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Antegrade cardioplegia is routinely given during cardiac surgery. The delivery of antegrade cardioplegia from the cardiopulmonary bypass machine has many variables. Many perfusionists rely exclusively on cardioplegia system pressure to ensure safe antegrade delivery. Our group reviewed antegrade cardioplegia delivery in 50 patients undergoing coronary artery bypass graft. The data collected included the cardioplegia system pressure and the patient's direct aortic root pressure. The analysis of the data found weak correlation between the two pressures with a large mean difference and a wide standard deviation. The results suggest the direct measurement of aortic root pressure as guidance to antegrade cardioplegia instead of relying solely on cardioplegia system pressure., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Introduction: Cardiopulmonary bypass is an essential component of cardiothoracic surgeries. However, significant complications such as systemic inflammatory response syndrome (SIRS) resulting from cardiopulmonary bypass (CPB) are a common occurrence due to contact between circulating blood and foreign surfaces that leads to platelet activation. It is suggested that different available CPB circuit coatings can potentially reduce platelet activation. However, there have been no published evidence-based reports confirming these claims. In addition, there is no well-established protocol for studying platelet activation biomarkers during CPB in vitro in a laboratory setting., Methods: CPB was simulated in the laboratory using bovine blood in two different types of coated CPB circuits: Trillium ® Biosurface by Medtronic, and Xcoating TM Surface by Terumo. Fresh bovine blood samples were collected and circulated through the CPB circuit following the standard protocol used in the operation rooms. Blood samples were then collected at 5 min, 30 min, and 55 min during the circulation. Blood plasmas were separated and subjected to enzyme-linked immunosorbent assay to measure most established platelet activation markers P-selectin, Platelet Factor 4 (PF4), Glycoprotein IIb/IIIa (GPIIb/IIIa), and β-thromboglobulin (β-TG) at different time points., Results: The biomarker values at 30 min and 55 min were compared to the base values at 5 min for each type of CPB circuit. The results of the means from all measured biomarkers showed data measurements that indicated no significant variability within each coating. All collected data points fell within ±2 SD of the means, which was considered acceptable variations across technical replicates.  Conclusion: In this study, we were able to establish an in vitro protocol in the laboratory setting that is precise and reliable with minimum intra-variability. This established protocol will allow for future studies in which different coated CPB circuits can be compared for their effectiveness in blocking platelet activation during the CPB., (© The Author(s), published by EDP Sciences, 2024.)

Background: The Perfusion Measures and Outcomes (PERForm) registry was established in 2010 to advance cardiopulmonary bypass (CPB) practices and outcomes. The registry is maintained through the Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative and is the official registry of the American Society of Extracorporeal Technology., Methods: This first annual PERForm registry report summarizes patient characteristics as well as CPB-related practice patterns in adult (≥18 years of age) patients between 2019 and 2022 from 42 participating hospitals. Data from PERForm are probabilistically matched to institutional surgical registry data. Trends in myocardial protection, glucose, anticoagulation, temperature, anemia (hematocrit), and fluid management are summarized. Additionally, trends in equipment (hardware/disposables) utilization and employed patient safety practices are reported., Results: A total of 40,777 adult patients undergoing CPB were matched to institutional surgical registry data from 42 hospitals. Among these patients, 54.9% underwent a CABG procedure, 71.6% were male, and the median (IQR) age was 66.0 [58.0, 73.0] years. Overall, 33.1% of the CPB procedures utilized a roller pump for the arterial pump device, and a perfusion checklist was employed 99.6% of the time. The use of conventional ultrafiltration decreased over the study period (2019 vs. 2022; 27.1% vs. 24.9%) while the median (IQR) last hematocrit on CPB has remained stable [27.0 (24.0, 30.0) vs. 27.0 (24.0, 30.0)]. Pump sucker termination before protamine administration increased over the study period: (54.8% vs. 75.9%)., Conclusion: Few robust clinical registries exist to collect data regarding the practice of CPB. Although data submitted to the PERForm registry demonstrate overall compliance with published perfusion evidence-based guidelines, noted opportunities to advance patient safety and outcomes remain., (© The Author(s), published by EDP Sciences, 2024.)

Abstract: A patient with a percutaneously inserted cardiopulmonary bypass cannula into the right internal jugular vein, connected to an extracorporeal membrane oxygenation (ECMO) circuit using tape, was referred for transport to our ECMO center. We describe management, quality improvement, and lessons learned., (Copyright © 2024 Copyright: © 2024 Annals of Cardiac Anaesthesia.)

Background: Cardiopulmonary bypass (CPB) techniques are becoming minimally invasive in clinical practice. The literature describes various extracorporeal techniques which seek to eliminate air-blood contact and reduce both hemodilution and the contact surface such as in Minimally invasive Extracorporeal Circulation (MiECC) and closed systems for CPB. However, the delivery of micro-embolic activity in the circuit and metabolic activity in terms of oxygen delivery for Goal-Directed Perfusion (GDP) management, in relation to the patient's blood volume and central venous pressure, have never been related and correlated. In this report, we present a cohort study that investigated these aspects between the closed SVR2000 System and modular MiECC (both from Eurosets SRL, Medolla, Italy)., Materials and Methods: Data were collected retrospectively and used to compare 60 consecutive patients who underwent isolated coronary artery bypass grafting (CABG) surgery by two surgeons using an SVR2000 oxygenator in 30 procedures, with a matched cohort of patients from the same period who underwent isolated CABG surgery by two other surgeons using a modular MiECC in 30 procedures. The primary endpoints collected were data on micro-embolic activity, including the number of gaseous micro-emboli in the circuit during the procedure, the mean maintenance value of oxygen delivery (DO2) and data relating to venous return volume and central venous pressure (CVP)., Results: During the CPB procedures, the following values were recorded for the closed SVR2000 and MiECC groups, respectively: the average number of gaseous micro-emboli (GME) in the venous line, 833 ± 23 vs 1221 ± 45 (p = 0.028); GME in the outlet of the pump, 375 ± 45 vs 429 ± 76 (p = 0.89; GME in the arterial line, 189 ± 36 vs 205 ± 27 (p = 0.92), and the volume of GME in the arterial line (mL), 0.32± 12 vs 0.49± 17 (p = 0.93). The mean Indexed Oxygen Delivery (DO2i) during cross-clamp (ml/min/m2) was 319 ±12 vs 278 ±9 (p = 0.0019), respectively. The maximum mean volume of venous return in the soft-shell venous reservoir (ml) was 1801 ±128 vs 824 ±192 (p = 0.038). The mean central venous pressure (CVP) during cross-clamp (mmHg) was 0 ± 2 vs 6 ± 2 (p = 0.019)., Conclusions: In this study, the results in the closed SVR2000 group were not statistically inferior to those in the modular MiECC group in terms of gaseous micro-embolic activity during CPB. Our analysis showed an important reduction of GME delivery in both systems. The closed SVR2000 group showed better management for GDP in terms of DO2i, associated with the flexibility of dynamic volume management and the absence of cavitation and regulation of the rate per minute and pump flow, which were reported in the MiECC group. The SVR2000 and modular MiECC systems were both safe and effective in perioperative practice without iatrogenic problems.

