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J Thorac Cardiovasc Surg 2000;119:188
© 2000 Mosby, Inc.

LETTERS TO THE EDITOR

Pulsatile perfusion during cardiopulmonary bypass

Yuji Kadoi, MD, Shigeru Saito, MD

Department of Anesthesiology and Reanimatology, Gunma University School of Medicine, 3-39-22, Showa-machi
Maebashi, Gunma 371-8511 Japan

Reply to the Editor:

We appreciate the interest and comments of Dr Bregman. We agree that pulsatility offers advantages over nonpulsatility to reduce requirements for postoperative inotropic support and intra-aortic balloon counterpulsation (IABP), as reported by Bregman and colleagues.Go 1 Furthermore, Murkin and associatesGo 2 reported that the duration of cardiopulmonary bypass (CPB), age, and use of nonpulsatile perfusion correlated significantly with adverse outcome. However, it still remains controversial whether pulsatility offers advantages over nonpulsatility for brain protection.Go 3

The pulse pressure used in our study (24 ± 8 mm Hg) was determined to obtain the physiologic dP/dt value. Since we did not examine the pulse pressure as recommended by Bregman (>40 mm Hg), further study with higher pulse pressure is required to evaluate the effect of high-pressure IABP on cerebral circulation.

Since the hemofiltration system was connected to the CPB circuit to increase hemoglobin concentration during CPB in most cases in our institutes, exact urinary output could not be examined during CPB. However, we also have the impression that pulsatile perfusion has a beneficial effect on renal blood flow.

Cook, Orszulak, and DalyGo 4 reported that pulsatility generated by IABP, with a pulse pressure of approximately 30 mm Hg, had no significant effect on cerebral perfusion. Lodge and associatesGo 5 also could not show any benefits of pulsatile perfusion on regional or global cerebral blood flow. Their pulse pressure was 36 ± 6 mm Hg. In contrast, several reportsGo 1 including the study by Dr Bregman showed benefits of pulsatile perfusion. At present, it is not clear which type of pulsatile wave form has positive effects on cerebral circulation and improves the outcome of patients. We admit that another type of pulse wave might be effective to alter brain oxygenation.

References

  1. Bregman D, Bowman FO Jr, Parodi NE, Haubert SM, Edie RN, Spotnitz HM, et al. An improved method of myocardial protection with pulsation during cardiopulmonary bypass. Circulation 1977;56(Suppl):II157-60.
  2. Murkin JM, Martzke JS, Buchan AM, Bentley C, Wong CJ. A randomized study of the influence of perfusion technique and pH management strategy in 316 patients undergoing coronary bypass surgery: mortality and cardiovascular morbidity. J Thorac Cardiovasc Surg 1995;110:340-8.[Abstract/Free Full Text]
  3. Hornick P, Taylor K. Pulsatile and nonpulsatile perfusion: the continuing controversy. J Cardiothorac Vasc Anesth 1997;11:310-5.[Medline]
  4. Cook DJ, Orszulak TA, Daly RC. The effects of pulsatile cardiopulmonary bypass on cerebral and renal blood flow in dogs. J Cardiothorac Vasc Anesth 1997;11:420-7.[Medline]
  5. Lodge AJ, Under K, Daggett CW, Runge TM, Calhoon JH, Ungerleider RM. Regional blood flow during pulsatile cardiopulmonary bypass and after circulatory arrest in an infant model. Ann Thorac Surg 1997;63:1243-50.[Abstract/Free Full Text]




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