ICVTS Click here to goto Smart Canula website
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
QUICK SEARCH:   [advanced]


     

Interact CardioVasc Thorac Surg 2009;8:93-99. doi:10.1510/icvts.2008.183608
© 2009 European Association of Cardio-Thoracic Surgery
This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Author home page(s):
Sahin Senay
Serdar Gunaydin
Cem Alhan
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Senay, S.
Right arrow Articles by Alhan, C.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Senay, S.
Right arrow Articles by Alhan, C.
Related Collections
Right arrowRelated Article

ESCVS article - Cardiopulmonary bypass

The impact of allogenic red cell transfusion and coated bypass circuit on the inflammatory response during cardiopulmonary bypass: a randomized study{star}

Sahin Senaya,*, Fevzi Toramana, Serdar Gunaydinb, Meltem Kilercikc, Hasan Karabuluta and Cem Alhana

a Department of Cardiovascular Surgery, Acibadem Kadikoy Hospital, Istanbul, Turkey
b Department of Cardiovascular Surgery, Kirikkale University School of Medicine, Ankara, Turkey
c Department of Clinical Laboratory, Acibadem Kadikoy Hospital, Istanbul, Turkey

Received 13 May 2008; received in revised form 11 August 2008; accepted 11 August 2008

{star} Presented at the 57th International Congress of the European Society for Cardiovascular Surgery, Barcelona, Spain, April 24–27, 2008. This paper was winner of ‘ESCVS Young Cardiac Surgeon Award 2008’.

*Corresponding author. Ozlem Sitesi B Blok D: 25 Kosuyolu- Uskudar, 81100 Istanbul, Turkey. Tel.: +90 533 3105202; fax: +90 216 3258759.

E-mail address: sahinsenay{at}gmail.com (S. Senay).


   Abstract
Top
 Abstract
1. Introduction
 2. Methods
 3. Results
 4. Discussion
 References
 
Objective: This study is designed to determine and compare the effects of transfusion and coated circuits on the inflammatory response during cardiopulmonary bypass. Methods: Forty patients were randomized into two groups according to the type of extracorporeal circuit used and later prospectively enrolled into two subgroups according to the need for red cell transfusion during CPB (leading to 4 groups – 10 patients per group; group 1: with no transfusion and standard oxygenator, group 2: with transfusion and standard oxygenator, group 3: with no transfusion and coated oxygenator, group 4: with transfusion and coated oxygenator). Serum lactate, interleukin 6, human tumor necrosis factor alpha (TNF-{alpha}), D-dimer and CRP levels were measured at three time points (T1: start of CPB, T2: before removal of aortic cross-clamp, T3: 45 min after the completion of proximal anastomoses). Protein adsorption of oxygenator fibers was measured. Outcome parameters were recorded. Results: Interleukin 6, TNF-{alpha}, D-dimer and lactate levels increased at T2 and T3 in all groups (P<0.05 within groups). The increase in interleukin 6 was significant at T2 in group 2 when compared to group 1 (8.0±3.9 vs. 4.4±1.8, P=0.03). The increase in TNF-alpha was higher at T2 in group 1 when compared to group 3 (16.0±4.2 vs. 11.7±2.8, P=0.05) and in group 2 when compared to group 3 at T2 and T3 (15.3±4.6 vs. 11.7±2.8, P=0.06; 17.6±5.0 vs. 13.7±3.9, P=0.06). Protein adsorption was higher in group 1 and group 2 (group 1 vs. group 3, 2.2±0.8 vs. 1.4±0.3, P=0.01; group 2 vs. group 3, 2.4±0.7 vs. 1.4±0.3, P=0.02; group 2 vs. group 4, 2.4±0.7 vs. 1.8±0.3, P=0.04), it was also higher at group 4 when compared to group 3 (1.8±0.3 vs. 1.4±0.3, P=0.03). Conclusions: Allogenic red cell transfusion enhances inflammatory response during CPB; coated circuit systems have a limiting effect on this inflammatory reaction.

