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PubMed1989

Beta 2-microglobulin kinetics in maintenance hemodialysis: a comparison of conventional and high-flux dialyzers and the effects of dialyzer reuse.

beta 2-Microglobulin (beta 2M) forms synovial and bony amyloid deposits in long-term hemodialysis patients. To define the kinetics of beta 2M during hemodialysis and the effects of dialyzer reprocessing, we measured serum beta 2M, plasma C3a, and neutrophil counts immediately predialysis; 15, 90, and 180 minutes after beginning dialysis; and 15 minutes postdialysis in ten chronic hemodialysis patients. The studies were performed during first and third uses of cuprammonium rayon and polysulfone dialyzers processed by rinsing with water, then bleach, in an automated system (Seratronics DRS 4) and then packed in 1.5% formaldehyde. Mean serum beta 2M (corrected for ultrafiltration) decreased by 16.6% +/- 18.1% with new cuprammonium dialyzers and 57.1% +/- 12.8% with new polysulfone dialyzers. Dialyzer reprocessing had no significant effect on this decline. Predialysis serum beta 2M decreased by 30.4% +/- 15.5% 1 month after switching from cuprammonium to polysulfone dialyzers; these levels remained stable after 3 months of dialysis with polysulfone. Complement activation and neutropenia during dialysis were significantly more marked with cuprammonium, but were not affected by reprocessing of either dialyzer. In vitro adsorption of 124I-beta 2M to polysulfone fibers was greater than to cuprammonium; adsorption was not influenced by dialyzer reprocessing.

Aged↗

PubMed1999

Comparative study of biocompatibility between the open circuit and closed circuit in cardiopulmonary bypass.

The theoretical benefit of a centrifugal pump or heparin coating demonstrated through in vitro or in vivo studies is not recognizable in cardiopulmonary bypass (CPB) during chemical open heart surgery. The objective of this study was to investigate the influence of the interface of air and blood in current CPB with an open circuit system and its relative significance in relationship to the heparin dose and heparin coating. Using the same oxygenator and circuit, an open circuit and closed circuit CPB with the same priming volume were prepared for a 4 h perfusion experiment using diluted and heparinized (3.6 U/ml) fresh human blood. In these experiments, both heparin-coated and noncoated circuits were examined. Blood was sampled before and 2, 30, 60, 120, and 240 min after the start of perfusion, and the platelet and white blood cell counts and beta-thromboglobulin (beta-TG) and C3a levels were measured. The amount of adsorbed protein in the hollow fibers was also measured after retrieval. Although the results demonstrated significantly better biocompatibility of the heparin-coated circuit than the noncoated circuit, the difference between the open and closed circuits was unexpectedly small and insignificant with either the heparin-coated circuit or noncoated circuit. In contrast, the C3a level was higher in the closed circuit than the open circuit. However, the amount of adsorbed protein was markedly lower in the closed circuit (0.7 microgram/cm2) than in the open circuit (11.1 micrograms/cm2). An immunoblot of the adsorbed protein showed a higher density of fibrinogen bands and conversion to fibrin in the open circuit. We speculate that the lower blood C3a level in the open circuit suggests that C3a was taken in by the adsorbed protein. In conclusion, analysis of the adsorbed protein indicates the lower biocompatibility of the open circuit. Similar experiments with less heparin use and more severe conditions will be necessary to elucidate the essential benefit of making a CPB closed circuit.

Adsorption↗

PubMed2003

Regional oxygenation and systemic inflammatory response during cardiopulmonary bypass: influence of temperature and blood flow variations.

