2. Ultrafiltration for Cirrhotic Patients during Cardiopulmonary Bypass: Egyptian Experience. Dr. Mohamed R. El–Tahan, M.D.

3. IntroductionIntroduction Cardiac Surgery & Cirrhosis History of UF Principle of UF Types of UF MUFMUFCUFCUFDUFDUF UF & Cirrhosis Our Study

4. IntroductionIntroduction Cardiac Surgery & Cirrhosis History of UF Principle of UF Types of UF MUFMUFCUFCUFDUFDUF UF & Cirrhosis Our Study

5. IntroductionIntroduction Cardiac Surgery & Cirrhosis History of UF Principle of UF Types of UF MUFMUFCUFCUFDUFDUF UF & Cirrhosis Our Study

6. IntroductionIntroduction Cardiac Surgery & Cirrhosis History of UF Principle of UF Types of UF MUFMUFCUFCUFDUFDUF UF & Cirrhosis Our Study

7. IntroductionIntroduction Cardiac Surgery & Cirrhosis History of UF Principle of UF Types of UF MUFMUFCUFCUFDUFDUF UF & Cirrhosis Our Study

8. IntroductionIntroduction Cardiac Surgery & Cirrhosis History of UF Principle of UF Types of UF MUFMUFCUFCUFDUFDUF UF & Cirrhosis Our Study

9. IntroductionIntroduction Cardiac Surgery & Cirrhosis History of UF Principle of UF Types of UF MUFMUFCUFCUFDUFDUF UF & Cirrhosis Our Study

10. IntroductionIntroduction Cardiac Surgery & Cirrhosis History of UF Principle of UF Types of UF MUFMUFCUFCUFDUFDUF UF & Cirrhosis Our Study

11. IntroductionIntroduction Cardiac Surgery & Cirrhosis History of UF Principle of UF Types of UF MUFMUFCUFCUFDUFDUF UF & Cirrhosis Our Study

12. IntroductionIntroduction Cardiac Surgery & Cirrhosis History of UF Principle of UF Types of UF MUFMUFCUFCUFDUFDUF UF & Cirrhosis Our Study

13. The hill of schistosomiasis in the Nile Delta, Lower and Upper Egypt Egypt is the Gift of the Nile

14. IntroductionIntroduction Cardiac Surgery & Cirrhosis History of UF Principle of UF Types of UF MUFMUFCUFCUFDUFDUF UF & Cirrhosis Our Study

15. Egypt has possibly the highest HCV prevalence worldwide (10%–20%) and is the leading cause of chronic liver disease and hepatocellular carcinoma. IntroductionIntroduction Cardiac Surgery & Cirrhosis History of UF Principle of UF Types of UF MUFMUFCUFCUFDUFDUF UF & Cirrhosis Our Study

16. IntroductionIntroduction Cardiac Surgery & Cirrhosis History of UF Principle of UF Types of UF MUFMUFCUFCUFDUFDUF UF & Cirrhosis Our Study

17. IntroductionIntroduction Cardiac Surgery & Cirrhosis History of UF Principle of UF Types of UF MUFMUFCUFCUFDUFDUF UF & Cirrhosis Our Study Patients with mild or moderate cirrhosis have prolonged hospitalization and high mortality and morbidity rates after cardiac surgery using cardiopulmonary bypass.

19. *

20. **

21. * *

22. Worsening postoperative function of vital organs may be attributed to the SIRS and capillary leak syndrome caused by CPB. IntroductionIntroduction Cardiac Surgery & Cirrhosis History of UF Principle of UF Types of UF MUFMUFCUFCUFDUFDUF UF & Cirrhosis Our Study

23. IntroductionIntroduction Cardiac Surgery & Cirrhosis History of UF Principle of UF Types of UF MUFMUFCUFCUFDUFDUF UF & Cirrhosis Our Study

24. The concept of removing excess fluid from the intravascular space of patients in renal failure by the filtration of blood through an ultraporous membrane dates back to 1928. Brull L. Realization de l'ultrafiltration in vivo. C R Soc Biol (Paris) 1928;99:1605–1608. IntroductionIntroduction Cardiac Surgery & Cirrhosis History of UF Principle of UF Types of UF MUFMUFCUFCUFDUFDUF UF & Cirrhosis Our Study