Key Words: Cardiopulmonary bypass; Inflammation; Blood transfusion; Coated circuits


   1. Introduction
Top
 Abstract
 1. Introduction
2. Methods
 3. Results
 4. Discussion
 References
 
Cardiac surgery induces a remarkable degree of cellular and cytokine activation [1]. Some of this activation can be attributed to the exposure of circulating cells to the cardiopulmonary bypass (CPB) circuit and the potent inflammatory reaction evoked by biomaterial contact, ischemia reperfusion injury, endotoxemia and operative trauma [1, 2]. As a consequence, postoperative complications including myocardial dysfunction, respiratory failure, coagulopathy, renal failure and neurocognitive dysfunction may be induced [1, 2].

Different methods have been employed to overcome this process [1–6]. Different circuit systems coated with heparin or polymer systems provided less inflammation and better preservation of serum proteins [3–6]. Poly-2-methoxyethyl acrylate) (PMEA) is an amphiphilic polymer with a polyethylene chain that is hydrophobic and a mildly hydrophilic tail. PMEA coating of CPB circuit systems has shown positive effects on protein adsorption, platelet loss, platelet aggregation and postoperative bleeding in previous studies. These systems caused significantly less activation of platelets, bradykinin release, and expression of genes encoding inflammatory cytokines. Therefore, PMEA-coated materials for CPB may ameliorate the inflammatory status arising from CPB [3–6].

Other strategies including off pump technique, miniaturized CPB circuits and new drugs are demonstrated to implement decreased inflammatory response but these alternatives have not prevented this process in total [7, 8]. These methods provide benefit for some subsets of patients; however, they are unlikely to obviate most of the complications. Therefore, investigations for the possible other factors involved in the complex interplay between perioperative stimuli and genetically modulated inflammatory response may aid in the identification of at-risk patients, as well as preventing organ dysfunction.

The use of blood products in cardiac surgical interventions differs in a wide range. In addition to the widely known detrimental effects (infectious diseases, major and minor transfusion reactions etc.), increased mortality and morbidity is reported due to transfusion after cardiac surgery [9, 10]. The underlying pathophysiology has not been described entirely; however, there is evidence on the activation of inflammatory genes and cytokines in circulating leukocytes with transfusion of red blood cells [11, 12].

This study is designed to determine and compare the effects of transfusion and use of coated circuits on the inflammatory response and protein adsorbtion of the circuit surface during cardiopulmonary bypass.


   2. Methods
Top
 Abstract
 1. Introduction
 2. Methods
3. Results
 4. Discussion
 References
 
This is a prospective, controlled and blinded study. Approval of the medical ethics committee of Acibadem Kadikoy Hospital was received. Informed consent was obtained from each patient.

2.1. Patients

Forty patients undergoing elective coronary bypass operations with cardiopulmonary bypass (CPB) were prospectively enrolled between April–August 2007. The patients with stable angina pectoris without any hemodynamic, enzymatic and electrocardiographic changes in the last 30 days were included. The patients with poor ventricular function (EF<30%), diabetes mellitus, history of any coagulopathy or ongoing anticoagulation therapy, chronic obstructive pulmonary disease, renal insufficiency, liver disease, a history of myocardial infarction, a systemic inflammatory disease or receiving immune suppressive drugs and patients who smoked or used steroids, non-steroidal anti-inflammatory drugs or aspirin within five days preoperatively were excluded from the study.

Firstly, patients were prospectively randomized into two groups according to the type of CPP circuit used, then each randomized group was enrolled into two groups again according to the need for transfusion [the patients received RBC when a hematocrit level of <23 is detected during CPB (the red cells transfused were prepared at the day before the surgery), blood samples for hematocrit measurement is taken 5 min after the cross-clamping and transfusion is started within 10 min after the cross-clamping whenever indicated], until the 10 patients per group was completed; leading to four groups with 10 patients in each at the end; group 1 included patients who received no blood products during CPB by using standard circuit system (Capiox SX18R, Terumo Medical Corporation, Somerset, NJ), group 2 included patients who received at least one unit of allogenic red blood cell during CPB with a standard circuit system, group 3 included patients who received no red cell during CPB with a poly-2-methoxyethylacrilate (PMEA) coated circuit system (Capiox SX18R, Terumo Medical Corporation, Somerset, NJ), group 4 included patients who received at least one unit of allogenic red blood cells during CPB with a PMEA-coated oxygenator. Preoperative evaluation of the patients is demonstrated in Table 1.