The equipment selected for cardiopulmonary bypass (CPB) in pediatric cardiac surgery critically influences the safety, efficiency, efficacy and pathophysiological impact in perioperative use and the post-operative outcome. In this report, we present a single-center retrospective analysis of the clinical efficacy, efficiency and safety of the Trilly oxygenator (Eurosets Srl, Medolla, MO, Italy), which has an integrated arterial filter. It has a blood flow capacity of 500 to 3500ml/min, an AAMI index of 4.000ml / min, and a static fill prime (oxygenating module + heat exchanger) of 130 ml. We used this device on 42 pediatric patients who underwent repair of various congenital heart defects with cardiopulmonary bypass. Pre- and intraoperative patient data were collected for the evaluation of gas transfer and metabolic parameters in relation to blood flow, temperature and hematologic profiles. The mean age of the patients was 8.07 ± 2.9 years. Eight patients had cyanotic heart disease, 7 had chromosomal abnormalities and 9 had previously undergone cardiac surgery. The STAT Mortality Category Score was distributed as follows: Cat. 1 (37.5%), Cat. 2 (35%), Cat. 3 (5%), Cat. 4 (22.5%), Cat. 5 (0%). The mean bodyweight was 29.03 ± 8.25 kg and the blood flow rate was 2664.88 ± 508.43 ml / min. The mean cardiopulmonary bypass time was 95±51.4 min and the cross-clamp time was 37±34.6 min. The mean gas transfer values were as follows: partial pressure of oxygen, post oxygenator, 224.7±28 mmHg; partial pressure of carbon dioxide, post oxygenator, 42±4 mmHg; oxygen delivery 356.9± 88.8 ml/min/m2; carbon dioxide transfer, 52.81± 1.98 mmHg, mixed venous saturation 77.78 %; and mean hematocrit value 29.0±4 %. The Trilly oxygenator was effective in terms of oxygen uptake, carbon dioxide removal, and heat exchange in a pediatric population undergoing cardiopulmonary bypass. This retrospective analysis showed that the Trilly is both safe and effective in clinical practice without iatrogenic problems.

Importance: In children undergoing heart surgery, nitric oxide administered into the gas flow of the cardiopulmonary bypass oxygenator may reduce postoperative low cardiac output syndrome, leading to improved recovery and shorter duration of respiratory support. It remains uncertain whether nitric oxide administered into the cardiopulmonary bypass oxygenator improves ventilator-free days (days alive and free from mechanical ventilation)., Objective: To determine the effect of nitric oxide applied into the cardiopulmonary bypass oxygenator vs standard care on ventilator-free days in children undergoing surgery for congenital heart disease., Design, Setting, and Participants: Double-blind, multicenter, randomized clinical trial in 6 pediatric cardiac surgical centers in Australia, New Zealand, and the Netherlands. A total of 1371 children younger than 2 years undergoing congenital heart surgery were randomized between July 2017 and April 2021, with 28-day follow-up of the last participant completed on May 24, 2021., Interventions: Patients were assigned to receive nitric oxide at 20 ppm delivered into the cardiopulmonary bypass oxygenator (n = 679) or standard care cardiopulmonary bypass without nitric oxide (n = 685)., Main Outcomes and Measures: The primary end point was the number of ventilator-free days from commencement of bypass until day 28. There were 4 secondary end points including a composite of low cardiac output syndrome, extracorporeal life support, or death; length of stay in the intensive care unit; length of stay in the hospital; and postoperative troponin levels., Results: Among 1371 patients who were randomized (mean [SD] age, 21.2 [23.5] weeks; 587 girls [42.8%]), 1364 (99.5%) completed the trial. The number of ventilator-free days did not differ significantly between the nitric oxide and standard care groups, with a median of 26.6 days (IQR, 24.4 to 27.4) vs 26.4 days (IQR, 24.0 to 27.2), respectively, for an absolute difference of -0.01 days (95% CI, -0.25 to 0.22; P = .92). A total of 22.5% of the nitric oxide group and 20.9% of the standard care group developed low cardiac output syndrome within 48 hours, needed extracorporeal support within 48 hours, or died by day 28, for an adjusted odds ratio of 1.12 (95% CI, 0.85 to 1.47). Other secondary outcomes were not significantly different between the groups., Conclusions and Relevance: In children younger than 2 years undergoing cardiopulmonary bypass surgery for congenital heart disease, the use of nitric oxide via cardiopulmonary bypass did not significantly affect the number of ventilator-free days. These findings do not support the use of nitric oxide delivered into the cardiopulmonary bypass oxygenator during heart surgery., Trial Registration: anzctr.org.au Identifier: ACTRN12617000821392.

Aim: This study aimed to evaluate the efficacy of the resin hemoperfusion device (HA380 hemoperfusion cartridge) on inflammatory responses during adult cardiopulmonary bypass (CPB)., Methods: Sixty patients undergoing surgical valve replacement were randomized into the HP group (n = 30) with an HA380 hemoperfusion cartridge in the CPB circuit or the control group (n = 30) with the conventional CPB circuit. The results of routine blood tests, blood biochemical indexes, and inflammatory factors were analyzed at V0 (pre-CPB), V1 (CPB 30 min), V2 (ICU 0 h), V3 (ICU 6 h), and V4 (ICU 24 h)., Results: The HP group had significantly lower levels of IL-6, IL-8, and IL-10. Significant estimation of group differences in the generalized estimating equation (GEE) models was also observed in IL-6 and IL-10. The HP group had significantly lower levels of creatinine (Cr), aminotransferase (AST), and total bilirubin (TBil) compared to the control group. The estimation of differences of Cr, AST, and TBil all reached statistical significance in GEE results. The HP group had significantly less vasopressor requirement and shorter mechanical ventilation time and ICU stay time as compared to the control group., Conclusion: The HA380 hemoperfusion cartridge could effectively reduce the systemic inflammatory responses and improve postoperative recovery of patients during adult CPB., (© 2021 S. Karger AG, Basel.)

The optical properties of hemoglobin could indicate the degree of hemolysis. We aimed to utilize this to develop a real-time blood damage monitoring device for cardiopulmonary bypass (CPB) systems. The real-time blood damage monitoring device comprised a near-infrared spectroscopy optical module with a fiber spectrometer and monitoring platform and computer software developed using LabVIEW 2017. The fiber spectrometer operated at wavelengths of 545, 660, and 940 nm and contained a detector fiber bundle (source-detector distance = 1.0-2.5 cm). CPB operation was simulated using an artificial heart-lung machine with a flow rate of 3, 4, or 5 L/min. Four hundred milliliter of anticoagulated porcine blood was continuously rotated for 4 h. The transmittance, reflectivity, and absorbance of the blood were measured using the optical device at a frequency of 25 Hz and then digitally averaged into 1-s interval. Samples of damaged blood were collected at regular intervals for in vitro hemolysis tests to calculate the normalized index of hemolysis (NIH). All experiments were repeated three times. We prepared 28 blood bags containing 400 ml of anticoagulant. Paired t test was used to examine the test-retest reliability of the differences between the three methods and control samples. Statistical tests revealed significant differences in the mean values between the test and control groups over time (P < 0.01). Relationship was established between the real-time monitoring results and the NIH values. An effective blood damage detection method that combined in vitro hemolysis tests and near-infrared spectroscopy was achieved. The results demonstrate the clinical potential of a real-time, low-cost, and reliable blood damage monitoring device to improve the safety of CPB operation.

