Eprints
AbstractBackground: Cardiopulmonary bypass is thought to propagate a global systemic response through contact with the non-physiological surfaces of the extracorporeal circuit leading to the stimulation of leucocytes, their adherence to endothelial cells and the release of cytotoxic molecules. This in turn has been shown to accelerate pulmonary injury. This study tested a new leucocyte filtration system (RemoweLL) against a conventional system with no leucocyte-depleting capacity, to determine the efficacy of the filtration system and its effects on pulmonary function.Methods: Thirty patients underwent coronary artery bypass graft surgery using either the RemoweLL filtration system (15 patients) or a conventional cardiopulmonary bypass circuit (15 patients). Data were collected on the total number of leucocytes, their differentiation, and activation using the leucocyte adhesion integrin CD11b as a surrogate marker. Pulmonary function was assessed using the Alveolar-Arterial Oxygenation Index (AaOI) and patients categorised using the Berlin definition of acute respiratory distress syndrome (ARDS).Results: Both groups showed significant increases in leucocyte numbers during CPB [p<0.001] with no differences noted between groups. CD11b showed a significant increase in both groups, with peak activation occurring at the end of CPB but no difference between groups [p=0.8]. There was a trend towards lower AaOI increases in the filtration group but this did not reach significance [p=0.075], and there was no difference in ARDS definitions [p=0.33].Conclusions: Leucocyte filtration of the cardiotomy suction did not influence total leucocyte counts or activation as measured by CD11b upregulation. Furthermore, no evidence could be found to suggest improved pulmonary function.IntroductionThe inflammatory response to cardiac surgery is multifactorial and can be categorised as either material dependent (i.e. the exposure of blood to non-physiological surfaces and conditions associated with Cardiopulmonary Bypass; CPB), or material independent (surgical trauma, release of endotoxin and changes in body temperature). It can also be due to allogeneic blood exposure in response to the haemodilution that occurs during CPBPEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Gcm9tZXM8L0F1dGhvcj48WWVhcj4yMDAyPC9ZZWFyPjxS
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ADDIN EN.CITE.DATA 1. Of major interest for more than a decade is the role that activated leucocytes play in the inflammatory response. Leucocyte action can be mediated by the complement C3a molecule enabling local release of elastase, myeloperoxidase and lactoferrin upon adhesion to endothelial cells, promoting endothelial damage and neutrophil extravasation ADDIN EN.CITE <EndNote><Cite><Author>Asimakopoulos</Author><Year>2002</Year><RecNum>299</RecNum><DisplayText><style face="superscript">2</style></DisplayText><record><rec-number>299</rec-number><foreign-keys><key app="EN" db-id="pw5wrzd0l2xzzge0xfkxfevgpwre0rtpf95v" timestamp="1485334591">299</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Asimakopoulos, G.</author></authors></contributors><auth-address>Hammersmith Hospital, London, UK. geoasi@</auth-address><titles><title>The inflammatory response to CPB: the role of leukocyte filtration</title><secondary-title>Perfusion</secondary-title><alt-title>Perfusion</alt-title></titles><periodical><full-title>Perfusion</full-title><abbr-1>Perfusion</abbr-1></periodical><alt-periodical><full-title>Perfusion</full-title><abbr-1>Perfusion</abbr-1></alt-periodical><pages>7-10</pages><volume>17 Suppl</volume><edition>2002/05/15</edition><keywords><keyword>Animals</keyword><keyword>Cardiopulmonary Bypass/*adverse effects</keyword><keyword>Humans</keyword><keyword>Inflammation/*etiology/*prevention & control</keyword><keyword>*Leukapheresis</keyword></keywords><dates><year>2002</year><pub-dates><date>May</date></pub-dates></dates><isbn>0267-6591 (Print)
0267-6591</isbn><accession-num>12009089</accession-num><urls></urls><remote-database-provider>Nlm</remote-database-provider><language>eng</language></record></Cite></EndNote>2. This is especially prevalent in the pulmonary system where CPB has been shown to induce increased pulmonary vascular permeability and arterial–alveolar gradients and decreased pulmonary compliance resulting in acute respiratory distress syndrome (ARDS; ADDIN EN.CITE <EndNote><Cite><Author>Asimakopoulos</Author><Year>2002</Year><RecNum>299</RecNum><DisplayText><style face="superscript">2</style></DisplayText><record><rec-number>299</rec-number><foreign-keys><key app="EN" db-id="pw5wrzd0l2xzzge0xfkxfevgpwre0rtpf95v" timestamp="1485334591">299</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Asimakopoulos, G.</author></authors></contributors><auth-address>Hammersmith Hospital, London, UK. geoasi@</auth-address><titles><title>The inflammatory response to CPB: the role of leukocyte filtration</title><secondary-title>Perfusion</secondary-title><alt-title>Perfusion</alt-title></titles><periodical><full-title>Perfusion</full-title><abbr-1>Perfusion</abbr-1></periodical><alt-periodical><full-title>Perfusion</full-title><abbr-1>Perfusion</abbr-1></alt-periodical><pages>7-10</pages><volume>17 Suppl</volume><edition>2002/05/15</edition><keywords><keyword>Animals</keyword><keyword>Cardiopulmonary Bypass/*adverse effects</keyword><keyword>Humans</keyword><keyword>Inflammation/*etiology/*prevention & control</keyword><keyword>*Leukapheresis</keyword></keywords><dates><year>2002</year><pub-dates><date>May</date></pub-dates></dates><isbn>0267-6591 (Print)
0267-6591</isbn><accession-num>12009089</accession-num><urls></urls><remote-database-provider>Nlm</remote-database-provider><language>eng</language></record></Cite></EndNote>2). This was refined in 2012 by the European Society of Intensive Care Medicine as “an acute diffuse, inflammatory lung injury, leading to increased pulmonary vascular permeability, increased lung weight, and loss of aerated lung tissue…[with] hypoxemia and bilateral radiographic opacities, associated with increased venous admixture, increased physiological dead space and decreased lung compliance” ADDIN EN.CITE <EndNote><Cite><Author>Ranieri</Author><Year>2012</Year><RecNum>59</RecNum><DisplayText><style face="superscript">3</style></DisplayText><record><rec-number>59</rec-number><foreign-keys><key app="EN" db-id="p5sw9zpfq0ea0te2rvjxxdames0x9rft99ae" timestamp="1485334781">59</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Ranieri, V. M.</author><author>Rubenfeld, G. D.</author><author>Thompson, B. T.</author><author>Ferguson, N. D.</author><author>Caldwell, E.</author><author>Fan, E.</author><author>Camporota, L.</author><author>Slutsky, A. S.