25. Unfortunately, the first clinical applications of ultrafiltration in patients with renal failure did not occur until the 1952. IntroductionIntroduction Cardiac Surgery & Cirrhosis History of UF Principle of UF Types of UF MUFMUFCUFCUFDUFDUF UF & Cirrhosis Our Study

26. During the 1970s, Lee West Henderson was the first who used the UF during open heart surgery. IntroductionIntroduction Cardiac Surgery & Cirrhosis History of UF Principle of UF Types of UF MUFMUFCUFCUFDUFDUF UF & Cirrhosis Our Study

27. IntroductionIntroduction Cardiac Surgery & Cirrhosis History of UF Principle of UF Types of UF MUFMUFCUFCUFDUFDUF UF & Cirrhosis Our Study

28. Ultrafiltration is the selective separation of plasma water and LMW solutes from the intravascular cellular components and plasma proteins, using a semipermeable membrane filter. IntroductionIntroduction Cardiac Surgery & Cirrhosis History of UF Principle of UF Types of UF MUFMUFCUFCUFDUFDUF UF & Cirrhosis Our Study

29. IntroductionIntroduction Cardiac Surgery & Cirrhosis History of UF Principle of UF Types of UF MUFMUFCUFCUFDUFDUF UF & Cirrhosis Our Study

30. UF is being categorized by the timing and technique used in the UF process: IntroductionIntroduction Cardiac Surgery & Cirrhosis History of UF Principle of UF Types of UF MUFMUFCUFCUFDUFDUF UF & Cirrhosis Our Study

31. Conventional ultrafiltration Conventional ultrafiltration is performed during CPB (usually during the rewarming phase) and the volume removed is based on the volume within the CPB circuit. IntroductionIntroduction Cardiac Surgery & Cirrhosis History of UF Principle of UF Types of UF MUFMUFCUFCUFDUFDUF UF & Cirrhosis Our Study

34. IntroductionIntroduction Cardiac Surgery & Cirrhosis History of UF Principle of UF Types of UF MUFMUFCUFCUFDUFDUF UF & Cirrhosis Our Study

35. Modified ultrafiltration Modified ultrafiltration refers to the use of ultrafiltration after the stabilization of the patient’s hemodynamics after CPB. IntroductionIntroduction Cardiac Surgery & Cirrhosis History of UF Principle of UF Types of UF MUFMUFCUFCUFDUFDUF UF & Cirrhosis Our Study

36. An ultrafilter is placed with the inlet connected to the aortic cannula and the outlet connected to the right atrium via the venous catheter.

38. Blood flow rate through the filter is maintained at 200 to 300 mL/min to produce an UF rate of 100 to 150 mL/min Infusion rates is adjusted to maintain appropriate CVP or LAP. IntroductionIntroduction Cardiac Surgery & Cirrhosis History of UF Principle of UF Types of UF MUFMUFCUFCUFDUFDUF UF & Cirrhosis Our Study

39. MUF The MUF removed volume after CPB is 20 to 30 mL/kg. IntroductionIntroduction Cardiac Surgery & Cirrhosis History of UF Principle of UF Types of UF MUFMUFCUFCUFDUFDUF UF & Cirrhosis Our Study

41. * * *

42. * *

48. IntroductionIntroduction Cardiac Surgery & Cirrhosis History of UF Principle of UF Types of UF MUFMUFCUFCUFDUFDUF UF & Cirrhosis Our Study

49. Continuous ultrafiltration Continuous ultrafiltration ( CUF+MUF) is a technique that using both CUF and MUF during and after the cessation of CPB, respectively. IntroductionIntroduction Cardiac Surgery & Cirrhosis History of UF Principle of UF Types of UF MUFMUFCUFCUFDUFDUF UF & Cirrhosis Our Study

50. CUF attenuates the inflammatory response, increases hemoglobin conc. and platelets, improves hemodynamics, decreases the need for transfusion, postoperative ventilation and ICU stay. IntroductionIntroduction Cardiac Surgery & Cirrhosis History of UF Principle of UF Types of UF MUFMUFCUFCUFDUFDUF UF & Cirrhosis Our Study

53. IntroductionIntroduction Cardiac Surgery & Cirrhosis History of UF Principle of UF Types of UF MUFMUFCUFCUFDUFDUF UF & Cirrhosis Our Study

54. Semi-continuous UF throughout CPB but it is interrupted during weaning from CPB. Allow UF rate = the crystalloid cardioplegia volume + 40–70 mL/kg/hr. IntroductionIntroduction Cardiac Surgery & Cirrhosis History of UF Principle of UF Types of UF MUFMUFCUFCUFDUFDUF UF & Cirrhosis Our Study