In roller pumps used for cardiopulmonary bypass (CPB), the degree of blockage within the tube resulting from compression of the tube by the rollers, or the degree of occlusion, is closely related to hemolysis, with both tight occlusive and non-occlusive degrees promoting hemolysis. There are as yet no international standards regarding methods of adjusting occlusiveness, and the amount of mechanical stress exerted upon blood remains unknown. To prevent hemolysis during CPB using roller pumps, there is a need to clarify and quantitatively assess the mechanical stress of the occlusiveness of the roller pump. In this study, we have developed a degree of occlusion quantification system which constructs the flow channel shape within an occluded tube from red optical density images, and we have verified the validity of this system. Utilizing a linear actuator, an acrylic roller and raceway, a solution colored with simulated blood powder, and a 3/8-inch vinyl chloride tube, this system uses a camera to capture red optical density images within an occluded tube and constructs the tube flow channel shape using a formula manipulation system. To verify the accuracy of this system, we compared the thickness of a cross-section of the flow channel constructed with the degree of occlusion quantification system with the thickness of a cross-section of silicone cured under the same occlusion conditions. Our experiments indicated that for areas with a small tube gap, this system can construct highly accurate three-dimensional shapes and obtain quantitative indicators assessing the degree of occlusion.

Our objective was to assess the effect of nitric oxide added to the sweep gas of the oxygenator during cardiopulmonary bypass (CPB) in infants on platelet count, platelet function, clinical outcomes, and safety. A randomized, double-blinded, placebo-controlled clinical trial in infants less than a year of age undergoing cardiac surgery requiring CPB was undertaken. Nitric oxide at a dose of 20 ppm was added to the sweep gas in the treatment group. Blood was collected at baseline and prior to separation from CPB to measure platelet count and function as determined by responsiveness to specific agonists. Clinical outcomes were observed through hospital discharge. Methemoglobin levels were measured preoperatively, at the conclusion of CPB, and upon admission to the ICU. Forty patients consented and were randomized in the trial. Eighteen patients were randomized to the treatment group and 22 were included in the placebo group. The groups were similar in terms of age, weight, gender, and surgical complexity. No significant differences were found in measures of platelet count, platelet response to agonist, or clinical outcomes. Patients in the treatment group had higher methemoglobin levels after receiving nitric oxide, but no levels approached toxicity (maximum 2.4%). Nitric oxide added to the sweep gas of the oxygenator during CPB in infants did not have an appreciable effect on the preservation of platelet count, platelet responsiveness to agonist, or clinical outcomes. Methemoglobin levels were increased after receiving nitric oxide but were far below a toxic level of 15%., (© 2020 International Center for Artificial Organ and Transplantation (ICAOT) and Wiley Periodicals LLC.)

Hemolysis in cardiac surgery is often related to the contact of blood with air or artificial surfaces. Variations of negative pressure in the suction cannulas may represent an additional factor. Limited data exist on the contribution of a roller pump-assisted (RPA) cardiotomy suction unit to hemolysis. Elevation of free hemoglobin (fHb) following air suction (AS) or suction tip occlusion (STO) events of a pump-assisted cardiotomy suction unit was investigated in a mock circuit filled with blood from slaughtered domestic pigs. AS-associated hemolysis was measured over 240 minutes with 2 minutes of AS occurring every 10 minutes. STO-associated hemolysis was analyzed over 80-minute periods: configuration 1 (c1) comprised a cycle of 20 minutes (min) occlusion and 60 minutes RPA flow (20/60 minutes); c2 comprised 20 cycles of 1/3 minutes; c3 comprised 40 cycles of 0.5/1.5 minutes; and c4 comprised 80 cycles of 0.25/0.75 minutes. The AS setup did not lead to significant hemolysis after 2 (P = .97), 3 (P = .40) or 4 (P = .11) hours. The STO setup showed the greatest hemolysis (ΔfHb of 30 mg/dL) in c1 after 20 minutes. ΔfHb was different in c1 from all other configurations at 20 minutes (P < .0001) and 80 minutes (P < .05). Ex vivo generation of large negative pressures by STO events is the main cause of cardiotomy suction-associated hemolysis. The clinical relevance of this mechanism needs further investigations., (© 2020 International Center for Artificial Organs and Transplantation and Wiley Periodicals LLC.)

Mechanically assisted circulation (MAC) sustains the blood circulation in the body of a patients undergoing cardiac surgery with cardiopulmonary bypass (CPB) or on ventricular assistance with a ventricular assist device (VAD) or on extracorporeal membrane oxygenation (ECMO) with a pump-oxygenator system. While MAC provides short-term (days to weeks) support and long-term (months to years) for the heart and/or lungs, the blood is inevitably exposed to non-physiological shear stress (NPSS) due to mechanical pumping action and in contact with artificial surfaces. NPSS is well known to cause blood damage and functional alterations of blood cells. In this review, we discussed shear-induced platelet adhesion, platelet aggregation, platelet receptor shedding, and platelet apoptosis, shear-induced acquired von Willebrand syndrome (AVWS), shear-induced hemolysis and microparticle formation during MAC. These alterations are associated with perioperative bleeding and thrombotic events, morbidity and mortality, and quality of life in MCS patients. Understanding the mechanism of shear-induce hemostatic disorders will help us develop low-shear-stress devices and select more effective treatments for better clinical outcomes.

Background: Minimally invasive mitral valve surgery is standard of care in many centres and it is commonly associated with the need for cardiopulmonary bypass. Conventional external aortic clamping (exoclamping) is not always feasible, so endoaortic clamping (endoclamping) has evolved as a viable alternative. The aim of this study is to compare endoclamping (Intraclude™, Edwards Lifesciences) with exoclamping (Chitwood) during minimally invasive mitral valve procedures., Methods: This single-centre study included 822 consecutive patients undergoing minimally invasive mitral valve procedures. The endoclamp was used in 64 patients and the exoclamp in 758. Propensity-score (PS) matching was performed resulting in 63 patients per group. Outcome measures included procedural variables, length of intensive care unit (ICU) and hospital stay, major adverse cardiac and cerebrovascular events (MACCE) and repeat surgery., Results: The mean age was similar in the two group (62.2 [endoclamp] vs. 63.5 [exoclamp] years; p = 0.554), as were the cardiopulmonary bypass (145 vs. 156 min; p = 0.707) and the procedure time (203 vs. 211 min; p = 0.648). The X-clamp time was significantly shorter in the endoclamp group (88 vs. 99 min; p = 0.042). Length of ICU stay (25.0 vs. 23.0 h) and length of hospital stay (10.0 vs. 9.0 days) were slightly longer in the endoclamp group, but without statistical significance. There were nominal but no statistically significant differences between the groups in the rates of stroke, vascular complications, myocardial infarction or repeat mitral valve surgery. The conversion rate to open sternotomy approach was 2.4% without difference between groups. The estimated 7-year survival rate was similar for both groups (89.9% [endoclamp]; 84.0% [exoclamp]) with a hazard ratio of 1.291 (95% CI 0.453-3.680)., Conclusions: Endoaortic clamping is an appropriate and reasonably safe alternative to the conventional Chitwood exoclamp for patients in which the exoclamp cannot be used because the ascending aorta cannot be safely mobilised.

Objectives: Direct true lumen cannulation (DTLC) of the aorta is an alternative cardiopulmonary bypass cannulation technique in the context of type A acute aortic dissection (A-AAD). DTLC has been reported to be effective in restoring adequate perfusion to jeopardized organs. This study reports and compares operative outcomes with DTLC or alternative cannulation techniques in a large cohort of patients with A-AAD., Methods: All patients who underwent surgery for A-AAD between January 2006 and January 2017 in Mainz university hospital were reviewed. The choice of cannulation technique was left to the operating surgeon, however DTLC was our preference in patients who were in state of shock or showed signs of tamponade or hypoperfusion, in cases of potential cerebral malperfusion, as well as in patients who were under resuscitation., Results: A total of 528 patients (63% males, mean age 64±13.8 years) underwent emergency surgery for A-AAD. The DTLC technique was used in 52.4% of patients. The DTLC group of patients had worse clinical status at the time of presentation with more shock, tamponade, true lumen collapse, cerebral and other malperfusion states. New neurologic events were diagnosed in around 8% of patients in each group following surgery, but there was a trend for quicker neurological recovery in the DTLC-group. Early mortality rates, short-term and long-term survival rates did not differ between the two groups., Conclusions: DTLC is a safe cannulation technique that enables effective antegrade true lumen perfusion in complicated A-AAD scenarios, and is an advantageous addition to the aortic surgeons' armamentarium., Competing Interests: The authors have declared that no competing interests exist.