</author></authors></contributors><titles><title>Acute respiratory distress syndrome: the Berlin Definition</title><secondary-title>Jama</secondary-title><alt-title>Jama</alt-title></titles><periodical><full-title>Jama</full-title><abbr-1>Jama</abbr-1></periodical><alt-periodical><full-title>Jama</full-title><abbr-1>Jama</abbr-1></alt-periodical><pages>2526-33</pages><volume>307</volume><number>23</number><edition>2012/07/17</edition><keywords><keyword>Humans</keyword><keyword>Meta-Analysis as Topic</keyword><keyword>Multicenter Studies as Topic</keyword><keyword>Respiratory Distress Syndrome, Adult/*classification/*diagnosis</keyword><keyword>Severity of Illness Index</keyword><keyword>*Terminology as Topic</keyword><keyword>Validation Studies as Topic</keyword></keywords><dates><year>2012</year><pub-dates><date>Jun 20</date></pub-dates></dates><isbn>0098-7484</isbn><accession-num>22797452</accession-num><urls></urls><electronic-resource-num>10.1001/jama.2012.5669</electronic-resource-num><remote-database-provider>Nlm</remote-database-provider><language>eng</language></record></Cite></EndNote>3. Furthermore the group categorized ARDS into 3 grades; mild, moderate and severe.The leucocyte integrin CD11b/CD18 promotes leucocyte-endothelial adhesion and has been shown to be a reliable surrogate marker of leucocyte activationPEVuZE5vdGU+PENpdGU+PEF1dGhvcj5XYXJyZW48L0F1dGhvcj48WWVhcj4yMDA3PC9ZZWFyPjxS
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ADDIN EN.CITE.DATA 4, and is in turn itself activated by the fatty acid oleic acid, the major component of Lipid Microemboli (LME) in the pericardial suction blood (PSB; ADDIN EN.CITE <EndNote><Cite><Author>Mastrangelo</Author><Year>1998</Year><RecNum>144</RecNum><DisplayText><style face="superscript">5</style></DisplayText><record><rec-number>144</rec-number><foreign-keys><key app="EN" db-id="pw5wrzd0l2xzzge0xfkxfevgpwre0rtpf95v" timestamp="0">144</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Mastrangelo, Anthony M.</author><author>Jeitner, Thomas M.</author><author>Eaton, John W.</author></authors></contributors><titles><title>Oleic Acid Increases Cell Surface Expression and Activity of CD11b on Human Neutrophils</title><secondary-title>J Immunol</secondary-title></titles><pages>4268-4275</pages><volume>161</volume><number>8</number><dates><year>1998</year><pub-dates><date>October 15, 1998</date></pub-dates></dates><urls><related-urls><url>). Leucocyte filtration (leucodepletion) has been proposed as a technique to attenuate the inflammatory response to bypass, with numerous studies investigating differing methodology to address this, although most have been small studies with limitations noted in the methodology, leading to inconsistent evidence for its usePEVuZE5vdGU+PENpdGU+PEF1dGhvcj5XYXJyZW48L0F1dGhvcj48WWVhcj4yMDA3PC9ZZWFyPjxS
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ADDIN EN.CITE.DATA 4.Previous work has demonstrated that there are no ideal methods of treating PSB in order to remove activated leucocytes whilst simultaneously retaining significant quantities of plasma clotting factors ADDIN EN.CITE <EndNote><Cite><Author>Issitt</Author><Year>2011</Year><RecNum>246</RecNum><DisplayText><style face="superscript">6</style></DisplayText><record><rec-number>246</rec-number><foreign-keys><key app="EN" db-id="pw5wrzd0l2xzzge0xfkxfevgpwre0rtpf95v" timestamp="0">246</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Issitt, Richard</author><author>Sheppard, Stuart</author></authors></contributors><titles><title>Dealing with pericardial suction blood and residual pump volume: a review of current practices in the UK</title><secondary-title>Perfusion</secondary-title></titles><periodical><full-title>Perfusion</full-title><abbr-1>Perfusion</abbr-1></periodical><pages>51-55</pages><volume>26</volume><number>1</number><dates><year>2011</year><pub-dates><date>January 1, 2011</date></pub-dates></dates><urls><related-urls><url>. We have previously shown that it is possible to remove LME from the PSB using a new oxygenation system (RemoweLL, Eurosets s.r.l, Mirandola, Italy; ADDIN EN.CITE <EndNote><Cite><Author>Issitt</Author><Year>2017</Year><RecNum>300</RecNum><DisplayText><style face="superscript">7</style></DisplayText><record><rec-number>300</rec-number><foreign-keys><key app="EN" db-id="pw5wrzd0l2xzzge0xfkxfevgpwre0rtpf95v" timestamp="1492500493">300</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Issitt, R.W., Harvey, I., Walsh, B., and Voegeli, D.</author></authors></contributors><titles><title>Quantification of lipid filtration and the effects on cerebral injury during cardiopulmonary bypass.</title><secondary-title>Ann Thorac Surg</secondary-title></titles><periodical><full-title>Ann Thorac Surg</full-title><abbr-1>The Annals of thoracic surgery</abbr-1></periodical><volume>In Press</volume><dates><year>2017</year></dates><urls></urls></record></Cite></EndNote>7). This combines a cardiotomy reservoir consisting of a 40?m membrane to provide multilayer filtration for leucocytes and lipids, with a sedimentation chamber that allows the siphoning of a lipid-rich supernatant (Figure 1). The next step was to assess whether this system could attenuate systemic leucocyte activation and how this might affect leucocyte differentiation and pulmonary function.MethodsThirty patients undergoing coronary artery bypass grafting (CABG) with CPB were prospectively randomised to either the RemoweLL (intervention) or conventional extracorporeal circuit (control; Admiral, Eurosets) using a previously compiled randomisation table system (QuickCalcs Randomise1, GraphPad Software Inc., USA). The study was approved by the Institutional Review Board, and Research Ethics Committee (10/H0606/30). Exclusion criteria included emergency or previous cardiac surgery, morbid obesity, pre-existing renal or pulmonary dysfunction and evidence of existing cognitive impairment. All patients provided written, informed consent. Anaesthesia was induced with Midazolam, Fentanyl and Pancuronium and maintained during CPB using a Propofol infusion. The CPB circuit consisted of an oxygenation system with integrated cardiotomy reservoir. This contained either a conventional cardiotomy filter (Control; Admiral, Eurosets s.r.l.) or a lipid/leucocyte filter (Intervention; RemoweLL, Eurosets s.r.l). The circuit was primed with 2L lactated Ringer’s solution (Baxter, Thetford, United Kingdom) and mannitol 20% w/v (2.5mL/kg; Baxter) that contained 5000 units of unfractionated heparin (Wockhart, Wrexham, United Kingdom). Alpha stat blood gas management was used and analysis of activated clotting time was checked every 20 to 30 minutes with a minimum activated clotting time of 480 seconds maintained during bypass. Cardiac output was based on a cardiac index of 2.4L/m2/min with mean arterial pressures maintained between 50-60mmHg with pharmacological manipulation using 0.5-1mg boluses of metaraminol as required. All patients were systemically cooled to nasopharyngeal temperatures between 32-34°C and myocardial protection was provided using cold (4°C) blood cardioplegia (Harefield Hospital Formulation, Terumo BCT Ltd. Larne, United Kingdom). Distal