Impact Of Pulsatile And Nonpulsatile Perfusion On Hemodynamics, Cardiac And Renal Functions And Cytokines In Patients

ObjectiveControversy continues concerning the utilization of pulsatile and non-pulsatile perfusion during cardiopulmonary bypass(CPB) from the beginning of the open heart surgery.Though studies on pulsatile and non-pulsatile perfusion have been carried out for many years,conclusions are still discordant.In general,non-pulsatile perfusion is widely used at present,and with the improvementing in CPB,surgical techniques,and postoperative managements,the safety of cardiac operations have been secured.However, pulsatile perfusion must be reconsidered because it is physiologic,and further studies need to be performed on its application to the growing numbers of the high-risk patients that are undergoing cardiac operations.In this study,we performed pulsatile perfusion and compared the procedure with non-pulsatile perfusion in terms of the effects on hemodynamics,cardiac and renal functions and cytokines in patients.Methods1,Operative patient managements.Forty patients undergoing cardiac surgery were studied.They were informed of the nature of the study and consent was obtained from all of them.Patients were divided into two groups for examination and comparison.A pulsatile perfusion group(PP group) of 20 patients who underwent pulsatile CPB with roller pump and T-PLS.A non-pulsatile perfusion group(NPP group) of 20 patients who underwent non-pulsatile CPB with a roller pump.2,To assess the impact of pulsatile and non-pulsatile CPB on hemodynamics and cardiac function.SVRI,PVRI,PCWP and LVSWI were calculated from data obtained by Swan-Ganz and IntelliVue monitors before CPB(T₁),2h after cessation of CPB(T₂), 4h(T₃),8h(T₄) and 24h(T₅).3,To assess the impact of pulsatile and non-pulsatile CPB on renal function.Blood and urine samples were taken for determination the concentration of Scr,BUN,plasmicβ2-MG and urinaryβ2-MG before CPB(T₁),6h after cessation of CPB(T₂),18h(T₃), 30h(T₄) and 42h(T₅).4,To assess the impact of pulsatile and non-pulsatile CPB on cytokines.Blood samples were taken from radial artery for determination the concentration of plasmic TNF-α,IL-8 and IL-10 before CPB(T₁),during CPB 0.5h(T₂),during CPB 1h(T₃),2h after cessation of CPB(T₄),4h(T₅),8h(T₆) and 24h(T₇).All of these cytokines were estimated by enzyme-linked immunoadsordent assay(ELISA).Results1,There were no significant differences between two groups in age,sex,stature, weight,cardiac functional grading,complications,CPBT,AACT,APBT,etc.2,The impact of pulsatile and non-pulsatile CPB on hemodynamics and cardiac function.(1) Changes of SVRI:In NPP group,SVRI was significantly higher at the time points of T₂-T₄ than that of T₁(P＜0.05),and reached peak value at T₂(3070.00±560.39 dyne. s/cm⁵·m²),then began to decline.The change tendency of PP group's SVRI were similitude with the NPP group's.The PP group's SVRI peaked at T₂(2646.00±559.95 dyne·s/cm⁵·m²),then declined.And there were no significant difference between two groups at T₁,T₃ and T₅(P＞0.05).But the SVRI of NPP group was significantly higher than that of PP group at T₂ and T₄(P＜0.05).(2) Changes of PVRI:Changes of PVRI:In NPP group,SVRI was significantly higher at the time points of T₂ and T₄ than that of T₁(P＜0.05),and reached peak value at T₂(368.50±92.52 dyne·s/cm⁵·m²),then began to decline.The change tendency of PP group's PVRI were similitude with the NPP group's.The PP group's PVRI peaked at T₂(308.05±85.47 dyne·s/cm⁵·m²),then declined.And there were no significant difference between two groups at T₁ and T₅(P＞0.05).But the PVRI of NPP group was significantly higher than that of PP group at T₂-T₄(P＜0.05).(3) Changes of PCWP:In both groups,PCWP was at the range of 12-15 mmHg,and there were no significant difference between two groups at the time point of T₁-T₅(P＞0.05).(4) Changes of LVSWI:In NPP group,LVSWI was significantly lower at the time points of T₃ and T₄ than that of T₁(P＜0.05),and reached peak value at T₂(56.35±7.88 rag-M/beat·m²),then declined to the minimum at T₃(42.75±8.89 mg-M/beat·m²), afterward began to increase.The change tendency of PP group's LVSWI were similitude with the NPP group's.The PP group's LVSWI peaked at T₂(57.6±9.86 mg-M/beat·m²), then declined to the minimum at T₃(49.65±8.95 mg-M/beat·m²),afterward began to increase,too.And there were no significant difference between two groups at T₁,T₂ and T₅ (P＞0.05).But the LVSWI of PP group was significantly higher than that of NPP group at T₃ and T₄(P＜0.05).3,The impact ofpulsatile CPB and non-pulsatile CPB on renal functions(1) Changes in the concentration of Scr:In NPP group,the concentration of Scr was significantly higher at the time points of T₂-T₅ than that of T₁(P＜0.05),and reached peak value at T₄(139.40±40.04 umol/l),then began to decline.The change tendency of PP group's Scr were similitude with the NPP group's.The PP group's Scr peaked at T₄(144.25±49.40 umol/l),then declined,too.And compared with NPP group,the concentration of Scr in the PP group was high at T₁(P＜0.05).But there were no significant difference between two groups at T₂-T₅(P＞0.05).The absolute increments of Scr in NPP group were significantly higher than those of in PP group at T₂-T₅(P＜0.05).