162 M. Bagherinasab and N. H. Darban: J Extra Corpor Technol 2025, 57, 160--163 [ 12, 13 ]. The cyclic endothelial shear stress that results from this process promotes the enhanced secretion of vasodilatory agents, which in turn reduces vascular resistance and improves perfusion and microcirculation in the target organs [ 14, 15 ].
The improvement in left ventricular ejection fraction( LVEF) observed in this instance can be attributed to the revascularization of coronary arteries, alongside the initiation of certain pharmacological agents, including beta-blockers. These medications have the potential to enhance cardiac function by facilitating adjustments in both preload and afterload conditions [ 16 ].
A higher PI during CPB is associated with improved LVEF after CABG because it ensures sufficient myocardial perfusion and oxygen delivery, thus reducing ischemic damage to the heart muscle [ 5 ]. Coupling this with pulsatile flow can further enhance these benefits; pulsatile flow mimics natural physiological conditions, promoting better hemodynamic stability and improving microcirculation to vital organs, including the myocardium [ 17 ]. Together, these interventions can significantly contribute to better myocardial function and recovery and subsequently enhanced postoperative LVEF.
It has been previously noted that we performed three liters of hemofiltration in response to volume overload [ 18 ]. This raises the consideration that research suggests the intensive application of hemofiltration during CPB can result in either absolute or relative hypovolemia, potentially jeopardizing renal perfusion. Sufficient kidney perfusion is indicated by the presence of PF, which enhances the delivery of oxygen to the tissues. This is supported by a DO 2 i value exceeding 280 L / min / m 2, demonstrating the effectiveness of this perfusion in meeting the metabolic demands of the kidneys.
Research indicates that the physiological characteristics of arterial PF can be effectively replicated through the use of HLM pulsatile flow settings [ 19 ]. We suggest that the combination of an enhanced PI with the use of PF may lead to a gradual enhancement of organ perfusion during CPB.
This study offers an innovative approach to assessing organ perfusion by altering the PI, while simultaneously employing PF methodologies.
Funding The project was not allocated any designated financial support.
Conflicts of interest The authors declared no conflict of interest.
Data availability statement The article integrates all accessible data into its content.
Author contribution statement
The initial drafts were primarily developed by MB and ND, while all authors contributed to the manuscript’ s revision process. Furthermore, every authors has given their approval for the final version of the draft.
Ethics approval There are no ethical declarations relevant to this case report.
References
1. Condello I, Santarpino G, Nasso G, Moscarelli M, Fiore F, Speziale G. Associations between oxygen delivery and cardiac index with hyperlactatemia during cardiopulmonary bypass. JTCVS Techn. 2020; 2:92--99.
2. Teixeira FdC, Fernandes TEdL, Leal KCdS, Ribeiro KRB, Dantas DV, Dantas RAN. Factors associated with increased lactate levels in cardiac surgeries: scoping review. Revista Brasileira de Enfermagem. 2024; 77( 1): e20230117.
3. Hendrix RH, Ganushchak YM, Weerwind PW. Oxygen delivery, oxygen consumption and decreased kidney function after cardiopulmonary bypass. PLoS One. 2019; 14( 11): e0225541.
4. Wang S, Haines N, Ündar A. Quantification of pressure-flow waveforms and selection of components for the pulsatile extracorporeal circuit. J Extra-Corp Technol. 2009; 41( 1): P20.
5. Clingan S, Reagor J, Lombardi J. Retrospective analysis of cardiac index and lactate production on cardiopulmonary bypass for a congenital cardiac patient population. Perfusion. 2019; 34( 3): 231--235.
6. Munoz R, Laussen PC, Palacio G, Zienko L, Piercey G, Wessel DL. Changes in whole blood lactate levels during cardiopulmonary bypass for surgery for congenital cardiac disease: an early indicator of morbidity and mortality. J Thorac Cardiovasc Surg. 2000; 119( 1): 155--162.
7. Ranucci M, Romitti F, Isgrò G, et al. Oxygen delivery during cardiopulmonary bypass and acute renal failure after coronary operations. Ann Thorac Surg. 2005; 80( 6): 2213--2220.
8. Newland RF, Baker RA, Woodman RJ, Barnes MB, Willcox TW. Predictive capacity of oxygen delivery during cardiopulmonary bypass on acute kidney injury. Ann Thorac Surg. 2019; 108( 6): 1807--1814.
9. Sunagawa G, Koprivanac M, Karimov JH, Moazami N, Fukamachi K. Is a pulse absolutely necessary during cardiopulmonary bypass? Expert Rev Med Devices. 2017; 14( 1): 27--35.
10. Ji B, Ündar A. An evaluation of the benefits of pulsatile versus nonpulsatile perfusion during cardiopulmonary bypass procedures in pediatric and adult cardiac patients. Asaio J. 2006; 52( 4): 357--361.
11. Baraki H, Gohrbandt B, Del Bagno B, Haverich A, Boethig D, Kutschka I. Does pulsatile perfusion improve outcome after cardiac surgery? A propensity-matched analysis of 1959 patients. Perfusion. 2012; 27( 3): 166--174.
12. Ündar A. Myths and truths of pulsatile and nonpulsatile perfusion during acute and chronic cardiac support. Wiley Online Library; 2004:439--443.
13. Wright G. Hemodynamic analysis could resolve the pulsatile blood flow controversy. Ann Thorac Surg. 1994; 58( 4): 1199--1204.
14. Nakano T, Tominaga R, Nagano I, Okabe H, Yasui H. Pulsatile flow enhances endothelium-derived nitric oxide release in the peripheral vasculature. Am J Physiol Heart Circ Physiol. 2000; 278( 4): H1098--H1104.
15. Koning NJ, Vonk AB, van Barneveld LJ, et al., Pulsatile flow during cardiopulmonary bypass preserves postoperative microcirculatory perfusion irrespective of systemic hemodynamics. J Appl Physiol. 2012; 112( 10): 1727--1734.
16. Higashino A, Tsuruta Y, Moriyama S, Miura S, Taketani T, Ohno T. Does cardiac function improvement with coronary artery bypass grafting reduce all-cause mortality? Ann Thorac Surg Short Rep. 2024; 2:737--741.
17. Hickey PR, Buckley MJ, Philbin DM. Pulsatile and nonpulsatile cardiopulmonary bypass: review of a counterproductive controversy. Ann Thorac Surg. 1983; 36( 6): 720--737.