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Objective: The growing life expectancy has led the elderly to be increasingly referred to coronary artery bypass grafting. Preexisting comorbidities may benefit from theoretical advantages of pulsatile perfusion during cardiopulmonary bypass (CPB)., Design: Prospective randomized trial., Setting: Cardiac surgery unit in a university hospital., Patients: Eighty consecutive patients older than 70 years., Interventions: Elective coronary artery bypass grafting on CPB, randomizing to conventional linear CPB (40 patients, group A) or intra-aortic balloon pump (IABP)-induced pulsatile CPB (40 patients, group B)., Measurements and Main Results: We evaluated hemodynamic response by pulmonary artery flotation catheter, metabolic/splanchnic response by lactate and transaminase, bilirubin, amylase, and renal function (creatinine clearance, creatinine, incidence of renal insufficiency and failure), respiratory response by Pao2/Fio2, respiratory compliance, scoring of chest radiograph, intubation time, and need for noninvasive positive-pressure ventilation, hematologic response by chest drainage, hemocoagulative and fibrinolytic cascades, and transfusions. IABP-related complications were recorded. Two minor IABP-related complications (2.5%) were registered. Hemodynamics was comparable, except for a slightly better cardiac index and indexed systemic vascular resistances at the end of CPB and at intensive therapy unit (ITU) admission (p < 0.05). Transaminases, bilirubin, amylase, proved lower in group B (p < 0.05 from ITU admission to 48 hours). Creatinine clearance, serum creatinine, and lactate were better in group B (p < 0.05), and acute renal insufficiency was accordingly lower (p = 0.02). Respiratory response demonstrated better Pao2/Fio2 and respiratory compliance from aortic declamping to 48 hours, with better scoring of chest radiograph (p < 0.05 from ITU admission to 48 hours), lower noninvasive positive-pressure ventilation (p = 0.002) and intubation time (p = 0.031) in group B. Lower chest drainage (p < 0.05 at first and second day), transfusions (p < 0.05), activated partial thromboplastin time, international normalized ratio, white blood cells, and D-dimer (p < 0.05 from ITU admission to 48 hours), together with higher platelets, fibrinogen, and antithrombin III (p < 0.05 from ITU admission to 48 hours) were demonstrated in the pulsated group., Conclusions: IABP-induced pulsatile flow significantly improves whole body perfusion in the elderly undergoing CPB.

Backgrounds/aims: We recently demonstrated that pulsatile cardiopulmonary bypass (CPB) versus standard linear CPB is associated with better perioperative renal function. Since older subjects have a higher risk of acute renal failure, we have extended our study to evaluate the specific impact of pulsatile CPB on the perioperative renal function in elderly patients., Methods: We enrolled 50 patients with normal preoperative renal function: they were stratified by age (65-75 vs. 50-64 years) and randomized to nonpulsatile (group A) or pulsatile CPB (group B). Twenty-seven patients aged > or =50 years and <65 years were randomized to group A (n = 12) or to group B (n = 15) and 23, aged > or =65 years and < or =75 years, to group A (n = 13) or to group B (n = 10). Glomerular filtrate rate (GFR), daily diuresis, lactatemia and other parameters were measured during the pre- and perioperative period., Results: The percent perioperative decrease in GFR was lower in group A than in group B (p < 0.001), without differences between older and younger patients. By contrast, perioperative plasma lactate levels were higher in group A than in group B (p < 0.001), both in older and younger patients. No difference was observed for 24 h urine output and blood urea nitrogen., Conclusions: Pulsatile CPB preserves renal function better than standard CPB even in patients older than 65. CPB could be adopted as the procedure of choice in this subgroup of patients., (Copyright (c) 2009 S. Karger AG, Basel.)

