Pulmonary artery perfusion versus no pulmonary perfusion during cardiopulmonary bypass in patients with COPD: a randomised clinical trial

Katrine B Buggeskov, Martin M Sundskard, Thomas Jonassen, Lars W Andersen, Niels H Secher, Hanne B Ravn, Daniel A Steinbrüchel, Janus C Jakobsen, Jørn Wetterslev, Katrine B Buggeskov, Martin M Sundskard, Thomas Jonassen, Lars W Andersen, Niels H Secher, Hanne B Ravn, Daniel A Steinbrüchel, Janus C Jakobsen, Jørn Wetterslev

Abstract

Introduction: Absence of pulmonary perfusion during cardiopulmonary bypass (CPB) may be associated with reduced postoperative oxygenation. Effects of active pulmonary artery perfusion were explored in patients with chronic obstructive pulmonary disease (COPD) undergoing cardiac surgery.

Methods: 90 patients were randomised to receive pulmonary artery perfusion during CPB with either oxygenated blood (n=30) or histidine-tryptophan-ketoglutarate (HTK) solution (n=29) compared with no pulmonary perfusion (n=31). The coprimary outcomes were the inverse oxygenation index compared at 21 hours after starting CPB and longitudinally in a mixed-effects model (MEM). Secondary outcomes were tracheal intubation time, serious adverse events, mortality, days alive outside the intensive care unit (ICU) and outside the hospital.

Results: 21 hours after starting CPB patients receiving pulmonary artery perfusion with normothermic oxygenated blood had a higher oxygenation index compared with no pulmonary perfusion (mean difference (MD) 0.94; 95% CI 0.05 to 1.83; p=0.04). The blood group had also a higher oxygenation index both longitudinally (MEM, p=0.009) and at 21 hours (MD 0.99; CI 0.29 to 1.69; p=0.007) compared with the HTK group. The latest result corresponds to a difference in the arterial partial pressure of oxygen of 23 mm Hg with a median fraction of inspired oxygen of 0.32. Yet the blood or HTK groups did not demonstrate a longitudinally higher oxygenation index compared with no pulmonary perfusion (MEM, p=0.57 and 0.17). Similarly, at 21 hours there was no difference in the oxygenation index between the HTK group and those no pulmonary perfusion (MD 0.06; 95% CI -0.73 to 0.86; p=0.87). There were no statistical significant differences between the groups for the secondary outcomes.

Discussion: Pulmonary artery perfusion with normothermic oxygenated blood during cardiopulmonary bypass appears to improve postoperative oxygenation in patients with COPD undergoing cardiac surgery. Pulmonary artery perfusion with hypothermic HTK solution does not seem to improve postoperative oxygenation.

Trial registration number: NCT01614951; Pre-results.

Keywords: ARDS; COPD ÀÜ Mechanisms; Lung Physiology.

Figures

Figure 1
Figure 1
CONSORT flow diagram.
Figure 2
Figure 2
Oxygenation indices inverse means for the three groups from cardiopulmonary bypass start and until 21 hours after.

