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SECTION 5 Management of cardiopulmonary bypass

Table23.2 Continued

ClassI EACTS/ EACTA/ EBCP Guidelines

When a supply system for volatile anaesthetics

Level of evidencea

C Y is used, a scavenging system at the outlet of the oxygenator is recommended.

Validated decontamination and maintenance

C Y procedures for HCUs are recommended.

It is recommended that HCUs be placed outside

C operating rooms to prevent the contaminated air from entering the operative ﬁeld.

It is recommended that the perfusionist collect

B Y data concerning the conduct of perfusion via a clinical registry or database and use such data to actively participate in institutional and departmental quality assurance and improvement programmes.

Part V.Cardiopulmonary bypass— the disposables

It is recommended that there is a preoperative

C Y agreement between the perfusionist and surgeon on the choice of the size and type of venous and arterial cannulas in order to provide an adequate and safe venous return and an appropriate arterial ﬂow tailored to the needs of the patient and the procedure.

Microporous membrane oxygenators are

B recommended as the ﬁrst choice for use in CPB.

Part VI. Preparation for cardiopulmonary bypass

It is recommended to use an institution-

C Y approved pre- CPB checklist during the set- up of and prior to initiating CPB.

It is recommended that completion of the

C perfusion checklist is acknowledged during the surgical safety checklist ‘time out’ procedure.

A preoperative assessment of the patient is

C Y recommended in preparation for CPB.

Part VII. Procedures during cardiopulmonary bypass

It is recommended that CO2 ﬂush of the CPB

B circuit before priming be established as the standard of care to reduce GME.

Retrograde and antegrade autologous

A Y primings are recommended as part of a blood conservation strategy to reduce transfusions.

In the absence of individual heparin dosing

C S8.1, 8.3 Y tools, it is recommended that ACT tests be performed at regular intervals based on institutional protocols, and heparin doses have to be given accordingly.

It is recommended to adjust the MAP during

A Y CPB with the use of arterial vasodilators (if MAP >80mmHg) or vasoconstrictors (if MAP <50mmHg), after checking and adjusting the depth of anaesthesia and assuming sufﬁciently targeted pump ﬂow.

It is recommended that vasoplegic syndrome

C during CPB be treated with α1 adrenergic agonist vasopressors.

It is recommended that the pump ﬂow rate be

C Y determined before initiation of CPB based on the BSA and the planned temperature.

GDT is recommended to reduce the rate of

A Y postoperative complications and length of hospital stay.

AmSECT 2017 S&G (1)

S6.8

18.1

S 17.1, 17.2

S3.1

S5.2 G5.2

S 3.1

G 13.1

S11.1, 11.2

S 10.1

S 9.1 G 9.2

ANZCA (2) GB&I (3) Safety AHA/

ACC(4)

4.2.2.5

3.3.3

5.4.4

Y ClassI

5.2.3.3

5.3.1

STS/ SCA/ AmSECT (5,6,7)

ClassI

Level B

Level A

ClassIIb

Level B

ClassI

Level C

Table23.2 Continued

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23 Management ofcardiopulmonarybypass

199

ClassI EACTS/ EACTA/ EBCP Guidelines

It is recommended that an approved venous reservoir be used for assisted venous drainage.

It is recommended that the venous line pressure be monitored when using assisted venous drainage.

It is recommended that PRBCs be transfused during CPB if the Hb value is <6.0 g/ dL.

It is recommended that antithrombin concentrate be used instead of FFP to treat antithrombin deﬁciency to improve heparin sensitivity.

It is recommended that patient- centred myocardial protective strategies be used based on clinical condition and procedural complexity rather than on the use of a ﬁxed institutional cardioplegic solution.

It is recommended that a set- up CPB circuit be available at all times for emergent procedures.

After the patient is weaned from CPB, it is recommended that the CPB circuit be kept functional until the patient’s chest has been closed.

Part VIII. Separation from cardiopulmonary bypass

The use of a checklist before the weaning process is recommended to enhance team performance and augment patient safety.

Positive inotropic and/ or vasopressor agents are recommended as a ﬁrst- line treatment to reduce mortality rates in patients with haemodynamic instability.

Retransfusion of the residual volume of the CPB circuit at the end of the procedure is recommended as a part of a blood management programme to minimise allogeneic blood transfusions.

