Advertisement

Con: Modified Ultrafiltration Should Not Be Routinely Used in Adult Cardiac Surgery

Published:January 12, 2023DOI:https://doi.org/10.1053/j.jvca.2023.01.009
      CARDIOPULMONARY BYPASS (CPB) is known to induce a systemic proinflammatory state and may contribute to postoperative organ dysfunction, primarily through complement activation secondary to blood passing through an artificial extracorporeal circuit.
      • Hall RI
      • Smith MS
      • Rocker G.
      The systemic inflammatory response to cardiopulmonary bypass: Pathophysiological, therapeutic, and pharmacological considerations.
      • Wang W
      • Huang HM
      • Zhu DM
      • et al.
      Modified ultrafiltration in paediatric cardiopulmonary bypass.
      • Thapmongkol S
      • Masaratana P
      • Subtaweesin T
      • et al.
      The effects of modified ultrafiltration on clinical outcomes of adult and pediatric cardiac surgery.
      Ultrafiltration may minimize some of the impact of the CPB-induced systemic inflammatory response.
      • Huang H
      • Yao T
      • Wang W
      • et al.
      Continuous ultrafiltration attenuates the pulmonary injury that follows open heart surgery with cardiopulmonary bypass.
      Traditionally, ultrafiltration may be conventional (CUF) or modified (MUF). Conventional ultrafiltration has been employed extensively during CPB, and involves hemoconcentration of both the priming volume and patient's blood volume at any point during CPB.
      • Darup J
      • Bleese N
      • Kalmar P
      • et al.
      Hemofiltration during extracorporeal circulation (ECC).
      ,
      • Klineberg PL
      • Kam CA
      • Johnson DC
      • et al.
      Hematocrit and blood volume control during cardiopulmonary bypass with the use of hemofiltration.
      In the early 1990s, Naik et al. introduced the concept of MUF
      • Elliott MJ.
      Ultrafiltration and modified ultrafiltration in pediatric open heart operations.
      ,
      • Andreasson S
      • Gothberg S
      • Berggren H
      • et al.
      Hemofiltration modifies complement activation after extracorporeal circulation in infants.
      ,
      • Naik SK
      • Knight A
      • Elliott MJ.
      A successful modification of ultrafiltration for cardiopulmonary bypass in children.
      in which the patient's blood volume is hemoconcentrated after separation from CPB.
      • Wang S
      • Palanzo D
      • Undar A.
      Current ultrafiltration techniques before, during and after pediatric cardiopulmonary bypass procedures.
      Naik et al. postulated it may permit blood-free cardiac surgery.
      • Naik SK
      • Knight A
      • Elliott M.
      A prospective randomized study of a modified technique of ultrafiltration during pediatric open-heart surgery.
      Blood is typically removed from the arterial cannula and returned through the venous cannula. Others employ a modified technique in which blood is removed from the right atrium and infused into the aorta, potentially reducing concerns about cerebral shunting.
      • Myers GJ
      • Leadon RB
      • Mitchell LB
      • et al.
      Simple modified ultrafiltration.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Journal of Cardiothoracic and Vascular Anesthesia
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Hall RI
        • Smith MS
        • Rocker G.
        The systemic inflammatory response to cardiopulmonary bypass: Pathophysiological, therapeutic, and pharmacological considerations.
        Anesth Analg. 1997; 85: 766-782
        • Wang W
        • Huang HM
        • Zhu DM
        • et al.
        Modified ultrafiltration in paediatric cardiopulmonary bypass.
        Perfusion. 1998; 13: 304-310
        • Thapmongkol S
        • Masaratana P
        • Subtaweesin T
        • et al.
        The effects of modified ultrafiltration on clinical outcomes of adult and pediatric cardiac surgery.
        Asian Biomedicine. 2015; 9: 591-599
        • Huang H
        • Yao T
        • Wang W
        • et al.
        Continuous ultrafiltration attenuates the pulmonary injury that follows open heart surgery with cardiopulmonary bypass.
        Ann Thorac Surg. 2003; 76: 136-140
        • Darup J
        • Bleese N
        • Kalmar P
        • et al.
        Hemofiltration during extracorporeal circulation (ECC).
        Thorac Cardiovasc Surg. 1979; 27: 227-230
        • Klineberg PL
        • Kam CA
        • Johnson DC
        • et al.
        Hematocrit and blood volume control during cardiopulmonary bypass with the use of hemofiltration.
        Anesthesiology. 1984; 60: 478-480
        • Elliott MJ.
        Ultrafiltration and modified ultrafiltration in pediatric open heart operations.
        Ann Thorac Surg. 1993; 56: 1518-1522
        • Andreasson S
        • Gothberg S
        • Berggren H
        • et al.
        Hemofiltration modifies complement activation after extracorporeal circulation in infants.
        Ann Thorac Surg. 1993; 56: 1515-1517
        • Naik SK
        • Knight A
        • Elliott MJ.
