2018 SCIENCELINE

Journal of Life Science and Biomedicine

J Life Sci Biomed, 8(2): 37-42, 2018

License: CC BY 4.0

ISSN 2251-9939

Red Blood Cells Morphology Monitoring to

Predict Hyperfunction of Subclavian-Pulmonary

Anastomosis in Patients with Fallot Tetralogy

(MD, PhD, DSc)

Ravshan Aliyevich IBADOV

^, Iskander Muhamedovich BAYBEKOV ^{(MD, PhD, DSc)}, Khakimdjan

Kabuldjanovich ABRALOV ^{(MD, PhD, DSc)}, Nikolay Alekseyevich STRIJKOV, Dano Ikramovna JULAMANOVA,

Sardor Khamdamovich IBRAGIMOV, Rauf Ravshanovich IBADOV

Republican Specialized Center of Surgery named after academician V.Vakhidov. Tashkent, Uzbekistan

Corresponding author’s Email: firebat2004@gmail.com

ABSTRACT

Original Article

PII: S225199391800007-8

Hyperfunction of subcluvian-pulmonary anastomosis in patients with tetralogy of

Fallot (TOF) is known to be a rather common condition in the early post-operative

period. It resulted in development of hypervolemic pulmonary circulation and

edema. Morphometry of peripheral blood cells of 81 TOF post-operative patients

revealed an increase in the number of pathologically shaped red blood cells (PS RBCs)

Rec. 02 Jan. 2018

Acc. 10 Feb. 2018

Pub. 25 Mar. 2018

in 14 of them. Mainly these were the ones with a ridge-like structure on their surface. Keywords

Red Blood Cell,

The hick drop express-technique (TDET) enables to evaluate the correlation of

normal RBCs/ PS RBCs for 10-15 min for the entire procedure. The progressive

deterioration of RBCs morphological features is suggested to be a predictor of the

anastomosis hyperfunction due to changed blood rheology. In addition the

correlation of normal and pathological forms of erythrocytes can be an evaluation

criterion of effectiveness of patient management tactics of cardiologic intensive

care.

Tetralogy of Fallot,

Subclavian-Pulmonary

Anastomosis,

Thick Drop Technique,

Scanning Electronic

Microscopy,

Cardiologic Resuscitation

INTRODUCTION

Tetralogy of Fallot is one of the most common congenital heart disorders across the world. For instance, the

centers for disease control and prevention (CDC) estimate that each year about 1,660 babies in the United States

are born with this pathology [1, 2]. If left untreated, TOF children face additional risks that include paradoxical

emboli leading to stroke, pulmonary embolus, and subacute bacterial endocarditis [3]. In most of these children,

the causes of stroke, along with thromboemboli, have been related to prolonged hypotension, anoxic

polycythemia.

Most TOF infants require surgery and a lot of surgical series have reported excellent short-term clinical

results since the time when the first classic Blalock-Taussig shunt between the subclavian artery and the

pulmonary artery was made. Primary repair of tetralogy of Fallot is known to have low surgical mortality;

however, some patients still experience significant postoperative morbidity [4, 5]. Several attempts have been

To cite this paper: Ibadov R.A., Baybekov I.M., Abralov Kh.K., Strijkov N.A., Julamanova D.I., Khamdamovich I.S., Ravshanovich I.R. 2018. Red Blood

Cells Morphology Monitoring to Predict Hyperfunction of Subclavian-Pulmonary Anastomosis in Patients with Fallot Tetralogy. J. Life Sci. Biomed. 8(2): 37-

42; www.jlsb.science-line.com

made recently to find out predictors of early post-operative complications in TOF patients depending on the

surgery profile [5-10].

One of the main problems of patients, who undergone cardiosurgery, in particular the ones with

congenital heart defects due to impaired blood circulation, is a considerable change in delivery of O₂to tissues

[4, 8]. Unfortunately, adequate attention has not been paid so far to the change in the hemorheology status and

transfusion indicators during post-operative adaptive transformation of hemodynamics as well as to the

methods of their evaluation and monitoring.

The research was focused on evaluating the efficiency of thick-drop technique of scanning electron

microscopy in predicting and monitoring the hyperfunction of subclavian-pulmonary anastomosis in TOF

patients at the early post-operative period.

MATERIAL AND METHODS

Eighty one TOF patients aged 1 - 22 years (mean age 8.7 ± 0.9), including 43 males (53%), 38 females (47%), have

been operated in Republican Specialized Center of Surgery named after academician V.Vakhidov (Tashkent,

Uzbekistan) from 2015 to 2017. In all the cases, the modified subclavian-pulmonary anastomosis (SPA) was

performed. Artificial lung ventilation was carried out to the SPA patients in the standard regimes in early post-

operative period. The relative predictors of intensive care unit (ICU) stay and morbidity were age and weight of

the patients, while the surgery profile suggested the duration of mechanical ventilation. Hyperfunction of the

anastomosis in the early post-operative period developed in 14 patients (17.3%). The median duration of their

mechanical ventilation was 19 hours. The ICU stay ranged from 2 to 14 days. Five of these patients were

randomly selected to form the study group; 8 patients with no SPA hyperfunction were matched by age, sex and

concomitant conditions to compose the comparison group.