Level of evidencea

C Y

C ClassIIa

B ClassI

C Y

C Y S13.1, G13.1 ClassIIa

AmSECT 2017 S&G (1)

S 6.1

G14.2

F14.1

G 5.2

ANZCA (2) GB&I (3) Safety AHA/

ACC(4)

5.2.4.2

STS/ SCA/ AmSECT (5,6,7)

Level C

Level A

Level C

The exact wording for the recommendations between the different recommendations and standards may vary, direct comparison should be undertaken with caution.

Level of evidence assigned by the EACT/ EACA/ EBCP Guidelines. 1.AmSECT Standards and Guidelines; 2.ANZCA Guidelines for Major Extracorporeal Perfusion; 3.GB&I Standards of

Practice Document41; 4.Wahr J, etal. (2013)14; 5.Ferraris VA etal. (2011)10; 6.Engelman R, etal. (2015)12; 7.Shore- Lesserson L, etal. (2018)13. Reproduced from Hessel, E, Groom RC, Guidelines for conduct of cardiopulmonary bypass. An editorial. Journal of Cardiothoracic and Vascular Anesthesia, May 2020, https:// doi.

org/ 10.1053/ j.jvca.2020.04.058 with permission from Elsevier.

ese practices are enhanced when coupled with appropriate clinical monitoring and reporting. AmSECT’s document ‘Standards and Guidelines For Perfusion Practice’ highlights a way by which good clinical monitoring and reporting can be integrated into routine clinical practice. is document provides a framework upon which clinical teams can enhance their local practices as it shows both standards

which comprise the mandatory practices and guidelines which comprise worthwhile practices that teams may consider adopting.

e best outcomes for patients undergoing CABG utilizing CPB can be gained from a multidisciplinary team that adopts evidencebased practices and works collaboratively in a highly functional communication rich setting.

200 SECTION 5 Management of cardiopulmonary bypass

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Table23.3 ClassIIa recommendations fromEACTS/ EACTA/ EBCP compared tosimilar statements fromreferenced documents

ClassIIa EACTS/ EACTA/ EBCP Guidelines

Level of evidencea

Part III. Training, education and service delivery

Simulation in perfusion should be considered to

improve quality of care and patient safety.

Recording and submitting activity and outcomes

B Y to a regional database or registry should be considered, and these data should be used for quality assurance and improvement.

Part IV. Heart– lung machine hardware

It should be considered that pump ﬂow is conﬁrmed

C by ultrasonic measurement on the arterial line.

Electronic automated data recording of perfusion

B Y parameters should be considered in a perfusion programme.

To limit trauma to blood elements, limited use

B ClassI of cardiotomy suction and avoidance of air entrainment into the cardiotomy and venting lines should be considered.

The use of a separated cardiotomy reservoir should

B B be considered to decrease the deleterious effect of shed mediastinal blood.

The use of centrifugal pumps should be considered

C for expected longer CPB times.

Part V.Cardiopulmonary bypass— the disposables

The use of any biocompatible coating to reduce

B Y postoperative complications should be considered.

Part VII. Procedures during cardiopulmonary bypass

MiECC should be considered over standard

B ClassI conventional CPB systems to reduce blood loss and the need for transfusion.

MiECC should be considered over standard

B conventional CPB systems to increase the biocompatibility of ECC.

A combination of MiECC features such as coating,

C the centrifugal pump, the separation of cardiotomy suction blood and the use of closed systems should be considered to improve conventional CPB.

ACT above 480 s during CPB should be considered

C ClassIIa, Level in CPB with uncoated equipment and cardiotomy suction. The required target ACT is dependent on the type of equipment used.

Individualized heparin and protamine management

B 8.4, 8.5 ClassIIb, Level should be considered to reduce postoperative coagulation abnormalities and bleeding complications in cardiac surgery with CPB.

Protamine overdosing should be avoided in order to

B 8.5 ClassIIa, reduce postoperative coagulation abnormalities and bleeding complications in cardiac surgery with CPB.

In patients with contraindications to heparin and/

B 8.1 ClassI or protamine usage and in need of an operation requiring CPB, anticoagulation with bivalirudin should be considered

Alpha- stat acid- base management should be

B ClassI applied in adult cardiac surgery with moderate to mild hypothermia because neurological and neurocognitive outcomes are improved.

Maintenance of a normal pH (7.35 e7.45) and

B avoidance of hyperchloraemic acidosis should be considered in order to reduce the risk of postoperative complications.

