Hostname: page-component-cd9895bd7-8ctnn Total loading time: 0 Render date: 2024-12-23T13:29:58.907Z Has data issue: false hasContentIssue false
  • English
  • Français

Impaired cerebral autoregulation and elevation in plasma glial fibrillary acidic protein level during cardiopulmonary bypass surgery for CHD

Published online by Cambridge University Press:  24 August 2017

Ronald B. Easley ,
Bradley S. Marino ,
Jacky Jennings ,
Amy E. Cassedy ,
Kathleen K. Kibler ,
Ken M. Brady ,
Dean B. Andropoulos ,
Marissa Brunetti ,
Charles W. Hogue  and
Eugenie S. Heitmiller
...Show all authors
Ronald B. Easley*
Affiliation:
Texas Children’s Hospital, Houston, Texas, United Sates of America
Bradley S. Marino
Affiliation:
Northwestern University Feinberg School of Medicine, Chicago, Illinois, United Sates of America Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, United Sates of America
Jacky Jennings
Affiliation:
Johns Hopkins Hospital, Baltimore, Maryland, United Sates of America
Amy E. Cassedy
Affiliation:
Northwestern University Feinberg School of Medicine, Chicago, Illinois, United Sates of America
Kathleen K. Kibler
Affiliation:
Texas Children’s Hospital, Houston, Texas, United Sates of America
Ken M. Brady
Affiliation:
Texas Children’s Hospital, Houston, Texas, United Sates of America
Dean B. Andropoulos
Affiliation:
Texas Children’s Hospital, Houston, Texas, United Sates of America
Marissa Brunetti
Affiliation:
Johns Hopkins Hospital, Baltimore, Maryland, United Sates of America
Charles W. Hogue
Affiliation:
Northwestern University Feinberg School of Medicine, Chicago, Illinois, United Sates of America Johns Hopkins Hospital, Baltimore, Maryland, United Sates of America
Eugenie S. Heitmiller
Affiliation:
Johns Hopkins Hospital, Baltimore, Maryland, United Sates of America
Jennifer K. Lee
Affiliation:
Johns Hopkins Hospital, Baltimore, Maryland, United Sates of America
James Spaeth
Affiliation:
Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, United Sates of America
Allen D. Everett
Affiliation:
Johns Hopkins Hospital, Baltimore, Maryland, United Sates of America
*
Correspondence to: R. B. Easley, MD, Baylor College of Medicine, Texas Children’s Hospital, 6621 Fannin WT17-417, Houston, TX 77030, United States of America. Tel: +832 826 5831; Fax: 832 825 5804; E-mail: [email protected]
Get access Rights & Permissions [Opens in a new window]

Abstract

Background

Cerebrovascular reactivity monitoring has been used to identify the lower limit of pressure autoregulation in adult patients with brain injury. We hypothesise that impaired cerebrovascular reactivity and time spent below the lower limit of autoregulation during cardiopulmonary bypass will result in hypoperfusion injuries to the brain detectable by elevation in serum glial fibrillary acidic protein level.

Methods

We designed a multicentre observational pilot study combining concurrent cerebrovascular reactivity and biomarker monitoring during cardiopulmonary bypass. All children undergoing bypass for CHD were eligible. Autoregulation was monitored with the haemoglobin volume index, a moving correlation coefficient between the mean arterial blood pressure and the near-infrared spectroscopy-based trend of cerebral blood volume. Both haemoglobin volume index and glial fibrillary acidic protein data were analysed by phases of bypass. Each patient’s autoregulation curve was analysed to identify the lower limit of autoregulation and optimal arterial blood pressure.

Results

A total of 57 children had autoregulation and biomarker data for all phases of bypass. The mean baseline haemoglobin volume index was 0.084. Haemoglobin volume index increased with lowering of pressure with 82% demonstrating a lower limit of autoregulation (41±9 mmHg), whereas 100% demonstrated optimal blood pressure (48±11 mmHg). There was a significant association between an individual’s peak autoregulation and biomarker values (p=0.01).

Conclusions

Individual, dynamic non-invasive cerebrovascular reactivity monitoring demonstrated transient periods of impairment related to possible silent brain injury. The association between an impaired autoregulation burden and elevation in the serum brain biomarker may identify brain perfusion risk that could result in injury.

Keywords

Autoregulationcerebrovascular reactivitycardiopulmonary bypassCHD
Type
Original Articles
Information
Cardiology in the Young , Volume 28 , Issue 1 , January 2018 , pp. 55 - 65
Check for updates
Copyright
© Cambridge University Press 2017 

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

Footnotes

*

Ronald B. Easley and Bradley S. Marino are co-first authors.