anastomoses were completed during a single period of aortic clamping, whilst proximal anastomoses were performed with a beating heart using an aortic partial occluding clamp. Termination of CPB occurred once the patient was re-warmed to a nasopharyngeal temperature of 36°C. The PSB was sent to the integrated cardiotomy reservoir where it was kept separated from the systemic circulation until immediately prior to the end of the CPB period, whereupon it was reintroduced via the venous reservoir back into the systemic circulation. After the operation, the patients were kept ventilated until standard extubation criteria were met. The ventilation protocol comprised of a respiratory rate of 10, tidal volume of 10 ml/kg of body weight, fraction of inspired oxygen of 60%, pressure support of 20 cmH2O, positive end expiratory pressure of 5 cmH2O and inspiratory to expiratory ratio of 1:2. Hydration was achieved with the intravenous administration of Dextrose 5% solution infused at 1 ml/kg/h. Blood, Gelofusine or Human Albumin Solution was given to maintain adequate filling and systemic perfusion pressures, and plasma haemoglobin levels above 8.5 g/dl.Leucocyte differentiation was undertaken using standard laboratory techniques. Samples were taken pre-CPB, pre-reintroduction of PSB back into the systemic circulation, post-reintroduction of the PSB, immediately preceding the end of CPB and 1 hour and 24 hours post-CPB. Data were collected on erythrocytes, haemoglobin, haematocrit, platelets and leucocytes plus differential (neutrophils, lymphocytes and monocytes).Assessment of Leucocyte ActivationA 5mL blood sample was taken for analysis of CD11b pre-CPB, 5 minutes before end of CPB, 1 and 24 hours post-CPB. Samples were kept on ice and were analysed within 24 hours by Fluorescence-Activated Cell Sorting (FACS), after staining with CD11b Phycoerythrin (PE). The samples were then mixed and incubated at 4-8°C for 30 minutes. Following lysing, the samples were washed and centrifuged at 3000rpm for 2 minutes and then the supernatant removed. The remaining pellet was re-suspended in cell wash and placed into the FACS machine for analysis. Samples were also stained for CD45 as a control marker and concentrations of monocytes, lymphocytes and total leucocytes were reported. Adjustment of the positions of displayed and preconfigured polygon gates to capture all populations of interest including neutrophils, monocytes and lymphocytes using the CD45/SSC plot were performed by Dr Adnan Mani, Head of the Flow Cytometry Unit, Southampton General Hospital.Assessment of Pulmonary FunctionAlveolar-arterial oxygenation index (AaOI) was calculated from blood gases and ventilation data taken pre-CPB, immediately post CPB and then 1, 2, 6, 12, 24 and 48 hours post-CPB. For the 48 hours sample the patient breathed room air for 10 minutes to allow for equilibration and then samples of arterial blood were taken for oxygen partial pressure (PaO2) and % saturation and carbon dioxide partial pressure (PaCO2). Samples obtained at 1 and 2 hours reflect intubation whilst 6, 12 and 24 hours reflected oxygen administered by facemask. The Alveolar-Arterial Oxygenation Index (AaOI) was determined using the following formula:AaOI = ((760-47)FiO2 – (PaCO2 x 7.6)1.25)) – (PaO2 x 7.6)/(PaO2 x 7.6)Where:FiO2 = the inspired oxygen concentration (%)PaCO2 = the partial pressure of arterial CO2 (kPa) PaO2 = the partial pressure of arterial O2 (kPa).ARDS classification was calculated using PaO2/FiO2 ratios at 1 and 2 hours post-CPB with the lowest value used for categorization according to the Berlin definition. Each category was given a number indicating severity, 1 – PaO2/FiO2 >300; none, 2 – PaO2/FiO2 200-300; mild, 3 – PaO2/FiO2 100-200; moderate and 4 – PaO2/FiO2 <100; severe.StatisticsAssessment of normal distribution was carried out using the Shapiro-Wilk Test, and confirmed using a QQ Plot. As many of the parameters were measured at various time points, Two Factor ANOVA for Repeated Measures was undertaken to explore differences between groups. Normally distributed data were analysed using T Test for Two Independent Samples whilst non-normally distributed values were LOG transformed and if shown to be normally distributed analysed as above. If still non-normally distributed, data were analysed using Mann-Whitney Test for Two Independent Samples. ARDS categorisation was tested using the Chi-square test. All tests were considered to be Two Tailed. A p value ≤0.05 was considered significant. Normally distributed data are presented as mean±standard deviation whilst non-normally distributed data are presented as median (IQR). Both are graphically displayed as box and whisker plots with boxes representing 25th-75th centiles with median and whiskers as maximum and minimum values.ResultsThirty patients successfully underwent the study assessments (15 per group). The demographics of the patients undergoing the study are given in Table 1. Both groups were well matched in terms of male:female ratio, preoperative statin regimen and number of patients with diabetes mellitus (p>0.05). All patients were on aspirin and clopidogrel anticoagulation therapy preoperatively. In line with hospital protocol, both treatments were stopped 10 days before surgery. There were no significant differences in terms of perioperative details including CPB time, number of grafts and fluid balance. There were no significant differences in transfusion rates or haemoglobin levels between the 2 groups at any time point (p>0.05).The number of total leucocytes rose significantly throughout the CPB period [p<0.001 for both groups]. Whilst there were no significant differences between the two groups, there was a tendency for greater leucocyte numbers in the RemoweLL group at 1-hour post CPB [Admiral 9.7 (4.5) x109/L vs. RemoweLL 13.4 (7.2) x109/L; p=0.06; Figure 2]. Differential leucocyte analysis showed a similar pattern for neutrophils. There were no significant differences in neutrophil counts between the groups at any sample point, and both groups showed significant increases in neutrophil numbers following CPB [p<0.001]. Lymphocytes were similar in both groups during the procedure but a significant difference was noted between the 2 groups in the immediate post op period [Admiral 1 (0.6) x109/L vs. RemoweLL 1.55 (0.73) x109/L; p=0.018]. Pre and post analysis showed a significant decrease in the Admiral group, but similar levels in the RemoweLL group [Admiral 1.6 (0.65) x109/L vs. 1 (0.6) x109/L; p<0.001, RemoweLL 1.6 (0.5) x109/L vs. 1.55 (0.73) x109/L; p=0.46]. The number of monocytes dropped significantly in both groups upon commencing bypass [Admiral 0.5 (0.4) x109/L vs. 0.25 (0.23) x109/L; p=0.004, RemoweLL 0.5 (0.2) x109/L vs. 0.3 (0.25) x109/L; p=0.005]. Post CPB the numbers of monocytes had recovered in the RemoweLL group [0.5 (0.2) x109/L vs. 0.4 (0.25) x109/L; p=0.15] but remained significantly suppressed in the Admiral group [0.5 (0.4) x109/L vs. 0.3 (0.3) x109/L; p=0.02].Leucocyte activation as measured by CD11b showed a significant increase in both groups, with peak activation occurring at the end of CPB, although there was no difference between the groups in terms of peak fluorescence [Admiral 230.5 (126.5) MFC vs. RemoweLL 193.5 (53) MFC; p=0.8; Figure 3]. A significant decrease in activation was observed in the RemoweLL group between 1 and 24 hours post CPB [169.5 (45.3) MFC vs. 120.5 (63) MFC; p=0.04] whilst the Admiral group saw an insignificant decrease [154 (58) MFC vs. 131 (40.5) MFC; p=0.43]. Twenty-Four hours post-op, the levels of activation had returned to baseline in the RemoweLL group [106.5 (37.5) MFC vs. 120.5 (63) MFC; p=0.24] but remained elevated in the Admiral group [99 (40.75) MFC vs. 131 (40.5) MFC; p=0.016].Baseline data for AaOI were similar in both groups, although the RemoweLL group had slightly lower values [Admiral 12.4 (3.2) vs. RemoweLL 10.4 (5.9); p=0.1; Figure 4]. ANOVA results showed a trend for lower AaOI in the RemoweLL group although this did not reach significance [p=0.075]. Further examination using pairwise analysis with TTest for 2 Independent Samples showed significantly lower AaOI post CPB in the RemoweLL group [Admiral 17.67 (14.15) vs. RemoweLL 13.25 (4); p=0.012]. There were no differences between the two groups at any other time points. Pre CPB vs. 18hr-post CPB showed significant differences in both groups [Admiral 12.4 (3.12) vs. 5.81 (6.6); p<0.001 and RemoweLL 10.4 (5.9) vs. 8.12 (6.7); p=0.033]. Repeated measures ANOVA showed significant interactions in both pO2 and pCO2 [p<0.001; Table 2] but this was not reflected in the lowest PaO2/FiO2 ratios and ARDS definitions, which showed no differences between the 2 groups [p=0.33; Table 3]. Although data were not collected on length of ventilation, as the study was not powered to detect such differences, all patients were extubated within 24 hours.DiscussionThe initial filtration step of the RemoweLL filter is designed to remove activated leucocytes from the cardiotomy suction via 2 layers of 40?m, non-woven polyester, the second treated with a polymeric coating. It is believed that leucocytes play a major role in the formation of ‘post-pump’ syndrome which can affect lungs, kidneys and the brain ADDIN EN.CITE <EndNote><Cite><Author>Skrabal</Author><Year>2006</Year><RecNum>39</RecNum><DisplayText><style face="superscript">8</style></DisplayText><record><rec-number>39</rec-number><foreign-keys><key app="EN" db-id="pw5wrzd0l2xzzge0xfkxfevgpwre0rtpf95v" timestamp="0">39</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Skrabal, Christian</author><author>Khosravi, Amir</author><author>Choi, Yeong</author><author>Kaminski, Alexander</author><author>Westphal, Bernd</author><author>Steinhoff, Gustav</author><author>Liebold, Andreas</author></authors></contributors><titles><title>Pericardial suction blood separation attenuates inflammatory response and hemolysis after cardiopulmonary bypass</title><secondary-title>Scandinavian Cardiovascular Journal</secondary-title></titles><pages>219-223</pages><volume>40</volume><number>4</number><dates><year>2006</year></dates><isbn>14017431
16512006</isbn><urls><related-urls><url>. The aim of the current study was to determine the effects the RemoweLL system had on the numbers and activation statuses of leucocytes, as measured by CD11b, and post-operative pulmonary function as judged by the ventilatory requirements of patients undergoing CABG surgery. Leucocyte Depletion & ActivationOur results did not demonstrate any leucocyte reduction compared to the control group, in fact there was a tendency for the RemoweLL group to have higher levels of leucocytes one-hour post CPB [p=0.06]. Leucocyte differential data showed that the number of neutrophils rose significantly in both groups compared to baseline [p<0.001]. This is in contrast to previous studies, which used leucocyte-depleting filers and have shown a decrease in neutrophil concentration. In particular, Dell’Amore and colleagues showed a decrease in neutrophil concentration from 76.2x103/mL to 69.7x103/mL using the same RemoweLL systemPEVuZE5vdGU+PENpdGU+PEF1dGhvcj5EZWxsJmFwb3M7QW1vcmU8L0F1dGhvcj48WWVhcj4yMDEw
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ADDIN EN.CITE.DATA 10. A common observation following cardiac surgery is the acute reduction in circulating lymphocytes, as observed in the current study. Rinder et al., have suggested that the loss of lymphocytes might be due to numerous factors including haemodilution, redistribution of cells to the tissues, loss due to bleeding and adhesion to CPB circuitry ADDIN EN.CITE <EndNote><Cite><Author>Rinder</Author><Year>1992</Year><RecNum>140</RecNum><DisplayText><style face="superscript">11</style></DisplayText><record><rec-number>140</rec-number><foreign-keys><key app="EN" db-id="pw5wrzd0l2xzzge0xfkxfevgpwre0rtpf95v" timestamp="0">140</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Rinder, CS</author><author>Bonan, JL</author><author>Rinder, HM</author><author>Mathew, J</author><author>Hines, R</author><author>Smith, BR</author></authors></contributors><titles><title>Cardiopulmonary bypass induces leukocyte-platelet adhesion</title><secondary-title>Blood</secondary-title></titles><pages>1201-1205</pages><volume>79</volume><number>5</number><dates><year>1992</year><pub-dates><date>March 1, 1992</date></pub-dates></dates><urls><related-urls><url>. Further work by the group proposed that cellular activation causes adhesion activation of lymphocytes and endothelial cells promoting exit from the circulationPEVuZE5vdGU+PENpdGU+PEF1dGhvcj5SaW5kZXI8L0F1dGhvcj48WWVhcj4xOTk3PC9ZZWFyPjxS
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ADDIN EN.CITE.DATA 12. In contrast to this study, they report observing a rise in monocytes to almost double baseline levels. However, this was on the 1st post-op day, later than measured in this study and they did not examine changes in the perioperative period. Interestingly, in this study, after the initial reduction in monocyte numbers, there was a trend towards a return to baseline levels in both groups, although in the Admiral group, this remained significantly lower than baseline [p=0.017]. Evidence suggests that monocytes, like lymphocytes, are removed from the circulation to tissues, as another marker, CD16, which is expressed on mature monocytes, decreases despite overall increases in monocyte numbers, suggesting immature monocyte recruitment from the bone marrow ADDIN EN.CITE <EndNote><Cite><Author>Clarkson</Author><Year>1988</Year><RecNum>278</RecNum><DisplayText><style face="superscript">14</style></DisplayText><record><rec-number>278</rec-number><foreign-keys><key app="EN" db-id="pw5wrzd0l2xzzge0xfkxfevgpwre0rtpf95v" timestamp="1473876618">278</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Clarkson, S. B.</author><author>Ory, P. A.