AmSECT 2017 S&G (1)

G 17.1

S 4.1

G 13.1

ANZCA (2) Shann

2006 (8)

Level B

ClassII a Level B

Level A

STS/ SCA/ AmSECT (5, 7)

Level A

Level C

ClassIIa, Level

Inﬂamm ation 2014 (9)

Table23.3 Continued

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23 Management ofcardiopulmonarybypass

201

ClassIIa EACTS/ EACTA/ EBCP Guidelines

In patients with vasoplegic syndrome refractory to

Level of evidencea

AmSECT 2017 S&G (1)

ANZCA (2) Shann

2006 (8)

a1- adrenergic agonist vasopressors, alternative drugs (vasopressin, terlipressin or methylene blue) should be used, alone or in combination with a1- agonists.

The adequacy of the pump ﬂow rate during CPB should be checked based on oxygenation

B Y

G 10.2 and metabolic parameters (SvO2, O2ER, NIRS, VCO2 and lactates).

The pump ﬂow rate should be adjusted according

B Y G 9.2 to the arterial oxygen content in order to maintain a minimal threshold of DO2 under moderate hypothermia.

Pulsatile perfusion may reduce postoperative

B pulmonary and renal complications and should be considered in patients at high risk for adverse lung and renal outcomes.

Volatile anaesthetics should be considered

B during CPB.

The oxygenator exhaust concentration of volatile

C 4.2.8.5 anaesthetic agents during CPB should be at least the same as that before CPB (if used as the sole anaesthetic agent), except during rewarming, when it should be increased.

Oxygenator exhaust concentrations of volatile

B agents should be monitored during CPB.

Doses of intravenous anaesthetics and opioids,

B except remifentanil, during maintenance of CPB should be at least the same as before CPB (if used as the sole anaesthetic agent).

Short- acting neuromuscular blocking agents

B should be considered in cardiac anaesthesia.

Blood cardioplegia should be considered in

B selected patients d to reduce haemodilution, bleeding complications and transfusion requirements.

Biocompatible modiﬁcations of circuits should be considered in order to protect the lungs from

B ClassII a

Level B inﬂammatory responses and provide less oxidative stress.

PEEP during CPB should be considered in order to

protect the lungs.

Discarding shed blood should be considered. B ClassI

Level B

Processing and secondary ﬁltration of red blood

B cells should be considered to decrease the deleterious effects of reinfused shed blood.

Perfusionists should be adequately trained and

C educated in the different aspects of minimally invasive cardiac surgery techniques.

TOE should be considered in open heart and thoracic aortic procedures unless there are

B ClassI

Level B

contraindications.

Part VIII. Separation from cardiopulmonary bypass

The use of phosphodiesterase inhibitors should be

B considered to increase weaning success.

STS/ SCA/ AmSECT (5, 7)

Inﬂamm ation 2014 (9)

The exact wording for the recommendations between the different recommendations and standards may vary, direct comparison should be undertaken with caution.

Level of evidence assigned by the EACT/ EACA/ EBCP Guidelines; 1.AmSECT Standards and Guidelines; 2.ANZCA Guidelines for Major Extracorporeal Perfusion; 5.Ferraris VA etal.

(2011)10; 7.Shore- Lesserson L, etal. (2018)13; 8.Shann KG, etal. (2006)9; 9.Landis RC, etal. (2014)46. Reproduced from Hessel, E, Groom RC, Guidelines for conduct of cardiopulmonary bypass. An editorial. Journal of Cardiothoracic and Vascular Anesthesia, May 2020, https:// doi.

org/ 10.1053/ j.jvca.2020.04.058 with permission from Elsevier.

SECTION 5 Management of cardiopulmonary bypass202

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Table23.4 ClassIIb recommendations fromEACTS/ EACTA/ EBCP compared tosimilar statements fromreferenced documents

ClassIIb EACTS/ EACTA/ EBCP Guidelines

Level of evidence

AmSECT 2017 S&G (1)

Part IV. Heart– lung machine hardware

Monitoring of all incoming and outgoing gases may be considered. C

Part V.Cardiopulmonary bypass— the disposables

Epiaortic ultrasonography may be considered to detect the plaque of the ascending aorta before aortic cannulation to reduce the incidence of stroke.

B ClassI

Level B

ALFs may be considered in order to reduce the number of microemboli. C ClassILevel A

Part VII. Procedures during cardiopulmonary bypass

CO2 ﬂooding of the operative ﬁeld may be considered to reduce GME. B

In patients with contraindications to heparin and/ or protamine usage, in need of an operation requiring CPB and

signiﬁcant renal dysfunction, anticoagulation with argatroban may be considered.