        A successful modification of ultrafiltration for cardiopulmonary bypass in children.
        Perfusion. 1991; 6: 41-50
        • Wang S
        • Palanzo D
        • Undar A.
        Current ultrafiltration techniques before, during and after pediatric cardiopulmonary bypass procedures.
        Perfusion. 2012; 27: 438-446
        • Naik SK
        • Knight A
        • Elliott M.
        A prospective randomized study of a modified technique of ultrafiltration during pediatric open-heart surgery.
        Circulation. 1991; 84 (III422-31)
        • Myers GJ
        • Leadon RB
        • Mitchell LB
        • et al.
        Simple modified ultrafiltration.
        Perfusion. 2000; 15: 447-452
        • Fudulu DP
        • Schadenberg A
        • Gibbison B
        • et al.
        Corticosteroids and other anti-inflammatory strategies in pediatric heart surgery: A national survey of practice.
        World J Pediatr Congenit Heart Surg. 2018; 9: 289-293
        • Walcƶak A
        • Klein T
        • Voss J
        • et al.
        International Pediatric Perfusion Practice: 2016 Survey Results.
        J Extra Corpor Technol. 2021; 53: 7-26
        • Tibi P
        • McClure RS
        • Huang J
        • et al.
        STS/SCA/AmSECT/SABM Update to the clinical practice guidelines on patient blood management.
        J Extra Corpor Technol. 2021; 53: 97-124
        • Schlünzen L
        • Pedersen J
        • Hjortholm K
        • et al.
        Modified ultrafiltration in paediatric cardiac surgery.
        Perfusion. 1998; 13: 105-109
        • Sever K
        • Tansel T
        • Basaran M
        • et al.
        The benefits of continuous ultrafiltration in pediatric cardiac surgery.
        Scand Cardiovasc J. 2004; 38: 307-311
        • Raja SG
        • Yousufuddin S
        • Rasool F
        • et al.
        Impact of modified ultrafiltration on morbidity after pediatric cardiac surgery.
        Asian Cardiovasc Thorac Ann. 2006; 14: 341-350
        • Hu J
        • Li P
        • Chen X
        • et al.
        Effects of modified ultrafiltration and conventional ultrafiltration combination on perioperative clinical outcomes in pediatric cardiac surgery: A meta-analysis.
        Medicine (Baltimore). 2021; 100: e24221
        • Kuratani N
        • Bunsangjaroen P
        • Srimueang T
        • et al.
        Modified versus conventional ultrafiltration in pediatric cardiac surgery: A meta-analysis of randomized controlled trials comparing clinical outcome parameters.
        J Thorac Cardiovasc Surg. 2011; 142: 861-867
        • McRobb CM
        • Ing RJ
        • Lawson DS
        • et al.
        Retrospective analysis of eliminating modified ultrafiltration after pediatric cardiopulmonary bypass.
        Perfusion. 2017; 32: 97-109
        • Elliott M.
        Modified ultrafiltration and open heart surgery in children.
        Paediatr Anesth. 1999; 9: 1-5
        • Portela FA
        • Pensado A
        • Sanchez A
        • et al.
        A simple technique to perform combined ultrafiltration.
        Ann Thorac Surg. 1999; 67: 859-861
        • Berdat PA
        • Eichenberger E
        • Ebell J
        • et al.
        Elimination of proinflammatory cytokines in pediatric cardiac surgery: Analysis of ultrafiltration method and filter type.
        J Thorac Cardiovasc Surg. 2004; 127: 1688-1696
        • Wu K
        • Meng B
        • Wang Y
        • et al.
        Impact of miniaturized cardiopulmonary bypass circuits on ultrafiltration during congenital heart surgery.
        Perfusion. 2021; 36: 832-838
        • Bierer J
        • Stanzel R
        • Henderson M
        • et al.
        Ultrafiltration in pediatric cardiac surgery review.
        World J Pediatr Congenit Heart Surg. 2019; 10: 778-788
        • Saatvedt K
        • Lindberg H
        • Geiran OR
        • et al.
        Ultrafiltration after cardiopulmonary bypass in children: Effects on hemodynamics, cytokines and complement.
        Cardiovasc Res. 1996; 31: 596-602
        • Chew MS
        • Brix-Christensen V
        • Ravn HB
        • et al.
        Effect of modified ultrafiltration on the inflammatory response in paediatric open-heart surgery: A prospective, randomized study.
        Perfusion. 2002; 17: 327-333
        • Ootaki Y
        • Yamaguchi M
        • Oshima Y
        • et al.
        Effects of modified ultrafiltration on coagulation factors in pediatric cardiac surgery.
        Surg Today. 2002; 32: 203-206
        • Masuda Z
        • Kurosaki Y
        • Ishino K
        • et al.
        Pharmacokinetic analysis of flomoxef in children undergoing cardiopulmonary bypass and modified ultrafiltration.
        Gen Thorac Cardiovasc Surg. 2008; 56: 163-169
        • Wilder NS
        • Andropoulos DB
        • Paugh T
        • et al.