Condensation and water loss from gas output of the cardiopulmonary bypass (CPB) oxygenator has been the study object of several research. However, little is known about the propagation of the condensation formed at the level of oxygenator and how potentially it can contaminate the surrounding environment. We aimed to document the moment of formation of the 'gas steam' derived from the CPB oxygenator during cardiac surgery with thermography imaging. Thermographic camera is a device that creates an image using infrared radiation, similar to a common camera that forms an image using visible light. The brightest (warmest) parts of the image are customarily colored white, the intermediate temperatures reds and yellows, and the dimmest (coolest) parts black. Thermal image captures the condensation phenomenon around the oxygenator perimeter with the same color/temperature code (yellow) of gas outlet. The use of aspiration at the level of the gas outlet could also favor the elimination of the condensation, improve gas exchanges, and potentially reduce the spread of hazardous substances in the operating room., (© 2020 Wiley Periodicals LLC.)

Background: Cardiopulmonary bypass (CPB) induces a systemic inflammatory response (SIRS) and affects the organ vascular bed. Experimentally, the lack of pulsatility alters myogenic tone of resistance arteries and increases the parietal inflammatory response. The purpose of this study was to compare the vascular reactivity of the internal thoracic arteries (ITAs) due to the inflammatory response between patients undergoing coronary artery bypass grafting (CABG) under CPB with a roller pump or with a centrifugal pump., Methods: Eighty elective male patients undergoing CABG were selected using one or two internal thoracic arteries under CPB with a roller pump (RP group) or centrifugal pump (CFP group). ITA samples were collected before starting CPB (Time 1) and before the last coronary anastomosis during aortic cross clamping (Time 2). The primary endpoint was the endothelium-dependent relaxation of ITAs investigated using wire-myography. The secondary endpoint was the parietal inflammatory response of arteries defined by the measurements of superoxide levels, leukocytes and lymphocytes rate and gene expression of inflammatory proteins using. Terminal complement complex activation (SC5b-9) and neutrophil activation (elastase) analysis were performed on arterial blood at the same times., Results: Exposure time of ITAs to the pump flow was respectively 43.3 minutes in the RP group and 45.7 minutes in the CFP group. Acetylcholine-dependent relaxation was conserved in the two groups whatever the time. Gene expression of C3 and C4a in the artery wall decreased from Time 1 to Time 2. No oxidative stress was observed in the graft. There was no difference between the groups concerning the leukocytes and lymphocytes rate. SC5b-9 and elastase increased between Time 1 and Time 2., Conclusion: Endothelium-dependent relaxation of the internal thoracic arteries was preserved during CPB whatever the type of pump used. The inflammatory response observed in the blood was not found in the graft wall within this time frame., Trial Registration: Name of trial study protocol: IPITA Registration number (ClinicalTrials.gov): NCT04168853., Competing Interests: The authors have declared that no competing interests exist.

Background: The aim of this study is to compare the effects of tubing length on systemic inflammatory response syndrome and myocardial protection in a rat model of cardiopulmonary bypass (CPB) from a histological standpoint., Methods: Twelve adult male Wistar Albino rats weighing >180 g were randomly selected and divided into 2 groups. In 1 group, the pump lines were kept 1 m shorter than standard. The right jugular vein and tail artery were cannulated using a 16-gauge catheter. Animals received 500 IU/kg intravenous heparin. Cardiac index and rectal temperature were set at 2.4 mL and 36°C, respectively. Total line volume was maintained at 8 mL. A roller pump was adjusted to supply a blood flow of 6 to 28 mL/min (mean 10 mL/min), similar to the typical cardiac output of rats. CPB duration was 15 minutes throughout the experiment. After sacrifice, tissue samples were collected from heart, liver, and kidney for histomorphologic examination., Results: All histochemical and histomorphologic analyses, performed by 2 blinded researchers, revealed band loss in cardiomyocytes, mononuclear (MNL) cell infiltration, and impaired fibrillar organization in the standard-line group. Additionally in that group, sinusoidal dilatation in the liver, low-level congestion, focal necrosis, and periportal MNL infiltration were noted. In the shorter-line group, on the other hand, MNL cell infiltration, band loss in myofibrils, and cardiomyocyte degeneration were rarely observed. Higher liver congestion and lower MNL cell infiltration were observed in the shorter-line group. No significant differences were found in kidney samples., Conclusion: In a shorter-line roller pump test model, less multiorgan damage and fewer systemic inflammatory responses were observed. It may be applicable to keep CPB lines as close to the table as possible, especially in pediatric cardiac surgery cases., (2020 Forum Multimedia Publishing, LLC)

Extracorporeal circulation using heart-lung-machines is associated with a profound activation of corpuscular and plasmatic components of circulating blood, which can also lead to deleterious events such as systemic inflammatory response and hemolysis. Individual components used to install the extracorporeal circulation have an impact on the level of activation, most predominantly membrane oxygenators and hardshell venous reservoirs as used in extracorporeal systems. The blood flows in two different hardshell reservoirs are computationally investigated. A special emphasis is placed on the prediction of an onset of transition and turbulence generation. Reynolds-averaged numerical simulations (RANS) based on a transitional turbulence model, as well as large eddy simulations (LES) are applied to achieve an accurate prediction. In the LES analysis, the non-Newtonian behavior of the blood is considered via the Carreau model. Blood damage potential is quantified applying the Modified Index of Hemolysis (MIH) based on the predicted flow fields. The results indicate that the flows in both reservoirs remain predominantly laminar. For one of the reservoirs, considerable turbulence generation is observed near the exit site, caused by the specific design for the connection with the drainage tube. This difference causes the MIH of this reservoir to be nearly twice as large as compared to the alternative design. However, a substantial improvement of these performance criteria can be expected by a local geometry modification., (© 2019 International Center for Artificial Organs and Transplantation and Wiley Periodicals, Inc.)

Assessing the platelets' functional status during surgery on cardiopulmonary bypass is challenging. This study used multiple electrode impedance aggregometry (Multiplate ® ) to create a timeline of platelet aggregation changes as induced by cardiopulmonary bypass in antiplatelet-naive patients undergoing elective surgery for mitral valve regurgitation. We performed six consecutive measurements (T1: pre-operatively, T2: after heparinization, T3: 3 min after establishment of cardiopulmonary bypass, T4: immediately after administration of cardioplegia, T5: 5 min after administration of cardioplegia, and T6: 45 min after administration of cardioplegia). Platelet aggregation was determined after stimulation with 3.2-μg/mL collagen, 6.4-μM adenosine diphosphate, and 32-μM thrombin receptor activating peptide. Five patients were included (age: 64 ± 10 years, one female). We observed a decrease in hematocrit levels by -17.1% ± 3.7% (T1 vs T6) with a drop after establishment of cardiopulmonary bypass (T2 vs T3) and slightly decreasing platelet counts by -6.2% ± 7.7% (T1 vs T6). Immediately after establishment of cardiopulmonary bypass (T2 vs T3), we observed reduced platelet aggregation responses for stimulation with adenosine diphosphate (-19.7% ± 12.8%) and thrombin receptor activating peptide (-19.3% ± 6.3%). Interestingly, we found augmented platelet aggregation for all stimuli 45 min after administration of cardioplegia (T5 vs T6) with the strongest increase for collagen (+83.4% ± 42.8%; adenosine diphosphate: +39.0% ± 37.2%; thrombin receptor activating peptide: +34.5% ± 18.5%). Thus, after an initial drop due to hemodilution upon establishment of cardiopulmonary bypass, platelet reactivity increased over time which was not outweighed by decreasing platelet counts due to mechanical platelet destruction and absorption. These findings have implications for rational transfusion, peri-operative antiplatelet therapy, and for the management of patients on other extracorporeal support, such as extracorporeal life support or extracorporeal membrane oxygenation.