References

1. McKenzie, ED, Andropoulos, DB, DiBardino, D, Fraser, CD Jr. Congenital heart surgery 2005: the brain: it’s the heart of the matter. Am J Surg 2005; 190: 289–294.Google Scholar
2. Mahle, WT. Neurologic and cognitive outcomes in children with congenital heart disease. Curr Opin Pediatr 2001; 13: 482–486.Google Scholar
3. Sarajuuri, A, Jokinen, E, Puosi, R, et al. Neurodevelopmental and neuroradiologic outcomes in patients with univentricular heart aged 5 to 7 years: related risk factor analysis. J Thorac Cardiovasc Surg 2007; 133: 1524–1532.CrossRefGoogle ScholarPubMed
4. McQuillen, PS, Barkovich, AJ, Hamrick, SE, et al. Temporal and anatomic risk profile of brain injury with neonatal repair of congenital heart defects. Stroke 2007; 38: 736–741.CrossRefGoogle ScholarPubMed
5. Andropoulos, DB, Ahmad, HB, Haq, T, et al. The association between brain injury, perioperative anesthetic exposure, and 12-month neurodevelopmental outcomes after neonatal cardiac surgery: a retrospective cohort study. Paediatr Anaesth 2014; 24: 266–274.Google Scholar
6. Kaltman, JR, Andropoulos, DB, Checchia, PA, et al. Report of the pediatric heart network and national heart, lung, and blood institute working group on the perioperative management of congenital heart disease. Circulation 2010; 121: 2766–2772.CrossRefGoogle Scholar
7. Hogue, CW Jr., Palin, CA, Arrowsmith, JE. Cardiopulmonary bypass management and neurologic outcomes: an evidence-based appraisal of current practices. Anesth Analg 2006; 103: 21–37.Google Scholar
8. Blauth, CI, Arnold, JV, Schulenberg, WE, McCartney, AC, Taylor, KM. Cerebral microembolism during cardiopulmonary bypass. Retinal microvascular studies in vivo with fluorescein angiography. J Thorac Cardiovasc Surg 1988; 95: 668–676.CrossRefGoogle ScholarPubMed
9. Taylor, KM. The hemodynamics of cardiopulmonary bypass. Semin Thorac Cardiovasc Surg 1990; 2: 300–312.Google Scholar
10. Shaw, PJ, Bates, D, Cartlidge, NE, et al. An analysis of factors predisposing to neurological injury in patients undergoing coronary bypass operations. Q J Med 1989; 72: 633–646.Google Scholar
11. Selim, M. Perioperative stroke. N Engl J Med 2007; 356: 706–713.Google Scholar
12. Bellinger, DC. Cardiac surgery and the brain: differences between adult and paediatric studies. Heart 2003; 89: 365–366.Google Scholar
13. Hovels-Gurich, HH, Konrad, K, Skorzenski, D, Herpertz-Dahlmann, B, Messmer, BJ, Seghaye, MC. Attentional dysfunction in children after corrective cardiac surgery in infancy. Ann Thorac Surg 2007; 83: 1425–1430.Google Scholar
14. Ferguson, TB Jr, Hammill, BG, Peterson, ED, DeLong, ER, Grover, FL, Committee STSND. A decade of change – risk profiles and outcomes for isolated coronary artery bypass grafting procedures, 1990-1999: a report from the STS National Database Committee and the Duke Clinical Research Institute. Society of Thoracic Surgeons. Ann Thorac Surg 2002; 73: 480–489; discussion 489–490.Google Scholar
15. Goto, T, Yoshitake, A, Baba, T, Shibata, Y, Sakata, R, Uozumi, H. Cerebral ischemic disorders and cerebral oxygen balance during cardiopulmonary bypass surgery: preoperative evaluation using magnetic resonance imaging and angiography. Anesth Analg 1997; 84: 5–11.CrossRefGoogle ScholarPubMed
16. Hall, RA, Fordyce, DJ, Lee, ME, et al. Brain SPECT imaging and neuropsychological testing in coronary artery bypass patients: single photon emission computed tomography. Ann Thorac Surg 1999; 68: 2082–2088.Google Scholar
17. Moraca, R, Lin, E, Holmes, JH, et al. Impaired baseline regional cerebral perfusion in patients referred for coronary artery bypass. J Thorac Cardiovasc Surg 2006; 131: 540–546.CrossRefGoogle ScholarPubMed
18. Rhee, CJ, Kibler, KK, Easley, RB, et al. The diastolic closing margin is associated with intraventricular hemorrhage in premature infants. Acta Neurochir Suppl 2016; 122: 147–150.CrossRefGoogle ScholarPubMed
19. Lee, JK, Easley, RB, Brady, KM. Neurocognitive monitoring and care during pediatric cardiopulmonary bypass current and future. Curr Cardiol Rev 2008; 4: 123–139.Google Scholar