55. Adding small aliquots of crystalloid < 20 mL/kg as necessary to maintain a safe blood level in the venous reservoir. IntroductionIntroduction Cardiac Surgery & Cirrhosis History of UF Principle of UF Types of UF MUFMUFCUFCUFDUFDUF UF & Cirrhosis Our Study

59. IntroductionIntroduction Cardiac Surgery & Cirrhosis History of UF Principle of UF Types of UF MUFMUFCUFCUFDUFDUF UF & Cirrhosis Our Study

60. Contributing factors for adverse outcome in cirrhotic patients after CPB include: IntroductionIntroduction Cardiac Surgery & Cirrhosis History of UF Principle of UF Types of UF MUFMUFCUFCUFDUFDUF UF & Cirrhosis Our Study  no pulsatile flow,  hemodilution,  hemolysis,  activation of the inflammatory cascade,  anticoagulation,  hypothermia,  and reduced end-organ perfusion.  no pulsatile flow,  hemodilution,  hemolysis,  activation of the inflammatory cascade,  anticoagulation,  hypothermia,  and reduced end-organ perfusion.

62. IntroductionIntroduction Cardiac Surgery & Cirrhosis History of UF Principle of UF Types of UF MUFMUFCUFCUFDUFDUF UF & Cirrhosis Our Study

63. IntroductionIntroduction Cardiac Surgery & Cirrhosis History of UF Principle of UF Types of UF MUFMUFCUFCUFDUFDUF UF & Cirrhosis Our Study

64. IntroductionIntroduction Cardiac Surgery & Cirrhosis History of UF Principle of UF Types of UF MUFMUFCUFCUFDUFDUF UF & Cirrhosis Our Study

65. IntroductionIntroduction Cardiac Surgery & Cirrhosis History of UF Principle of UF Types of UF MUFMUFCUFCUFDUFDUF UF & Cirrhosis Our Study

67. We postulated that CUF + MUF may decrease the need for transfusion and shorten the durations of ventilation and ICU stay in the cirrhotic patients after valve surgery. IntroductionIntroduction Cardiac Surgery & Cirrhosis History of UF Principle of UF Types of UF MUFMUFCUFCUFDUFDUF UF & Cirrhosis Our Study

68. A priori power analysis indicated that 30 patients in each group would be a sufficiently sample size to detect a 20% reduction in aminotransferase values, with a type-I error of 0.05 and a power of 87%. IntroductionIntroduction Cardiac Surgery & Cirrhosis History of UF Principle of UF Types of UF MUFMUFCUFCUFDUFDUF UF & Cirrhosis Our Study

69. Sixty cirrhotic ASA II – IV patients (Child-Pugh Grade A–C) scheduled for valvular heart surgery using CPB were studied. IntroductionIntroduction Cardiac Surgery & Cirrhosis History of UF Principle of UF Types of UF MUFMUFCUFCUFDUFDUF UF & Cirrhosis Our Study

70. Patients with history of IHD, LV dysfunction, cirrhotic cardiomyopathy, thyrotoxicosis, neurological, renal diseases, pregnancy, preoperative circulatory or ventilatory support, or re-do or emergency surgery were excluded. IntroductionIntroduction Cardiac Surgery & Cirrhosis History of UF Principle of UF Types of UF MUFMUFCUFCUFDUFDUF UF & Cirrhosis Our Study

71. The CUF group (n = 30) conventional ultrafiltration was used. CUF volume of 20 – 30 mL kg -1 was removed during CPB and it was stopped if the venous reservoir level fell low. IntroductionIntroduction Cardiac Surgery & Cirrhosis History of UF Principle of UF Types of UF MUFMUFCUFCUFDUFDUF UF & Cirrhosis Our Study

72. The CUF+MUF group (n = 30) conventional ultrafiltration was performed during CPB and MUF was performed after termination of CPB. MUF volume of 20 – 30 mL kg -1 was removed after CPB. IntroductionIntroduction Cardiac Surgery & Cirrhosis History of UF Principle of UF Types of UF MUFMUFCUFCUFDUFDUF UF & Cirrhosis Our Study