Background: Vacuum-assisted venous drainage has gained widespread use within the pediatric perfusion community for use during cardiopulmonary bypass. It is questioned whether its efficiency may be compromised with application of excessive cardiotomy suction to the infant hard-shell venous reservoir. An in vitro simulation circuit was used to research this phenomenon. A comparison of three different infant hard-shell venous reservoirs also took place to determine if one reservoir type was more advantageous when handling cardiotomy suction. The reservoirs tested were the Maquet VHK 11000, Medtronic Affinity Pixie, and Terumo Capiox FX05., Methods: The in vitro simulation circuit consisted of a 1 L reservoir bag that was cannulated at one access point with an Edwards Lifesciences 10Fr aortic cannula and the other access area with an Edwards Lifesciences 10Fr right angle venous cannula and 12Fr right angle venous cannula that were joined together. Key points of measurement and response variables were the pressures on the connection of the venous cannulas, inlet of the venous reservoir, and flow through the venous line. Vacuum was applied and manipulated with a Maquet VAVD Controller to settings of -20 mmHg, -30 mmHg, -40 mmHg, -50 mmHg, and -60 mmHg. Cardiotomy suction was added at settings of 1 LPM, 2 LPM, 3 LPM, and 4 LPM. Values from each response variable were monitored and recorded. These data were utilized to compare the reservoirs with a random coefficient model for each response variable., Conclusions: There is an adverse effect of excessive cardiotomy suction on the efficacy of vacuum-assisted venous drainage in infant hard-shell venous reservoirs. There is no significant difference between the VHK 11000, Pixie, and FX05 regarding their ability to handle this occurrence. An important discovery was that the FX05 showed a greater transfer of vacuum to the venous cannulas and reservoir inlet.

The advancement of cardiac surgery benefits from the continual technological progress of cardiopulmonary bypass (CPB). Every improvement in the CPB technology requires further clinical and laboratory tests to prove its safety and effectiveness before it can be widely used in clinical practice. In order to reduce the priming volume and eliminate a separate arterial filter in the CPB circuit, several manufacturers developed novel hollow-fiber membrane oxygenators with integrated arterial filters (IAF). Clinical and experimental studies demonstrated that an oxygenator with IAF could reduce total priming volume, blood donor exposure and gaseous microemboli delivery to the patient. It can be easily set up and managed, simplifying the CPB circuit without sacrificing safety. An oxygenator with IAF is expected to be more beneficial to the patients with low body weight and when using a minimized extracorporeal circulation system. The aim of this review manuscript was to discuss briefly the concept of integration, the current oxygenators with IAF, and the in-vitro / in-vivo performance of the oxygenators with IAF., (Copyright© Bentham Science Publishers; For any queries, please email at epub@benthamscience.net.)

Background: Cardiac surgery using cardiopulmonary bypass carries a high risk of bleeding and need for blood transfusion. Blood administration is associated with increased rates of morbidity and mortality. Perioperatively, strategies are often employed to reduce blood transfusions in high-risk patients or in situations where blood transfusion is contraindicated. Normovolemic hemodilution is a blood conservation technique used during cardiac surgery that involves replacement of blood with fluids. SANGUINATE ® (PEGylated carboxyhemoglobin bovine) is a novel hemoglobin-based oxygen carrier that can deliver oxygen effectively to tissues in the presence of severe hypoxia. The use of a hemoglobin-based oxygen carrier during hemodilution may augment tissue oxygen delivery and reduce blood transfusion., Methods: Six standardized cardiopulmonary bypass runs simulating normovolemic hemodilution using varying proportions of bovine whole blood and SANGUINATE were performed. Pump speed, flow rate, line pressures, hemoglobin concentration, oxygenation, and degree of anticoagulation were assessed at regular intervals. Membrane oxygenators and arterial line filters were inspected for evidence of clotting following each run., Results: Increases in the pressure drop across the membrane oxygenator were detected during runs 5 and 6. Median activated clotting time values were able to be maintained at goal during the runs, and SANGUINATE did not appear to be thrombogenic. Hemoglobin concentration decreased following the addition of SANGUINATE. Oxygenation was maintained during all runs that included SANGUINATE., Conclusion: SANGUINATE does not impact the performance of the cardiopulmonary bypass circuit in a bovine whole blood model. The results support further evaluation of SANGUINATE in the setting of normovolemic hemodilution and cardiopulmonary bypass.

The purpose of this study was to evaluate the hemodynamic properties and microemboli capture associated with different vacuum-assisted venous drainage (VAVD) vacuum levels and venous reservoir levels in a neonatal cardiopulmonary bypass circuit. Trials were conducted in 2 parallel circuits to compare the performance of Capiox Baby RX05 oxygenator with separate AF02 arterial filter to Capiox FX05 oxygenator with integrated arterial filter. Arterial cannula flow rate to the patient was held at 500 mL/min and temperature maintained at 32°C, while VAVD vacuum levels (0 mm Hg, -15 mm Hg, -30 mm Hg, -45 mm Hg, -60 mm Hg) and venous reservoir levels (50 mL, 200 mL) were evaluated in both oxygenators. Hemodynamic parameters measuring flow, pressure, and total hemodynamic energy were made in real time using a custom-made data acquisition system and Labview software. Nearly 10 cc bolus of air was injected into the venous line and gaseous microemboli detected using an Emboli Detection and Classification Quantifier. Diverted blood flow via the arterial filter's purge line and mean pressures increased with increasing VAVD levels (P < 0.01). Mean pressures were lower with lower venous reservoir levels and were greater in RX05 groups compared to FX05 (P < 0.01). Microemboli detected at the preoxygenator site increased with higher VAVD vacuum levels and lower venous reservoir levels (P < 0.01). The amount of microemboli captured by the FX05 oxygenator with integrated arterial filter was greater than by the RX05 oxygenator alone, although both oxygenators were able to clear microemboli before reaching the pseudo-patient., (© 2019 International Center for Artificial Organs and Transplantation and Wiley Periodicals, Inc.)

