Non-pulsatile blood flow is associated with enhanced cerebrovascular carbon dioxide reactivity and an attenuated relationship between cerebral blood flow and regional brain oxygenation

Cecilia Maria Veraar, Harald Rinösl, Karina Kühn, Keso Skhirtladze-Dworschak, Alessia Felli, Mohamed Mouhieddine, Johannes Menger, Ekaterina Pataraia, Hendrik Jan Ankersmit, Martin Dworschak, Cecilia Maria Veraar, Harald Rinösl, Karina Kühn, Keso Skhirtladze-Dworschak, Alessia Felli, Mohamed Mouhieddine, Johannes Menger, Ekaterina Pataraia, Hendrik Jan Ankersmit, Martin Dworschak

Abstract

Background: Systemic blood flow in patients on extracorporeal assist devices is frequently not or only minimally pulsatile. Loss of pulsatile brain perfusion, however, has been implicated in neurological complications. Furthermore, the adverse effects of absent pulsatility on the cerebral microcirculation are modulated similarly as CO2 vasoreactivity in resistance vessels. During support with an extracorporeal assist device swings in arterial carbon dioxide partial pressures (PaCO2) that determine cerebral oxygen delivery are not uncommon-especially when CO2 is eliminated by the respirator as well as via the gas exchanger of an extracorporeal membrane oxygenation machine. We, therefore, investigated whether non-pulsatile flow affects cerebrovascular CO2 reactivity (CVR) and regional brain oxygenation (rSO2).

Methods: In this prospective, single-centre case-control trial, we studied 32 patients undergoing elective cardiac surgery. Blood flow velocity in the middle cerebral artery (MCAv) as well as rSO2 was determined during step changes of PaCO2 between 30, 40, and 50 mmHg. Measurements were conducted on cardiopulmonary bypass during non-pulsatile and postoperatively under pulsatile blood flow at comparable test conditions. Corresponding changes of CVR and concomitant rSO2 alterations were determined for each flow mode. Each patient served as her own control.

Results: MCAv was generally lower during hypocapnia than during normocapnia and hypercapnia (p < 0.0001). However, the MCAv/PaCO2 slope during non-pulsatile flow was 14.4 cm/s/mmHg [CI 11.8-16.9] and 10.4 cm/s/mmHg [CI 7.9-13.0] after return of pulsatility (p = 0.03). During hypocapnia, non-pulsatile CVR (4.3 ± 1.7%/mmHg) was higher than pulsatile CVR (3.1 ± 1.3%/mmHg, p = 0.01). Independent of the flow mode, we observed a decline in rSO2 during hypocapnia and a corresponding rise during hypercapnia (p < 0.0001). However, the relationship between ΔrSO2 and ΔMCAv was less pronounced during non-pulsatile flow.

Conclusions: Non-pulsatile perfusion is associated with enhanced cerebrovascular CVR resulting in greater relative decreases of cerebral blood flow during hypocapnia. Heterogenic microvascular perfusion may account for the attenuated ΔrSO2/ΔMCAv slope. Potential hazards related to this altered regulation of cerebral perfusion still need to be assessed.

Trial registration: The study was retrospectively registered on October 30, 2018, with Clinical Trial.gov (NCT03732651).

Keywords: Cerebral blood flow velocity; Cerebral microcirculation; Cerebrovascular carbon dioxide reactivity; Extracorporeal cardiopulmonary resuscitation; Extracorporeal membrane oxygenation; Non-pulsatile blood flow; Non-pulsatile left ventricular assist device; Regional brain saturation.

Conflict of interest statement

The authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
Absolute MCAv measures determined during non-pulsatile and pulsatile flow at hypo-, normo-, and hypercapnia MCAv blood flow velocity in the middle cerebral artery
Fig. 2
Fig. 2
Relative MCAv changes of single patients after induction of hypo- and hypercapnia ΔMCAv relative change in blood flow velocity in the middle cerebral artery
Fig. 3
Fig. 3
Cerebrovascular CO2 reactivity during hypo- and hypercapnia and pulsatile as well as non-pulsatile blood flow CVR cerebrovascular CO2 reactivity
Fig. 4
Fig. 4
Correlation of ΔMCAv and ΔrSO2.r correlation coefficient, ΔMCAv relative change in blood flow velocity in the middle cerebral artery, ΔrSO2 relative change in regional cerebral oxygen saturation

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