        Sequestration of dexmedetomidine in ex vivo cardiopulmonary bypass circuits.
        ASAIO J. 2022; 68: 592-598
        • Taenzer AH
        • Groom R
        • Quinn RD.
        Fentanyl plasma levels after modified ultrafiltration in infant heart surgery.
        J Extra Corpor Technol. 2005; 37: 369-372
        • Papadopoulos N
        • Bakhtiary F
        • Grun V
        • et al.
        The effect of normovolemic modified ultrafiltration on inflammatory mediators, endotoxins, terminal complement complexes and clinical outcome in high-risk cardiac surgery patients.
        Perfusion. 2013; 28: 306-314
        • Weber CF
        • Jámbor C
        • Strasser C
        • et al.
        Normovolemic modified ultrafiltration is associated with better preserved platelet function and less postoperative blood loss in patients undergoing complex cardiac surgery: A randomized and controlled study.
        J Thorac Cardiovasc Surg. 2011; 141: 1298-1304
        • Mejak BL
        • Ing RJ
        • McRobb C
        • et al.
        Cryoprecipitate and platelet administration during modified ultrafiltration in children less than 10 kg undergoing cardiac surgery.
        J Extra Corpor Technol. 2013; 45: 107-111
        • Milovanovic V
        • Bisenic D
        • Mimic B
        • et al.
        Reevaluating the importance of modified ultrafiltration in contemporary pediatric cardiac surgery.
        J Clin Med. 2018; 7: 498
        • Huebler M
        • Koster A
        • Buz S
        • et al.
        Cardiopulmonary bypass for complex cardiac surgery using bivalirudin anticoagulation in a patient with heparin antibodies.
        J Card Surg. 2006; 21: 286-288
        • Medlin WM
        • Sistino JJ.
        Cerebral oxygen saturation changes during modified ultrafiltration.
        Perfusion. 2006; 21: 325-328
        • Onoe M
        • Magara T
        • Yamamoto Y
        • et al.
        Modified ultrafiltration removes serum interleukin-8 in adult cardiac surgery.
        Perfusion. 2001; 16: 37-42
        • Tassani P
        • Richter JA
        • Eising GP
        • et al.
        Influence of combined zero-balanced and modified ultrafiltration on the systemic inflammatory response during coronary artery bypass grafting.
        J Cardiothorac Vasc Anesth. 1999; 13: 285-291
        • Steffens TG
        • Kohmoto T
        • Edwards N
        • et al.
        Effects of modified ultrafiltration on coagulation as measured by the thromboelastograph.
        J Extra Corpor Technol. 2008; 40: 229-233
        • Abbas U
        • Loomba RS
        • Urbas C
        • et al.
        Effects of modified ultrafiltration on thromboelastographic profile after pediatric cardiac surgery.
        J Extra Corpor Technol. 2021; 53: 50-56
        • Harm SK
        • Waters JH
        • Lynn P
        • et al.
        Changes in mechanical fragility and free hemoglobin levels after processing salvaged cardiopulmonary bypass circuit blood with a modified ultrafiltration device.
        J Extra Corpor Technol. 2012; 44: 21-25
        • Romlin BS
        • Wahlander H
        • Synnergren M
        • et al.
        Earlier detection of coagulopathy with thromboelastometry during pediatric cardiac surgery: A prospective observational study.
        Paediatr Anaesth. 2013; 23: 222-227
        • Leyh RG
        • Bartels C
        • Joubert-Hübner E
        • et al.
        Influence of modified ultrafiltration on coagulation, fibrinolysis and blood loss in adult cardiac surgery.
        Eur J Cardiothorac Surg. 2001; 19: 145-151
        • Boodhwani M
        • Williams K
        • Babaev A
        • et al.
        Ultrafiltration reduces blood transfusions following cardiac surgery: A meta-analysis.
        Eur J Cardiothorac Surg. 2006; 30: 892-897
        • Boodhwani M
        • Hamilton A
        • de Varennes B
        • et al.
        A multicenter randomized controlled trial to assess the feasibility of testing modified ultrafiltration as a blood conservation technology in cardiac surgery.
        J Thorac Cardiovasc Surg. 2010; 139: 701-706
        • Pérez-Vela JL
        • Ruiz-Alonso E
        • Guillén-Ramírez F
        • et al.
        ICU outcomes in adult cardiac surgery patients in relation to ultrafiltration type.
        Perfusion. 2008; 23: 79-87
        • Kandil OA
        • Motawea KR
        • Darling E
        • et al.
        Ultrafiltration and cardiopulmonary bypass associated acute kidney injury: A systematic review and meta-analysis.
        Clin Cardiol. 2021; 44: 1700-1708
        • Zakkar M
        • Guida G
        • Angelini GD.
        Modified ultrafiltration in adult patients undergoing cardiac surgery.
        Interact Cardiovasc Thorac Surg. 2015; 20: 415-421