References

    1. LaPar DJ, Gillen JR, Crosby IK et al. . Predictors of operative mortality in cardiac surgical patients with prolonged intensive care unit duration. J Am Coll Surg 2013;216:1116–23.
    1. Kaul TK, Fields BL, Riggins LS et al. . Adult respiratory distress syndrome following cardiopulmonary bypass: incidence, prophylaxis and management. J Cardiovasc Surg (Torino) 1998;39:777–81.
    1. Koch C, Li L, Figueroa P et al. . Transfusion and pulmonary morbidity after cardiac surgery. Ann Thorac Surg 2009;88:1410–18.
    1. Milot J, Perron J, Lacasse Y et al. . Incidence and predictors of ARDS after cardiac surgery. Chest 2001;119:884–8.
    1. Christenson JT, Aeberhard J-M, Badel P et al. . Adult respiratory distress syndrome after cardiac surgery. Cardiovasc Surg 1996;4:15–21.
    1. Massoudy P, Zahler S, Becker BF et al. . Evidence for inflammatory responses of the lungs during coronary artery bypass grafting with cardiopulmonary bypass. Chest 2001;119:31–6.
    1. Schlensak C, Doenst T, Beyersdorf F. Lung ischemia during cardiopulmonary bypass. Ann Thorac Surg 2000;70:337–8.
    1. den Hengst WA, Gielis JF, Lin JY et al. . Lung ischemia-reperfusion injury: a molecular and clinical view on a complex pathophysiological process. Am J Physiol Heart Circ Physiol 2010;299:H1283–99.
    1. Chai PJ, Williamson JA, Lodge AJ et al. . Effects of ischemia on pulmonary dysfunction after cardiopulmonary bypass. Ann Thorac Surg 1999;67:731–5.
    1. Friedman M, Sellke FW, Wang SY et al. . Parameters of pulmonary injury after total or partial cardiopulmonary bypass. Circulation 1994;90Pt 2):II262–268.
    1. Schlensak C, Doenst T, Preusser S et al. . Bronchial artery perfusion during cardiopulmonary bypass does not prevent ischemia of the lung in piglets: assessment of bronchial artery blood flow with fluorescent microspheres. Eur J Cardiothorac Surg 2001;19: 326–32.
    1. Kuratani T, Matsuda H, Sawa Y et al. . Experimental study in a rabbit model of ischemia-reperfusion lung injury during cardiopulmonary bypass. J Thorac Cardiovasc Surg 1992;103:564–8.
    1. da Costa Freitas CR, Sa Malbouisson LM, Benicio A et al. . Lung perfusion and ventilation during cardiopulmonary bypass reduces early structural damage to pulmonary parenchyma. Anesth Analg 2016;122:943–52.
    1. Grossherr M, Bechtel JFM, Heinze H et al. . Effects of pulmonary artery perfusion on gas exchange and alveolar matrix metalloproteinases after cardiopulmonary bypass in a swine model. App Cardiopulm Pathophysiol 2009;13:123–9.
    1. Serraf A, Robotin M, Bonnet N et al. . Alteration of the neonatal pulmonary physiology after total cardiopulmonary bypass. J Thorac Cardiovasc Surg 1997;114:1061–9.
    1. Zheng JH, Xu ZW, Wang W et al. . Lung perfusion with oxygenated blood during aortic clamping prevents lung injury. Asian Cardiovasc Thorac Ann 2004;12:58–60.
    1. Li JA, Liu YL, Liu JP et al. . Pulmonary artery perfusion with HTK solution prevents lung injury in infants after cardiopulmonary bypass. Chin Med J 2010;123:2645–50.
    1. Suzuki T, Fukuda T, Ito T et al. . Continuous pulmonary perfusion during cardiopulmonary bypass prevents lung injury in infants. Ann Thorac Surg 2000;69:602–6.
    1. Suzuki T, Ito T, Kashima I et al. . Continuous perfusion of pulmonary arteries during total cardiopulmonary bypass favorably affects levels of circulating adhesion molecules and lung function. J Thorac Cardiovasc Surg 2001;122:242–8.
    1. Wei B, Liu Y, Wang Q et al. . Lung perfusion with protective solution relieves lung injury in corrections of Tetralogy of Fallot. Ann Thorac Surg 2004;77:918–24.
    1. De Santo LS, Romano G, Amarelli C et al. . Surgical repair of acute type A aortic dissection: continuous pulmonary perfusion during retrograde cerebral perfusion prevents lung injury in a pilot study. J Thorac Cardiovasc Surg 2003;126:826–31.