</author></authors></contributors><auth-address>Rosalind Russell Arthritis Research Laboratory, University of California, San Francisco 94102.</auth-address><titles><title>CD16. Developmentally regulated IgG Fc receptors on cultured human monocytes</title><secondary-title>J Exp Med</secondary-title><alt-title>The Journal of experimental medicine</alt-title></titles><periodical><full-title>J Exp Med</full-title><abbr-1>The Journal of experimental medicine</abbr-1></periodical><alt-periodical><full-title>J Exp Med</full-title><abbr-1>The Journal of experimental medicine</abbr-1></alt-periodical><pages>408-20</pages><volume>167</volume><number>2</number><edition>1988/02/01</edition><keywords><keyword>Antigens, Differentiation/analysis</keyword><keyword>Antigens, Surface/*analysis/immunology</keyword><keyword>Cell Differentiation</keyword><keyword>Cell Survival</keyword><keyword>Cells, Cultured</keyword><keyword>Humans</keyword><keyword>Immunoglobulin G/metabolism</keyword><keyword>Lymphocyte Function-Associated Antigen-1</keyword><keyword>Monocytes/classification/immunology/*metabolism</keyword><keyword>Neutrophils/immunology/metabolism</keyword><keyword>Phagocytosis</keyword><keyword>Phenotype</keyword><keyword>Receptors, Fc/*analysis/physiology</keyword><keyword>Receptors, IgG</keyword></keywords><dates><year>1988</year><pub-dates><date>Feb 1</date></pub-dates></dates><isbn>0022-1007 (Print)
0022-1007</isbn><accession-num>2964496</accession-num><urls></urls><custom2>Pmc2188855</custom2><remote-database-provider>Nlm</remote-database-provider><language>eng</language></record></Cite></EndNote>14. Therefore this study could not demonstrate significant differences in total or leucocyte differential counts between the two groups or the published literature using the RemoweLL cardiotomy reservoir.In order to assess the extent of leucocyte activation that occurred during the procedure, CD11b (a surface adhesion molecule that regulates the adhesion of activated leucocytes), was measured using FACs analysis. The CD11b integrin is a key factor in allowing the transendothelial migration of leucocytes, through the modulation of the endothelial cytoskeleton. When inappropriate activation occurs, this is a primary cause of tissue oedema ADDIN EN.CITE <EndNote><Cite><Author>Vestweber</Author><Year>2000</Year><RecNum>294</RecNum><DisplayText><style face="superscript">15</style></DisplayText><record><rec-number>294</rec-number><foreign-keys><key app="EN" db-id="swds9peahrvz90edfflpstv62vx9rpvxxafs" timestamp="1474108233">294</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Vestweber, D.</author></authors></contributors><auth-address>Institute of Cell Biology, ZMBE, University of Munster, and Max-Planck-Institute of Physiological and Clinical Research, Bad Nauheim, Germany. vestweb@uni-muenster.de</auth-address><titles><title>Molecular mechanisms that control endothelial cell contacts</title><secondary-title>J Pathol</secondary-title><alt-title>The Journal of pathology</alt-title></titles><periodical><full-title>J Pathol</full-title><abbr-1>The Journal of pathology</abbr-1></periodical><alt-periodical><full-title>J Pathol</full-title><abbr-1>The Journal of pathology</abbr-1></alt-periodical><pages>281-91</pages><volume>190</volume><number>3</number><edition>2000/02/24</edition><keywords><keyword>Cell Adhesion/physiology</keyword><keyword>Cell Communication/physiology</keyword><keyword>Cell Membrane Permeability/physiology</keyword><keyword>Cell Movement</keyword><keyword>Connexins/physiology</keyword><keyword>Endothelium, Vascular/*physiology</keyword><keyword>Gap Junctions/*physiology</keyword><keyword>Humans</keyword><keyword>Leukocytes/physiology</keyword><keyword>Neovascularization, Physiologic/physiology</keyword></keywords><dates><year>2000</year><pub-dates><date>Feb</date></pub-dates></dates><isbn>0022-3417 (Print)
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ADDIN EN.CITE.DATA 16, 17. In contrast to inline leucocyte filtration, this study showed no statistical difference in peak CD11b expression between the Admiral and RemoweLL groups [p=0.8]. Of particular interest to this study is the observation of Mastrangelo et al., who demonstrated a direct interaction between the CD11b integrin and oleic acid, the major fatty acid component of bone marrow derived fat emboli ADDIN EN.CITE <EndNote><Cite><Author>Mastrangelo</Author><Year>1998</Year><RecNum>144</RecNum><DisplayText><style face="superscript">5</style></DisplayText><record><rec-number>144</rec-number><foreign-keys><key app="EN" db-id="pw5wrzd0l2xzzge0xfkxfevgpwre0rtpf95v" timestamp="0">144</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Mastrangelo, Anthony M.</author><author>Jeitner, Thomas M.</author><author>Eaton, John W.</author></authors></contributors><titles><title>Oleic Acid Increases Cell Surface Expression and Activity of CD11b on Human Neutrophils</title><secondary-title>J Immunol</secondary-title></titles><pages>4268-4275</pages><volume>161</volume><number>8</number><dates><year>1998</year><pub-dates><date>October 15, 1998</date></pub-dates></dates><urls><related-urls><url> that is also removed by the RemoweLL cardiotomy reservoir ADDIN EN.CITE <EndNote><Cite><Author>Issitt</Author><Year>2017</Year><RecNum>300</RecNum><DisplayText><style face="superscript">7</style></DisplayText><record><rec-number>300</rec-number><foreign-keys><key app="EN" db-id="pw5wrzd0l2xzzge0xfkxfevgpwre0rtpf95v" timestamp="1492500493">300</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Issitt, R.W., Harvey, I., Walsh, B., and Voegeli, D.</author></authors></contributors><titles><title>Quantification of lipid filtration and the effects on cerebral injury during cardiopulmonary bypass.</title><secondary-title>Ann Thorac Surg</secondary-title></titles><periodical><full-title>Ann Thorac Surg</full-title><abbr-1>The Annals of thoracic surgery</abbr-1></periodical><volume>In Press</volume><dates><year>2017</year></dates><urls></urls></record></Cite></EndNote>7. This interaction, they reported, caused the leucocytes to aggregate and adhere with CD11b/CD18 to endothelial membranes. Moreover, previous work by the group showed that free-fatty acids caused and amplified the mobilisation of myeloperoxidase-containing granules within the leucocyte ADDIN EN.CITE <EndNote><Cite><Author>Qian</Author><Year>1994</Year><RecNum>295</RecNum><DisplayText><style face="superscript">18</style></DisplayText><record><rec-number>295</rec-number><foreign-keys><key app="EN" db-id="swds9peahrvz90edfflpstv62vx9rpvxxafs" timestamp="1474108458">295</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Qian, M.</author><author>Eaton, J. W.</author></authors></contributors><auth-address>Division of Experimental Pathology, Albany Medical College, NY 12208.