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Reduktion neuropsychologischer Dysfunktionen nach Herzoperation durch Heparinbeschichtung des extrakorporalen Zirkulationssystems

  • R. Feyrer
  • U. Blum
  • A. Disput
  • A. Eyni
  • A. Katalinic
  • J. von der Emde
Originalarbeit

Zusammenfassung

Unter den verschiedenen Ursachen für neuropsychologische Dysfunktionen nach Herzoperationen wird den cerebralen Mikroembolisationen durch die extrakorporale Zirkulation (EKZ) eine erhebliche Bedeutung beigemessen. Fragestellung der Studie war, ob im Rahmen einer Heparinbeschichtung der EKZ neuropsychologische Störungen reduziert werden.

Zwischen Mai und Oktober 1996 wurden bei 72 Patienten im Rahmen aortocoronarer Bypassoperationen EKZ-Systeme mit gleicher Oberfläche eingesetzt (Oxygenator Quadrox, Beschichtung Bioline, Fa. Jostra), 36 mal heparinbeschichtete (Gruppe I) und 36 mal unbeschichtete Systeme (Gruppe II). Präoperativ, 6 und 9 Tage postoperativ erfolgten Aufmerksamkeitsbelastungstests (d2-Test, Brickenkamp).

Laborchemischer Marker für eine cerebrale Schädigung war das S-100 Protein (Bestimmung präoperativ, 1 und 5 Stunden postoperativ). Zusätzlich erfolgten bei 38 Patienten (19 aus jeder Gruppe) aus den arteriellen Filtern der EKZ-Systeme elektronenmikroskopische, quantitative Bestimmungen von Zellaggregationen.

Die d2-Tests ergaben in Patientengruppe II am 6. postop. Tag eine signifikant stärker reduzierte Konzentrationsleistung als in Gruppe I (mediane Depression 14% versus 4%, p=0,05). Die Werte normalisierten sich in beiden Gruppen bis zum 9. postop. Tag. Der Anstieg von S-100 1 und 5 Std. postop. war in Gruppe II deutlich höher als in Gruppe I (median 0,91 versus 0,75, median 0,20 versus 0,10), erreichte jedoch keine Signifikanz. Die Zahl der Zellaggregationen auf den arteriellen Filtern in unbeschichteten Systemen unterschied sich hoch signifikant von der in beschichteten Systemen (p<0,01). In unbeschichteten Systemen nahmen die Zellaggregationen linear mit der Bypasszeit zu, in beschichteten Systemen nicht.

Mikroemboliebedingte zerebrale Schädigungen durch EKZ können durch Heparinbeschichtung der Systeme reduziert werden. Indikation zum Einsatz heparinbeschichteter Systeme stellen u. E. Eingriffe mit langen Bypasszeiten dar, bei denen mit einer höheren Rate passagerer neurologischer Störungen gerechnet werden muß und sich die Reduktion von Zellaggregationen im heparinbeschichteten EKZ-System besonders deutlich darstellen läßt.

Schlüsselwörter

Extracorporale Zirkulation Heparinbeschichtung Aortocoronare Bypassoperation Neuropsychologische Dysfunktionen Cerebrale Mikroembolisation 

Reduction of neuropsychological dysfunctions following cardiopulmonary bypass procedures by a heparin couting of the bypass circuits

Summary

Cerebral embolic events have been postulated as a causative factor for neuropsychological dysfunction and cognitive decline after cardiopulmonary bypass procedures (CPB). In a prospective study we evaluated whether brain injury resulting from microemboli during CPB could be reduced by heparin-coated surfaces of the bypass circuits (BC). From May until October 1996 in 72 patients (coronary artery bypass procedures), identical cardiopulmonary system configurations were used (Quadrox membrane oxygenator, Fa. Jostra), 36 systems were heparin-coated (group I) and 36 systems remained uncoated (group II). Neuropsychological tests, which required visual scanning, attention, and concentration (d2-test, Brickenkamp), were performed in each patient preoperatively and 6 and 9 days following the operation. Blood samples for analysis of S-100 protein (marker of cerebral injury) were collected preoperatively, 1 and 5 hours after CBP. In 38 patients (19 from each group) arterial filters of BC were analyzed by scanning electron microscopy (SEM) to determine platelet and leucocyte deposition and fibrin deposits.

D2-tests revealed a stronger depression in group II postoperatively with a high significance (median depression 14% versus 4% in group I, p=0.05). Both groups returned to normal within 9 days. S-100 levels 1 and 5 hours postoperatively were higher in group II (median 0.91 versus 0.75, median 0.20 versus 0.10 respectively). The difference did not reach statistical significance.

Statistically significant differences in the surface coverage units of the arterial filters were observed between the two groups (p<0.01). In standard circuits the number of cell or fibrin deposits increased according to the duration of extracorporeal circulation but not in heparin-coated circuits.

