Limitation of thrombin generation, platelet activation, and inflammation by elimination of cardiotomy suction in patients undergoing coronary artery bypass grafting treated with heparin-bonded circuits.
OBJECTIVE
Reports evaluating the efficacy of heparin-bonded circuits to blunt inflammation, platelet dysfunction, and thrombin generation in response to cardiopulmonary bypass have varied. We hypothesized that this variability may in part be related to the use of cardiotomy suction, which has been demonstrated to reintroduce procoagulant and proinflammatory factors into the systemic circulation during cardiopulmonary bypass. A prospective, randomized study was undertaken to evaluate the specific effects of cardiotomy suction.


METHODS
Thirty-six patients undergoing first-time, nonemergency coronary artery bypass grafting with cardiopulmonary bypass were randomly assigned to one of three treatment groups: group I, non-heparin-bonded circuits with the use of cardiotomy suction (n = 12); group II, Duraflo II (BCR-3500; Jostra Bentley Corp, Irvine, Calif) heparin-bonded circuits with cardiotomy suction (n = 12); and group III, Duraflo II heparin-bonded circuits without cardiotomy suction (n = 12). Thrombin generation, neutrophil activation (polymorphonuclear elastase), platelet activation (beta-thromboglobulin), and neuronal injury (neuron-specific enolase) were analyzed by enzyme-linked immunosorbent assays after cardiopulmonary bypass and compared with prebypass levels. Results are presented as mean +/- SEM.


RESULTS
Prebypass levels of all markers were similar among treatment groups. However, postbypass levels were significantly and consistently highest in group I relative to groups II and III. Thrombin generation levels were 5.0 +/- 0.9 nmol/L in group I, 3.0 +/- 0.6 nmol/L in group II, and 1.5 +/- 0.1 nmol/L in group III (P <.05 vs group II and P <.001 vs group I). Polymorphonuclear elastase levels were 307 +/- 64 microg/L in group I, 128 +/- 24 microg/L in group II (P <.05 vs group I), and 75 +/- 14 microg/L in group III (P <.001 vs group I). beta-Thromboglobulin levels were 2692 +/- 401 IU/mL in group I, 912 +/- 99 IU/mL in group II (P =.001 vs group I), and 646 +/- 133 IU/mL in group III (P =.001 vs group I). Neuron-specific enolase levels were 9.8 +/- 0.9 ng/mL in group I, 10.5 +/- 1.6 ng/mL in group II, and 4.2 +/- 0.5 ng/mL in group III (P =.001 vs groups I and II).


CONCLUSIONS
Use of cardiotomy suction resulted in significant increases in thrombin, neutrophil, and platelet activation, as well as the release of neuron-specific enolase, after cardiopulmonary bypass. Limiting increases in these markers would be best accomplished by eliminating cardiotomy suction and routinely using heparin-bonded circuits whenever possible.
Aldea
Gabriel S
GS
Division of Cardiothoracic Surgery, Department of Surgery, University of Washington School of Medicine, Seattle, WA 98195-3166, USA. aldea@u.washington.edu
Soltow
Louise O
LO
Chandler
Wayne L
WL
Triggs
Christopher M
CM
Vocelka
Craig R
CR
Crockett
Gregory I
GI
Shin
Yong T
YT
Curtis
William E
WE
Verrier
Edward D
ED
D000368:Aged; D000925:Anticoagulants / Q000627:therapeutic use*; D015415:Biomarkers / Q000097:blood; D002315:Cardiopulmonary Bypass; D020099:Coated Materials, Biocompatible / Q000627:therapeutic use*; D015938:Complement Membrane Attack Complex / Q000187:drug effects / Q000378:metabolism; D001026:Coronary Artery Bypass; D023381:Endpoint Determination; D004867:Equipment Design; D005260:Female; D006493:Heparin / Q000627:therapeutic use*; D006801:Humans; D018836:Inflammation Mediators / Q000097:blood*; D015850:Interleukin-6 / Q000097:blood; D016209:Interleukin-8 / Q000097:blood; D019272:Leukocyte Elastase / Q000097:blood / Q000187:drug effects; D008297:Male; D008875:Middle Aged; D015539:Platelet Activation / Q000187:drug effects* / Q000502:physiology*; D011446:Prospective Studies; D013223:Statistics as Topic; D013396:Suction; D013917:Thrombin / Q000096:biosynthesis* / Q000187:drug effects*; D013997:Time Factors; D016896:Treatment Outcome; D014861:Washington
D000925:Anticoagulants; D015415:Biomarkers; D020099:Coated Materials, Biocompatible; D015938:Complement Membrane Attack Complex; D018836:Inflammation Mediators; D015850:Interleukin-6; D016209:Interleukin-8; D006493:Heparin; D019272:Leukocyte Elastase; D013917:Thrombin