OBJECTIVE: To evaluate the role of target temperature (28 degrees or 34 degrees C) in cardiac surgery on regional oxygenation during hypothermia and rewarming and systemic inflammatory response. DESIGN: Prospective, controlled, and randomized clinical study. SETTING: University hospital. PARTICIPANTS: Elderly patients (mean age 70 +/- 2 years) with acquired heart disease with an anticipated bypass time exceeding 120 minutes (n = 30). INTERVENTIONS: The patients were cooled to either 28 degrees C (n = 15) or 34 degrees C (n = 15). At hypothermia, bypass blood flow was reduced twice from full flow (2.4 L/min/m(2) body surface area [BSA]) to 2.0 L/min/m(2). MEASUREMENTS AND MAIN RESULTS: Hepatic and jugular venous oxygen tension and saturation were higher at 28 degrees C than at 34 degrees C. In comparison with the preoperative values, at 28 degrees C hepatic venous values were higher; whereas at 34 degrees C, they were lower. The reduction of pump blood flow during hypothermia, from 2.4 to 2.0 L/min/m(2)was accompanied by reductions of central, jugular, and hepatic oxygenation at both target temperatures. During rewarming, central and regional venous oxygenation decreased irrespective of the preceding temperature. The decrease was most pronounced in hepatic venous blood, with the lowest individual values <10%. Serum concentrations of C3a and IL-6 increased during hypothermia and increased further during rewarming irrespective of the preceding temperature. CONCLUSION: During cardiopulmonary bypass, hypothermia at 28 degrees C increases regional and central venous oxygenation better than at 34 degrees C. In contrast, venous oxygenation decreases during rewarming irrespective of the preceding temperature. No significant difference in the systemic inflammatory response associated with target temperature was detected.

Aged↗

PubMed2000

Clinical investigation of the role of membrane structure on blood contact and solute transport characteristics of a cellulose membrane.

Regenerated cellulose membranes contain cellulose chains with crystalline and amorphous regions in the direction of extrusion. A study was undertaken to investigate if reduced contact surface arising from alteration of pore size alters biocompatibility (complement activation (C3a and C5a) and neutropenia) and solute transport. The average pore size for the membrane studied (RC HP400A) was 7.23 compared to 2.76 nm for the standard membrane (Cuprophan). C3a levels rose to 6861+/-1595 compared to 2723+/-1228 ng/ml for Cuprophan at 15 min after initial blood contact (P < 0.0001). C5a levels also rose to 30.1+/-11.9 compared to 21.3+/-6.6 ng/ml for Cuprophan (P = 0.18). Both fractions gradually returned to baseline levels thereafter. Circulating white cell count fell rapidly over the same time period to 39+/-17% of the baseline value by 15 min and was similar to Cuprophan (27.5+/-11.2%) (P = 0.25). A small (< 10%) change in platelet numbers was noted for both membranes. Removal of urea (60 Da) was independent of pore size; however, the RC HP400A removed r2 microglobulin (11818 Da). These findings indicate that pore distribution fails to influence material-induced complement activation but influences large solute transport.

Biocompatible Materials↗

PubMed1991

Differential effects of human anaphylatoxin C3a on glucose output and flow in rat liver during orthograde and retrograde perfusion: the periportal scavenger cell hypothesis.

1) During orthograde perfusion of rat liver human anaphylatoxin C3a caused an increase in glucose and lactate output and reduction of flow. These effects could be enhanced nearly twofold by co-infusion of the carboxypeptidase inhibitor MERGETPA, which reduced inactivation of C3a to C3adesArg. 2) During retrograde perfusion C3a caused a two- to threefold larger increase in glucose and lactate output and reduction of flow than in orthograde perfusions. These actions tended to be slightly enhanced by MERGETPA. 3) The elimination of C3a plus C3adesArg immunoreactivity during a single liver passage was around 67%, irrespective of the perfusion direction and the presence of the carboxypeptidase inhibitor MERGETPA; however, less C3adesArg and more intact C3a appeared in the perfusate in the presence of MERGETPA in orthograde and retrogade perfusions. It is concluded that rat liver inactivated human anaphylatoxin C3a by conversion to C3adesArg and moreover eliminated it by an additional process. The inactivation to C3adesArg seemed to be located predominantly in the proximal periportal region of the liver sinusoid, since C3a was less effective in orthograde perfusions, when C3a first passed the proximal periportal region before reaching the predominant mass of parenchyma as its site of action, than in retrograde perfusions, when it first passed the perivenous area. These data may be evidence for a periportal scavenger mechanism, by which the liver protects itself from systemically released mediators of inflammation that interfere with the local regulation of liver metabolism and hemodynamics.

3-Mercaptopropionic Acid↗

PubMed1985

Cell electrophoretic investigations of peripheral blood lymphocytes during hemodialysis with different membranes.

