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Cited by 6Cardiac and Coronary Surgery TechniquesHemodynamic Monitoring and TherapyBlood transfusion and management

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Microcirculation dysfunction and cardioprotection in cardiac surgery with cardiopulmonary bypass: mechanisms, monitoring, and therapeutic strategies

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Zheng, Clark, Muir, Kelsey, Kaushik, Himanshu, Yalamanchili, Keertana, Zahiri, Keyana, Yeo, Adam, Kim, Justin, Sellke, Frank W.·2026·Frontiers in Cardiovascular Medicine
DOI 10.3389/fcvm.2026.1843167PMC PMC13278890
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Abstract

Cardiopulmonary bypass (CPB) is a crucial component of cardiac surgery, yet postoperative organ dysfunction remains common despite apparently adequate systemic hemodynamics. This mismatch underscores the importance of the microcirculation, where oxygen delivery and extraction ultimately occur. Increasing evidence suggests that CPB disrupts capillary perfusion through endothelial dysfunction, glycocalyx shedding, inflammation, oxidative stress, hemodilution, functional shunting, and microthromboemboli, thereby causing tissue hypoxia despite normal macro-hemodynamic stability. This review summarizes the physiology of microcirculation and examines the mechanisms by which CPB impairs microvascular function. We also review current tools for microcirculatory assessment, including orthogonal polarization spectral, sidestream dark field, and incident dark field imaging, near-infrared spectroscopy, and circulating biomarkers of endothelial and glycocalyx injury. Although these approaches have improved mechanistic insight, their clinical use remains limited by technical challenges and the lack of standardized endpoints. We further evaluate cardioprotective strategies aimed at preserving microcirculatory function during CPB. These include perfusion and mechanical approaches, ischemic preconditioning, glycocalyx-preserving therapies, and various pharmacologic interventions such as volatile anesthetics, nitric oxide, statins, antioxidants, and antithrombotic agents. Across these domains, preclinical studies often support biologic plausibility, whereas clinical evidence remains heterogeneous and inconclusive and frequently relies on indirect evidence of organ dysfunction rather than direct measures of microvascular perfusion. Important gaps remain in translating findings from experimental models to patients, and greater integration of bedside imaging and biomarkers with biophysiological principles may help establish microcirculation as both a mechanistic endpoint and a therapeutic target in cardiac surgery.

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References 144 · Cited by 6

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Metadata

Authors
Zheng, C., Muir, K., Kaushik, H., Yalamanchili, K., Zahiri, K., Yeo, A., Kim, J., & Sellke, F. W.
Affiliations
  • Brown University (US)
  • Rhode Island Hospital (US)
Corresponding author
Sellke, Frank W.
ORCID
Venue
Frontiers in Cardiovascular Medicine
Publisher
Frontiers Media SA
Published
2026-06-05
Volume
13
Pages
1843167-1843167
ISSN
2297-055X (ISSN-L)
DOI
10.3389/fcvm.2026.1843167
PMC
PMC13278890
OpenAlex
W7163643384
Cited by
6
References
144
Citations by year
2026: 6
FWCI
8.73
Type
journal article
Language
en
Open access
Licence
Locations
  • Frontiers in Cardiovascular Medicine (publishedVersion, cc-by)
  • PubMed (publishedVersion)
  • PubMed Central (publishedVersion, cc-by)
  • DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
Topics
  • Health Sciences › Medicine › Surgery › Cardiac and Coronary Surgery Techniques
  • Health Sciences › Medicine › Surgery › Hemodynamic Monitoring and Therapy
  • Health Sciences › Medicine › Hematology › Blood transfusion and management
Keywords
cardiopulmonary bypass, microvascular dysfunction, cardioprotection, endothelial dysfunction, glycocalyx shedding, microcirculatory monitoring, orthogonal polarization spectral imaging, sidestream dark field imaging, near-infrared spectroscopy, endothelial markers, ischemic preconditioning, volatile anesthetics, nitric oxide, statins, antioxidants, antithrombotic agents, postoperative organ dysfunction

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