To monitor the RBC status, scanning electronic microscopy (SEM) was used since it enables to

differentiate and count precisely normal RBCs having the shape of biconcave discocytes (D) from pathologically

shaped RBCs (PS RBC). Usually, the most frequent PS RBCs found are echinocytes, i.e. RBCs with numerous

processes, stomatocytes, RBCs with a ridge-like structure, and considerably changed PS RBCs or so called

irreversible RBCs.

Most scanning electron microscopes are comparatively easy to operate, with user-friendly interfaces.

Many applications require minimal sample preparation and data acquisition is rapid (less than 5 min/image).

The thick-drop express-technique (TDET) has been elaborated at the NSCS for practical and research purposes.

This technique and relevant software have been developed and patented in Uzbekistan [3, 6]. One of advantages

of the technique is that it preserves the natural condition of RBCs and quickly evaluates the correlation of D/ PS

RBCs (for 10-15 min).

Ethical approval

The review board and ethics committee of Republican Specialized Center of Surgery named after

academician V.Vakhidov approved the study protocol and gave permission for study.

RESULTS AND DISCUSSION

The TDET enabled to monitor the RBCs morphologic condition and evaluate the hemodynamic changes in the

early post-operative period of 14 TOF patients, in particular the development of hypervolemia of the pulmonary

circulation and pulmonary edema. The proportion of the PS RBCs in TOF-SPA patients’ blood significantly

increased. Studying the RBC profile in patients with cyanotic TOF (CTOF) demonstrated that the discocyte

count in the early post-operative period made 40% with 85% reference value. The most part of the rest RBCs

(60%) was presented by the population of pathologicaly-shaped and lysed cells (Figures 1 and 2).

The echinocyte population of adult patients with CTOF was more remarkable; it included 26% of

echinocytes of class I; 8% of the second class echinocytes and 5% of the third class cells. The number of

stomatocytes and hydrocytes proved to be larger than in children with CTOF. It made 3% of stomatocytes of

class I, while the stomatocytes of the second and third classes made 7% and 5%, respectively. The population of

discocytes with a ridge-like structure was distributed as follows: small ridges were found in 1.5-2%, the

medium-sized ones were found in 1-1.5%, and 0.5% of the discocytes had large ridges.

To cite this paper: Ibadov R.A., Baybekov I.M., Abralov Kh.K., Strijkov N.A., Julamanova D.I., Khamdamovich I.S., Ravshanovich I.R. 2018. Red Blood

Cells Morphology Monitoring to Predict Hyperfunction of Subclavian-Pulmonary Anastomosis in Patients with Fallot Tetralogy. J. Life Sci. Biomed. 8(2): 37-

42; www.jlsb.science-line.com

The morphological cell variability reflected differences in the physical condition and compensation-

adaptation mechanism of the patients. It is worth mentioning that children elder than 10 years need to be

monitored more closely due to a notable increase in the number of pathologically shaped erythrocytes before

the surgery. It should be taken into consideration at the next stages of treatment, in particular during the

surgery, anesthetic management and perfusion.

After the SPA-surgery the proportion of discocytes decreased while that one of PS RBCs increased; at the

same time number of echinocytes increased, as well as the number of irreversibly altered RBCs. Two hours after

the surgery, the proportion of pathologically shaped RSCs increased, mainly those ones with ridges and

echinocytes (Figure 3). Twelve hours after the surgery the number of discocytes in the blood significantly

increased with a considerable drop in the number of RSCs with ridge and echinocytes.

The TDET used to evaluate alterations in the RBC shape in TOF patients before and after the surgery

enabled to estimate the discocytes/PS RBC within 15 min after the surgery and conduct rather large

hemomorphologic study. The TDET evaluation of RBCs in the comparison group demonstrated significant

domination of discocytes. In addition to the characteristic shapes of the biconcave discs, they had a smooth

external membrane with no processes, folds and depressions (Table 1).

The TDET made to TOF patients before the surgery showed a considerable increase in the PS RBC

proportion. They made 1/3 of the RBCs, 61% of them were discocytes, but RBCs with a ridge dominated (Table 1,

Figure 4). Immediately after the surgery, a lot of PS RBCs were found with higher proportion of echinocytes

(Table 1). Two hours after the surgery the counts of discocytes and stomatocytes tended to diminish while the

number of RBCs with ridge increased (Figure 5).

When anastomosis hyperfunction has developed, the clinical changes are manifested by pulmonary edema

with an increase in PS RBC count in peripheral blood and a decrease in the number of discocytes up to 49%. The

RBCs with ridge composed up to 16%, and echinocytes of classes 1 and 2 made 14%. Stomatocytes, the cells with

coarse echinocyte transformations, and irreversibly shaped cells were presented in relatively equal numbers:

6%, 7% and 8%, respectively (Table 1).