Background: Recent scientific reports have brought into light a new concept of goal-directed perfusion (GDP) that aims to recreate physiological conditions in which the risk of end-organ malperfusion is minimalized. The aim of our study was to analyse patients' interim physiology while on cardiopulmonary bypass based on the haemodynamic and tissue oxygen delivery measurements. We also aimed to create a universal formula that may help in further implementation of the GDP concept., Methods: We retrospectively analysed patients operated on at the Wroclaw University Hospital between June 2017 and December 2018. Since our observations provided an extensive amount of data, including the patients' demographics, surgery details and the perfusion-related data, the Data Science methodology was applied., Results: A total of 272 (mean age 62.5 ± 12.4, 74% male) cardiac surgery patients were included in the study. To study the relationship between haemodynamic and tissue oxygen parameters, the data for three different values of DO 2 i (280 ml/min/m 2 , 330 ml/min/m 2 and 380 ml/min/m 2 ), were evaluated. Each set of those lines showed a descending function of CI in Hb concentration for the set DO 2 i., Conclusions: Modern calculation tools make it possible to create a common data platform from a very large database. Using that methodology we created models of haemodynamic compounds describing tissue oxygen delivery. The obtained unique patterns may both allow the adaptation of the flow in relation to the patient's unique morphology that changes in time and contribute to wider and safer implementation of perfusion strategy which has been tailored to every patient's individual needs.

In a typical open-heart surgery, the blood flow through the aortic cannula is a critical element of the cardiopulmonary bypass (CPB) procedure. Especially for the neonatal and pediatric CPB flow conditions, the need for small hydraulic diameter and large blood flow results confined turbulent jet flow regimes that exacerbate blood damage and platelet activation. Simultaneously, the confined jet wake leads to complex stagnation and recirculating flows that cause considerable thrombosis, blood, and endothelial cell damage through the aorta. Thus, an ideal neonatal CPB cannula should be able to generate optimal jet expansion so that sufficient cerebral perfusion is achieved through the head-neck vessels to avoid postoperative neurological complications and developmental defects in children. To address these challenges, a formal bio-inspired design framework is conducted to reach the desired cannula function through novel analogous biological components, first-time in literature. Among the biological jet flow regimes studied, the ventricle filling-jet generated through the atrio-ventricle (AV) valves are found to be the most promising. Inspired from human AV valve shapes, 8 different novel cannula designs, considering the size constrains of neonatal and pediatric patients are built via high-accurate micro stereo-lithography. Using 2-dimensional time-resolved particle image velocimetry the turbulent jet wake characteristics are measured and compared. The proposed designs have exhibited a significant improvement as compared to standard circular cannula by around 30% reduction in maximum outflow velocity and more than 80% reduction in potential core length and spatial energy dissipation which results in a lower risk of cardiovascular and blood damage., (© 2019 International Center for Artificial Organs and Transplantation and Wiley Periodicals, Inc.)

Perfusion strategies for cardiopulmonary bypass have direct consequences on pediatric cardiac surgery outcomes. However, inconsistent study results and a lack of uniform evidence-based guidelines for pediatric cardiopulmonary bypass management have led to considerable variability in perfusion practices among, and even within, institutions. Important aspects of cardiopulmonary bypass that can be optimized to improve clinical outcomes of pediatric patients undergoing cardiac surgery include extracorporeal circuit components, priming solutions, and additives. This review summarizes the current literature on circuit components and priming solution composition with an emphasis on crystalloid, colloid, and blood-based primes, as well as mannitol, bicarbonate, and calcium., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objective: To observe the impact of the use of capnography system adapted to cardiopulmonary bypass (CPB). To measure the concordance between values obtained from continuous monitoring of partial pressure of carbon dioxide in membrane oxygenator exhaustion (PeCO2) and the results observed on arterial blood gas test., Methods: Participated in this study 40 patients submitted to elective cardiovascular surgery with CPB. They were divided into two groups: Group 1, with 20 patients submitted to the surgical procedure using blood gas analysis at intermittent intervals (20 - 30 minutes); Group 2, with 20 patients operated with a capnography system adapted applied to membrane oxygenator exhaustion and blood gas test. A test was used to compare arterial partial pressure of carbon dioxide (PaCO2) from group 1 and group 2. In group 2, the strength of the correlation between PeCO2 and PaCO2 was evaluated by a linear regression test. The Bland-Altman method was used to determine the degree of agreement between the two variables., Results: Average and standard deviation of Group 1's PaCO2 (34.6 ± 7.44) and Group 2's PaCO2 / PeCO2 (36.5 ± 4.42) / (39.9 ± 3.98). There was no statistically significant difference in PaCO2 between the groups (P = 0.21). In group 2, PeCO2 and PaCO2 analyzed corrected for esophageal temperature obtained a positive linear correlation (r = 0.79, P < 0.001), the degree of agreement presented an average 3.47 ± 2.70 mmHg., Conclusion: The continuous PeCO2 monitoring from cardiopulmonary bypass circuit has a positive impact on the result of PaCO2. This instrument confirms and maintains the carbon dioxide (CO2) values into reference parameters.

Renal medullary hypoxia may contribute to cardiac surgery-associated acute kidney injury (AKI). However, the effects of cardiopulmonary bypass (CPB) on medullary oxygenation are poorly understood. Here we tested whether CPB causes medullary hypoxia and whether medullary oxygenation during CPB can be improved by increasing pump flow or mean arterial pressure (MAP). Twelve sheep were instrumented to measure whole kidney, medullary, and cortical blood flow and oxygenation. Five days later, under isoflurane anesthesia, CPB was initiated at a pump flow of 80 mL kg -1 min -1 and target MAP of 70 mm Hg. Pump flow was then set at 60 and 100 mL kg -1 min -1 , while MAP was maintained at approximately 70 mm Hg. MAP was then increased by vasopressor (metaraminol, 0.2-0.6 mg/min) infusion at a pump flow of 80 mL kg -1 min -1 . CPB at 80 mL kg -1 min -1 reduced renal blood flow (RBF), -61% less than the conscious state, perfusion in the cortex (-44%) and medulla (-40%), and medullary Po 2 from 43 to 27 mm Hg. Decreasing pump flow from 80 to 60 mL kg -1 min -1 further decreased RBF (-16%) and medullary Po 2 from 25 to 14 mm Hg. Increasing pump flow from 80 to 100 mL kg -1 min -1 increased RBF (17%) and medullary Po 2 from 20 to 29 mm Hg. Metaraminol (0.2 mg/min) increased MAP from 63 to 90 mm Hg, RBF (47%), and medullary Po 2 from 19 to 39 mm Hg. Thus, the renal medulla is susceptible to hypoxia during CPB, but medullary oxygenation can be improved by increasing pump flow or increasing target MAP by infusion of metaraminol., (Copyright © 2019 International Society of Nephrology. Published by Elsevier Inc. All rights reserved.)

Brain injury associated with deep hypothermic circulatory arrest (DHCA) has been recognized in patients with congenital heart diseases and those undergoing aortic arch surgeries. However, the preclinical investigation of long-term cerebral injury and recovery mechanisms related to DHCA has been restricted to a satisfactory recovery animal model with a determined recovery time. This study aimed to evaluate the feasibility of a long-term surviving DHCA model without blood priming in rats, in order to investigate the pathophysiology of long-term complications in further studies. Twelve Sprague-Dawley rats were divided into 2 groups: sham group (n = 3) and DHCA group (n = 9). The DHCA group was further assigned to the surviving time of postoperative day 2, 14, and 30 (n = 3, respectively). The entire cardiopulmonary bypass (CPB) circuit consisted of a modified reservoir, a custom-designed small-volume membrane oxygenator, a roller pump and a heater/cooler. A 24-G catheter was cannulated in the branch of the left femoral artery for arterial blood pressure monitoring. Cardiopulmonary bypass was established via the right external jugular vein-right atrium and tail artery. Rats were cooled to a rectal temperature of 18°C, followed by 30 minutes of DHCA with global ischemia. After re-warming for approximately 40 minutes, the animals were weaned from the CPB at 35.5°C. Blood gas and hemodynamic parameters were recorded preoperatively and intraoperatively, and at 2, 14, and 30 days postoperatively. Thereafter, the brains were perfusion fixed and histologically analyzed. All DHCA processes were successfully achieved, and none of the rats died. Blood gas analysis and hemodynamic parameters at each time point were normal, and vital signs of all rats were stable. Histopathologic deficits in the hippocampus (pathological score, surviving hippocampal neurons, and Ki67-positive neurons) manifested after 30 minutes of DHCA, which persisted for at least 14 days and recovered after 30 days. A novel and simple long-term recovery model of DHCA in rats was established in the present study, and histopathologic deficits were observed after clinically relevant 30-minute DHCA durations, in order to determine the 30-day recovery time frame., (© 2019 International Center for Artificial Organs and Transplantation and Wiley Periodicals, Inc.)