View this table:
[in this window]
[in a new window]

  		Table 1 Peroperative evaluation of the patients regarding to the demographic and operative variables revealed no significance

 
2.2. Anesthesia and operative technique

On the night prior to the operation, all patients received alprazolam 0.5 mg PO. MgSO4 infusion of 1.5 g/day in 100 ml 0.9 NaCl solution (25 ml/h) were applied the day before surgery, just after operation, and once daily for 4 days following surgery for atrial fibrillation prophylaxis. Midazolam 125 µg/kg IM was given 30 min before the operation. Anesthetic induction consisted of midazolam 50 µg/kg, pancronium 0.15 mg/kg, and fentanyl 25–35  µg/kg. After endotracheal intubation, 50% O2, 50% N2O, and 3–4% desflurane were used for all hemodynamically stable patients. All the patients were administered heparin sodium (Liquemine; Roche, Istanbul, Turkey), 3 mg/kg. Activated clotting time was measured using a Hemochron 801 (International Technidyne Corporation, Edison, NJ) and maintained for 480 s. The ascending aorta was cannulated for arterial inflow and the right atrium for venous return. Moderate hypothermia was induced. Myocardial viability was preserved with antegrade cold hyperkalemic crystalloid cardioplegia, 10–15 ml/kg at 20-min intervals (Plegisol®, Abbott Laboratories, IL, USA). The left internal mammary artery for left anterior descending coronary artery and saphenous vein grafts for other coronary vessels were used for coronary bypass for all patients. Desflurane and N2O were discontinued at times of hemodynamic instability. Maintenance anesthesia and muscle relaxation were accomplished with midazolam and vecuronium 80 µg/kg/h. Furosemid, 0.5 mg/kg, was routinely administered. Priming solution for CPB included 900 ml Ringer's lactate solution, 150 ml 20% Mannitol, and 60 ml of 8.4% sodium bicarbonate for all groups. During CPB mean arterial pressure and pump flow are kept between 50–80 mmHg, and 2.2–2.5 l/m2, respectively. Hematocrit level of <23% at any time point during cardiopulmonary bypass was accompanied with transfusion of one unit of allogenic red blood cell and these patients was classified as the transfused ones (group 2 and group 4). No other transfusion of red cell or blood products was done. Adequacy of tissue perfusion was monitored with arterio-venous partial carbon dioxide difference (Pv-aCO2), lactate level, urine output, and base deficit. Moderate hypothermia was used during CPB. Midazolam and vecuronium doses were decreased to 60 µg/kg/h when the body temperature reached 32 °C. Rewarming was initiated during left internal mammary artery grafting. CPB was discontinued and heparin was reversed with protamine sulfate (Protamine, Roche) when temperature reached 36.5 °C and stable hemodynamic parameters were reached. During rewarming, midazolam and vecuronium doses were increased back to 80 µg/kg/h. After the termination of CPB, midazolam and vecuronium were decreased to 50 µg/kg/h and discontinued at skin closure.

2.3. Blood samples and assays

Serum lactate, interleukin 6 (IL-6), human tumor necrosis factor alpha (TNF-{alpha}), D-dimer and CRP levels were measured at three time points (T1: start of CPB, T2: before removal of aortic cross clamp, T3: 45 min after the completion of proximal anastomoses). Serum interleukin 6 (IL-6) and human tumor necrosis factor alpha (TNF-{alpha}) were measured by ELISA (Biosource International Inc, Camarillo, CA, USA) and D-dimer with an automated method of microcapillary fluidics and a fluorescence immunoassay (Triage Stroke Panel, Biosite Ltd, Belfast, UK).