Determining the relative percentage of LMC in PBL histograms of RDT patients during hemodialysis we observed a temporary decrease of the LMC proportion during the first 15 minutes of hemodialysis using Cuprophan in contrast to AN 69S and MC Cellulose. These results correlate with the increase of C3a plasma concentration and the decrease of total count of granulocytes. In all investigated RDT patients higher proportions of LMC could be found in relation to healthy donors already before dialysis treatment. Our study therefore seems to indicate that the application of cell electrophoresis is a useful method for the characterization of lymphocytes during extracorporeal circulation as an additional parameter of blood compatibility.

Acrylic Resins↗

PubMed1982

Proteolytic activity of selected clinical isolates of Serratia marcescens against human serum proteins.

Six representative clinical isolates of Serratia marcescens were examined for proteolytic activity against various proteins of normal fresh human serum. The extent of proteolytic activity was screened with micro-scale immunoelectrophoresis and quantitatively documented with the aid of Laurell's rocket electroimmuno assay. The 6 S. marcescens strains regularly altered, albeit to varying degrees, complement components C3a, C3c, C4, C5, and C9, and haptoglobin. Apolipoprotein and immunoglobulin A, the latter derived from human colostrum, were attacked by 5 and 4 isolates, respectively. Two isolates altered alpha 1-antitrypsin, whereas only one isolate interacted with alpha 2-macroglobulin and transferrin. In contrast, alpha 2-HS-glycoprotein, alpha 1-antichymotrypsin, and serum IgA, IgG, and IgM immunoglobulins were not affected by the test strains.

Alpha-Globulins↗

PubMed1990

Chemical modification of cellulosic membranes and their blood compatibility.

Blood compatibility is determined by interactions at the blood-material interface that depend on the material surface chemical structure. Through selective modifications of the chemically reactive hydroxyl groups of cellulose, the aim was to improve the biocompatibility of cellulose membranes. The number of potentially reactive hydroxyl groups on the cellulose membrane surface were reduced through isocyanate cross-links or through the introduction of hydrophilic, hydrophobic, or ionic functionalities by graft copolymerization. To assess blood compatibility, levels of C3a desArg were determined in plasma after membrane contact. Using the electrophoretic mobility test, the release of cytokines were measured after in-vitro incubation of mononuclear cells with membranes. Adsorption of 131J-human fibrinogen was additionally investigated. With respect to the biocompatibility parameters selected, the modified cellulose membranes show improved in-vitro blood compatibility in comparison to unmodified cellulose membranes.

Biocompatible Materials↗

PubMed1992

Interleukin-8 in sepsis: relation to shock and inflammatory mediators.

Because of its neutrophil-activating properties, interleukin-8 (IL-8) may play an important role in the pathophysiology of sepsis. We measured circulating IL-8 levels in 47 patients with clinical sepsis. Levels on admission were elevated in 42 of the 47 patients (89%) and were comparable in patients with gram-positive or gram-negative infections. Patients with shock had significantly higher IL-8 levels than normotensive patients (P = 0.0014, Wilcoxon-Mann-Whitney test), whereas no differences in IL-8 levels were found between patients with or without adult respiratory distress syndrome. Patients who died had higher IL-8 levels on admission than the patients who survived. The largest differences in IL-8 levels between survivors and nonsurvivors was found when only patients with positive cultures were considered (P = 0.0342). IL-8 levels appeared to correlate significantly with lactate levels and inversely with leukocyte and platelet numbers and mean arterial pressure. In addition, the IL-8 level in the sepsis patients was found to correlate significantly with levels of IL-6, elastase-alpha 1-antitrypsin, and C3a. Serial observations revealed that in most patients IL-8 levels decreased, irrespective of the outcome. Thus, our results demonstrate that IL-8 levels are increased in most patients with sepsis and correlate with some important clinical, biochemical, and inflammatory parameters. These findings suggest a role for IL-8 in the pathophysiology of sepsis.

Adolescent↗

PubMed1998

The influence of oral lipid loads on acylation stimulating protein (ASP) in healthy volunteers.

