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Recent Trends in Cardiopulmonary bypass
- Pathophysiology -
부천 세종병원 김 재 현
대한흉부외과학회 제대한흉부외과학회 제 2424 차 춘계학술대회차 춘계학술대회Sejong General Hospital
대한흉부외과학회 제 24 차 춘계학술대회Sejong General Hospital
History
o 1953. John Gibbon• the first successful cardiac surgery(ASD repai
r) using a pump-oxygenator
o 1955. John Kirklin• the second successful cardiac surgery(VSD re
pair) using a pump-oxygenator(‘Mayo-Gibbon bypass machine’)
대한흉부외과학회 제 24 차 춘계학술대회Sejong General Hospital
22ndnd Mayo-Gibbon Bypass Mayo-Gibbon Bypass Machine, since 1957Machine, since 1957
대한흉부외과학회 제 24 차 춘계학술대회Sejong General Hospital
Cohn LH. 3rd Edi. Fig 12-1.
Basic CPB Circuit
대한흉부외과학회 제 24 차 춘계학술대회Sejong General Hospital
CPB Circuit in Real Setting
대한흉부외과학회 제 24 차 춘계학술대회Sejong General Hospital
Venous Cannulas
대한흉부외과학회 제 24 차 춘계학술대회Sejong General Hospital
Venous Drainage
o Gravity or Siphonage
o Affected by• CVP, PVR• Height differential• Resistance in cannula, tubing• Absence of air
대한흉부외과학회 제 24 차 춘계학술대회Sejong General Hospital
Tips to controlpoor venous drainage
o Check air-lock and tubing lineo Check venous cannula positiono Control table Heighto Check CVP, PVR – Volume replacem
ent or alpha agonistso Change venous cannula
대한흉부외과학회 제 24 차 춘계학술대회Sejong General Hospital
Assisted Venous Drainage(AVD)
o Kinetic-AVD / Vaccum-AVDo Advantages
• smaller diameter catheter• smaller priming volume
o Drawbacks• risk of aspirating gross or microscopic air• hemolysis• positive pressure in the venous reservoir – air enterin
g to RA (Davila RM. Ann Thorac Surg 2001;71:1369.)
대한흉부외과학회 제 24 차 춘계학술대회Sejong General Hospital
Venous Reservoir
대한흉부외과학회 제 24 차 춘계학술대회Sejong General Hospital
o Open type(ORS)• easier management, larger capacity, easier prime, le
ss expensive• Hemolysis, material-dependent activation, silicon anti
foam compounds, massive air embolism risk(* safety device)
o Closed type(CRS)• soft, collapsible, eliminate blood-gas interface, reduc
e the risk of massive air embolism
Venous Reservoir
대한흉부외과학회 제 24 차 춘계학술대회Sejong General Hospital
Venous Reservoir
o Schönberger JP. Ann Thorac Surg 1995;59:1549.• CABG, ORS(10)/CRS(10), prospective randomized –
decreased systemic blood activation, hemolysis, postop. Blood loss.
o Brown mahoney C. Perfusion 2000;15:467.• CABG, ORS(616)/CRS(1065), retrospective – sepsis
(1%/0%), resp. failure(4%/1%), shorter hospital stay(9.8d/7.5d), less blood product use
대한흉부외과학회 제 24 차 춘계학술대회Sejong General Hospital
Pump
대한흉부외과학회 제 24 차 춘계학술대회Sejong General Hospital
o Nearly occlusiveo Afterload independento Low prime volumeo Low costo No potential for backflowo Shallow sine-wave pulseo Excessive positive and negative pres
sureo Spallation / Tubing ruptureo Risk of massive air embolism
o Nonocclusiveo Afterload sensitiveo Large priming volumeo Higher costo Potential passive backflowo Safe positive and negative press
ureo Adapts to venous returno Superior for right or left heart byp
asso Preferred for long-term bypasso Protects against massive air emb
olism
Roller Vs. Centrifugal
대한흉부외과학회 제 24 차 춘계학술대회Sejong General Hospital
Pumpo Moen O. Ann Thorac Surg 1996;62:1134.