2.4. Microscopy and spectrophotometry

At the termination of CPB, the complete circuit was rinsed with saline solution. The oxygenator was removed, treated with glutaraldehyde solution and dismantled by a saw under sterile conditions. Hollow fibers were collected for later protein adsorption studies. A mean number of 300 fibers (6 cm) were put into a 15-ml plastic tube with 1% sodium dodecyl sulfate (SDS, Pharmacia Biotechnology, Sweden) and 1% Triton X-100 solution (Biorad, Cambridge, MA). The tube was then placed in a 38 kHz, 80 W ultrasonic washer (Kaijyo, Japan) for 1 h and treated in PBS buffer solution at pH 7.4 under constant temperature of 25 °C for 6 h. The sample was passed through a filter (Milipore Corporation, Bedford, MA). The amount of desorbed protein in each specimen for every patient was evaluated quantitatively with a COBAS MIRA Spectrophotometer (Roche Diagnostics Systems Inc, Branchburg, NJ) with its range adjusted to 0.01.

2.5. Perioperative follow-up

Demographic, operative and postoperative variables and outcome parameters including entubation time, total drainage, intensive care unit stay time, hospital stay time, rate of atrial fibrillation, stroke and mortality were recorded.

2.6. Statistical analysis

Data were analyzed using an SPSS version 11.0 statistical program for Windows (SPSS Inc; Chicago, IL) computer program. All the results are expressed as mean±S.D. from the mean. Study groups are compared by two-way analysis of variance for evaluation of the differences over different time points (repeated measures analysis of variance). Preoperative variables are evaluated with Student's t-test or Pearson's {chi}2-test where appropriate. A P-value <0.05 was considered significant.


   3. Results
Top
 Abstract
 1. Introduction
 2. Methods
 3. Results
4. Discussion
 References
 
Preoperative physical and laboratory evaluation revealed no difference among patient groups. The demographics and the operative characteristics of the patients in each of the four groups were not significantly different (Table 1).

3.1. Intragroup comparison of blood samples and assays

Basal (T1) measurements of TNF-{alpha}, IL-6, D-dimer, CRP and lactate were similar between groups (Table 2). IL-6, TNF-{alpha}, D-dimer and lactate levels were increased at T2 and T3 in all groups (T2 vs. T1, T3 vs. T2; P<0.05 within group 1, 2, 3 and 4) (Figs. 1–3GoGo). No significant change in CRP levels was determined at T2 and T3.


View this table:
[in this window]
[in a new window]

  		Table 2 Measurements in different time intervals of blood samples, assays and microscopy and spectrofotometry

 

Figure 1
View larger version (15K):
[in this window]
[in a new window]

  		Fig. 1. TNF-{alpha} measurements of the groups (*group 1 vs. group 3 at T2; 16.0±4.2 vs. 11.7±2.8; P=0.05, group 2 vs. group 3; 15.2±4.6 vs. 11.7±2.8; at T2; P=0.06 and 17.6±5.0 vs. 13.7±3.9 at T3; P=0.06).

 

Figure 2
View larger version (14K):
[in this window]
[in a new window]

  		Fig. 2. IL-6 measurements of the groups (*group 2 vs. group 1 at T2; 8.0±3.9 vs. 4.4±1.8; P=0.03).

 

Figure 3
View larger version (14K):
[in this window]
[in a new window]

  		Fig. 3. D-dimer measurements of the groups (*group 2 vs. group 3 at T3; 811.3±448.4 vs. 428.7±371.3; P=0.04).

 
3.2. Intergroup comparison of blood samples and assays

IL-6 levels were significantly increased at T2 in group 2 when compared to group 1 (8.0±3.9 vs. 4.4±1.8; P=0.03). TNF-{alpha} levels were higher at T2 in group 1 when compared to group 3 (16.0±4.2 vs. 11.7±2.8; P=0.05), TNF-{alpha} levels were also higher in group 2 when compared to group 3 (15.2±4.6 vs. 11.7±2.8; at T2; P=0.06 and 17.6±5.0 vs. 13.7±3.9 at T3; P=0.06). D-dimer levels were significantly increased at T3 in group 2 when compared to group 3 (811.3±448.4 vs. 428.7±371.3; at T3; P=0.04). Lactate levels of all time intervals in all groups were in acceptable limits leading to no significant difference between groups. The measured protein adsorption was significantly higher in group 1 and group 2 (2.2±0.8 vs. 1.4±0.3; group 1 vs. group 3; P=0.01 and 2.4±0.7 vs. 1.4±0.3; group 2 vs. group 3; P=0.02 and 2.2±0.8 vs. 1.8±0.3; group 2 vs. group 4; P=0.04) (Fig. 4). It was also higher at group 4 when compared to group 3 (1.8±0.3 vs. 1.4±0.3; P=0.03).