OBJECTIVES: To examine the hypothesis that a sustained rise in plasma acylation stimulating protein (ASP, C3a desarg) accompanies the elevation in triacylglycerol that follows the ingestion of an oral fat load. DESIGN: Following an overnight fast, blood samples were obtained from healthy volunteers while fasting and 15 min, 1, 2, 4, 6 and 8 h following ingestion of: (i) a liquid meal, rich in dairy fat (eight subjects) and (ii) a semi-liquid meal, with higher total fat content and rich in polyunsaturated fat (six subjects). SUBJECTS AND METHODS: Four male and four female volunteers (age range: 22-51 y; body mass index (BMI): 17.9-26.9 kg/m2) received the first meal. Six subjects (age range: 32-60 y; BMI: 18.0-28.4 kg/m2), including three from the first study, received the second meal using the same protocol. ASP and C5a were measured by radioimmunoassay (RIA) and the complement proteins C3, factor B and C5 by radial immunodiffusion or nephelometry. Tumour necrosis factor (TNF)-alpha was measured by enhanced ELISA, and plasma cholesterol and triacylglycerol by an automated enzymatic method. The presence of chylomicrons was assessed in post-prandial plasma samples taken after the second meal. RESULTS: There was no significant change in mean ASP concentration in either group at any time point, following ingestion of either meal. However, there was a significant positive linear trend in ASP following the second fat challenge (ANOVA; P < 0.05). There was also no change in complement proteins, plasma cholesterol or TNF-alpha. Plasma triacylglycerol rose significantly after the first and second meals (P < 0.05 and P < 0.001 at 2 h post-prandially); the mean maximum rise above the fasting level was 58 +/- 41% and 89 +/- 38% respectively (mean +/- s.d.). Chylomicrons were detected in samples taken from each subject after the second meal. Analysis of individual ASP data showed a sustained rise in one subject after the first meal and two subjects after the second meal. Substantial variation in ASP concentration was observed in samples taken in the first 2 h post-prandially. CONCLUSION: There was no significant change in ASP nor other complement proteins for either group of subjects following ingestion of the lipid loads. Individual data showed substantial variation in post-prandial ASP, but multiple plasma sampling did not define the basis for this variation.

Adult↗

PubMed2004

Blood-air interface during cardiopulmonary bypass.

The aim of this study was to compare the systemic blood activation with open and closed perfusion management during cardiopulmonary bypass. In 30 patients undergoing coronary artery bypass grafting, we prospectively studied systemic blood activation, blood loss and the need for donor blood. In 15 patients we used an open venous reservoir consisting of a hard shell venous reservoir with an integrated cardiotomy filter. In another 15 patients we used a totally closed venous reservoir consisting of a collapsible venous reservoir, no coronary suction, modified vent and cell saver. Venous blood samples were collected pre, post and 24 hours postoperatively. Sex, age and perfusion times were identical in both groups. There were no statistically significant differences in concentrations of FXIIa and C3a, amount of blood loss and need for donor blood. Interleukin-6 and Elastase levels showed trends toward a lesser inflammatory reaction in closed venous reservoir patients. Modification of perfusion management with optimized air management does not seem to be an effective strategy in reducing the inflammatory response and influencing the coagulation system in this small cohort.

Adult↗

PubMed2006

Inflammatory response and platelet activation after off-pump coronary artery bypass surgery.

BACKGROUND: Cardiac surgery induces a systemic inflammatory activation and alterations in the hemostatic cascade. The responses contribute to postoperative complications but may also have protective effects. We investigated the relationship between inflammation, hemostasis and bleeding after off-pump coronary artery bypass surgery (OPCAB). METHODS: Ten OPCAB patients were included in a prospective descriptive study. Selected markers of inflammation (IL-6, IL-8, PMN-elastase, C3a, and SC5b-9), and hemostasis (platelet count, ss-thromboglobulin, anti-thrombin, D-dimer and fibrinogen) were measured before and immediately after surgery. Postoperative bleeding was registered. RESULTS: Inflammatory variables did not alter significantly during surgery while ss-thromboglobulin concentrations increased and anti-thrombin and fibrinogen decreased. There were significant postoperative correlations between PMN-elastase and ss-thromboglobulin (r=0.82, p=0.004), between PMN-elastase and fibrinogen (r=0.69, p=0.03) and between C3a and ss-thromboglobulin (r=0.71, p=0.02). In addition, there were significant inverse correlations between postoperative bleeding and pre- and postoperative fibrinogen levels (r=-0.76, p=0.011 and r=-0.84, p=0.002 respectively), between bleeding and postoperative ss-thromboglobulin levels (r=-0.66, p=0.04) and between bleeding and postoperative PMN-elastase (r=-0.75, p=0.01). CONCLUSIONS: The results give further evidence for an association between the inflammatory response and hemostasis after cardiac surgery.