</auth-address><titles><title>Free fatty acids enhance hypochlorous acid production by activated neutrophils</title><secondary-title>J Lab Clin Med</secondary-title><alt-title>The Journal of laboratory and clinical medicine</alt-title></titles><periodical><full-title>J Lab Clin Med</full-title><abbr-1>The Journal of laboratory and clinical medicine</abbr-1></periodical><alt-periodical><full-title>J Lab Clin Med</full-title><abbr-1>The Journal of laboratory and clinical medicine</abbr-1></alt-periodical><pages>86-95</pages><volume>124</volume><number>1</number><edition>1994/07/01</edition><keywords><keyword>Adult</keyword><keyword>Animals</keyword><keyword>Cell Survival</keyword><keyword>Epithelial Cells</keyword><keyword>Fatty Acids, Nonesterified/*pharmacology</keyword><keyword>Humans</keyword><keyword>Hydrogen Peroxide/metabolism</keyword><keyword>Hypochlorous Acid/*metabolism</keyword><keyword>Lung/cytology</keyword><keyword>Middle Aged</keyword><keyword>Mink</keyword><keyword>Neutrophils/drug effects/*metabolism/physiology</keyword><keyword>Peroxidase/pharmacology</keyword><keyword>Stimulation, Chemical</keyword><keyword>Superoxides/metabolism</keyword><keyword>Tetradecanoylphorbol Acetate/pharmacology</keyword></keywords><dates><year>1994</year><pub-dates><date>Jul</date></pub-dates></dates><isbn>0022-2143 (Print)
0022-2143</isbn><accession-num>8035107</accession-num><urls></urls><remote-database-provider>NLM</remote-database-provider><language>eng</language></record></Cite></EndNote>18. As the 2nd time point (End CPB) would have been shortly after the release of cardiotomy PSB in both groups, it is of little surprise that this is where peak activation occurs, as this is the point at which oleic acid, in the form of LME, would enter the circulation. However, there appears to have been little, if any research on the length of action of oleic acid on leucocytes. Mastrangelo et al., saw increasing expression of CD11b with time following the addition of oleic acid to leucocytes, but the experiments only measured expression for 10 minutes post-treatment, and was undertaken in an in vitro environment, so translation to the present study is difficult. Furthermore, leucocyte activation does not occur solely from oleic acid interactions; exposure to artificial surfaces, anaesthesia, even the surgery itself can cause neutrophil activation ADDIN EN.CITE <EndNote><Cite><Author>Matheis</Author><Year>2001</Year><RecNum>150</RecNum><DisplayText><style face="superscript">19</style></DisplayText><record><rec-number>150</rec-number><foreign-keys><key app="EN" db-id="pw5wrzd0l2xzzge0xfkxfevgpwre0rtpf95v" timestamp="0">150</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Matheis, G</author><author>Scholz, M</author><author>Simon, A</author><author>Dzemali, Omer</author><author>Moritz, A</author></authors></contributors><titles><title>Leukocyte filtration in cardiac surgery: a review</title><secondary-title>Perfusion</secondary-title></titles><periodical><full-title>Perfusion</full-title><abbr-1>Perfusion</abbr-1></periodical><pages>361-370</pages><volume>16</volume><number>5</number><dates><year>2001</year><pub-dates><date>September 1, 2001</date></pub-dates></dates><urls><related-urls><url>. Therefore this study could not demonstrate any significant differences in leucocyte activation statuses between the two groups using the RemoweLL cardiotomy reservoir, a phenomenon that has been described with inline leucodepletion.Pulmonary FunctionPulmonary dysfunction following surgery is not unique to cardiothoracic surgery involving CPB, with multiple factors indicated such as general anaesthesia ADDIN EN.CITE <EndNote><Cite><Author>Cox</Author><Year>2000</Year><RecNum>166</RecNum><DisplayText><style face="superscript">20</style></DisplayText><record><rec-number>166</rec-number><foreign-keys><key app="EN" db-id="pw5wrzd0l2xzzge0xfkxfevgpwre0rtpf95v" timestamp="0">166</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Cox, Craig M.</author><author>Ascione, Raimondo</author><author>Cohen, Alan M.</author><author>Davies, Ian M.</author><author>Ryder, Ian G.</author><author>Angelini, Gianni D.</author></authors></contributors><titles><title>Effect of cardiopulmonary bypass on pulmonary gas exchange: a prospective randomized study</title><secondary-title>Ann Thorac Surg</secondary-title></titles><periodical><full-title>Ann Thorac Surg</full-title><abbr-1>The Annals of thoracic surgery</abbr-1></periodical><pages>140-145</pages><volume>69</volume><number>1</number><dates><year>2000</year><pub-dates><date>January 1, 2000</date></pub-dates></dates><urls><related-urls><url>. However, due to the nature of the extracorporeal circuit, its non-endothelial material, the opening of the pleural space for harvesting of the internal mammary artery, and the deflation of the lungs during cardiac surgery, the incidence of pulmonary dysfunction associated with CPB-facilitated cardiac surgery is more common and severe ADDIN EN.CITE <EndNote><Cite><Author>Clark</Author><Year>2006</Year><RecNum>164</RecNum><DisplayText><style face="superscript">21</style></DisplayText><record><rec-number>164</rec-number><foreign-keys><key app="EN" db-id="pw5wrzd0l2xzzge0xfkxfevgpwre0rtpf95v" timestamp="0">164</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Clark, Stephen C</author></authors></contributors><titles><title>Lung Injury after Cardiopulmonary Bypass</title><secondary-title>Perfusion</secondary-title></titles><periodical><full-title>Perfusion</full-title><abbr-1>Perfusion</abbr-1></periodical><pages>225-228</pages><volume>21</volume><number>4</number><dates><year>2006</year><pub-dates><date>July 1, 2006</date></pub-dates></dates><urls><related-urls><url>. Whilst the manifestation of pulmonary dysfunction can be quantified in terms of a widening of the alveolar-arterial oxygen gradient, the underlying causes are many and varied, as are the physiological characteristics. An increase in AaOI was observed in all patients following CPB. This has also been demonstrated in previous studies and is thought to arise from several factors; the disruption of pulmonary endothelial membranes, haemodilution and the subsequent sudden decrease in colloid osmotic pressure, and the use mechanical ventilation ADDIN EN.CITE <EndNote><Cite><Author>Alexiou</Author><Year>2004</Year><RecNum>176</RecNum><DisplayText><style face="superscript">22</style></DisplayText><record><rec-number>176</rec-number><foreign-keys><key app="EN" db-id="pw5wrzd0l2xzzge0xfkxfevgpwre0rtpf95v" timestamp="0">176</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Alexiou, Christos</author><author>Tang, Augustine A.T.</author><author>Sheppard, Stuart V.</author><author>Smith, David C.</author><author>Gibbs, Roz</author><author>Livesey, Steven A.</author><author>Monro, James L.</author><author>Haw, Marcus P.