Figure 4
View larger version (7K):
[in this window]
[in a new window]

  		Fig. 4. Protein adsorbtion levels of the groups (*group 1 vs. group 3; 2.2±0.8 vs. 1.4±0.3; P=0.01, group 2 vs. group 3; 2.4±0.7 vs. 1.4±0.3; P=0.02, group 2 vs. group 4; 2.2±0.8 vs. 1.8±0.3; P=0.04, group 4 vs. group 3; 1.8±0.3 vs. 1.4±0.3; P=0.03).

 
3.3. Follow-up parameters

Demographic, operative and postoperative variables and outcome parameters including, total drainage, hospital stay time, intensive care unit stay time, rate of atrial fibrillation, stroke and mortality were similar between groups. Only the intubation time was tended to be longer in group 2 (group 2 vs. group 1; 7.7±3.7 vs. 5.2±2.6; P=0.09) (Table 3).


View this table:
[in this window]
[in a new window]

  		Table 3 Follow-up parameters reveals a tendency of longer intubation time in group 2

 

   4. Discussion
Top
 Abstract
 1. Introduction
 2. Methods
 3. Results
 4. Discussion
References
 
There is an increasing number of high-risk patients undergoing cardiac surgery with CPB. New strategies for CPB management gained importance to overcome and limit the systemic activation of inflammatory status. Therefore, we studied the effect of transfusion in comparison with the circuit systems with coated surfaces to determine possible feasible new strategies.

There were four specific components evaluated in this trial; systemic inflammation/blood activation (IL-6, TNF-{alpha}, D-dimer, CRP) oxidative capacity of the tissues (lactate), surface biocompatibility (protein adsorbtion) and outcome analysis (intubation time, total drainage, intensive care unit stay time, hospital stay time, rate of atrial fibrillation, stroke and mortality).

Systemic inflammatory activation was decreased in patients operated with coated circuit surfaces without receiving any transfusion. In particular, interleukin release was significantly decreased in patients with no transfusion; there was a combined anti-inflammatory effect of using coated surfaces and not transfusing the patient. Plasma proteins were better preserved in the patients with coated circuit systems; this effect was more prominent when there was no transfusion. The clinical outcome in aspect of intubation time was better in the patients with coated surfaces and no transfusion.

Coated circuit systems; having a chemically inactive surface, are demonstrated to have a decreased tendency to react with blood components [3, 4]. Thus the adsorbtion of blood components related to the coagulation and fibrinolytic systems to surfaces of the circuits are decreased and activation of the blood components is reduced. Our current study verified this effect of coated systems; however, the distinctive result was the comparative effect of transfusion under coated conditions (which may provide a more isolated condition in means of inflammatory stimulus) during CPB. CPB has been shown to activate blood components and induce systemic inflammation and massive defense reaction which may lead to a powerful thrombotic stimulus and the production, release, and circulation of a host of micro emboli and vasoactive and cytotoxic substances that affect every organ and tissue within the body [7]. The contact with synthetic surfaces in the perfusion circuit and multiple tissues within the wound is well studied for being responsible for these reactions; however, the effect of transfusion during cardiopulmonary bypass is missed out in many studies.

