Rohit K. Singal, MD, Leanne M. Docking, MD, Linda G. Girling, BS, M

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Biologically Variable Bypass Reduces Enzymuria After Deep Hypothermic Circulatory Arrest Rohit K. Singal, MD, Leanne M. Docking, MD, Linda G. Girling, BS, M. Ruth Graham, MD, Peter W. Nickerson, MD, Bruce M. McManus, PhD, MD, Alexander B. Magil, MD, Elizabeth K.-Y. Walker, BS, R. Keith Warrian, MD, Mary S. Cheang, MMath, W. Alan C. Mutch, MD The Annals of Thoracic Surgery Volume 82, Issue 4, Pages 1480-1488 (October 2006) DOI: 10.1016/j.athoracsur.2006.05.015 Copyright © 2006 The Society of Thoracic Surgeons Terms and Conditions

Fig 1 Experimental protocol for the two groups of animals undergoing deep hypothermic circulatory arrest (DHCA). Animals underwent cooling with cardiopulmonary bypass (CPB), DHCA at 18°C (nasopharyngeal) for 1 hour, resumption of CPB with rewarming to 37°C (nasopharyngeal). Hemodynamic measurements, blood gases, and blood and urine samples were obtained at time periods denoted by circles. (Temp = temperature.) The Annals of Thoracic Surgery 2006 82, 1480-1488DOI: (10.1016/j.athoracsur.2006.05.015) Copyright © 2006 The Society of Thoracic Surgeons Terms and Conditions

Fig 2 Representative femoral arterial pressure traces for pigs undergoing (1) conventional nonpulsatile perfusion (NP [gray trace]), and (2) biologically variable perfusion (BVP [black trace]). Time scales decrease by a factor of 10 with each trace from (A) to (C). Mean blood pressure was identical for both traces (65 mm Hg for the 150 s period). Long-term oscillations of approximately 75 s are evident with BVP in (A) as well as oscillations at 15/minute—reflective of encoded breathing rhythm. In (B), three complete respiratory oscillations are seen. Small rhythmic oscillations, best seen in (C) are reflective of the beat-to-beat variation with individual stroke volume and instantaneous heart rate (black trace); different from the monotonous rectified sine wave typical of nonpulsatile bypass (gray trace). (MAP = mean arterial pressure.) The Annals of Thoracic Surgery 2006 82, 1480-1488DOI: (10.1016/j.athoracsur.2006.05.015) Copyright © 2006 The Society of Thoracic Surgeons Terms and Conditions

Fig 3 Hourly measures of (A) hemogloblin concentration (g/L) and serum enzyme activity (U/L) for (B) gamma glutamyl transpeptidase (GGT), (C) alkaline phosphatase (AP), and (D) glutathione S-transferase (GST). *Difference between deep hypothermic circulatory arrest (DHCA) groups at time interval by least mean squares test. +Differences between sham-treated group and other three groups. The time scale references experiments with DHCA. For nonpulsatile perfusion (NP) without DHCA and sham-treated groups, the time intervals were similar. —⧫— = BVP; = NP; = CPB-No DHCA; = Sham-Treated. The Annals of Thoracic Surgery 2006 82, 1480-1488DOI: (10.1016/j.athoracsur.2006.05.015) Copyright © 2006 The Society of Thoracic Surgeons Terms and Conditions

Fig 4 Hourly measures of protein/creatinine ratio and “enzymuria” for the four groups for urine enzyme activity (U/L): (A) protein/creatinine ratio, (B) gamma glutamyl transpeptidase (GGT), (C) alkaline phosphatase (AP), and (D) total glutathione S-transferase (GST). *Significant difference between deep hypothermic circulatory arrest (DHCA) groups at time interval by least mean squares test. +Differences between nonpulsatile perfusion (NP) group and sham-treated and NP without DHCA group. #Differences between biologically variable perfusion (BVP) group and sham-treated and NP without DHCA group. The time scale references experiments with DHCA. For NP without DHCA and sham-treated groups, the time intervals were similar. —⧫— = BVP; = NP; = CPB-No DHCA; = Sham-Treated. The Annals of Thoracic Surgery 2006 82, 1480-1488DOI: (10.1016/j.athoracsur.2006.05.015) Copyright © 2006 The Society of Thoracic Surgeons Terms and Conditions

Fig 5 Representative urine protein spectra over time for one experiment in each group subjected to deep hypothermic circulatory arrest (DHCA). Spectra were generated using surface-enhanced laser desorption/ionization time of flight mass spectrometry (SELDI-TOF-MS). The time periods for measurement are shown between the two panels (refer to Fig 1 for time periods). Note, after DHCA there is more rapid attenuation of the protein peaks in the biologically variable perfusion (BVP) group. (CPB = cardiopulmonary bypass; NP = nonpulsatile perfusion.) The Annals of Thoracic Surgery 2006 82, 1480-1488DOI: (10.1016/j.athoracsur.2006.05.015) Copyright © 2006 The Society of Thoracic Surgeons Terms and Conditions