC Favours Control

Neurologic damage

Int J Cardiol 2013;164:158-69.

cCPB

cCPB

MiECC ATTENUATES

COGNITIVE DECLINE

Heart 2011;97:1082-1088.

Better neurocognitive performance 3 months postop

Higher rSO2 values in patients operated with MiECC

Fewer episodes of cerebral desaturation

CONCLUSION: Use of MiECC in coronary surgery is associated with reduced GME formation in the CPB circuit which may be related to better neurocognitive outcome.

Neurocognitive function at one month observed in patients operated on MiECCwas better preserved (neurocognitive dysfunction: 16.7% MiECC vs. 36% cCPB, p=0.2).Reduced GME activity could have contributed to this preserved cognitive result sincethere were no major desaturated episodes intraoperatively as recorder by NIRS.

submitted for publication

TIME POINTS GME-MiECC (μl ) GME-cCPB (μl ) p

TOTAL VOLUME OF GME IN THE

ARTERIAL LINE

0.2±0.1 1.1±1.1 p=0.004

VENOUS LINE GME DURING INITIATION

OF CPB

0.17±0.2 0.43±0.5 p=0.07

AFTER X-CLAMPING THE AORTA

0.001±0.002 0.28±0.7 p<0.001

AFTER CARDIOPLEGIA ADMINISTRATION

0.003±0.007 0.3±0.7 p<0.001

AFTER WEANING-OFF CPB

<0.0001 5.4±27.6 p<0.001

TOTAL COUNT OF MACROBUBBLES (>500 ΜL) IN THE

ARTERIAL LINE

0.2±0.8 0.7±2.5 p=0.5

Liebold et al; J Thorac Cardiovasc Surg 2006;131:268-276.

MiECC REDUCES GASEOUS MICROEMBOLI

In Press: EJCTS 2016

CONCLUSIONS: The current study proves that MiECC significantly improves HRQoL after coronary surgery compared with cCPB. Thisfinding, combined with results from large-scale studies showing superior clinical outcomes from its use, enhances the role of MiECCas a dominant technique in coronary revascularization surgery.

The SF-36 provides quantifiedinformation (on a scale from 0 to 100with higher scores indicating betterhealth) in 8 domains of health:

physical functioning,

role physical,

bodily pain,

general health,

vitality,

social functioning,

role emotional and

mental health

multiple technologic advancements in the CPB apparatus

were also identified, thus forming the early basis

for non-pharmacologic methods to prevent neurologic injury

PERIOPERATIVE USE OF ERYTHROMYCIN REDUCES COGNITIVE DECLINE AFTER CORONARY ARTERY BYPASS GRAFTING

SURGERY; A PILOT STUDY

POCD erythromycin had significantly lower occurrence compared to the controlgroup (47.4% vs. 95.2%, p<0.001) just after hospital discharge. Three months aftersurgery the respective values were still significantly lower in the erythromycingroup (31.6% vs. 76.2%, p<0.01).

TAU levels in the control group where significantly increased postoperatively.

Evanthia Thomaidou, Helena Argiriadou, Georgios Vretzakis, Kalliopi Megari, Nikolaos Taskos, Georgios Chatzigeorgiou, Kyriakos Anastasiadis

submitted for publication

MiECC systems reduce cerebral gaseous microembolismand better preserve neurocognitive function (Class IIA, LOE B)

IMPROVED CEREBRAL PERFUSION DURING CPB

AND REDUCED - incidence of stroke

- neurological damage

- gaseous microemboli

MiECC PRESERVES HAEMATOCRIT

Postoperative stroke based on quartile of transfusion, comparing individuals with post cardiopulmonary bypass (CPB) hemoglobin levels below (dark bars) and above (light bars) the median.

ST

RO

KE

RA

TE

0-1

2-3

4-5

>5

PRBC units

Artificial Organs 2012

• stroke• transfusion• myocardial protection

• mortality

• Ht• PLT• blood loss• transfusion• PMI• myocardial protection• inotropic support• ARF• arrhythmias• mechanical ventilation• ICU stay

2,770 patients

Anastasiadis et al; Int J Cardiol 2012

P Ht = Predicted Pump Ht

Pt BV = Patient Calculated Blood Volume

Pt Ht = Patient Ht

Prime BV = Total Priming Volume

PHt = PtBV x PtHt

PtBV + PrimeBV

Retrograde Autologous Priming

PLOS ONE | DOI:10.1371/May 18, 2015

BETTER BRAIN PERFUSION

IS BETTER TISSUE PERFUSION

Βecause there are physiologic mechanisms to preserve cerebral blood flow

at the expense of relative systemic hypoperfusion, the presence of low ScO2

may thus reflect significant systemic circulatory compromise

without brain

monitoring…..

Kyriakos Anastasiadis

Polychronis Antonitsis

Helena Argiriadou

Apostolos Deliopoulos

increm

entally

real time

rSO2

Lac

urine output

SvO2

CCO DO2i / VCO2i

DO2i SvO2

CCO

PO2

PCO2

action

1. Ht

2. CO

3. drugs

real time

rSO2

Lac

urine output

SVO2

CCO DO2/DCO2i

DO2i SVO2

CCO

LEVEL ALARM

PO2

PCO2

action

1. Ht

2. CO

3. drugs

CEREBRAL PROTECTION

• Period 2012-2015

• 975 cardiac procedures

• All case-mix

• Emergency operations

• < 50% CABG

• Stroke:0.4% (4/975 pts)

0

0,5

1

1,5

2

2,5

3

3,5

4

Stroke rate after Cardiac Surgery

STS Database(1996-1997)

Mount Sinai(1998-2004)

AHEPA(2011-2015)

CASE 1

PATIENT DESCRIPTION

♂ 72 yr

MI, preoperative cardiogenic shock on inotropic support

Emergency CABGX3

MiECC

CLINICAL COURSE SUMMARY

pulmonary oedema, systolic BP 75 mmHg, systolic PAP 60 mmHg,

CVP, LVEF30%, ongoing ischemia

on

CP

B

off

C

PB

INTRAOPERATIVE

BASELINE CEREBRALL/R 48/53

BASELINESOMATICL/R 55/47

Cerebral and somatic (biceps) sensors

NIRS stable during procedure

NIRS POSTOPERATIVELY –ICU CEREBRAL AND SOMATIC VALUES

BASELINE CEREBRALL/R 64/59

BASELINE SOMATICL/R 76/64

EXTUBATION

NIRS stable postoperatively in the ICU

Extubated 3h post-op, neurologically intact

CASE 2

PATIENT DESCRIPTION

77 yr ♀

Renal dysfunction, poor mobility

MVR+CABGX2

MiECC

SOMATIC SENSORS

CEREBRAL SENSORS

CPB

NIRS stable during procedure

Extubated 5h post-op, neurologically intact

MiECC is

not only a circuit

a perfusion strategy

physiologic perfusion

NEUROPROTECTION

end-organ protection