Background: Nonpulsatile perfusion during cardiopulmonary bypass can induce renal damage. We evaluated whether pulsatile perfusion using an intra-aortic balloon pump preserves renal function in patients undergoing myocardial revascularization., Study Design: Randomized controlled trial, nonmasked parallel-group design., Setting & Participants: 100 patients undergoing preoperative perfusion using an intra-aortic balloon pump; 64 with baseline estimated glomerular filtration rate (eGFR) of 60 mL/min/1.73 m(2) or greater (>or=1 mL/s/1.73 m(2); stage 1 or 2) and 36 with eGFR of 30 to 59 mL/min/1.73 m(2) (0.5 to 0.98 mL/s/1.73 m(2); stage 3)., Intervention: Patients were randomly assigned to nonpulsatile perfusion during cardiopulmonary bypass (group A) or automatic intra-aortic balloon pump-induced pulsatile perfusion during cardiopulmonary bypass (group B)., Outcomes & Measurements: Renal function, daily diuresis, complications, serum lactate levels, and other biochemical indices at 24 and 48 hours., Results: GFR, adjusted for baseline eGFR, was 16 mL/min/1.73 m(2) [0.27 mL/s/1.73 m(2)] less in group A (58.1 mL/min/1.73 m(2); 95% confidence interval [CI], 56.1 to 60.1 mL/min/1.73 m(2) [0.97 mL/s/1.73 m(2); 95% CI, 0.94 to 1.0 mL/s/1.73 m(2)]) than in group B (74.0 mL/min/1.73 m(2); 95% CI, 72.0 to 76.1 mL/min/1.73 m(2) [1.23 mL/s/1.73 m(2); 95% CI, 1.20 to 1.27 mL/s/1.73 m(2)]; P < 0.001). Plasma lactate levels were +3.9 mg/dL (+0.43 mmol/L) higher in group A (19.5 mg/dL; 95% CI, 18.4 to 20.5 mg/dL [2.16 mmol/L; 95% CI, 2.04 to 2.28 mmol/L]) than in group B (16.7 mg/dL; 95% CI, 14.4 to 16.7 mg/dL [1.73 mmol/L; 95% CI, 1.60 to 1.85 mmol/L]; P < 0.001). No significant difference between the 2 groups was observed for 24-hour diuresis. Patients with eGFR stage 3 had a greater decrease in GFR and daily diuresis and greater increase in lactate levels than those with eGFR stages 1 to 2., Limitations: Short-term change in kidney function as a surrogate outcome for "hard" clinical outcomes of mortality, morbidity, and length of hospitalization. Other limitations are short-term follow-up and absence of measurement of hemodynamic parameters or inflammatory mediators., Conclusions: Use of automatic pulsatile intra-aortic balloon pumps during cardiopulmonary bypass is associated with better renal function during myocardial reperfusion. More studies are needed to verify the effects of pulsatile intra-aortic balloon pumps.

Cardiopulmonary bypass (CPB) may trigger organs damage, including kidney injury, due to a massive cytokine release. In this observational, prospective study, we analyzed the possible impact of chronic treatment with ACE-Inhibitors (ACE-I) on the inflammatory response and renal function after CPB. Sixty-nine patients undergoing major cardiac surgery with CPB were enrolled. Patients were stratified according to long-term (> 6 mo.) ACE-I use (n = 38) or not (n = 31). The primary endpoint was the change in IL-1alpha, IL-1beta, IL-2, IL-4, IL-6, IL-8, IL-10, TNF alpha, EGF and VEGF plasma levels. Secondary (renal) endpoints were postoperative acute kidney injury (AKI), recovery of baseline GFR values and the absolute changes in renal function indexes. After CPB, IL-1alpha, IL-1beta, IL-4 and TNF-alpha remained stable over time while a significant decrease in IL-2 levels was noticed in the ACE-I group (p = 0.01). IL-6 and IL-8 increased after surgery and tended to decrease after 48 h. IL-10 levels showed a similar variation, but both their rise and decrease were more pronounced in patients under ACE-I treatment (p = 0.007). Finally, VEGF and EGF showed a marked initial decrease with a tendency to normalization 10 days after surgery (p for trend ranging from 0.01 to 0.001). The occurrence of AKI within 2 days after surgery, the rate of GFR recovery and the absolute changes in renal function indexes were not statistically different between groups. Chronic, long-term ACE-I treatment may influence the inflammatory response following CPB. On the other hand, this drug class apparently has neutral impact on perioperative renal outcomes. [ABSTRACT FROM AUTHOR]