Iris C. Vermeulen Windsant, MD, Sebastiaan J. Hanssen, MD, Wim A

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Cardiovascular surgery and organ damage: Time to reconsider the role of hemolysis Iris C. Vermeulen Windsant, MD, Sebastiaan J. Hanssen, MD, Wim A. Buurman, PhD, Michael J. Jacobs, MD, PhD The Journal of Thoracic and Cardiovascular Surgery Volume 142, Issue 1, Pages 1-11 (July 2011) DOI: 10.1016/j.jtcvs.2011.02.012 Copyright © 2011 The American Association for Thoracic Surgery Terms and Conditions

Figure 1 Association between cardiopulmonary bypass time and extent of hemolysis. A correlation analysis between cardiopulmonary bypass (CPB) time and total free hemoglobin (fHb) release (defined as the area under the curve) was performed in 54 patients undergoing open surgical repair of thoracoabdominal aortic aneurysms with cardiopulmonary bypass. A significant correlation (Pearson r = 0.33, P < .05) was found between cardiopulmonary bypass time and plasma free hemoglobin release (unpublished data). The Journal of Thoracic and Cardiovascular Surgery 2011 142, 1-11DOI: (10.1016/j.jtcvs.2011.02.012) Copyright © 2011 The American Association for Thoracic Surgery Terms and Conditions

Figure 2 Hemolysis during open surgical repair of thoracoabdominal aortic aneurysms with cardiopulmonary bypass (CPB). Plasma free hemoglobin (fHb) levels increased during surgery and continued to increase significantly in the early postoperative period. This indicates ongoing lysis of red blood cells after cardiopulmonary bypass had stopped. Asterisk indicates P < .05 versus preoperative level; triple asterisk indicates P < .001 versus preoperative level; crosshatch indicates P < .05 versus end-CPB level; double crosshatch indicates P < .01 versus end-CPB level (unpublished data). R, Reperfusion. The Journal of Thoracic and Cardiovascular Surgery 2011 142, 1-11DOI: (10.1016/j.jtcvs.2011.02.012) Copyright © 2011 The American Association for Thoracic Surgery Terms and Conditions

Figure 3 Association between storage time and free hemoglobin (fHb) levels in packed red blood cell transfusion bags. A significant correlation (Pearson r = 0.43, P < .001) was found between packed red blood cell storage duration and free hemoglobin concentration in packed red blood cell transfusion bags (n = 60) used for transfusion during cardiovascular surgery. These data indicate that prolonged storage duration results in more red blood cell injury, with concomitantly more free hemoglobin being transfused into the patient (unpublished data). The Journal of Thoracic and Cardiovascular Surgery 2011 142, 1-11DOI: (10.1016/j.jtcvs.2011.02.012) Copyright © 2011 The American Association for Thoracic Surgery Terms and Conditions

Figure 4 Potential sources and effects of plasma free hemoglobin (HB) during cardiovascular surgery with cardiopulmonary bypass, and therapeutic options to attenuate hemolysis-induced organ damage. Intravascular hemolysis during cardiovascular surgery can be attributed to the cardiopulmonary bypass, transfusion of red blood cells, and cell salvage use (left). Lysis of red blood cells results in increased circulating plasma free hemoglobin (Hb) levels (orange squares). Under physiologic conditions, free hemoglobin is rapidly cleared by the scavenger haptoglobin. Haptoglobin–hemoglobin (Hp-Hb) complexes bind to CD163 expressed by monocytes and macrophages, initiating endocytosis and degradation (middle, bottom). Haptoglobin is not recycled, so excessive hemolysis depletes haptoglobin storages rapidly. Nonscavenged free hemoglobin (fHb) potently binds circulating nitric oxide (NO), thereby limiting its bioavailability. In this way high free hemoglobin levels increase the nitric oxide–scavenging capacity of blood, causing impaired vasodilation as a result of vascular nitric oxide shortage. Decreased vasodilation contributes to impaired tissue perfusion and development of organ damage and organ dysfunction (right, bottom). The adverse effects of free hemoglobin may be counteracted by either increasing haptoglobin levels to support free hemoglobin scavenging or enhancing the nitric oxide donor pool to increase nitric oxide bioavailability. Haptoglobin can be administered intravenously, or haptoglobin synthesis may be upregulated through corticosteroid administration (center, bottom). The nitric oxide donor pool could be increased by oral or intravenous administration of nitrite, which is oxidized to nitric oxide under low Po2 or low pH. Nitric oxide inhalation inactivates free hemoglobin in the pulmonary circulation (or oxygenator in the cardiopulmonary bypass circuit) by transforming it to bioinactive methemoglobin (metHb, center, top). In this way scavenging and inactivation of free hemoglobin and supplementation of nitric oxide prevent the adverse effects of plasma free hemoglobin during cardiovascular surgery (right, top). The Journal of Thoracic and Cardiovascular Surgery 2011 142, 1-11DOI: (10.1016/j.jtcvs.2011.02.012) Copyright © 2011 The American Association for Thoracic Surgery Terms and Conditions