Our study suggests that cerebral injury following CPB may be reduced by a heparin coating of the bypass circuits. We recommend heparin-coated bypass circuits in cardiac procedures with a long duration of extracorporeal circulation. Reduction of cell and fibrin deposits in the extracorporeal bypass circuits may be heightened in this patient population.

Key words

Extracorporeal circulation heparin-coating aortocoronary bypass procedure neuropsychological dysfunction cerebral microembolism 

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Literatur

  1. 1.
    Newman MF, Croughwell ND, Blumenthal JA, Lowry E, White WD, Spillane W, Davis RD, Glower DD, Smith LR, Mahanna EP, Reves JG (1995) Predictors of cognitive decline after cardiac operation. Ann Thorac Surg 59: 1326–30CrossRefGoogle Scholar
  2. 2.
    Sotaniemi A (1995) Long-term neurologic outcome after cardiac operation. Ann Thorac Surg 59: 1336–9CrossRefGoogle Scholar
  3. 3.
    Smith PLC (1995) Cerebral dysfunction after cardiac surgery: closing adress. Ann Thorac Surg 59: 1359–62CrossRefGoogle Scholar
  4. 4.
    Blumenthal JA, Mahanna EP, Madden DJ, White WD, Croughwell ND, Newman MF (1995) Methodical issues in the assessment of neuropsychologic function after cardiac surgery. Ann Thorac Surg 59: 1345–50CrossRefGoogle Scholar
  5. 5.
    Newman SP (1995) Analysis and interpretation of neuropsychological tests in cardiac surgery. Ann Thorac Surg 59: 1351–5CrossRefGoogle Scholar
  6. 6.
    Savageau JA, Stanton BA, Jenkins CD, Klein MD (1982) Neuropsychological dysfunction following elective cardiac operation. J Thorac Cardiovasc Surg 84: 585–549PubMedGoogle Scholar
  7. 7.
    Horning CR, Lammers C, Stertmann WA, Scheld HH, Dorndorf W (1990) Neurologische Komplikationen koronarer Bypassoperationen — eine prospektive Untersuchung. Fortsch Neurol Psychiat 58: 76–83CrossRefGoogle Scholar
  8. 8.
    Zurbrügg HR, Mühlemann W, Althaus U (1990) Risikofaktoren für neurologische Komplikationen bei der Chirurgie des aortocoronaren Bypass. Helv chir Acta 57: 255–259PubMedGoogle Scholar
  9. 9.
    Blauth Ch I (1995) Macroemboli and microemboli during cardiopulmonary bypass. Ann Thorac Surg 59: 1300–3CrossRefGoogle Scholar
  10. 10.
    Borowiec JW, Bylock A, van der Linden L, Thelin S (1993) Heparin coating reduces blood cell adhesion to arterial filters during coronary bypass: a clinical study. Ann Thorac Surg 55: 1540–5CrossRefGoogle Scholar
  11. 11.
    Pugsley W, Klinger L, Paschalis C, Reasure T, Harrison M, Newman S (1994) The impact of microemboli during cardiopulmonary bypass on neuropsychological functioning. Stroke 25: 1393–1399CrossRefGoogle Scholar
  12. 12.
    Moody DM, Brown WR, Challa VR, Stump DA, Reboussin DM, Legault C (1995) Brain microemboli associated with cardiopulmonary bypass: a histologic and magnetic resonance imaging study. Ann Thorac Surg 59: 1304–7CrossRefGoogle Scholar
  13. 13.
    Pekna M, Hagmann L, Halden E, Nilsson UR, Nilsson B, Thelin S (1994) Complement activation during cardiopulmonary bypass: effects of immobilized heparin. Ann Thorac Surg 58: 421–4CrossRefGoogle Scholar
  14. 14.
    Jansen PGM, Velthuis te H, Huybregts RAJM, Paulus R, Bulder ER, van der Spoel HI, Bezemer PD, Slaats EH, Eijsman L, Wildevuur Ch R H (1995) Reduced complement activation and improved postoperative performance after cardiopulmonary bypass with heparincoated circuits. J Thorac Cardiovasc Surg 101: 829–834CrossRefGoogle Scholar
  15. 15.
    Fosse E, Moen O, Johnson E, Semb G, Brockmeier V, Mollnes TE, Fagerhol MK, Venge P (1994) Reduced complement and granulocyte activation with heparin-coated cardiopulmonary bypass. Ann Thorac Surg 58: 472–7CrossRefGoogle Scholar
  16. 16.
    Muehrecke DD, McCarthy PM, Kottke-Marchant K, Harasaki H, Pierre-Yared J, Borsh JA, Ogella DA, Cosgrove DM (1996) Biocompatibility of hepatincoated extracorporeal bypass circuits: a randomized, masked clinical trial. J Thorac Cardiovasc Surg 112472–83Google Scholar