• CABG, R(10 H/10 U)/C(10 H/10 U), prospective randomized – less hemolysis in centrifugal, heparin coating reduces complement, granulocyte, platelet activation.
o Morgan IS. Eur J Cardiothorac Surg 1998;13:526.• pediatric pts, R(23)/C(22), prospective randomized – less blood traum
a, reduced platelet activation, less imflammatory response, better clinical outcomes
o Klein M. Artif Organs 2001;25:300.• Adult OHS pts, R(500)/C(500), prospective randomized – less chest tu
be drainage, transfusion, shorter hospital stay
대한흉부외과학회 제 24 차 춘계학술대회Sejong General Hospital
o Ashraf S. Ann Thorac Surg 1998;66:1958.• CABG, R(21)/C(20), prospective randomized – IL-6, TCC, neutro
phil, elastase ↑, greater systemic inflammatory response
o Baufreton C. Ann Thorac Surg 1999;67:972.• CABG, R(15)/C(14), prospective randomized – greater complem
ent(SC5b-9) and neutrophil(elastase) activation during op., similar inflammatory response(TNF-α, IL-6…)
• *afterload sensitive – inadequate intestinal perfusion during hypothermia – additional inflammatory responses(endotoxin)
대한흉부외과학회 제 24 차 춘계학술대회Sejong General Hospital
Heat Exchanger
대한흉부외과학회 제 24 차 춘계학술대회Sejong General Hospital
Tips on Temperature control
o Gases are more soluble in cold than in warm blood.• Temperature difference ≤ 5~10°C
o Hypothermia increases blood viscosity.• Hemodilution
Hct 25% ( 20% in deep hypothermia)
• During rewarming – packed cells, ultrafiltration
o Heat may cause protein denaturation.• < 40°C
대한흉부외과학회 제 24 차 춘계학술대회Sejong General Hospital
Hemodilutiono DeFoe GR. Ann Thorac Surg 2001;71:769.
• 6980 CABG pts, Multi-center trial – The lowest Hct. during CPB increases the risk of hospital mortality, IABP, CPB weaning failure.
o Habib RH. J Thorac Cardiovasc Surg 2003;125:1436.• 5000 OHS, retrospective – Increased hemodilution d
uring CPB was associated with worse periop. vital organ dysfunction, morbidity, increased resource use, greater intermediate-term mortality.
대한흉부외과학회 제 24 차 춘계학술대회Sejong General Hospital
Oxygenator
대한흉부외과학회 제 24 차 춘계학술대회Sejong General Hospital
Oxygenator
o Membrane oxygenator(vs. Bubble)• Safer, less particulate and gaseous microemboli, les
s reactive to blood elements, superior control of blood gases
• Hollow fiber type / Spiral coil type* (prolonged perfusions)
o Membrane Polypropylene(PLP) - 0.3 ~ 0.8 μm Silicon rubber Polymethylpentene(PMP) - 0.05 μm
대한흉부외과학회 제 24 차 춘계학술대회Sejong General Hospital
PMP oxygenator
o PMP(poly-4-methyl-1-pentene) membr.• (Memrana GmbH, Wuppertal, Germany)
o 0.05 μm pore, tight membrane• solution-diffusion, low resistance, low priming volum
e, reduced blood contact
o reduce the risk of gas emboli & plasma leakage
대한흉부외과학회 제 24 차 춘계학술대회Sejong General Hospital
PMP oxygenator
o Hortons. Perfusion 2004;19(1):17.• 2000.7~, 23 ECMO pts(mean wt; 3.56kg) – no oxyge
nator change due to device failure, Longest time 1119hrs(47d)
o Khoshbin E. Perfusion 2007;22:15.• PMP(20:20)/Silicon(20:20), ECMO pts., retrospective
–significant reduction in X-ray signs of inflammation and in time taken to subsidence of X-ray changes(neonate group), delayed inflammatory changes in X-ray(adult group)