The use of blood products in cardiac surgical interventions varies from 10% to 100% despite published transfusion guidelines [13]. There is evidence that in ex vivo studies, transfusion of packed red blood cells (PRBCs) stimulates circulating leukocytes and produce inflammatory gene expression. As a result, neutrophil priming and chemotaxis as well as hematopoietic stem cell mobilization is activated [14]. It is also demonstrated that the donor plasma for transfusion may have the ability to activate peripheral blood mononuclear cells (PBMNCs) derived from healthy subjects leading to production in vitro of inflammatory cytokines (i.e. IL-1b, IL-6, and TNF-{alpha}) and neutrophil attractant chemokines (i.e. IL-8 and GRO-a) [12]. These chemokines are powerful activators of human neutrophils, inducing chemotaxis, exocytosis, and respiratory burst in vitro and neutrophil sequestration in vivo [15]. Identification of the mediator(s) in stored blood responsible for the deleterious proinflammatory effects of transfusions remains incompletely understood. Although leukoreduction reduces levels of cytokines in stored blood, adverse transfusion-related outcomes continue to occur [16]. Our current finding of increased cytokine levels in the patients who received red blood cells suggests that transfusion – itself – may be an important source for the increased inflammatory response during cardiopulmonary bypass. This may be a considerable factor as its effect is comparable with using a coated circuit system.

The efficacy of blood transfusion is mainly measured by the capacity to improve tissue oxygenation. Underlying the decision for transfusion is the assumption that more hemoglobin means more oxygen available to hypoxic tissues. However, it is demonstrated that stored blood cells was not able to improve tissue oxygenation [17]. Moreover, it is reported that there have been serious loss of physiological features of blood cells in the first few hours of collection of blood [18, 19]. These results may suggest that the efficacy of each transfusion during CPB should be re-evaluated and strict guidelines for decision making to transfuse patients should be constructed. It is recommended to transfuse in a patient whose hemoglobin level is <7 g/dl in a new guideline for blood transfusion and conservation in cardiac surgery [20]. But the level of evidence is ‘C’ with a recommendation of ‘Class 2b’ which means that we still need more evidence on this topic.

Hemodilutional anemia is inevitable during cardiopulmonary bypass, thus a decision making for choice between low hematocrit and transfusion is needed. There have been several reports on the adverse effects of low hematocrit during cardiopulmonary bypass; however, transfusion of blood products during this period to overcome this hemodilution is reported to be associated with adverse outcome after coronary bypass surgery irrespective to the extent of anemia [21]. Moreover, blood transfusion is reported to be an independent risk factor for mortality and morbidity in cardiac surgery [22, 23].

As a conclusion, we may say that there is incomplete evidence regarding to the transfusion decisions during CPB. Our results imply that transfusion of red blood cells during CPB may cause an undesirable inflammatory stimulus. This inflammatory response is comparable with the one that is observed in the patients operated with uncoated CPB circuits. The combination of transfusion and not using a coated system has the highest risk of increased inflammatory response. This result may explain the key link between transfusion and adverse outcome with poor long-term survival in cardiac surgery. Expanding our understanding of the immunomodulatory effects of stored blood cells may lead to more selective and effective use of blood transfusion which can help decreasing deleterious perioperative adverse events.


   References
Top
 Abstract
 1. Introduction
 2. Methods
 3. Results
 4. Discussion
 References
 