73. The target volume for UF removal was: (priming solution + any additional fluid during CPB) – (CUF fluid + UOP during bypass). IntroductionIntroduction Cardiac Surgery & Cirrhosis History of UF Principle of UF Types of UF MUFMUFCUFCUFDUFDUF UF & Cirrhosis Our Study

74. Perioperative LFTs, haematocrit, platelet count, doses of inotropic support, the time to extubation, the durations of the postoperative ventilation and ICU and hospital stays were recorded. IntroductionIntroduction Cardiac Surgery & Cirrhosis History of UF Principle of UF Types of UF MUFMUFCUFCUFDUFDUF UF & Cirrhosis Our Study

77. 71.3% mortality 52.6% mortality 19.6% mortality 6.0% mortality 1.9% mortality

78. Un-paired student t- test and Mann-Whitney U test were used as appropriate with repeated measure analysis of variance. IntroductionIntroduction Cardiac Surgery & Cirrhosis History of UF Principle of UF Types of UF MUFMUFCUFCUFDUFDUF UF & Cirrhosis Our Study

79. The main causes of hepatic cirrhosis were hepatitis C in 47 (78.3%), hepatitis B in 10 (16.7%), and undetermined conditions in 3 (5%). IntroductionIntroduction Cardiac Surgery & Cirrhosis History of UF Principle of UF Types of UF MUFMUFCUFCUFDUFDUF UF & Cirrhosis Our Study

80. IntroductionIntroduction Cardiac Surgery & Cirrhosis History of UF Principle of UF Types of UF MUFMUFCUFCUFDUFDUF UF & Cirrhosis Our Study CUFCUF + MUF (n=30) Age (years)27.3±7.828.4±8.3 Sex (M/F)21 / 30 (70%)18 / 30 (60%) Weight(Kg)67.5±11.673.4±9.2 Height(cm)166.5±3.7167.2±4.3 Child-Pugh Grade A14 (46.7%)11 (36.7%) Grade B13 (43.3%)15 (50%) Grade C3 (10%)4 (13.3%) MELD score20 [21]19 [23] EuroSCORE3.7 [6]3.2 [6] Height(cm)166.5±3.7167.2±4.3 Types of surgery Aortic valve replacement9 (30%)12 (40%) Mitral valve replacement14 (46.7%)10 (33.4%) Double valve replacement5 (16.6%)4 (13.3%) Triple valve Surgery2 (6.7%)4 (13.3%) CPB time (min)102.4±20.5110.1±27.3 Aortic clamping time (min)57.5±25.160.2±28.8 Table (1): Patients data.

81. IntroductionIntroduction Cardiac Surgery & Cirrhosis History of UF Principle of UF Types of UF MUFMUFCUFCUFDUFDUF UF & Cirrhosis Our Study CUFCUF + MUFP value (n=30) NTG dose (µg kg -1 min -1 )1.7±0.671.9±2.1 0.770 Epinephrine dose (ng.kg -1.min -1 )97±40.01102±27.3 0.814 Volume of CUF (mL)1687.5±278.41908.4±202.4 0.671 Volume of MUF (mL)1541.4±239.23 Time to extubation (hrs)10.3±5.616.3±2.61 0.006 Ventilation time (hrs)8.6±6.215.5±2.41 0.007 Perioperative bleeding (mL)1064±337.13808±137.42 0.02 PRBCs transfusion (n)4.4±1.322.8±0.82 0.004 ICU length of stay (days)7.6±3.914.1±1.61 0.02 Hospital length of stay (days)18.7±10.610.4±2.11 0.03 Mortality (n(%))2 (6.7%)1 (3.3%) 0.481 Table (2): Clinical data. Data are mean ± SD and number (%). * P< 0.05 significant compared with CUF group.

82. IntroductionIntroduction Cardiac Surgery & Cirrhosis History of UF Principle of UF Types of UF MUFMUFCUFCUFDUFDUF UF & Cirrhosis Our Study Figure (1): Haematocrit (%) changes. Data are mean ± SD. * P< 0.05 significant compared with CUF group.

83. IntroductionIntroduction Cardiac Surgery & Cirrhosis History of UF Principle of UF Types of UF MUFMUFCUFCUFDUFDUF UF & Cirrhosis Our Study Data are mean ± SD. * P< 0.05 significant compared with CUF group. Figure (2): Platelets (10 4 /µmL) changes.