  17. 17.
    Jansen PGM, Baufreton Ch, Le Besnerais P, Loisance DY, Wildevuur Ch RH (1996) Heparin-coated circuits and aprotinin prime for coronary artery bypass grafting. Ann Thorac Surg 61: 1363–6CrossRefGoogle Scholar
  18. 18.
    Stump DA (1995) Selection and clinical significance of neuropsychologic tests. Ann Thorac Surg 59: 1340–4CrossRefGoogle Scholar
  19. 19.
    Aberg T (1995) Signs of brain cell injury during open heart operations: past and present. Ann Thorac Surg 59: 1312–5CrossRefGoogle Scholar
  20. 20.
    Johnsson P, Lundqvist C, Lindgren A, Ferencz I, Alling C, Stahl E (1995) Cerebral complications after cardiac surgery assessed by S-100 and NSE levels in blood. J Cardiothorac Vasc Anesth Dec 9(6): 694–9CrossRefGoogle Scholar
  21. 21.
    Johnsson P (1996) Markers of cerebral ischemia after cardiac surgery. J Cardiothorac Vasc Anest Jan; 10(1): 120–6CrossRefGoogle Scholar
  22. 22.
    Lamers KJB, van Engelen BGM, Gabreels FJM, Hommes OR, Borm GF, Wevers RA (1995) Cerebrospinal neuron-specific enolase, S-100 and myelin basic protein in neurological disorders. Acta Neurol Scand 92: 247–251CrossRefGoogle Scholar
  23. 23.
    Sellman M, Iver T, Ronquist G, Caesarini K, Persson L, Semb BK (1992) Central nervous system damage during cardiac surgery assessed by 3 different biochemical markers in cerebrospinal fluid. Scand J Thor Cardiovasc Surg 26: 39–45CrossRefGoogle Scholar
  24. 24.
    Ingebrigtsen T, Romner B, Kongstad P, Langbakk B Increased serum concentrations of protein S 100 after minor head injury: a biochemical serum marker with prognostic value? J Neurol Neurosurg Psychiat (in press)Google Scholar
  25. 25.
    Usul A, Kato K, Abe T, Murase M, Tanaka M, Takeuchi E (1989) S-100ao Protein in blood and urine during open heart surgery. Clinical chemistry, Vol 35, No 9Google Scholar
  26. 26.
    Westaby et al (1996) Cardiopulmonary bypass and S 100 Protein. Ann Thorac Surg 61: 88–92CrossRefGoogle Scholar
  27. 27.
    Clark RE, Brillman J, Davis DA, Lovell MR, Price TRP, Magovern GJ (1995) Mikroemboli during coronary artery bypass grafting. J Thorac Cardiovasc Surg 109: 249–58CrossRefGoogle Scholar
  28. 28.
    Blauth C, Smith P, Neewman S, Arnold J, Siddons F, Harrison MJ, Treasure T, Klinger L, Taylor KM (1989) Retinal microembolism and neuropsychological deficit following clinical cardiopulmonary bypass: comparison of a membrane and a bubble oxygenator. Eur J Cardiothorac Surg 3: 135–139CrossRefGoogle Scholar
  29. 29.
    Pradhan MJ, Fleming JS, Nkere UU, Arnold J (1991) Clinical experience with heparin-coated cardiopulmonary bypass in circuits. Perfusion 6: 235–24CrossRefGoogle Scholar
  30. 30.
    Videm V, Mollnes TE, Garred P, Svennevig JL, L Biocomptability of extracorporeal circulation. Thorac Cardiovasc Surg 101: 654–60Google Scholar
  31. 31.
    Matheis G, Beholz S, Skupin M, Baum RP, Meisel M, Beyersdorf F (1996) Heparin-beschichtete extracorporale Zirkulation führt zu geringerer Komplementaktivierung und Granulozytenaktivierung sowie zu verminderter cerebraler Schädigung. 25. Jahrestagung der Deutschen Gesellschaft für Herz- Thorax-und Gefäßchirurgie. WienGoogle Scholar
  32. 32.
    Müllges W, Berg D, Schmidtke A, Weinacker B, Babin-Ebell J (1996) Test battery for seriel neuropsychologic testing in coronary artery bypass surgery (CABS). presented in 14th international cardiovascular surgical symposium, Zürs, 9–16, March 1996Google Scholar

Copyright information

© Steinkopff Verlag 1997

Authors and Affiliations

  • R. Feyrer
    • 1
  • U. Blum
    • 1
  • A. Disput
    • 1
  • A. Eyni
    • 1
  • A. Katalinic
    • 2
  • J. von der Emde
    • 1
  1. 1.Abteilung für Chirurgie des Herzens und der Thorakalen GefäßeUniversität Erlangen-NürnbergErlangen
  2. 2.Institut für Medizinische Statistik und DokumentationErlangen

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