  1. Rinder C. Cellular inflammatory response and clinical outcome in cardiac surgery. Curr Opin Anaesthesiol 2006 Feb;19:65–68.[CrossRef][Medline]
  2. Paparella D, Yau TM, Young E. Cardiopulmonary bypass induced inflammation: pathophysiology and treatment. An update. Eur J Cardiothorac Surg 2002;21:232–244.[Abstract/Free Full Text]
  3. Gunaydin S, Farsak B, Kocakulak M, Sari T, Yorgancioglu C, Zorlutuna Y. Clinical performance and biocompatibility of poly (2-methoxyethylacrylate)-coated extracorporeal circuits. Ann Thorac Surg 2002 Sep;74:819–824.[Abstract/Free Full Text]
  4. Rubens FD, Nathan H, Labow R, Williams KS, Wozny D, Karsh J, Ruel M, Mesana T. Effects of methylprednisolone and a biocompatible copolymer circuit on blood activation during cardiopulmonary bypass. Ann Thorac Surg 2005;79:655–665.[Abstract/Free Full Text]
  5. Kocakulak M, Ozgürtas T, Ayhan H. Effect of poly (2-methoxyethyl acrylate)-coated oxygenators on haemolysis. J Biomater Sci Polym Ed 2006;17:449–460.[CrossRef][Medline]
  6. Zimmermann AK, Aebert H, Reiz A, Freitag M, Husseini M, Ziemer G, Wendel HP. Hemocompatibility of PMEA coated oxygenators used for extracorporeal circulation procedures. ASAIO J 2004, May-Jun, 50:193–199.[CrossRef][Medline]
  7. Raja SG, Berg GA. Impact of off-pump coronary artery bypass surgery on systemic inflammation: current best available evidence. J Card Surg 2007, Sep-Oct, 22:445–455.[CrossRef][Medline]
  8. Bical OM, Fromes Y, Gaillard D, Fischer M, Ponzio O, Deleuze P, Gerhardt MF, Trivin F. Comparison of the inflammatory response between miniaturized and standard CPB circuits in aortic valve surgery. Eur J Cardiothorac Surg 2006 May;29:699–702.[Abstract/Free Full Text]
  9. Kuduvalli M, Oo AY, Newall N, Grayson AD, Jackson M, Desmond MD, Fabri BM, Rashid A. Effect of peri-operative red blood cell transfusion on 30-day and 1-year mortality following coronary artery bypass surgery. Eur J Cardiothorac Surg 2005;27:592–598.[Abstract/Free Full Text]
  10. Surgenor SD, DeFoe GR, Fillinger MP, Likosky DS, Groom RC, Clark C, Helm RE, Kramer RS, Leavitt BJ, Klemperer JD, Krumholz CF, Westbrook BM, Galatis DJ, Frumiento C, Ross CS, Olmstead EM, O'Connor GT. Intraoperative red blood cell transfusion during coronary artery bypass graft surgery increases the risk of postoperative low-output heart failure. Circulation 2006;114(1 Suppl):I43–I48.[Medline]
  11. Escobar GA, Cheng AM, Moore EE, Johnson JL, Tannahill C, Baker HV, Moldawer LL, Banerjee A. Stored packed red blood cell transfusion up-regulates inflammatory gene expression in circulating leukocytes. Ann Surg 2007 Jul;246:129–134.[CrossRef][Medline]
  12. Sakagawa H, Miyazaki T, Fujihara M, Sato S, Yamaguchi M, Fukai K, Morioka M, Kato T, Azuma H, Ikeda H. Generation of inflammatory cytokines and chemokines from peripheral blood mononuclear cells by HLA Class II antibody-containing plasma unit that was associated with severe non-hemolytic transfusion reactions. Transfusion 2007 Jan;47:154–161.[CrossRef][Medline]
  13. Goodnough LT, Despotis GJ, Hogue CW, Ferguson TB. On the need for improved transfusion indicators in cardiac surgery. Ann Thorac Surg 1995;60:473–480.[Abstract/Free Full Text]
  14. Escobar GA, Cheng AM, Moore EE, Johnson JL, Tannahill C, Baker HV, Moldawer LL, Banerjee A. Stored packed red blood cell transfusion up-regulates inflammatory gene expression in circulating leukocytes. Ann Surg 2007 Jul;246:129–134.[CrossRef][Medline]
  15. Geiser T, Dewald B, Ehrengruber MU, Clark-Lewis I, Baggiolini M. The interleukin-8-related chemotactic cytokines GROa, GROb, and GROg activate human neutrophil and basophil leukocytes. J Biol Chem 1993;268:15419–15424.[Abstract/Free Full Text]
  16. Uhlmann EJ, Isgriggs E, Wallhermfechtel M, Goodnough LT. Prestorage universal WBC reduction of RBC units does not affect the incidence of transfusion reactions. Transfusion 2001;41:997–1000.[CrossRef][Medline]
  17. Gonzalez AM, Yazici I, Kusza K, Siemionow M. Effects of fresh versus banked blood transfusions on microcirculatory hemodynamics and tissue oxygenation in the rat cremaster model. Surgery 2007 May;141:630–639.[CrossRef][Medline]
  18. Reynolds JD, Ahearn GS, Angelo M, Zhang J, Cobb F, Stamler JS. S-nitrosohemoglobin deficiency: a mechanism for loss of physiological activity in banked blood. Proc Natl Acad Sci USA 2007 Oct 23;104:17058–17062.[Abstract/Free Full Text]
  19. Bennett-Guerrero E, Veldman TH, Doctor A, Telen MJ, Ortel TL, Reid TS, Mulherin MA, Zhu H, Buck RD, Califf RM, McMahon TJ. Evolution of adverse changes in stored RBCs. Proc Natl Acad Sci USA 2007 Oct 23;104:17063–17068.[Abstract/Free Full Text]
  20. Society of Thoracic Surgeons Blood Conservation Guideline Task Force, Ferraris VA, Ferraris SP, Saha SP, Hessel EA 2nd, Haan CK, Royston BD, Bridges CR, Higgins RS, Despotis G, Brown JR, Society of Cardiovascular Anesthesiologists Special Task Force on Blood Transfusion, Spiess BD, Shore-Lesserson L, Stafford-Smith M, Mazer CD, Bennett-Guerrero E, Hill SE, Body S. Perioperative blood transfusion and blood conservation in cardiac surgery: the Society of Thoracic Surgeons and The Society of Cardiovascular Anesthesiologists clinical practice guideline. Ann Thorac Surg 2007 May;83(5 Suppl):S27–S86; Review.[Abstract/Free Full Text]
  21. Surgenor SD, DeFoe GR, Fillinger MP, Likosky DS, Groom RC, Clark C, Helm RE, Kramer RS, Leavitt BJ, Klemperer JD, Krumholz CF, Westbrook BM, Galatis DJ, Frumiento C, Ross CS, Olmstead EM, O'Connor GT. Intraoperative red blood cell transfusion during coronary artery bypass graft surgery increases the risk of postoperative low-output heart failure. Circulation 2006 Jul 4;114(1 Suppl):I43–I48.[Medline]
  22. Scott BH, Seifert FC, Grimson R. Blood transfusion is associated with increased resource utilization morbidity and mortality in cardiac surgery. Ann Card Anaesth 2008, Jan-Jun, 11:15–19.[Medline]
  23. Murphy GJ, Reeves BC, Rogers CA, Rizvi SI, Culliford L, Angelini GD. Increased mortality postoperative morbidity, and cost after red blood cell transfusion in patients having cardiac surgery. Circulation 2007 Nov 27;116:2544–2552.[Abstract/Free Full Text]