84. IntroductionIntroduction Cardiac Surgery & Cirrhosis History of UF Principle of UF Types of UF MUFMUFCUFCUFDUFDUF UF & Cirrhosis Our Study GroupPostoperative Baseline12 hDay 1Day 3Day 7 AST (IU/L) CUF 47.2±22.63101.1±27.83137.7±51.42124.9±26.5488.9±27.94 CUF + MUF 39.9±19.1750.5±25.64 *84.1±29.14 *90.7±14.74 *53.6±18.92 * ALT (IU/L) CUF 46.7±22.43112.4±31.23152.1±31.44134.8±31.2398.9±37.81 CUF + MUF 38.5±18.9355.7±21.54 *82.1±14.91 *96.6±13.64 *59.2±16.50 * ALP (IU/L) CUF 154.9±101.6211.1±114.62255.8±120.63283.2±122.60222.5±128.90 CUF + MUF 161.3±79.30176.4±74.42*186.4±74.42*166.1±60.53*127.7±54.80 * GGTP (IU/L) CUF 112.9±67.13196.0±80.34224.0±85.41208.4±80.24189.1±78.61 CUF + MUF 115.8±65.94136.0±61.80*176.6±56.40*139.8±49.21*121.7±42.84 * Table (3): Liver enzymes changes. Data are mean ± SD. * P< 0.05 significant compared with CUF group.

85. IntroductionIntroduction Cardiac Surgery & Cirrhosis History of UF Principle of UF Types of UF MUFMUFCUFCUFDUFDUF UF & Cirrhosis Our Study Figure (3): Bilirubin (mg dL -1 ) changes. Data are mean ± SD. * P< 0.05 significant compared with CUF group.

86. IntroductionIntroduction Cardiac Surgery & Cirrhosis History of UF Principle of UF Types of UF MUFMUFCUFCUFDUFDUF UF & Cirrhosis Our Study Figure (4): Albumin (gm dL -1 ) changes. Data are mean ± SD. * P< 0.05 significant compared with CUF group.

87. IntroductionIntroduction Cardiac Surgery & Cirrhosis History of UF Principle of UF Types of UF MUFMUFCUFCUFDUFDUF UF & Cirrhosis Our Study Figure (5): Prothrombin time (sec) changes. Data are mean ± SD. * P< 0.05 significant compared with CUF group.

88. IntroductionIntroduction Cardiac Surgery & Cirrhosis History of UF Principle of UF Types of UF MUFMUFCUFCUFDUFDUF UF & Cirrhosis Our Study CUFCUF + MUF P value (n=30) Coagulopathy4 (13.3%)2 (6.7%)0.770 Pulmonary1 (3.3%)0 (0%)0.814 Renal1 (3.3%)0 (0%)0.556 New onset or worsening of ascites5 (16.7%)3 (10%)0.477 Encephalopathy3 (10%)1 (3.3%)0.442 Wound dehiscence or infection1 (3.3%)2 (6.7%)0.544 Mortality2 (6.7%)1 (3.3%)0.544 Table (4): Perioperative Complications. Data are number (%). * P< 0.05 significant compared with CUF group.

90. IntroductionIntroduction Cardiac Surgery & Cirrhosis History of UF Principle of UF Types of UF MUFMUFCUFCUFDUFDUF UF & Cirrhosis Our Study

91. The studied population is quite different from other institutions with the extreme youth of the studied patients (30 years). IntroductionIntroduction Cardiac Surgery & Cirrhosis History of UF Principle of UF Types of UF MUFMUFCUFCUFDUFDUF UF & Cirrhosis Our Study

92. The small BMI (24-26 kg/m 2 ) of the studied population would have a significant hemodilutional effect from CPB & the use of CUF+MUF might have a greater effect than with a larger size population. IntroductionIntroduction Cardiac Surgery & Cirrhosis History of UF Principle of UF Types of UF MUFMUFCUFCUFDUFDUF UF & Cirrhosis Our Study

93. We concluded that CUF + MUF reduced postoperative bleeding and transfusions, improved liver function and shortened the hospital stay in cirrhotic patients after valvular heart surgery. IntroductionIntroduction Cardiac Surgery & Cirrhosis History of UF Principle of UF Types of UF MUFMUFCUFCUFDUFDUF UF & Cirrhosis Our Study

94. IntroductionIntroduction Cardiac Surgery & Cirrhosis History of UF Principle of UF Types of UF MUFMUFCUFCUFDUFDUF UF & Cirrhosis Our Study