</author></authors></contributors><titles><title>The effect of leucodepletion on leucocyte activation, pulmonary inflammation and respiratory index in surgery for coronary revascularisation: a prospective randomised study</title><secondary-title>Eur J Cardiothorac Surg</secondary-title></titles><periodical><full-title>Eur J Cardiothorac Surg</full-title><abbr-1>European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery</abbr-1></periodical><pages>294-300</pages><volume>26</volume><number>2</number><dates><year>2004</year><pub-dates><date>August 1, 2004</date></pub-dates></dates><urls><related-urls><url>. If an increase in alveolar-endothelial permeability did occur, the fluid balance of both groups was similar [1678.60±842.38ml vs. 1562.27±867.16ml; p=0.71] and so this study would not be powered to detect any differences in this situation. One of the key components believed to facilitate changes in pulmonary function is the inflammatory response. Previous studies have shown contact with the extracorporeal circuit initiates the activation of leucocytes facilitating the transmigrating of leucocytes into the lung parenchyma which mediate lung parenchymal damage through cellular and tissue injury ADDIN EN.CITE <EndNote><Cite><Author>Clark</Author><Year>2006</Year><RecNum>164</RecNum><DisplayText><style face="superscript">21</style></DisplayText><record><rec-number>164</rec-number><foreign-keys><key app="EN" db-id="pw5wrzd0l2xzzge0xfkxfevgpwre0rtpf95v" timestamp="0">164</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Clark, Stephen C</author></authors></contributors><titles><title>Lung Injury after Cardiopulmonary Bypass</title><secondary-title>Perfusion</secondary-title></titles><periodical><full-title>Perfusion</full-title><abbr-1>Perfusion</abbr-1></periodical><pages>225-228</pages><volume>21</volume><number>4</number><dates><year>2006</year><pub-dates><date>July 1, 2006</date></pub-dates></dates><urls><related-urls><url>. The resulting injury destroys the ultrastructure of the lung increasing the permeability of alveolar-endothelium. Therefore, theoretically, it could be assumed that filtration of activated leucocytes should provide significant protection from lung injury. This study focussed on the calculation of the AaOI, which is an established method for the assessment of peri-operative changes in lung function and is invariably elevated after cardiac surgery. Furthermore, this study aimed to use the Berlin definitions of ARDS to examine any differences in arterial oxygenation to determine if either group exhibited a more severe rating than the other. Repeated measures ANOVA showed no significant difference between the 2 groups in terms of AaOI [p=0.075]. Stepwise analysis of log transformed data using unpaired TTests showed a significant difference in the immediate post-op period [p=0.01] but any functional difference had resolved by 1 hour following surgery [p=0.9] and remained insignificant for the remaining period of observation. Furthermore, analysis revealed that the fraction of inspired oxygen showed a trend for lower values immediately post-CPB, which may explain the differences in the post-op AaOI [p=0.06]. Chi-square testing of the ARDS classification showed no significant differences between the two groups [p=0.33]. This study therefore could not demonstrate any evidence of improved pulmonary function using the RemoweLL cardiotomy reservoir.LimitationsThere are several important limitations to this study that should be noted. The numbers of patients in this study is relatively small, and therefore this study may not have the power to detect subtle differences. As the sample for measurement were taken from the sampling port (which is connected to the arterial limb of the CPB circuit) rather than the cardiotomy reservoir, one could speculate that the level of leucocyte activation would be similar in both study groups as this measures activation at the systemic level. Whether leucocyte activation in the cardiotomy suction with the RemoweLL compared to the Admiral group is different cannot be confirmed. Furthermore, this study was not designed to examine differences in length of ventilation (as far greater numbers of patients would be required), so cannot comment on the duration of ventilation with or without leucocyte filtration. Finally, there are issues with using the Berlin definitions of ARDS, in particular that they don’t include the underlying aetiology and lack a true measure of lung injury. For example, the use of vasopressors at the time of ARDS diagnosis (which is associated with a much higher mortality) is independent of the PaO2:FiO2 ratio. It also does not allow the early identification of patients who may be amenable to therapies before ARDS becomes established, and as none of the patients exhibited signs of severe ventilation requirements, the usefulness of this parameter in the current study could also be questioned. SummaryContact with the extracorporeal circuit initiates the activation of leucocytes as well as a host of proinflammatory mediators including the CD18 and CD11b surface adhesion molecules on leucocytes, which promote adhesion to specific ligands on the pulmonary endothelium, with the resulting injury destroying the ultrastructure of the lung, and increasing the permeability of the alveolar-endothelium. This study aimed to determine whether leucocyte filtration of the PSB, that is known to contain high concentrations of activated leucocytes, using the RemoweLL cardiotomy reservoir could attenuate these adverse effects. An increase in total numbers and activation statuses of leucocytes was confirmed in both groups with no statistical differences between the two groups. Furthermore, analysis of pulmonary function revealed no significant differences between the two groups during the post-operative period. Therefore this study was unable to demonstrate the clinical efficacy of the RemoweLL oxygenation system in providing targeted leucodepletion.References ADDIN EN.REFLIST 1.Fromes Y, Gaillard D, Ponzio O, et al. Reduction of the inflammatory response following coronary bypass grafting with total minimal extracorporeal circulation. European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery. 2002; 22: 527-33.2.Asimakopoulos G. The inflammatory response to CPB: the role of leukocyte filtration. Perfusion. 2002; 17 Suppl: 7-10.3.Ranieri VM, Rubenfeld GD, Thompson BT, et al. Acute respiratory distress syndrome: the Berlin Definition. Jama. 2012; 307: 2526-33.4.Warren O, Alexiou C, Massey R, et al. The effects of various leukocyte filtration strategies in cardiac surgery. European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery. 2007; 31: 665-76.5.Mastrangelo AM, Jeitner TM and Eaton JW. Oleic Acid Increases Cell Surface Expression and Activity of CD11b on Human Neutrophils. J Immunol. 1998; 161: 4268-75.6.Issitt R and Sheppard S. Dealing with pericardial suction blood and residual pump volume: a review of current practices in the UK. Perfusion. 2011; 26: 51-5.7.Issitt RW, Harvey, I., Walsh, B., and Voegeli, D. Quantification of lipid filtration and the effects on cerebral injury during cardiopulmonary bypass. The Annals of thoracic surgery. 2017; In Press.8.Skrabal C, Khosravi A, Choi Y, et al. Pericardial suction blood separation attenuates inflammatory response and hemolysis after cardiopulmonary bypass. Scandinavian Cardiovascular Journal. 