Magnesium sulphate may be considered perioperatively for prophylaxis of postoperative arrhythmias. B

Hydroxocobalamin may be used to treat vasoplegic syndrome during CPB. C

Pump ﬂow rates may be settled based on lean mass in obese patients. B

For HCT values between 18% and 24%, PRBCs may be transfused based on an assessment of the adequacy of tissue

oxygenation.

Tight glycaemic control may be considered during CPB. B ClassILevel B

After the initiation of CPB, the remifentanil dose may be reduced after 20- 30 min by 30% at 32°C. Hypothermia below

27°C requires immediate reduction by 60%.

MUF and selective pulmonary artery perfusion may be considered for improving postoperative respiratory function. B

Ventilation during CPB may be considered for lung protection. B

High- dose dexamethasone may be considered in order to protect the lungs in selected patients. B

Routine use of processed EEG monitoring to reduce the incidence of intraoperative awareness may be considered. B

The use of NIRS- guided algorithms to improve clinical outcomes may be considered B

Part VIII. Separation from cardiopulmonary bypass

Minimally invasive heart valve surgery may be considered to reduce blood loss and the need for transfusion. B

Minimally invasive heart valve surgery may be considered in experienced units with respect to the patient’s preference. B

A PAC may be indicated in selected cases. B

Cardiac output with pulse contour analysis may be indicated in selected cases. B

Levosimendan as a therapeutic strategy in selected difﬁcult- to wean patients having CPB may be considered. C

The exact wording for the recommendations between the different recommendations and standards may vary, direct comparison should be undertaken with caution.

Level of evidence assigned by the EACT/ EACA/ EBCP Guidelines. 1.AmSECT Standards and Guidelines.

Reproduced from Hessel, E, Groom RC, Guidelines for conduct of cardiopulmonary bypass. An editorial. Journal of Cardiothoracic and Vascular Anesthesia, May 2020, https:// doi. org/ 10.1053/ j.jvca.2020.04.058 with permission from Elsevier.

Table23.5 ClassIII recommendations fromEACTS/ EACTA/ EBCP compared tosimilar statements fromreferenced documents

ClassIII EACTS/ EACTA/ EBCP Guidelines

Part V.Cardiopulmonary bypass— the disposables

Polymethylpentene membrane oxygenators are not recommended when volatile anaesthetics are used during the procedure.

The routine use of LD ﬁlters, when combined with membrane oxygenators, is not recommended. B ClassIII

Part VII. Procedures during cardiopulmonary bypass

The use of modern low- molecular- weight starches in priming and non- priming solutions to reduce bleeding and transfusions is not recommended.

The use of vasopressors to force the MAP during CPB at values higher than 80mmHg is not recommended. B

Excessive negative venous pressures are not recommended due to the deleterious haemolytic effects. B

PRBCs should not be transfused during CPB if the HCT is >24%. C ClassIII

Level of evidencea

STS/ SCA/ AmSECT (5)

Level B

Level C (>30%)

Inﬂammation 2014 (9)

Table23.5 Continued

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23 Management ofcardiopulmonarybypass

203

ClassIII EACTS/ EACTA/ EBCP Guidelines

FFP should not be used prophylactically during CPB to reduce perioperative blood loss. B ClassIII Level A

Routine use of prophylactic intravenous corticosteroids is not recommended during cardiac surgery. A A

Leucocyte ﬁltration and hyperoxia are not recommended for protecting the lungs during CPB. A ClassIII

Part VIII. Separation from cardiopulmonary bypass

The prophylactic infusion of levosimendan to reduce adverse events and mortality is not recommended. A

In patients requiring haemodynamic support after cardiac surgery, adding levosimendan to other positive inotropes or vasopressors is not recommended.

a Level of evidence assigned by the EACT/ EACA/ EBCP Guidelines. 5.Ferraris VA, etal. (2011)10; 9.Landis RC, etal. (2014)46. The exact wording for the recommendations between the different recommendations and standards may vary, direct comparison should be undertaken with caution; Reproduced from Hessel, E, Groom RC, Guidelines for conduct of cardiopulmonary bypass. An editorial. Journal of Cardiothoracic and Vascular Anesthesia, May 2020, https:// doi.

org/ 10.1053/ j.jvca.2020.04.058 with permission from Elsevier.