Aged↗

PubMed1987

Ex vivo and in vivo protein A perfusion: background, basic investigations, and first clinical experiences.

During the past several years clinical protein A perfusion has attracted much attention because it allows to selectively remove IgG subclasses 1, 2, 4 and probably IgG-containing immune complexes, and has a tumoricidal effect in experimental animals and in some cancer patients. Due to several drawbacks, this therapy is not yet generally accepted. Our first experience with laboratory and clinical protein A perfusions confirms several limitations of this new apheresis therapy. Plasma IgG extraction in the ex vivo system under investigation and during clinical application of protein A perfusion reached a 10:1 ratio of grams IgG removed per gram solid-phase protein A only in 2 of 5 runs. Nevertheless, the absolute amount of IgG removed was very low in all runs due to the restricted protein A load (maximum 200 mg) per column. Removal capacity can be increased by a two-column switch-over system with subsequent perfusion and elution. Furthermore, the side effects observed in both in vivo treatments exceeded by far those of other extracorporeal therapies and had not been observed in more than 1,200 unselective plasma exchanges or in 50 cascade filtrations in our center. C3a generation in protein A perfusion is, however, comparable to cascade filtration, but exceeds that of unselective plasma exchange and is lower than in hemodialysis. Consequently, side effects in protein A perfusion cannot be correlated with the total amount of anaphylatoxin generated but may be due to a leakage of protein A or contaminants. Clinical application of protein A perfusion needs a more detailed elaboration in respect to biocompatibility, removal capacity, and the significance of the induced biological effects.

Adsorption↗

PubMed1997

LDL hemoperfusion--a new procedure for LDL apheresis: biocompatibility results from a first pilot study in hypercholesterolemic atherosclerosis patients.

Current lipid apheresis techniques can remove atherogenic lipoproteins only from plasma. The initial mandatory separation of plasma and blood cells renders the extracorporeal circuit complex. We recently described the first clinical application of a new lipid adsorber that adsorbs low-density lipoprotein (LDL) and lipoprotein (a) (Lp[a]) directly from whole blood. In continuation of our work, this paper describes the clinical biocompatibility of this new LDL hemoperfusion system. In a 2 center phase II clinical trial, 12 hypercholesterolemic patients suffering from overt coronary or peripheral artery disease were treated once with LDL hemoperfusion. The new LDL adsorber (DALI, Fresenius, St. Wendel, Germany) contained 480 ml of polyacrylate coated polyacrylamide gel. The anticoagulation protocol consisted of an initial heparin bolus followed by an acid citrate dextrose-A (ACD-A) infusion during the treatment. One patient blood volume was treated per session. All sessions were clinically uneventful. No signs of hemolysis or extracorporeal clot formation could be detected, and cell counts remained virtually constant. In a subgroup of patients (n = 4-6), further biocompatibility parameters were studied. Activation of leukocytes (elastase release), thrombocytes (beta-thromboglobulin [beta-TG] extrusion), and monocytes (interleukin (IL)-1beta and IL-6) were minimal. Complement activation (C3a and C5a generation) was negligible. The chosen anticoagulation protocol was both safe (constant ionized calcium levels) and effective (low thrombin-antithrombin formation). In summary, within the scope of a first pilot study, this new LDL hemoperfusion procedure combined the features of excellent clinical tolerance, good biocompatibility, and ease of handling. Phase III clinical trials will have to show whether these encouraging preliminary results can be corroborated in a larger patient population.

Acrylic Resins↗

PubMed1992

Enhanced biopotency of synthetic C3a analogues by membrane binding. A fluorescence anisotropy decay study.

The biological activity of oligopeptide analogues of C3a is markedly increased by N-terminal attachment of a hydrophobic group as, for instance, 9-fluorenylmethoxycarbonyl (Fmoc), either direct or via a flexible 6-aminohexanoyl (Ahx) spacer. This study presents evidence from fluorescence anisotropy decay measurements that the hydrophobic appendix mediates non-specific binding of the synthetic peptide analogues to phospholipid vesicles. According to quantitative considerations no alternative or additional rate-enhancing mechanisms other than surface diffusion are required to account for the gain in biopotency.

Amino Acid Sequence↗

PubMed1992

Synthetic peptides as antagonists of the anaphylatoxin C3a.