대한흉부외과학회 제 24 차 춘계학술대회Sejong General Hospital
Filters
대한흉부외과학회 제 24 차 춘계학술대회Sejong General Hospital
Filters
대한흉부외과학회 제 24 차 춘계학술대회Sejong General Hospital
Filters
대한흉부외과학회 제 24 차 춘계학술대회Sejong General Hospital
Microembolio <500 μm diametero Sources:
• Gas – bubble oxygenator, air entry into the circuit, residual air in the heart, loose purse-string sutures, cardiotomy reservoir, rapid warming, cavitation
• Foreign – atheromatous debris, fat, fibrin clot, cholesterol crystals, calcium particles, muscle fragments, tubing debris, dust, bone wax, silicone antifoam, glue, surgicel, cotton sponge fiber
• Blood – fibrin, free fat, aggregated chylomicrons, denatured proteins, platelet aggregates, platelet-leukocyte aggregates, hemolyzed red cells, transfused blood
대한흉부외과학회 제 24 차 춘계학술대회Sejong General Hospital
Tips tominimize microemboli
o Membrane oxygenator, centrifugal pumpo Cardiotomy reservoir filtero Arterial line filter/bubble trapo Temperature difference < 8~10°Co Prime with CO2 flush; recirculate with saline and filtero Prevent air entry into the circuito Use cell savero Adequate anticoagulationo Epiaortic ultrasound scanningo Consider use of special aortic cannula
Intracardiac irrigation and Deairing
대한흉부외과학회 제 24 차 춘계학술대회Sejong General Hospital
Aortic cannulas
대한흉부외과학회 제 24 차 춘계학술대회Sejong General Hospital
High velocity jets from A. Cannula
o “Sand-blasting effect”• damage the aortic wall• dislodge atheroemboli• produce dissections• disturb flow to nearby vessels• cause cavitation and hemolysis
대한흉부외과학회 제 24 차 춘계학술대회Sejong General Hospital
Breakdown of Atheromatous Plaque
Preop. Postop.
Ann Thorac Surg 2007;84:e17– 8.
대한흉부외과학회 제 24 차 춘계학술대회Sejong General Hospital
Sarns Soft-flow cannula
Baxter RMI dispersion cannula
2217 CABGs – 2.3% stroke, Left side(75%)
Ann Thorac Surg 2001;71:128.
Flow Characteristics of A. Cannulas
대한흉부외과학회 제 24 차 춘계학술대회Sejong General Hospital
Mean Velocities of A. Cannulas
Mean velocities in TEE
----- 318/296/271
(Cm/s)
----- 351/240/171
----- 174/138/90
(P<0.05)
Ann Thorac Surg 2003;75:1919.
대한흉부외과학회 제 24 차 춘계학술대회Sejong General Hospital
EMBOL-X® filtration system
Heparin-coated 120μm polyester mesh net
대한흉부외과학회 제 24 차 춘계학술대회Sejong General Hospital
EMBOL-X® cannulao Banbury MK. Ann Thorac Surg 2003;76:508.
• EmbolX(645)/control(644), multi-center(22) trial – emboli(96.8%), more than moderate risk pts. - renal Cx(14%/24%), Composite endpoint(24%/36%)
o Horvath KA. Heart Surg Forum 2005;8:E161.• EmbolX(2297), multi-center(39) trial – emboli(98%), high risk pt
s.(No. 8.5/5.8, SA 6.6/4.0mm2), fibrous atheroma(79%), platelets/fibrin(44%), thrombus(8%), foreign(2%)
o Leyh RG. Eur J Cardiothorac Surg 2002;21:100.• 60/M, Redo MVR in endocarditis pt. – Acute type A dissection
대한흉부외과학회 제 24 차 춘계학술대회Sejong General Hospital
Dual-stream baffle cannula(CobraTM catheter)
대한흉부외과학회 제 24 차 춘계학술대회Sejong General Hospital
Ascending a. cannulation
o Site selection• mannual palpation, TEE• epiaortic ultrasonic scanning *
o Complications• Difficult insertion, bleeding, tear, malposition, athero
matous emboli, injury to aortic back wall, problems with cerebral perfusion, aortic dissection, late bleeding and false aneurysm.