Technological advances in the field of extracorporeal circulation (ECC) over the past decade have led to numerous methods for monitoring metabolism and coagulation during cardiopulmonary bypass (CPB), as well as materials with improved biocompatibility, which has reduced the risk associated with cardiopulmonary bypass. However, ECC is still predominantly based on a traditional design that involves the use of roller pumps. This exposes the patient to a variety of pathophysiological consequences, both intra- and postoperative, such as postoperative cognitive disorders, hemolysis and hemodilution, systemic inflammation and changes in coagulation. This article describes the advantages of an ECC circuit inspired by the Fibonacci Golden Ratio, which does not use a roller pump, in a prospective study on patients undergoing elective cardiac surgery, compared to conventional ECC. During CPB, echocardiography was used to estimate the quality of fluid dynamics in the extracorporeal circuit and the patient's arterial vessels, a DO2 management system was used to evaluate metabolism, and an electronic system was used to determine gaseous microemboli (GME) counts. Fibonacci ECC offered superior intraoperative fluid dynamics, reduced the production of and improved the elimination of GME, and improved intraoperative metabolism, particularly with regard to oxygen delivery and extraction. The improvements in fluid dynamics and metabolic variables were associated with a reduction in the incidence of pathophysiological events compared to the conventional system, particularly regarding transitory cognitive disorders, and a shorter stay in intensive care.

Leukocyte (LE) activation during cardiopulmonary bypass (CPB) promotes a systemic inflammatory response that contributes to organ injury and postoperative organ dysfunction. A leukocyte modulatory device (L-MOD) for use during (and after) CPB to limit leukocyte-mediated organ injury was tested in a preclinical model. Twenty-two pigs underwent 180 minutes of CPB and 5 hours postoperative observation. Pigs received no intervention (group 1, n = 9), 3 hours of therapy by incorporation of L-MOD into the CPB circuit (group 2, n = 6), or 8 hours of therapy using a femoral venovenous L-MOD circuit during and after CPB (group 3, n = 7). Leukocyte activation was increased at the end of CPB and leukocyte counts, namely neutrophils, increased postoperatively in most animals. These indices trended much lower in group 3. Systemic vascular resistance was not as reduced post-CPB for the L-MOD-treated pigs, and urine output was significantly greater for group 3 (p < 0.01). At 5 hours post-CPB, group 3 had a lower troponin-I (1.59 ± 0.68 ng/ml) than group 1 or group 2 (3.97 ± 2.63 and 3.55 ± 2.04 ng/ml, respectively, p < 0.05) and a lower urine neutrophil gelatinase-associated lipocalin (7.57 ± 3.59 ng/ml) than the average of the other groups (50.71 ± 49.17, p < 0.05). These results demonstrate the therapeutic potential of L-MOD therapy to mitigate the inflammatory response to CPB. Eight hours of venovenous L-MOD resulted in less organ injury and post-op organ dysfunction in this model.

Background: Extracorporeal circuit coating has been shown to improve coagulation derangements during pediatric cardiopulmonary bypass (CPB). This study compared platelet function and hemostasis activation in pediatric cardiac surgery conducted with nonheparin coating (Balance; Medtronic, Minneapolis, MN) versus heparin-based coating (Carmeda; Medtronic) circuits., Methods: A prospective, randomized, double-center trial was conducted in children older than 1 month undergoing congenital heart disease treatment. Blood samples were collected at baseline (T0), 15 minutes after the start of CPB (T1), and 15 minutes (T2) and 1 hour after the conclusion of CPB (T3). The primary end point of the study was to detect potential differences in β-thromboglobulin levels between the two groups at T2. Other coagulation and platelet function indicators were analyzed as secondary end points., Results: The concentration of β-thromboglobulin increased significantly at T2 in both groups. However, there was no significant difference between the groups across all time points. There was no difference in the secondary end points between the groups., Conclusions: The two circuits showed similar biological effects on platelet function and coagulation. This observation may be useful in optimizing the conduct of CPB and in rationalizing its cost for the treatment of congenital heart disease., (Copyright © 2019 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background and Objective: A multi-discipline cardiac and cardiopulmonary bypass (CPB) team simulation scenario was established to compare three different de-airing approaches dealing with massive air embolism in CPB, so as to formulate a standardized procedure to handle this adverse acute event more proficiently and ensure clinical safety., Method: A simulation-based clinical CPB massive air embolism scenario was developed by a cardiac and CPB team. Study Objects: Five licensed perfusionists and five CPB trainees were matched randomly into five pairs. Each pair would simulate the three different de-airing approaches separately as followed: (1) Conventional Method: arterial line filter (ALF) de-airing purge line and oxygenator self-recirculation bypass were used to de-air; (2) Arterial-Venous Loop (A-V Loop) Method: surgeons reconnected the arterial and venous lines to de-air by restoring the original priming A-V loop configuration; (3) Isolation of the ALF Method: this ensures de-bubbling of the CPB circuit, but bypasses the ALF function. Assessment Criteria: (1) Times to recovery (duration of the circulation suspension); (2) Subjective evaluation of skill and non-skill performances., Results: As to times to recovery, the Conventional Method group took 290.6 s ± 36.2, the A-V Loop Method group took 196.8 s ± 52.0 and the Isolation of ALF group took 99.4 s ± 15.1. The statistical difference is significant among the three groups (p<0.01). The subjective evaluation of training performance indicates that this simulation-based training is effective in assessing both skill and non-skill abilities., Conclusion: CPB simulation-based training was effective in comparing de-airing strategies and can instruct perfusion practices how to optimize techniques. For well-trained, multi-discipline cardiac teams, the A-V Loop Method is highly efficient and reliable in managing CPB massive air embolism. For cardiac teams that do not have this sophisticated training, the Isolation of ALF Method should be their alternative option.

Introduction: The association of Mycobacterium chimaera infection in patients undergoing cardiopulmonary bypass (CPB) with the use of heater-cooler units (HCU) has been reported in various literature. We described microbiological monitoring and the extent of microbiological contamination of HCUs utilized in our centre and strategies employed to reduce the high microbial load., Methods: Since August 2016, we have been following the new Instructions for Use from the manufacturer for the cleaning and disinfection of three units of Stöckert 3T and four units of Stöckert 1T HCU at the National Heart Centre Singapore. Microbiological monitoring began in January 2017 and included acid-fast bacilli (AFB) culture, Pseudomonas aeruginosa, total colony and total coliform count. Methods, such as increasing disinfection frequency and making the HCU inactive by keeping it empty in storage, were used to reduce the high colony count., Results: All three units of Stöckert 3T and two units of Stöckert 1T were contaminated with Mycobacterium chimaera. Pseudomonas aeruginosa and total coliform count were consistently <1 colony-forming unit (CFU)/100 mL in every water sample of each HCU. High colony counts were encountered initially in all units. Step-up frequency of disinfection was found to be not as effective as keeping the HCU inactive in bringing the total colony count to an acceptable level., Conclusions: All monitoring and maintenance measures of HCUs need to be established and maintained to mitigate potential infection risks to patients. Strict adherence to all cleaning and disinfection processes and keeping the HCU inactive maintained the water quality of the HCU at acceptable levels.