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37. Newland RF, Baker RA, Sanderson AJ, Tuble SC, Tully PJ. Oxygenator safety evaluation:a focus on connection grip strength and arterial temperature measurement accuracy. J Extra Corpor Technol. 2012;44(2):53– 9.

38. Lazar HL, McDonnell M, Chipkin SR, Furnary AP, Engelman RM, Sadhu AR, etal. e Society of oracic Surgeons practice guideline series:blood glucose management during adult cardiac surgery. Ann orac Surg. 2009;87(2):663– 9.

39. Umpierrez G, Cardona S, Pasquel F, Jacobs S, Peng L, Unigwe M, etal. Randomized controlled trial of intensive versus conservative glucose control in patients undergoing coronary artery bypass gra surgery:GLUCO- CABG trial. Diabetes Care. 2015;38(9):1665– 72.

40. Hillis LD, Smith PK, Anderson JL, Bittl JA, Bridges CR, Byrne JG, etal. 2011 ACCF/ AHA guideline for coronary artery bypass gra surgery:a report of the American College of Cardiology Foundation/ American Heart Association Task Force on Practice Guidelines. Circulation. 2011;124(23):e652– 735.

41. Society of Clinical Perfusion Scientists of Great Britain and Ireland. Standards of Practice [Internet]. 2019. Available from:https:// www.scps.org.uk/ society/ society- documents

42. Australian and New Zealand College of Anaesthetists (ANZCA). Guidelines for major extracorporeal perfusion [Internet]. 2015. Available from:https:// www.anzca.edu.au/ safety- advocacy/ standards- of- practice/ policies,- statements,- and- guidelines

43. Puis L, Milojevic M, Boer C, De Somer FMJJ, Gudbjartsson T, van den Goor J, etal. 2019 EACTS/ EACTA/ EBCP Guidelines on cardiopulmonary bypass in adult cardiac surgery. Interact Cardiovasc orac Surg. 2020;30(2):161– 202.

44. Hessel EA, Groom RC. Guidelines for conduct of cardiopulmonary bypass. J Cardiothorac Vasc Anesth. 2020 15 May;S1053- 0770(20):30417- 1. doi:10.1053/ j.jvca.2020.04.058. Epub ahead of print.

45. American Society of ExtraCorporeal Technology (AmSECT). Standards and guidelines for perfusion practice [Internet]. 2017. Available from:http:// www.amsect.org/ p/ cm/ ld/ d=1617

46. Landis RC, Brown JR, Fitzgerald D, Likosky DS, ShoreLesserson L, Baker RA, etal. Attenuating the systemic inammatory response to adult cardiopulmonary bypass:a critical review of the evidence base. J Extra Corpor Technol. 2014;46(3):197– 211.

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Minimal invasive extracorporeal circulation forcoronary revascularizationsurgery

Kyriakos Anastasiadis and Thierry Carrel

Coronary artery bypass graing (CABG) is associated with improved long- term outcome in severe coronary artery disease compared to percutaneous techniques since renements in surgical technique have reduced morbidity and mortality. Use of cardiopulmonary bypass (CPB) remains the standard strategy to perform cardiac surgery, which also applies to CABG surgery. However, despite major advancements, systemic inammatory response syndrome and coagulation derangement during conventional CPB are still involved in postoperative end- organ injury.

O- pump CABG techniques (OPCAB) were introduced into clinical practice in the late 1980s to overcome these issues. Supported by industry, there was signicant enthusiasm for OPCAB technique in the 1990s, based on the encouraging early results of observational studies. However, these results were not conrmed in subsequent meta- analyses of randomized controlled trials, where no statistically signicant reductions in short- term morbidity and mortality were found in the mostly low- risk patients enrolled in these trials., ese results tempered enthusiasm for OPCAB and raised questions about its superiority over conventional CABG (cCPB) using CPB. Recent guidelines on myocardial revascularization recommend mainly (classI, level of evidence B) OPCAB and preferably no- touch techniques on the ascending aorta, by experienced operators in patients with signicant atherosclerotic aortic disease. OPCAB remains controversial due to the greater technical diculty of the operation which may result in inecacious coronary anastomoses with a lower gra patency, less complete revascularization, and a higher rate of early reintervention or reoperation. us, while OPCAB may oer signicant benet to higher- risk patients, the lack of proven clinical benets in lower- risk patients combined with the technical challenges of OPCAB have led the vast majority (up to 85%) of myocardial revascularization procedures worldwide to be performed with the use of CPB.