20. Czosnyka, M, Brady, K, Reinhard, M, Smielewski, P, Steiner, LA. Monitoring of cerebrovascular autoregulation: facts, myths, and missing links. Neurocrit Care 2009; 10: 373–386.CrossRefGoogle ScholarPubMed
21. Czosnyka, M, Smielewski, P, Kirkpatrick, P, Laing, RJ, Menon, D, Pickard, JD. Continuous assessment of the cerebral vasomotor reactivity in head injury. Neurosurgery 1997; 41: 11–17; discussion 17–19.Google Scholar
22. Lee, JK, Kibler, KK, Benni, PB, et al. Cerebrovascular reactivity measured by near-infrared spectroscopy. Stroke 2009; 40: 1820–1826.CrossRefGoogle ScholarPubMed
23. Zweifel, C, Castellani, G, Czosnyka, M, et al. Continuous assessment of cerebral autoregulation with near-infrared spectroscopy in adults after subarachnoid hemorrhage. Stroke 2010; 41: 1963–1968.Google Scholar
24. Brunetti, MA, Jennings, JM, Easley, RB, et al. Glial fibrillary acidic protein in children with congenital heart disease undergoing cardiopulmonary bypass. Cardiol Young 2014; 24: 623–631.CrossRefGoogle ScholarPubMed
25. Magruder, JT, Hibino, N, Collica, S, et al. Association of nadir oxygen delivery on cardiopulmonary bypass with serum glial fibrillary acid protein levels in paediatric heart surgery patients. Interact Cardiovasc Thorac Surg 2016; 23: 531–537.CrossRefGoogle ScholarPubMed
26. Bembea, MM, Savage, W, Strouse, JJ, et al. Glial fibrillary acidic protein as a brain injury biomarker in children undergoing extracorporeal membrane oxygenation. Pediatr Crit Care Med 2011; 12: 572–579.Google Scholar
27. Czosnyka, M, Smielewski, P, Kirkpatrick, P, Menon, DK, Pickard, JD. Monitoring of cerebral autoregulation in head-injured patients. Stroke 1996; 27: 1829–1834.Google Scholar
28. Brady, K, Joshi, B, Zweifel, C, et al. Real-time continuous monitoring of cerebral blood flow autoregulation using near-infrared spectroscopy in patients undergoing cardiopulmonary bypass. Stroke 2010; 41: 1951–1956.Google Scholar
29. Jenkins, KJ, Gauvreau, K, Newburger, JW, Spray, TL, Moller, JH, Iezzoni, LI. Consensus-based method for risk adjustment for surgery for congenital heart disease. J Thorac Cardiovasc Surg 2002; 123: 110–118.Google Scholar
30. Hosmer, DW, Lemeshow, LS. Applied Logistic Regression. Wiley, New York, 2000.Google Scholar
31. Brady, KM, Mytar, JO, Lee, JK, et al. Monitoring cerebral blood flow pressure autoregulation in pediatric patients during cardiac surgery. Stroke 2010; 41: 1957–1962.Google Scholar
32. Diedler, J, Zweifel, C, Budohoski, KP, et al. The limitations of near-infrared spectroscopy to assess cerebrovascular reactivity: the role of slow frequency oscillations. Anesth Analg 2011; 113: 849–857.Google Scholar
33. Steiner, LA, Pfister, D, Strebel, SP, Radolovich, D, Smielewski, P, Czosnyka, M. Near-infrared spectroscopy can monitor dynamic cerebral autoregulation in adults. Neurocrit Care 2009; 10: 122–128.Google Scholar
34. Aries, MJ, Czosnyka, M, Budohoski, KP, et al. Continuous monitoring of cerebrovascular reactivity using pulse waveform of intracranial pressure. Neurocrit Care 2012; 17: 67–76.CrossRefGoogle ScholarPubMed
35. Hori, D, Ono, M, Rappold, TE, et al. Hypotension after cardiac operations based on autoregulation monitoring leads to brain cellular injury. Ann Thorac Surg 2015; 100: 487–493.Google Scholar
36. Hori, D, Everett, AD, Lee, JK, et al. Rewarming rate during cardiopulmonary bypass is associated with release of glial fibrillary acidic protein. Ann Thorac Surg 2015; 100: 1353–1358.Google Scholar
37. Rappold, T, Laflam, A, Hori, D, et al. Evidence of an association between brain cellular injury and cognitive decline after non-cardiac surgery. Br J Anaesth 2016; 116: 83–89.Google Scholar
38. Ennen, CS, Huisman, TA, Savage, WJ, et al. Glial fibrillary acidic protein as a biomarker for neonatal hypoxic-ischemic encephalopathy treated with whole-body cooling. Am J Obstet Gynecol 2011; 205: 251.e251–251.e257.Google Scholar