2006; 40: 219-23.9.Dell'Amore A, Tripodi A, Cavallucci A, et al. Efficacy of a new oxygenator-integrated fat and leukocyte removal device. Asian cardiovascular & thoracic annals. 2010; 18: 546-50.10.Santa Ursula Tolosa JA, Criado A, Garcia del Valle S, Pensado A, Barbolla L and Carmona Aurioles JA. [Changes in total and differential leukocyte counts during heart surgery with extracorporeal circulation]. Revista espanola de anestesiologia y reanimacion. 1991; 38: 94-7.11.Rinder C, Bonan J, Rinder H, Mathew J, Hines R and Smith B. Cardiopulmonary bypass induces leukocyte-platelet adhesion. Blood. 1992; 79: 1201-5.12.Rinder CS, Mathew JP, Rinder HM, Tracey JB, Davis E and Smith BR. Lymphocyte and monocyte subset changes during cardiopulmonary bypass: effects of aging and gender. The Journal of laboratory and clinical medicine. 1997; 129: 592-602.13.van Kooyk Y and Figdor CG. Activation and inactivation of adhesion molecules. Current topics in microbiology and immunology. 1993; 184: 235-56.14.Clarkson SB and Ory PA. CD16. Developmentally regulated IgG Fc receptors on cultured human monocytes. The Journal of experimental medicine. 1988; 167: 408-20.15.Vestweber D. Molecular mechanisms that control endothelial cell contacts. The Journal of pathology. 2000; 190: 281-91.16.Hurst T, Johnson D, Cujec B, et al. Depletion of activated neutrophils by a filter during cardiac valve surgery. Canadian journal of anaesthesia = Journal canadien d'anesthesie. 1997; 44: 131-9.17.Chen YF, Tsai WC, Lin CC, et al. Leukocyte depletion attenuates expression of neutrophil adhesion molecules during cardiopulmonary bypass in human beings. The Journal of thoracic and cardiovascular surgery. 2002; 123: 218-24.18.Qian M and Eaton JW. Free fatty acids enhance hypochlorous acid production by activated neutrophils. The Journal of laboratory and clinical medicine. 1994; 124: 86-95.19.Matheis G, Scholz M, Simon A, Dzemali O and Moritz A. Leukocyte filtration in cardiac surgery: a review. Perfusion. 2001; 16: 361-70.20.Cox CM, Ascione R, Cohen AM, Davies IM, Ryder IG and Angelini GD. Effect of cardiopulmonary bypass on pulmonary gas exchange: a prospective randomized study. The Annals of thoracic surgery. 2000; 69: 140-5.21.Clark SC. Lung Injury after Cardiopulmonary Bypass. Perfusion. 2006; 21: 225-8.22.Alexiou C, Tang AAT, Sheppard SV, et al. The effect of leucodepletion on leucocyte activation, pulmonary inflammation and respiratory index in surgery for coronary revascularisation: a prospective randomised study. European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery. 2004; 26: 294-300.Table 1.?AdmiralRemoweLLpMale (n)12.0011.00?Diabetes (n)2.00?3.00??Statin (n)8.00?8.00??Age (years)69.93±7.5469.33±7.290.83Height (m)1.76±0.101.71±0.080.10Weight (kg)87.51±13.3782.84±14.900.37Body Mass Index28.15±3.5628.31±4.150.91Body Surface Area2.07±0.201.98±0.210.24Calculated Flow (l/min)4.96±0.474.74±0.500.24Bypass Time (min)101.40±22.0188.47±23.510.13X-Clamp Time (min)62.67±17.6751.20±17.110.08Procedure (CABG x N)3.33±0.493.13±0.830.43Fluid Balance (mL)1678.60±842.381562.27±867.160.71Time of Cardiotomy Release (min)74.93±19.2767±170.23Volume in Cardiotomy Reservoir (mL)776.67±632.14780.00±567.200.99Pre CPB LME Count (n/?L)400 (200)400 (400)0.47Post CPB LME Count (n/?L)1200 (2000100 (75)<0.001*Table 1. Demographic data. Data presented as mean±standard deviations or median (IQR). X-Clamp; aortic cross clamp. CABG; coronary artery bypass grafts. Time of cardiotomy release is the amount of time the PSB was left separated from the systemic circulation. There were no significant differences between both groups of patients with regards to morbidity, preoperative drug regimens and perioperative details. * A p value ≤0.05 was considered significant.Table 2.?TimeAdmiralRemoweLLpFiO2Pre-Op0.57 (0.02)0.57 (0.02)0.69?Post-CPB0.58 (0.03)0.57 (0.04)0.06?1 Hr Post-Op0.5 (0.07)0.5 (0.08)0.79?2 Hr Post-Op0.5 (0.1)0.45 (0.08)0.65?4 Hr Post-Op0.4 (0)0.4 (0.08)0.09?8 Hr Post-Op0.35 (0.1)0.35 (0.05)0.55?18 Hr Post-Op0.3 (0.09)0.28 (0.09)0.98paO2 (kPa)Pre-Op33.5 (3.2)36.3 (4.6)0.223?Post-CPB30.2 (11.8)33.4 (2.3)0.13?1 Hr Post-Op19.3 (5.9)18.6 (2.4)0.82?2 Hr Post-Op16.4 (3.6)16.2 (3.2)0.37?4 Hr Post-Op15.9 (3.9)14.8 (2.7)0.12?8 Hr Post-Op14.9 (3.2)12 (2)<0.001?18 Hr Post-Op11.2 (2.2)11.6 (1.3)0.87paCO2 (kPa)Pre-Op5.32±0.425.42±0.560.63?Post-CPB5.68±0.645.38±0.290.18?1 Hr Post-Op5.39±0.494.89±0.630.05?2 Hr Post-Op5.28±0.554.66±0.370.002?4 Hr Post-Op5.22±0.544.94±0.530.21?8 Hr Post-Op5.12±0.395.59±0.430.02?18 Hr Post-Op5.03±0.335.34±0.220.01Table 2. Ventilation Settings. FiO2; fraction of inspired oxygen. paO2; arterial partial pressure of oxygen. paCO2; arterial partial pressure of carbon dioxide. Samples taken pre-CPB, immediately post CPB and then 1, 2, 6, 12, 24 and 48 hours post-CPB. A p value ≤0.05 was considered significant.Table 3ARDS ClassificationAdmiralRemoweLLpNone200.33Mild1011Moderate34Severe00Table 3. ARDS Classification. Classifications based upon Berlin Definitions; None PaO2/FiO2 >300, Mild PaO2/FiO2 = 200 – 300, Moderate PaO2/FiO2 = 100 – 200, Severe PaO2/FiO2 < 100. A p value ≤0.05 was considered significant. LINK Excel.Sheet.12 "E:\\Richard's PhD\\Stats\\Pulmonary.xlsx" Sheet1!R1C7:R5C10 \a \f 4 \h \* MERGEFORMAT Figure 1.Figure 1. RemoweLL Cardiotomy Schematic. The RemoweLL? ECC system comprising a leucocyte filter and lipid microemboli siphon. Figure 2 Figure 2. White blood Cell differential during cardiopulmonary bypass. Samples taken pre-CPB, pre PSB release into the systemic circulation, post-release of PSB into the systemic circulation, 5 minutes before the end of CPB and 1 hour post-CPB. Blue; control (Admiral), Red; intervention (RemoweLL). Data presented as box and whiskers plots with boxes representing 25th-75 centiles with median and whiskers as maximum and minimum values.Figure 3Figure 3. Neutrophil activation profile. MFC; Mean fluorescence channel. Activation of neutrophil adhesion molecule CD11b used as an indicator of neutrophil activation as measured by FACs analysis. Samples taken pre-CPB, 5 minutes before the end of CPB and 1 And 24 hours post-CPB. Blue; control (Admiral), Red; intervention (RemoweLL). Data presented as box and whiskers plots with boxes representing 25th-75 centiles with median and whiskers as maximum and minimum values. Figure 4Figure 4. Alveolar-Arterial Oxygenation Index. Samples taken pre-CPB, immediately post CPB and then 1, 2, 6, 12, 24 and 48 hours post-CPB. For the 48 hours sample the patient breathed room air for 10 minutes to allow for equilibration and then samples of arterial blood were taken. Blue; control (Admiral), Red; intervention (RemoweLL). Data presented as box and whiskers plots with boxes representing 25th-75 centiles with median and whiskers as maximum and minimum values. *p≤0.05. ................
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