In an attempt to attenuate the pathological eects of CPB, minimal invasive extracorporeal circulation (MiECC) systems were developed and initiated into clinical practice in the 2000s to allow the ease of surgery on- pump while tempering the disadvantages of CPB, and hence compete with OPCAB. e MiECC systems integrate all advances that have emerged through clinical research towards oering

better global end- organ protection. To achieve this goal, such a system should include a blood pump with optimal biocompatibility, all components should be minimized to reduce the priming volume required and therefore haemodilution, it should provide access to all coronary regions as well as to intracardiac structures, allow every form of temperature management depending on need, incorporate modern concepts of myocardial protection, and nally it should support concepts for fast- track anaesthesia. Conventional extracorporeal circulation (cCPB) systems can meet these criteria only in part.

us, MiECC technology was established as an attractive alternative to ensure adequate perfusion through a closed and a better biocompatible circuit as well as pump- oxygenator technology. Consequently, the benecial eects of these systems are derived from the implementation of all advances in CPB into one technology:this includes the use of a closed system with coated short tubing and oxygenator, minimized prime volume, use of a centrifugal pump, as well as elimination of cardiotomy suction and traditional venous reservoir. Avoidance of cardiotomy suction not only reduces the recirculation of debris and lipids from the shed mediastinal blood but also reduces haemolysis, preserves adequate haemostasis, and attenuates postoperative bleeding. In general, MiECC systems eliminate blood– air contact in the venous reservoir, signicantly reduce the contact of blood with foreign surfaces, minimize haemodilution and limit mechanical blood trauma. All these advantages result in less systemic inammatory response syndrome and blood activation, shed blood loss, need for crystalloid infusion, and need for blood transfusion., Use of coated circuits results in lower heparin dosage while an activated clotting time over 300 seconds is sucient (cCPB requires a signicantly higher activated clotting time). is policy is followed by a low- dose administration of protamine, which restores blood coagulation but not the platelet responses to thrombin during heparin neutralization. Moreover, lower heparin requirement and reduced haemodilution oered by MiECC further facilitate the management of postoperative bleeding.

e Minimal invasive Extracorporeal Technologies international Society (MiECTiS) has dened the main components of a CPB system in order to be characterized as MiECC (Table 24.1).

SECTION 5 Management of cardiopulmonary bypass206

Blood management

so as to facilitate air handling and avoid air

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Table24.1 Components ofa CPB circuit inorder tobe

characterized asMiECC system

Main components Additional components

Closed CPB circuit Pulmonary artery vent

Biologically inert blood contact surfaces

Reduced priming volume Pulmonary vein vent

Centrifugal pump Soft bag/ soft- shell reservoir

Membrane oxygenator Hard- shell reservoir (modular systems)

Heat exchanger Regulated smart suction device

Cardioplegia system Arterial line ﬁltration

Venous bubble trap/ venous air removing device

Shed blood management system

Source data from Anastasiadis K, Murkin J, Antonitsis P, Bauer A, Ranucci M, Gygax E, etal. Use of minimal invasive extracorporeal circulation in cardiac surgery:principles, deﬁnitions and potential beneﬁts. Aposition paper from the Minimal invasive ExtraCorporeal Technologies international Society (MiECTiS). Interact Cardiovasc Thorac Surg. 2016;22:647– 62.

Aortic root (left ventricular) vent

Advancement in MiECC technology prompted the classication of circuits into standard circuit (type Icircuit), those with venous bubble trap/ air- removing device (type II circuit), and those with a so- shell reservoir (type III circuit). ese modications enhanced the safety of the system and allowed it to be used for valve surgery. In chronological order, safety issues regarding

air handling led to the incorporation of venous bubble traps (or, lately, automatic venous air- removing devices) as well as pulmonary artery and aortic root (le ventricular) vents (type II), which enabled aortic valve surgery to become safe and feasible. e need for volume management during intracardiac surgery required the addition of a so bag to the circuit (type III). Complex cardiac surgical procedures with a high possibility of unexpected perfusion scenarios necessitated the integration of a second open circuit with a venous reservoir and cardiotomy suction as a standby component (type IV) for immediate transition to an open system whenever needed, that is, massive air entry to the system or massive bleeding to the surgical eld, thus expanding its potential use to every type of adult cardiac surgical procedure., See

Figs. 24.1– 24.3.