When post-SPA hyperfunction developed, the set of intensive therapy interventions procedures included

application of the regulating cuff. It contributed to restoration of the peripheral blood RBCs shape in 120-180

minutes with the increase in discocyte count from 49% to 55%, while the number of PS RBCs decreased by 6%

(Figures 6 and 7).

Twelve hours after the surgery we noted the tendency to an increase in the number of discocytes and a

decrease in the PS RBC number (Table 1). The dynamics of morphological monitoring is as follows: at hours 12-

15 after SPA hyperfunction development the number of discocytes in peripheral blood is increasing because of

the restoration of pathologically changed erythrocytes (Table 1).

Figure 1. The blood sample of the CTOF patient. The Figure 2. The blood of the same patient. Numerous

evident domination of pathologically shaped RBCs. echinocytes, cells with ridges and stomatocytes. TDET

SEM × 1.000

10 × 60.

To cite this paper: Ibadov R.A., Baybekov I.M., Abralov Kh.K., Strijkov N.A., Julamanova D.I., Khamdamovich I.S., Ravshanovich I.R. 2018. Red Blood

Cells Morphology Monitoring to Predict Hyperfunction of Subclavian-Pulmonary Anastomosis in Patients with Fallot Tetralogy. J. Life Sci. Biomed. 8(2): 37-

42; www.jlsb.science-line.com

Figure 3. The RBC of the TOF patient 2 hours after the Figure 4. The RBCs of the TOF patient before the

surgery: the increasing proportions of PS RBC, RBCs surgery: domination of PS RBCs, RBCs with ridge in

with ridge and echinocytes.

SEM × 4.000

particular. TDET 10 × 40

Table 1. Dynamics of the subclavian-pulmonary anastomosis effect on peripheral blood RBCs of TOF patients (%)

Immediately

after the

surgery

n=10

Anastomosis

hyper-function

Pulmonary

Comparison Before the

120 min.

after the

surgery n=5

120 min.

after RSPA the surgery

12 hr after 12 hr after the

Items

group

n=8

surgery

n=10

RSPA

n=5

edema, n=5

Discocytes

85±1.2

2±0.1

59±1.1

7±0.2

57±2.5*

10±0.6*

56±2.3**

11±0.7**

49±2.9**

14±1.3**

55±2.4 **

12±0.8 **

61±2.2***

10±0.6***

64±2.4***

9±0.5***

Echinocytes

Stomatocytes

With ridge

3±0.2

4±0.2

8±0.4

7±0.4*

4±0.3**

6±0.6**

5±0.4**

4±0.4***

15±0.3

4±0.3***

12±0.4

19±0.2

14±0.3*

17±0.3**

16±0.5**

15±0.3 **

Echinocytes

rough

4±0.3

2±0.1

5±0.4

2±0.7

6±04

6±0.5

7±0.3

5±0.3

7±04

5±0.3

5±0.4

4±0.3

7±0.3

Irreversible

cells

8±0.5

6±0.8

*significant difference (Р<0.05) from the previous group; **significant difference (Р<0.05) from group*; *** significant difference (Р<0.05)

from group**; RSPA= Regulated subclavian-pulmonary anastomosis.

Figure 5. Two hours after SPA. A higher proportion of pathologically shaped RBCs, RBCs with ridge and

echinocytes. TDET 10 × 40

To cite this paper: Ibadov R.A., Baybekov I.M., Abralov Kh.K., Strijkov N.A., Julamanova D.I., Khamdamovich I.S., Ravshanovich I.R. 2018. Red Blood

Cells Morphology Monitoring to Predict Hyperfunction of Subclavian-Pulmonary Anastomosis in Patients with Fallot Tetralogy. J. Life Sci. Biomed. 8(2): 37-

42; www.jlsb.science-line.com

Figure 6. Two hours after application of the Figure 7. Two hours after application of the regulating

regulating cuff in post-SPA hyperfunction. An

increase in the number of discocytes with a

significantly decreased proportion of the cells with

processes. TDEM 10 × 40

cuff in post-SPA hyperfunction. The RBC count teds to

normalize. TDEM 10 × 40

CONCLUSION

Morphological features of peripheral blood cells in patients with tetralogy of Fallot demonstrated that the

number of pathologically shaped RBCs increased up to 41 %, these were mainly erythrocytes with ridge (up to 16

%). The early post-operative period after performance of subclavian-pulmonary anastomosis is characterized by

the decrease of RBCs count up to 56-57%. The share of pathologically shaped RBCs in peripheral blood below 49

% is the morphological predictor of anastomosis hyperfunction development. The morphological monitoring of

the correlation between normal and pathologically shaped erythrocytes after SPA-surgery for tetralogy of Fallot

can provide the criterion of efficiency of the medical and diagnostic tactics in anastomosis hyperfunction

development.

DECLARATIONS

Authors’ Contributions

All authors contributed equally to this work.

Acknowledgements

This work was supported by Republican Specialized Center of Surgery named after academician

V.Vakhidov. Tashkent, Uzbekistan.

Competing interests

The authors declare that they have no competing interests.

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