This report describes one of the early cases of open surgical correction of tetralogy of Fallot performed by C. Walton Lillehei and colleagues at the University of Minnesota and discusses findings from the patient's follow-up 60 years later., (Copyright © 2019 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Cardiac surgery using cardiopulmonary bypass (CPB) is associated with a coagulopathy due to haemodilution, thrombocytopenia and platelet dysfunction and the activation of coagulation and fibrinolysis, despite the use of large doses of unfractionated heparin. Conventional red cell salvage may exacerbate post-operative bleeding as plasma containing haemostatic factors is discarded. We hypothesized that a novel cell salvage device (HemoSep) may attenuate haemostatic changes associated with red cell salvage. We studied haemostatic markers following autologous transfusion from conventional cell salvage or the HemoSep device., Methods: This randomised, controlled trial compared haemostatic markers in patients undergoing coronary artery bypass grafting or aortic valve replacement who received autologous blood returned from cell salvage (control) or HemoSep (study). Blood samples were taken pre-operatively, end of CPB, post-transfusion of salvaged blood and 3 hours post-operatively and analysed for full blood count (FBC), prothrombin time (PT), activated partial thromboplastin time (aPTT), fibrinogen, D-dimer and endogenous thrombin potential (ETP)., Results: Fifty-four patients were recruited (n=28 control, n=26 study). Processed blood volume for transfusion was significantly (p<0.001) higher in the HemoSep group. In the HemoSep group, the PT was shorter (18.7±0.3 vs 19.9±0.3 sec; p<0.05) post-operatively and the aPTT was longer (48.6±3.8 vs 37.3±1.0 sec; p<0.01) following autologous transfusion. In the control group, D-dimer and ETP levels were higher (1903±424 vs.1088±151; p<0.05 and 739±46 vs. 394±60; p<0.001, respectively) following autologous transfusion., Conclusions: Although centrifuged cell salvage is known to adequately haemoconcentrate and remove unwanted substrates and bacteriological contamination, the process can exacerbate coagulopathy. The HemoSep device demonstrated some increase in haemostatic markers when used in low-risk cardiac surgery patients.

Surgical adhesive agents are frequently applied to reinforce aortic sutures in cardiac and aortic surgery. They are thought to provide hemostasis and safely and effectively reduce morbidity. Complications owing to surgical glue remnants, however, have been reported. In our recent case, a surgical glue remnant was detected on the aortic valve by transesophageal echocardiography. For detection of such surgical glue remnants, and to prevent associated serious potential complications, comprehensive transesophageal echocardiography is important. If surgical glue is applied during operative procedures, the heart and aorta should be carefully examined by transesophageal echocardiography.

Clinical observation of condensation at the gas flow exit of blood oxygenators is a recurrent event during cardiopulmonary bypass. These devices consist of a bundle of hollow fibers made of a microporous membrane that allows the exchange of O 2 and CO 2 . The fibers carry a gas mixture inside (intraluminal flow), while blood flows externally around them (extraluminal flow). Although different studies described this effect in the past, the specific role of the different sections of the device requires further analysis, and the total condensation rate remains unquantified. In this study, a closer look is taken at the transition of gas between the oxygenation bundle and the external room air. A method is proposed to estimate the total condensate output, combining computational fluid dynamics (CFD) of thermal distribution and a simplified 1D model of water vapor saturation of gas. The influence of a number of different parameters is analyzed, regarding material properties, environmental conditions, and clinical use. Results show that condensation rate could vary in a 30-fold range within reasonably small variations of the different variables considered., (© 2018 The Authors. Artificial Organs published by Wiley Periodicals, Inc. on behalf of International Center for Artificial Organ and Transplantation (ICAOT).)

Background: The major source of hemolysis during cardiopulmonary bypass (CPB) remains the cardiotomy suction. 1 Previous research has shown that the combination of negative pressures and the massive air-blood interface exponentially increases hemolysis in suctioned blood., Objective: This research aims to decrease hemolysis by eliminating the air-to-blood interface by implementing the Venturi effect to create powerful suction. This research effort hypothesizes that the Venturi suction will result in less hemolysis, indicated by lower plasma free hemoglobin levels (PFH) compared to current vacuum suction., Method: The research hypothesizes that a paradigm approach to cardiotomy suction that utilizes the Venturi effect with shorter tubing lengths and weighted sucker tips will further reduce hemolysis., Results: The vacuum-suctioned blood showed PFH levels significantly increased from baseline levels (p=0.0039). Neither the Venturi nor paradigm groups showed PFH levels significantly increased from baseline levels (p=0.0625 and p=0.125, respectively). There was a significant difference in PFH levels among the three conditions (p<0.0001). The vacuum condition showed significantly higher levels of PFH compared to both the Venturi and the paradigm conditions (p<0.001 for both). There was no significant difference in the PFH levels between the Venturi and the paradigm groups (p=1.00)., Conclusion: This study concludes that vacuum suction causes excessive hemolysis. A Venturi-powered suction system does not cause hemolysis and can be employed to reduce the damaging effects of vacuum suction on blood.

Objective: To report the results of four mock femoral venous cannulas and the hydrodynamical superiority of one of them, which is the completely punched (CP) model, upon the other three., Methods: Four simulated femoral venous cannulas (single-stage, two-stage, multi-stage, and CP model) were designed from a 1/4" x 1/16" x 68 cm polyvinyl chloride (PVC) tubing line for testing. Holes on the PVC tubes were opened by a 5 mm aortic punch. In order to evaluate the cannulas' drainage performance, gelofusine was used as fluid. The fluid was drained for 60 seconds by gravitation and then measured for each model separately., Results: Mean drained volumes of single-stage, two-stage, and multi-stage cannulas were 2.483, 2.561, and 2.603 mL, respectively. However, the CP cannula provided us a mean drained volume of 2.988 mL. There were significant differences among the variables of the CP cannula and the other three mock cannulas concerning the drained fluid flow (P<0.01)., Conclusion: In our study, the measured mean volumes showed us that more drainage surface area provides better fluid drainage.

Minimally invasive cardiac surgery(MICS)rapidly has become popular in recent years. To perform meticulous surgical procedures in the limited space, specially designed surgical instruments are very useful. For excellent exposure of the surgical target, thoracoscopic system with high imaging quality such as 4K or 3D HD endoscopy is often used. An articulated rib spreader and/or soft tissue retractor is also useful since those instruments do not interfere with other surgical instruments. A suture catcher is used to pull traction sutures through the chest wall. There are various types of atrial retractor designed for MICS. For fine manipulation in the limited space, long-shafted forceps, needle holders, and scissors are necessary. Those instruments reach deeply located targets and do not interfere surgeon's and endoscopic view or other instruments. A knot pusher is another essential device to tie knots through a small incision. The automatic tying device is available outside the country. For cardiopulmonary bypass, cannulas designed for peripheral access are used. Most of those cannulas have multiple side holes that work well for excellent perfusion and drainage. There are also specially designed aortic cross-clamps. To make surgeons more comfortable and improve quality of MICS, surgical devices for MICS need to be further innovated.