    1. Kiessling AH, Guo FW, Gökdemir Y et al. . The influence of selective pulmonary perfusion on the inflammatory response and clinical outcome of patients with chronic obstructive pulmonary disease undergoing cardiopulmonary bypass. Interact Cardiovasc Thorac Surg 2014;18:732–9.
    1. Santini F, Onorati F, Telesca M et al. . Selective pulmonary pulsatile perfusion with oxygenated blood during cardiopulmonary bypass attenuates lung tissue inflammation but does not affect circulating cytokine levels. Eur J Cardiothorac Surg 2012;42:942–50.
    1. Santini F, Onorati F, Telesca M et al. . Pulsatile pulmonary perfusion with oxygenated blood ameliorates pulmonary hemodynamic and respiratory indices in low-risk coronary artery bypass patients. Eur J Cardiothorac Surg 2011;40:794–803.
    1. Liu LM, Hu JG, Yin BL et al. . [Lung protection of continuous pulmonary artery perfusion with oxygenated blood during cardiopulmonary bypass]. [Chinese] Zhong Nan Da Xue Xue Bao Yi Xue Ban 2005;30:413–16.
    1. Griffith BP, Zenati M. The pulmonary donor. Clin Chest Med 1990;11:217–26
    1. Buggeskov KB, Wetterslev J, Secher NH et al. . Pulmonary perfusion with oxygenated blood or custodiol HTK solution during cardiac surgery for postoperative pulmonary function in COPD patients: a trial protocol for the randomized, clinical, parallel group, assessor and data analyst blinded Pulmonary Protection Trial. Trials 2013;14:30
    1. World Medical Association. World Medical Association Declaration of Helsinki: ethical principles for medical research involving human subjects. JAMA 2013;310:2191–4.
    1. Buggeskov KB, Jakobsen JC, Secher NH et al. . Detailed statistical analysis plan for the pulmonary protection trial. Trials 2014;15:510
    1. GOLD_Report 2016.pdf. [cited 2 Feb 2016].
    1. Gøtzsche PC. Blinding during data analysis and writing of manuscripts. Control Clin Trials 1996;17:285–90–293
    1. Waldau T, Larsen VH, Bonde J. Evaluation of five oxygen delivery devices in spontaneously breathing subjects by oxygraphy. Anaesthesia 1998;53:256–63.
    1. Jakobsen JC, Tamborrino M, Winkel P. Count data analysis in randomised clinical trials. J Biomet Biostat 2015[cited 2015 Nov 18];6:227
    1. Jakobsen JC, Gluud C, Winkel P et al. . The thresholds for statistical and clinical significance—a five-step procedure for evaluation of intervention effects in randomised clinical trials. BMC Med Res Methodol 2014;14:34
    1. Adabag AS, Wassif HS, Rice K et al. . Preoperative pulmonary function and mortality after cardiac surgery. Am Heart J 2010;159:691–7.
    1. Ried M, Unger P, Puehler T et al. . Mild-to-moderate COPD as a risk factor for increased 30-day mortality in cardiac surgery. Thorac Cardiovasc Surg 2010;58:387–91.
    1. Roques F, Nashef SA, Michel P et al. . Risk factors and outcome in European cardiac surgery: analysis of the EuroSCORE multinational database of 19030 patients. Eur J Cardiothorac Surg 1999;15:816–23.
    1. Fuster RG, Argudo JAM, Albarova OG et al. . Prognostic value of chronic obstructive pulmonary disease in coronary artery bypass grafting. Eur J Cardiothorac Surg 2006;29:202–9.
    1. Leavitt BJ, Ross CS, Spence B et al. . Long-term survival of patients with chronic obstructive pulmonary disease undergoing coronary artery bypass surgery. Circulation 2006;114(1 Suppl):I430–434.
    1. Manganas H, Lacasse Y, Bourgeois S et al. . Postoperative outcome after coronary artery bypass grafting in chronic obstructive pulmonary disease. Can Respir J 2007;14:19–24.
    1. ARDS Definition Task Force Ranieri VM, Rubenfeld GD, Thompson BT et al. . Acute respiratory distress syndrome: the Berlin Definition. JAMA 2012;307:2526–33.
    1. Thomas L, Peterson ED. The value of statistical analysis plans in observational research: defining high-quality research from the start. JAMA 2012;308:773–4.

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