In clinical terms, MiECC is associated with improved circulatory support and end- organ protection (renal, cerebral, lung, liver), that translates into improved clinical outcome in terms of morbidity and mortality. Reported benets include higher intraoperative haematocrit values, less mediastinal bleeding, reduced need for blood transfusion, improved myocardial protection, reduced length of intensive care unit stay, and better renal, inammatory, and neurological function. Alarge- scale meta- analysis of the reported randomized trials including 24 studies with a total of 2770 patients conrmed the above- mentioned results and concluded that use of MiECC in coronary and valve surgery resulted in improved short- term outcomes as reected by reduced mortality and morbidity compared with cCPB (Table 24.2).

Type I

Type II

Type III

Type IV

This closed circuit comprises of an afferent tube (blue line) which drains blood from the right atrium to the pump ( ), then to the oxygenator ( o ) and returns it to the arterial circulation with the efferent tube (red line). The oblique arrow indicates cardiopledgia line with its pump (©).

A venous bubble trap/air removing device ( T ) is added to the standard MiECC circuit

entrainment to the venous line. Venting (green) lines (V) drain blood from the aortic root and/or pulmonary artery/vein.

A soft shell reservoir ( S ) is added to the circuit to collect blood volume from the patient and return it back during perfusion according to the needs.

Volume management Air handling Standard

A hard shell reservoir ( as an extra component integrated to the venous line, so as to convert the system to an open circuit that could facilitate blood management as well as overcome any other intraoperative issue (modular conﬁguration).

H ) is added

Fig.24.1 Classiﬁcation of MiECC circuits.

Reproduced from Anastasiadis K, Antonitsis P, Argiriadou H, Deliopoulos A, Grosomanidis V, Tossios P.Modular minimally invasive extracorporeal circulation systems; can they become the standard practice for performing cardiac surgery? Perfusion 2015;30:195– 200 with permission from SAGE.

24 Minimal invasive extracorporeal circulation forcoronary revascularizationsurgery 207

Since 2011 (type II)

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comparing MiECC versus OPCAB resulted in comparable outcomes between them.

Furthermore, beating- heart surgery on MiECC could provide an optimal operative exposure which may allow for more complete coronary revascularization when compared to OPCAB while reducing the number of aortic manipulations. Beating- heart CABG on MiECC is an acceptable trade- o and may represent the preferred procedure when complete coronary revascularization is required and OPCAB is not technically feasible, especially in high- risk patients who may tolerate cardioplegic arrest poorly. Some strong advocates of OPCAB surgery have questioned in the literature whether we need to add MiECC technology in our practice.

Despite these excellent clinical results, which are widely disseminated in the literature, penetration of MiECC technology in contemporary practice remains low. In a recent survey, only 20% of the perfusion departments within the United Kingdom and Ireland are using MiECC technology, interestingly, while this use is claimed to be in certain clinical scenarios. e low penetration of MiECC

Fig.24.2 MIECC system (type IV) from Aristotle University Thessaloniki.

1:pump, 2:oxygenator, 3:air removing device, 4:soft cell reservoir, 5:hard cell reservoir (not in use), 6:cardioplegia system, 7:CPB monitor, 8:Spectrum monitor (for goal- directed perfusion).

Courtesy of Aristotle University Thessaloniki.

MiECC compares favourably with OPCAB:the former has a haemocompatible coating, and the system avoids return of the pleuropericardial aspirations into the systemic circulation; as a consequence, results are very comparable to those obtained by beating- heart surgery. Synthesis from a network meta- analysis of 134 randomized controlled trials involving 22,778 patients showed that MiECC and OPCAB are both associated with improved perioperative outcomes following coronary bypass surgery when compared with CABG performed on- pump. Moreover, marked reductions were observed in the incidence of postoperative atrial brillation and stroke aer both MiECC and OPCAB when compared with cCPB. is analysis also demonstrated a signicant reduction in renal dysfunction. However, it is emphasized that OPCAB is still technically more demanding and kidneys are prone to impaired perfusion in instances when haemodynamic instability may accompany lateral and posterior heart wall revascularization, which is not the case in MiECC. Similarly, another meta- analysis from seven randomized controlled trials by Benedetto et al.

2000–2010 (type I)

Fig.24.3 MIECC system from Bern University Hospital.

Courtesy of Bern University Hospital.

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