대한흉부외과학회 제 24 차 춘계학술대회Sejong General Hospital
Aortic dissection
o 0.01~ 0.1% of a. cannulationso Clues
• adventitia discoloration• arterial line pressure increase• sharp reduction in venous return
o Management• Prompt a. cannulation site change – HCA - repair or r
eplacemento Survival rate
• 66~85%(early recognition), 50%(late discovery)
대한흉부외과학회 제 24 차 춘계학술대회Sejong General Hospital
MBC 드라마
‘ 뉴하트’
대한흉부외과학회 제 24 차 춘계학술대회Sejong General Hospital
Circuit coatings
o To increase biocompatability• ↓: SIR(systemic inflammatory response) -Compleme
nt activation, granulocyte activation, platelet adhesion, cytokine release
• ↑: platelet function, clinical outcomes(pulmonary function)
o Coating materials• Heparin coating(ionic or covalent)• PMEA(poly-2-methylethylacrylate)• Triblock copolymer
대한흉부외과학회 제 24 차 춘계학술대회Sejong General Hospital
Heparin Coating Circuit
o Ranucci MR. Ann Thorac Surg 1999;67:994.• High risk OHS pts, H(442)/U(444), Multi-center(12) randomize
d, full heparin – ICU & hospital stay ↓, severely impaired clinical outcomes ↓, protective effect on lung and kidney function
o McCarthy PM. Ann Thorac Surg 1999;67:1268.• Redo-operation pts, H(173)/U(177), prospective randomized, fu
ll haparin – major bleeding(1.2%/5.4%), protection from reoperation for bleeding
대한흉부외과학회 제 24 차 춘계학술대회Sejong General Hospital
Summaryo Assisted venous drainage
• smaller cannula and smaller priming volumeo Closed reservoir system
• less hemolysis and systemic blood activationo Centifugal pump
• less blood trauma and sytemic inflammatory response(normothrmic condition)
o Hemodilution• increase morbidity and motality
o PMP oxygenator• reduced blood contact, increased durability
o Circuit coating• Increase biocompatibility
대한흉부외과학회 제 24 차 춘계학술대회Sejong General Hospital
Miniaturized CPB
o Alternative method of OPCAB
o Choices• MECC®(Jostra AG, Germany)• Carmeda coating(Medtronic, USA)• CorX®(Cardiovention Inc., USA)• Synergy mini-bypass system(Cobe)
대한흉부외과학회 제 24 차 춘계학술대회Sejong General Hospital
MECC®
Components• PMP oxygenator(Quadrox D®)• Centrifugal pump(Rotaflow®) • Heparin coated short lines(Bioline®)• Integral heat exchanger• KAVD / No venous reservoir
o Closed circuit →+vent→ Semiclosed o Heparin: 150 IU/kgo Warm high potassium blood cardioplegia(Calafio
re formula)o Mild hypothermia
대한흉부외과학회 제 24 차 춘계학술대회Sejong General Hospital
MECC®
system
대한흉부외과학회 제 24 차 춘계학술대회Sejong General Hospital
MECC®
o Characteristics• Hemodilution ↓(priming vol. 450~500cc), for
eign surface area ↓, air-blood interface xo Drawbacks
• Air entry and lock, volume control – close observation
• Distal anastomosis in CABG – bloody field
대한흉부외과학회 제 24 차 춘계학술대회Sejong General Hospital
MECC®
o Wiesenack C. Artif Organs 2004;28:1082.• CABG, MECC(485)/Control(485), retrospective – intraop. lactate
↓, postop. Complication, blood usage ↓
o Remandi JP. Am Heart J 2006;151:198.e1.• CABG, MECC(200)/control(200), prospective randomized – LCO
S(0.66%/4%), CRP ↓, transfusion(6%/12.8%), BUN/Cr ↓• 450 MECC cases (150 AVRs, 5 Mitral ops, 4 redo.) – air entry
(3)
경청해 주셔서 감사합니다 .
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