(2) Changes in the concentration of BUN:In NPP group,the concentration of BUN was significantly higher at the time points of T₂-T₅ than that of T₁(P＜0.05),and reached peak value at T₄(9.96±2.49mmol/l),then began to decline.The change tendency of PP group's BUN were similitude with the NPP group's.The PP group's Scr peaked at T4(10.75±3.42mmol/l),then declined,too.And compared with NPP group,the concentration of BUN in the PP group was high at T₁(P＜0.05).But there were no significant difference between two groups at T₂-T₅(P＞0.05).The absolute increments of BUN in NPP group were significantly higher than those of in PP group at T₂-T₅(P＜0.05).(3) Changes in the concentration of plasmicβ₂-MG:In NPP group,the concentration of plasmicβ₂-MG was significantly higher at the time points of T₂-T₅ than that of T₁ (P＜0.05),and reached peak value at T₄(5.85±1.61mg/l),then began to decline.The change tendency of PP group's plasmicβ₂-MG were similitude with the NPP group's.The PP group's plasmicβ₂-MG peaked at T₄(5.28±1.75 mg/l),then declined,too.And compared with NPP group,the concentration of plasmicβ₂-MG in the PP group was high at T₁(P＜0.05).But there were no significant difference between two groups at T₂-T₅(P＞0.05).The absolute increments of plasmicβ₂-MG in NPP group were significantly higher than those of in PP group at T₂-T₅(P＜0.05).(4) Changes in the concentration of urinaryβ₂-MG:In NPP group,the concentration of urinaryβ₂-MG was significantly higher at the time points of T₂-T₅ than that of T₁ (P＜0.05),and reached peak value at T₃(529.95±158.75ug/l),then began to decline.The change tendency of PP group's urinaryβ₂-MG were similitude with the NPP group's.The PP group's urinaryβ₂-MG peaked at T₃(344.50±124.43ug/1),then declined.And there were no significant difference between two groups at T₁(P＞0.05).But the concentration of urinaryβ₂-MG in NPP group was significantly higher than that of in PP group at T₂-T₅ (P＜0.05).4,The impact of pulsatile and non-pulsatile CPB on the concentration of cytokines.(1) Changes in the concentration of plasmic TNF-α:In NPP group,the concentration of TNF-αwas significantly higher at the time points of T₂-T₇ than that of T₁(P＜0.05),and reached peak value at T₄(72.98±14.59 pg/ml),then began to decline.The change tendency of PP group's TNF-αwere similitude with the NPP group's.The PP group's TNF-αpeaked at T₃(52.38±10.48 pg/ml),then declined.And there were no significant difference between two groups at T₁(P＞0.05).But the concentration of TNF-αin NPP group was significantly higher than that of in PP group at T₂-T₇(P＜0.05).(2) Changes in the concentration of plasmic IL-8:In NPP group,the concentration of IL-8 was significantly higher at the time points of T₂-T₇ than that of T₁(P＜0.05),and reached peak value at T₅(65.31±13.15 pg/ml),then began to decline.The change tendency of PP group's IL-8 were similitude with the NPP group's.The PP group's IL-8 peaked at T₅ (45.24±9.95pg/ml),then declined.And there were no significant difference between two groups at T₁(P＞0.05).But the concentration of IL-8 in NPP group was significantly higher than that of in PP group at T₂-T₇(P＜0.05).(3) Changes in the concentration of plasmic IL-10:In NPP group,IL-10 was significantly higher at the time points of T₂-T₇ than that of T₁(P＜0.05),and reached peak value at T₂(192.78±53.95pg/ml),then declined to the minimum at T₃(162.24±51.84pg/ml), afterward began to increase.The PP group's IL-10 peaked at T₅(363.39±91.60pg/ml),then declined.And there were no significant difference between two groups at T₁(P＞0.05).But the concentration of IL-10 in PP group was significantly higher than that of in NPP group at T₃-T₇(P＜0.05).Conclusions1,Non-pulsatile perfusion caused the peripheral vasoconstriction,enhanced the peripheral vascular resistance and aggravated the cardiac afterload.Pulsatile perfusion not only suppressed the increasing extent of the peripheral vascular resistance and the decreasing degree of cardiac function,but also maintained the hemodynamics and cardiac function stabilization.2,Non-pulsatile perfusion damaged the renal function.Pulsatile perfusion lightened the renal tissue injury and suppressed the decreasing degree of renal function.3,Non-pulsatile perfusion activated cytokines and induced the releasing of TNF-α, IL-8 and L-10,and played an important role in SIRS/CARS during and after CPB. Pulsatile perfusion not only suppressed the releasing of proinflammatory cytokines,such as TNF-αand IL-8,but also enhanced the releasing of anti-inflammatory cytokine IL-10. Pulsatile perfusion regulated the balance of SIRS/CARS and reduced the injury of the tissues and organs.