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The Journal of Thoracic and Cardiovascular Surgery, Vol 95, 668-676, Copyright © 1988 by The American Association for Thoracic Surgery and The Western Thoracic Surgical Association
CI Blauth, JV Arnold, WE Schulenberg, AC McCartney and KM Taylor
To observe microembolic events in the central nervous system during
cardiopulmonary bypass, we subjected 21 patients undergoing elective
coronary operations to retinal fluorescein angiograms 5 minutes before
cardiopulmonary bypass was discontinued. Patients with diabetes or
clinically evident cerebrovascular disease were excluded. Bubble
oxygenation and nonpulsatile perfusion were used for bypass. After 31 to
167 minutes of cardiopulmonary bypass, all 21 (100%) patients had retinal
microvascular occlusions indicative of microembolism. Control fluorescein
angiograms obtained preoperatively and in five patients immediately before
bypass but after aortic cannulation showed retinal perfusion. During bypass
there was a mean of 3.5 (range 1 to 7) blocked arterioles of less than 50
micron caliber and a mean of 6.3 (range 1 to 10) focal areas of capillary
nonperfusion per 30-degree field of retina centered on the macula per
patient. Repeat studies 30 minutes after discontinuation of bypass showed
partial reperfusion with occlusions in four of the five (80%) patients and
a decrease in the mean total microembolic count from 12.6 to 4.8 (38%). In
later studies at a median of 8 days postoperatively, only two of 16 (12.5%)
patients had persistently occluded retinal vessels. The total microembolic
count did not correlate with bypass time (r = 0.14) and was not reduced by
arterial line filtration with a Pall 40 micron filter (Ultipore) in a
subgroup of 11 patients. Twenty patients completed four standardized
psychometric tests. Retinal microvascular occlusions were more numerous in
those patients with a psychometric deficit (n = 7) than in those with no
deficit (n = 13; p = 0.075). In a dog model of cardiopulmonary bypass,
eight of nine (88.9%) had retinal microvascular occlusions after 10 to 90
minutes of bypass. Retinal histologic studies revealed intravascular
platelet-fibrin microaggregates 20 to 70 micron in diameter and focal
ischemic changes in seven of the nine (77.8%) dogs. Six dogs undergoing
sham bypass had normal retinal perfusion and histologic findings. This
study demonstrates a very high incidence of microvascular occlusions in the
territory of the internal carotid artery during bypass consistent with a
microembolic origin. The clinical significance of these findings is
uncertain.
ARTICLES
Cerebral microembolism during cardiopulmonary bypass. Retinal microvascular studies in vivo with fluorescein angiography
Royal Postgraduate Medical School, Hammersmith Hospital, London, England.
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