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Original Articles

Detection and Elimination of Microemboli Related to Cardiopulmonary Bypass

Robert C. Groom, MS, CCP; Reed D. Quinn, MD; Paul Lennon, MD; Desmond J. Donegan, MD; John H. Braxton, MBA, MD; Robert S. Kramer, MD; Paul W. Weldner, MD; Louis Russo, MD; Seth D. Blank, MD; Angus A. Christie, MD; Andreas H. Taenzer, MD; Richard J. Forest, CCP; Cantwell Clark, MS, MD; Janine Welch, MS, CCP; Cathy S. Ross, MS; Gerald T. O'Connor, PhD, ScD; Donald S. Likosky, PhD for the Northern New England Cardiovascular Disease Study Group

From Cardiac Surgery (R.C.G., R.D.Q., D.J.D., J.H.B., R.S.K., P.W.W., L.R., S.D.B., R.J.F., J.W.) and the Department of Anesthesia (P.L., A.A.C.), Maine Medical Center, Portland; and the Departments of Surgery (D.S.L.) and Community & Family Medicine (D.S.L., C.S.R., G.T.O.), Dartmouth Medical School, the Department of Anesthesiology (A.H.T., C.C.), Dartmouth-Hitchcock Medical Center, and the Dartmouth Institute for Health Policy & Clinical Practice (D.S.L., G.T.O.), Dartmouth College, Lebanon, NH.

Correspondence to Robert C. Groom, MS, CCP, Associate Vice President of Cardiac Services, Director of Cardiovascular Perfusion, Maine Medical Center, 22 Bramhall Street, Portland, ME 04102. E-mail groomr{at}mmc.org

Received July 2, 2008; accepted February 9, 2009.

Background— Neurobehavioral impairment is a common complication of coronary bypass surgery. Cerebral microemboli during cardiopulmonary bypass (CPB) are a principal mechanism of cognitive injury. The aim of this work was to study the occurrence of cerebral embolism during CPB and to evaluate the effectiveness of evidence-based CPB circuit component and process changes on the exposure of the patient to emboli.

Methods and Results— M-Mode Doppler was used to detect emboli in the inflow and outflow of cardiopulmonary circuit and in the right and left middle cerebral arteries. Doppler signals were merged into a single display to allow real-time associations between discrete clinical techniques and emboli detection. One hundred sixty-nine isolated coronary artery bypass grafting (CABG) patients were studied between 2002 and 2008. There was no statistical difference in median microemboli detected in the inflow of the CPB circuit, (Phase I, 931; Phase II, 1214; Phase III, 1253; Phase IV, 1125; F [3,158]=0.8, P=0.96). Significant changes occurred in median microemboli detected in the outflow of the CPB circuit across phases, (Phase I, 702; Phase II, 572; Phase III, 596; Phase IV, 85; F [3,157]=13.1, P<0.001). Significant changes also occurred in median microemboli detected in the brain across phases, (Phase I, 604; Phase II, 429; Phase III, 407; Phase IV, 138; F [3,153]=14.4, P<0.001). Changes in the cardiopulmonary bypass circuit were associated with an 87.9% (702 versus 85) reduction in median microemboli in the outflow of the CPB circuit (P<0.001), and a 77.2% (604 versus 146) reduction in microemboli in the brain (P<0.001).

Conclusions— Changes in CPB techniques and circuit components, including filter size and type of pump, resulted in a reduction in more than 75% of cerebral microemboli.

Key Words: surgery • cardiopulmonary bypass • cerebrovascular circulation • embolism • coronary disease

The online-only Data Supplement can be found at http://circep.ahajournals.org/cgi/content/full/10.1161/CIRCOUTCOMES.108.803163/DC1.

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