Peptide compounds resembling the receptor-binding C-terminal domain of the anaphylatoxic peptide C3a were synthesized to examine two kinds of C3a antagonism: (a) specific desensitization of C3a-sensitive cells and (b) competitive binding to the C3a receptor. We used guinea-pig platelets, which express a C3a receptor and specifically release ATP upon stimulation, to evaluate the actions of the C3a analogues. The ATP liberation can be inhibited by pretreatment (i.e. desensitization) of the guinea-pig platelets with substimulatory concentrations of C3a or its analogues. Compared to C3a, several peptides were found with at least a tenfold greater difference between the required concentrations for C3a-specific half-maximal desensitization (DD50) and half-maximal platelet activation (ED50). The most potent compounds were YAAALKLAR and Fmoc-EAALKLAR (Fmoc: 9-fluorenylmethoxycarbonyl) with an ED50/DD50 of 140 +/- 28 and 80 +/- 17, respectively (mean +/- standard deviation). The ED50/DD50 of human C3a was found to be only 6 +/- 2. Some C3a derivatives were also tested in competitive binding studies for their ability to compete with C3a for receptor sites on guinea-pig platelets. Three of them were considered partial antagonists [YRRGRCGGLCLAR, YRRGRXCGGLCLAR and YRRGRXCGALCLAR (X = 6-aminohexanoyl)] because their Ki were smaller than their ED50 (Ki/ED50 = 0.6 +/- 0.3, 0.5 +/- 0.1 and 0.4 +/- 0.2, respectively). Interestingly, the last two compounds also had ED50/DD50 values greater than 60. Common to all three peptides are N-terminal arginine-rich sequences and intramolecular disulfide bridges which introduce conformational constraint.

Amino Acid Sequence↗

PubMed1996

Biocompatibility of sulphonated polyurethane surfaces.

Surfaces of medical devices made of polymeric materials may promote thrombosis and inflammation. Therefore, in an attempt to produce surfaces which might diminish biomaterial-mediated thrombosis and inflammation, surface derivatization with 2-acrylamido-2-methylpropanesulphonic acid (AMPS) was carried out. The derivatization procedure generates free radicals which initiate the copolymerization of AMPS monomers directly to a polyurethane surface. In an in vitro blood loop study using non-anticoagulated human blood, the resulting AMPS-derivatized material completely abrogates the generation of fibrinopeptide A, decreases the production of beta-thromboglobulin and C3a, and decreases the adherence of platelets. The derivatized material also attracts fewer adherent neutrophils when implanted in mice. However, AMPS derivatization unexpectedly increases the recruitment of macrophages to implanted material and promotes the formation of adherent sleeve thrombi on central venous catheters indwelling in non-anticoagulated canine femoral veins. Thus, AMPS derivatization has highly variable effects on inflammatory and thrombotic systems. Further investigation is clearly required to determine the mechanisms underlying both desired and adverse effects.

Acrylamides↗

PubMed2002

Effect of off-pump coronary surgery with right ventricular assist device on organ function and inflammatory response: a randomized controlled trial.

BACKGROUND: Right ventricular assist devices (RVADs) have been proposed to improve exposure of the coronary arteries in off-pump surgery. In this study we investigated the impact of the A-Med RVAD on inflammatory response and organ function in patients undergoing coronary artery bypass grafting. METHODS: Sixty patients were prospectively randomized to conventional surgery with cardiopulmonary bypass (CPB) and cardioplegic arrest, beating heart surgery (off-pump), or beating heart surgery with the RVAD. Serial blood samples were collected postoperatively, for analysis of inflammatory markers, troponin I, protein S100, and free hemoglobin. Renal tubular function was assessed by measuring urine N-acetyl-glucosaminidase activity. RESULTS: No hospital deaths or major postoperative complications occurred in the study population. Interleukin-6, interleukin-8, C3a, and troponin I levels after surgery were significantly higher in the CPB group compared with the off-pump and RVAD groups. Free hemoglobin levels immediately after the operation, peak and total S100 levels, and N-acetyl-glucosaminidase activity were also significantly higher in the CPB group. CONCLUSIONS: Off-pump coronary revascularization, with or without RVAD, reduces inflammatory response, myocardial, neurologic, and renal injury, and decreases hemolysis when compared with conventional surgery with CPB and cardioplegic arrest.

Acetylglucosaminidase↗