Related Article

eComment: Re: The impact of allogenic red cell transfusion and coated bypass circuit on the inflammatory response during cardiopulmonary bypass: a randomized study
Leo A. Bockeria and Rachik G. Grigoryants
Interactive CardioVascular and Thoracic Surgery 2009 8: 99. [Full Text] [PDF]



This article has been cited by other articles:


Home page
 ICVTSHome page
L. A. Bockeria and R. G. Grigoryants
eComment: Re: Multi-modality blood conservation strategy in open heart surgery: an audit
Interactive CardioVascular and Thoracic Surgery, September 1, 2009; 9(3): 482 - 483.
[Full Text] [PDF]

Home page
 ICVTSHome page
L. A. Bockeria and R. G. Grigoryants
eComment: Re: The impact of allogenic red cell transfusion and coated bypass circuit on the inflammatory response during cardiopulmonary bypass: a randomized study
Interactive CardioVascular and Thoracic Surgery, January 1, 2009; 8(1): 99 - 99.
[Full Text] [PDF]

This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Author home page(s):
Sahin Senay
Serdar Gunaydin
Cem Alhan
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Senay, S.
Right arrow Articles by Alhan, C.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Senay, S.
Right arrow Articles by Alhan, C.
Related Collections
Right arrowRelated Article

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
ANN THORAC SURG ASIAN CARDIOVASC THORAC ANN EUR J CARDIOTHORAC SURG
J THORAC CARDIOVASC SURG ICVTS ALL CTSNet JOURNALS